Hallux Limitus/Rigidus

Hallux Limitus and Hallux Rigidus are terms that refer to different stages of the same foot problem.

Terms:

Hallux - refers to the big toe.

Limitus - refers to decreased motion of the joint. There is less than normal motion available. This is the early stage.

Rigidus - denotes a joint that is rigid…very little, if any motion is available. This is the later stage.

Definition:

Hallux Limitus and Hallux Rigidus involves the 1st metatarso-phalangeal joint. This joint is located at the base of the big toe. Hallux Rigidus/Limitus causes pain and stiffness in the big toe, and with time it becomes increasingly harder to bend the toe. This is a progressive condition during which the toe’s motion decreases as time goes on. In the early stages, motion of the big toe is only limited, and at this point, the disorder is called Hallux Limitus.  As the problem advances, the big toe’s motion gradually decreases until it becomes rigid or frozen. At this point, the disorder is referred to as Hallux Rigidus. As motion becomes progressively limited, pain increases, especially when the big toe is extended, or pushed up. This condition is frequently seen in younger adults and can occur secondary to athletic sports or injury. Often times a relatively minor injury to the area in high school can precipitate an early painful and limited joint. Essentially this condition is a type of osteoarthritis which may be post-traumatic arthritis to this specific joint. There is an early type of Hallux Limitus, which does not shoe any x-ray signs, but there is limitation of motion dorsally especially when the foot is on weight bearing load. This is referred to as Functional Hallux Limitus.

Anatomy:

The problem occurs at the 1st metatarsal head and the base of the 1st proximal phalanx. The fibro-elastic tissue that covers the head of the metatarsal and the base of the phalanx is known as the articular cartilage. The cartilage allows for fluid motion at the joint surface and good cartilage allows free and unrestricted motion at the joint.

 

Early Symptoms and Diagnostic Signs (Hallux Limitus):

  • Pain and stiffness in the big toe when it is pushed upwards, as occurs when we walk, run, squat, and stand on our toes.
  • Swelling and inflammation of the joint, especially on the top of the joint.
  • Discomfort in the joint that occurs when the weather is damp and cold.
  • A feeling of “tightness” in and around the joint.

Later Symptoms and Diagnostic Signs (Hallux Rigidus):

  • Pain in the joint that is almost constant.  May even be felt when resting and the shoe has been removed.
  • Crepitus, or a “grinding” feeling in the joint when the big toe is moved up and down.
  • A bump, or “hardness” can be felt on the top of the joint. Eventually, this bump which is actually a bone spur, becomes large enough to be seen with the naked eye.
  • Difficulty wearing shoes, especially high heels, due to the bone spur and stiffness of the big toe joint.
  • Walking becomes so painful that we try to walk without bending the big toe.
  • Limping and Pain in other parts of the foot, as we try to throw our weight off of the big toe on to the adjacent foot structures.
  • Pain in the knee, hip, and lower back due to changes in the way we walk.
  • Weight gain due to lack of walking and exercise, because of this pains.

Causes:

Hallux Limitus and Rigidus are due to a premature ”wearing down and tearing” of the cartilage in the 1st metatarsal-phalangeal joint. As the cartilage begins to wear down, the proximal phalanx of the big toe, and head of the metatarsal begin to rub against each other.  Without the protection of the cartilage between these bones, each time the toe is moved, friction and pain occur. Each step that is taken causes more deterioration of the joint cartilage. Continued deterioration of the cartilage results in the development of weakened cartilage, the bone tries to regenerate and replace worn down areas. This leads to an over-growth of bone called bone spurs. These spurs can be felt, and sometimes seen, all around the big toe joint, especially on the top of the joint. Sometimes referred to as a dorsal button. A narrowing of the 1st metatarso-phalangeal joint, which is evident when radiographs of the foot are taken. Increased stiffness, swelling, inflammation, and pain in the big toe. Eventually, when the cartilage has been worn down completely, there is no movement at this joint….the big toe is said to be “rigid.”
Osteoarthritis, or degenerative joint disease, is a term that is used to describe the progressive deterioration of the cartilage in a joint. Therefore, Hallux Limitus and Hallux Rigidus can be thought of as osteoarthritis of the 1st metatarso-phalangeal joint.

 

What causes the cartilage to deteriorate?  

Repetitive Injuries to the joint occur when the big toe is repeatedly jammed backwards, with force, against the joint cartilage. This retrograde pressure on the cartilage causes the cartilage to prematurely wear down and tear. Some of the most common causes of this type of injury include:

  • Frequent wearing of high heel shoes.
  • Wearing shoes that are too short.
  • Squatting for long periods of time.
  • Stubbing the big toe.
  • Improper running technique. Running on your toes, so that your heel does not touch the ground.
  • Dropping a heavy object on your big toe joint.
  • Age-related changes of the big toe joint, or osteoarthritis. Osteoarthritis, or degenerative joint disease, is the most common form of arthritis that affects human beings. It is due to the normal wear and tear that our joints undergo during our lifetime. This disease produces a gradual deterioration of the joint cartilage throughout our entire body, including the big toe joint. The saying is true: “If you live long enough, you will develop osteoarthritis.” As we age, and osteoarthritis sets in, we begin to notice stiffness, swelling, and a little pain in all of our joints. One of the most common sites that this occurs in is the big toe joint. As osteoarthritis progresses, and the cartilage in the big toe joint deteriorates more, we begin to notice more and more of the symptoms of Hallux Limitus at first, and Hallux Rigidus later on. As mentioned earlier, this problem often manifests in younger patients due to athletic injury or even something as simple as dropping something on the affected area.
  • Hereditary Defects are those defects that we are born with, which predisposes us to Hallux Limitus/Rigidus. Pronation occurs when the foot rolls outward at the ankle, causing one to walk more on the inner border of the foot than is normal. As we walk, pronation causes us to place excessive weight and pressure on the big toe and big toe joint. When the big toe joint needs to work harder to help push us forward every time we take a step, due to the extra weight placed on it, the joint cartilage becomes overly compressed. Eventually, this causes the cartilage to prematurely wear down, resulting in the symptoms of Hallux Limitus.
  • Feet with high arches are usually more rigid than normal, and will not allow the high arch to come into contact with the ground when we step down. Therefore, as we step forward, all of our weight is thrown on to the balls of the feet, rather than some of the weight being carried by the arch. This will force the bones and joints in the balls of the feet to bear excessive weight, especially the big toe joint. The results of this repetitive and excessive weight on the big toe and big toe joint result in compression, deterioration, and eventually tearing of the joint cartilage. As this continues, the signs and symptoms of Hallux Limitus appear.
  • An elevated first metatarsal causes the big toe to excessively flex (push downward) with every step we take. When the big toe is in a flexed position and strikes the ground, it is jammed back into the big toe joint cartilage with excessive force, or retrograde pressure. Over time, this results in a thinning and wearing down of the joint cartilage. As this continues, the individual begins to experience the symptoms of Hallux Limitus.
  • An abnormally long first metatarsal increases stress on the big toe joint each time the big toe pushes us forward. This stress is further increased if the shoe is too short or the heel is too high, as this forces the big toe back into the joint cartilage with excessive force. The joint cartilage becomes pinched between the big toe and the metatarsal, causing premature wearing and deterioration of the cartilage. This results in the uncomfortable symptoms of Hallux Limitus. (In most instances you can determine if your first metatarsal is too long by the fact that the big toe appears too long, in relation to your other toes). This also applies if the 2nd metatarsal is very short creating an abnormal parabola thereby increasing stress on the 1st metatarsal joint.

Prevention:

Hallux Limitus or Hallux Rigidus is difficult to prevent since it is due to the structure of the foot you were born with. Many times surgery is recommended for the condition. Proper shoe wear and controlling the structure of your foot at all times may be the easiest treatment. A shoe with a wider toe box to accommodate the foot structure as well as avoiding high heeled shoes is necessary. If the area is irritated with redness, swelling, and pain some ice and anti-inflammatory medications may be helpful. The best prevention may be to get advice from your podiatrist.

 

Podiatric Care:

May include using other anti-inflammatory oral medications or an injection of medication and local anesthetic to reduce this swelling or if a bursitis is present. When you go to your doctor, x-rays are usually required to evaluate the structure of your foot and determine how much damage has been done to the bone. The podiatrist may see you to take care of any cornsor callouses that develop due to the bone deformities. They may advise you on different shoewear or prescribe a custom made orthotic to try and control the foot structure especially if you have excessive pronation. Your podiatric physician may also recommend a surgical procedure to actually fix the structural problem of your foot.

 

Surgery:

To correct Hallux Limitus and Hallux Rigidus surgery is very common and may be the best prevention. Your surgeon may even use the term bunionectomy for this correction as similar procedures may be used for both conditions. As your big toe joint worsens over time, there is increased damage being done to joints of the foot. With a longstanding deformity of the joint surface the cartilage may be worn down producing degenerative arthritisthat is not reversible. As jamming of this joint progresses, there maybe extra build up of bone on the top and sides of this joint. There are many ways to correct the deformity of this joint depending on the stage of deformity and the foot structure. This can range from simply removing the excessive bone around the joint known as a Cheilectomy. There may be bone cuts made to decompress the joint to stop the jamming similar to what is done with bunioncorrections. The surgeon may place fixation in your foot as it heals which may include a screw, pin, or wires. The joint may need complete removal if it is destroyed. Sometimes the bones are actually fused together to become one bone to relieve the pain and misalignment. Other times a first metatarsal joint implant is placed in the joint to simulate the joint and allow for some flexibility. Typically only one foot is done at a time so that you have one good foot while the foot having surgery can recover.

 

Post-operative Care and Risks:

Risks of a surgical correction of Hallux Limitus and Hallux Rigidus depends on the exact surgery performed. You may need a cast to protect you for a short time. Sometimes a soft bandage with a post-operative shoe is allowed. You should expect some pain following surgery as well as swelling. Especially for the first 48 hours you should keep your leg elevated and occasional ice placed over the area of surgery (about 20 minutes per hour). Surgical cuts are made through the skin so a scar is expected. If you are a keloid former, let your surgeon know. Surgical cuts are not only made through skin, but through other layers of tissue as well, a scar may form within your foot and lead to adhesions. For many procedures you will be required to keep all weight off of your foot for several weeks, typically 5-8 weeks depending on procedure. Your surgeon may allow you to place some weight on the heel. You may use crutches, a walker, or wheelchair to help you keep weight off of this foot. Healing time is typically 6-8 weeks for all bone cuts. This is influenced by many factors including your nutrition, circulation, and other medical conditions. If you are a smoker you can expect to take longer to heal. If your bone heals real slow it may be a delayed union, or if not at all a non-union. If you are required to keep pressure off of your foot your leg muscles are not being used as they were before surgery. This allows for slower movement of the blood through the leg vessels. Occasionally this can lead to a blood clot in the leg which can become life threatening. Hip and knee flexion and extension exercises as well as wiggling your toes gently can help prevent this from occurring. If you have a history of blood clots you should let your surgeon know.