Hallux rigidus is a condition that refers to degenerative arthritis of the first metatarsophalangeal (MTP) joint. Davies-Colley first described the condition in 1887, who coined the term as hallux flexus due to the plantar-flexed position of the proximal phalanx relative to the metatarsal head. Cotterill later described the term hallux rigidus to characterize the painful limitation of motion of the first MTP joint. The condition is associated with restriction of dorsiflexion. To emphasize the importance of the first MTP joint, approximately 119% of body weight is carried by it during the gait cycle with each step. In the early stages, the first MTP joint goes through osteophyte formation and degeneration of cartilage; this can progress to involve the entirety of the first MTP joint in the late stages.
Multiple other mechanisms and risk factors have been proposed to explain the pathology of hallux rigidus. Repetitive stress or inflammatory conditions such as gout, rheumatoid arthritis, metabolic conditions, damage to the MTP joint articular surface due to osteochondritis dissecans, and structural factors.
Hallux rigidus is the second most common condition affecting the first MTP joint after hallux valgus. It affects about 2.5% of people over the age of 50. Females are twice as likely than men to suffer from the hallux rigidus. The condition can occur in adolescence but uncommon. It is associated with osteochondritic lesion when present in the adolescent patient.
The majority of cases of hallux rigidus are idiopathic. However, multiple authors have noted an association with the development of arthritis changes through both traumatic and iatrogenic causes. The underlying cause is likely multifactorial. Bilateral involvement is more common and is associated with family history and the female gender. Up to two-thirds of patients have a family history of hallux valgus. Achilles contracture, shoe wear, and an elevated metatarsal head do not appear to contribute to the development of first MTP joint arthritis.
Treatment & management
Must differentiate from other causes of first metatarsophalangeal joint pain, such as a bunion, hallux valgus, infection, turf toe, etc. Restriction in dorsiflexion, along with the presence of dorsal osteophytes, can lead to the diagnosis of hallux rigidus. Turf toe would present more acutely after traumatic injury. While hallux rigidus can have a swollen and painful great toe, laboratory evaluation can differentiate from other diseases such as septic first MTP joint or gout.
Nonoperative treatment should be the first attempted intervention, as it has shown to have good outcomes. Grady and colleagues reviewed 772 patients with either operative or nonoperative management; 55% percent of all patients had treatment success with conservative care alone. As per operative treatment, first metatarsophalangeal joint arthrodesis has demonstrated an excellent outcome with a success rate as high as 85%.
Cheilectomy does not prevent disease progression. Conversion rates to arthrodesis have ranged from 7% to 9% within ten years. If the procedure fails, it does not compromise further revision surgery. A systematic review by Stevens et al. demonstrated a nonunion or delayed union rate of about 6.6% associated with arthrodesis. Also, the study showed about 20% of patients had asymptomatic nonunion that did not require treatment. Other complications may include hardware removal, joint stiffness, and metatarsalgia. Complications associated with Keller resection arthroplasty include hallux cock-up deformity, toe-off weakness, and transfer metatarsalgia. Arthroplasty related complications include failure of arthroplasty. It has correlated with implant-related complications of 26% with the majority due to prosthetic loosening causing instability and pain during gait.
Patients need to understand that shoe wear does not cause nor contribute to hallux rigidus. Acute and/or repetitive trauma predisposes to arthritic changes.
Hallux rigidus is a common condition encountered by primary care providers. Referal to foot and ankle surgeons and podiatrists may be needed. Surgical treatment should only be an option after the failure of nonoperative treatment. Nonoperative treatments are successful for about half of all patients. Cheilectomy has demonstrated promising outcomes for the early stages of hallux rigidus. Arthrodesis of the first MTP joint remains the gold standard of treatment for advanced arthritis. Other treatments, such as PVA hydrogel implants, have good short term outcomes; however, these require additional long term studies. Foot and nail care nurses are an integral part of the interprofessional team.
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