87: Hallux Rigidus

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CHAPTER 87

Hallux Rigidus

David Wexler, MD, FRCS (Tr & Orth); Dawn M. Grosser, MD; Todd A. Kile, MD

Synonyms

Osteoarthritis or degenerative joint disease of the first metatarsophalangeal joint

Osteoarthritis of the great toe [1]

ICD-9 Code

735.2  Hallux rigidus

ICD-10 Codes

M20.20  Hallux rigidus, unspecified foot

M20.21  Hallux rigidus, right foot

M20.22  Hallux rigidus, left foot

Definition

Degenerative joint disease or loss of articular cartilage from the first metatarsophalangeal (MTP) joint leading to painful restriction of motion is called hallux rigidus. The normal range of motion of the first MTP joint is 30 to 45 degrees of plantar flexion to almost 90 degrees of dorsiflexion. The limited range of motion and pain with hallux rigidus are exacerbated by overgrowth of bone (osteophytes or “bone spurs”) on the dorsal aspects of the base of the proximal phalanx and the head of the metatarsal, which impinge on one another as the great toe dorsiflexes [2]. Hallux rigidus is the second most common problem in the first MTP joint, after hallux valgus; 1 in 40 people older than 50 years will develop hallux rigidus [3].

In general, the cause is unknown, although it is associated with generalized osteoarthritis of other joints and repeated microtrauma (e.g., in soccer players). Sustaining repetitive turf toe–type injuries may lead to this form of early joint degeneration [4]. As the plantar capsuloligamentous complex of the first MTP joint is injured by hyperflexion of the great toe, it may acutely compress the articular surfaces of the joint, causing articular damage, or become chronically unstable, predisposing the MTP joint to degeneration and hallux rigidus [5].

Symptoms

Patients typically report pain, either intermittent or constant, that occurs with walking and is relieved by rest. It is insidious in onset and may be associated with stiffness, swelling, and sometimes inflammation. On occasion, there can be locking due to a cartilaginous loose body. Patients may notice that they are walking on the outside of the foot to avoid pushing off with the great toe during the terminal stance and toe-off phases of the gait cycle. As degeneration increases, the pain may intensify and result in an alteration of gait.

Physical Examination

On inspection, there will usually be swelling around the MTP joint with tenderness of the joint line. Dorsal osteophytes may be palpable and may cause irritation of overlying skin with shoe wear abrasion. Pain is reproduced with forcible dorsiflexion of the great toe, which is also restricted in range of movement. Plantar flexion may also be affected. Patients may have an antalgic (painful) gait, and single-stance heel raise may be difficult secondary to a painful MTP joint, as opposed to posterior tibial tendon deficiency. Findings of the neurologic examination, including strength, sensation, and reflexes, are typically normal.

Functional Limitations

Functional limitations include walking long distances, running any distance, and ascending stairs. As the severity increases, walking even short distances, daily errands, and standing for long periods may be difficult. Flexible shoes as well as shoes with a tight toe box may prove to be uncomfortable. This may lead to pressure areas dorsally over the osteophytes.

Diagnostic Studies

Plain anteroposterior and lateral standing radiographs will usually suffice in confirming the diagnosis (Fig. 87.1

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