Hallux Limitus Rigidus / 1st MPJ Big Toe Joint Arthritis in Perth

Do you suffer from a painful big toe especially during weight-bearing movements?  Increased pain and stiffness in cold temperatures?  Difficulty wearing shoes, especially high heels, due to increased pressure on the joint?  Please read on for how we can help you.

Hallux limitus/rigidus is a condition affecting the big toe joint, known as the first metatarsal phalangeal joint (1^st MPJ). Although the terms “hallux limitus” and “hallux rigidus” have been used interchangeably, there is a difference in definition.

Hallux limitus in Perth:

Hallux limitus is when motion is present but not enough for normal walking or ambulation to occur. For normal walking there is minimum of 60 degrees dorsiflexion or upward motion of the big toe required. As the limitation of motion occurs, the cartilage starts to wear off and extra bones or bone spurs (osteophytes) form around the joint eventually making the big toe joint rigid.

Hallux rigidus in Perth:

When the rigidity occurs and the big toe completely becomes rigid then by definition the condition becomes hallux rigidus i.e., no movement of the big toe.

Why is movement of the big toe so important?

The big toe joint or first metatarsal phalangeal joint is an important joint for ambulation. Lack of motion in the big toe joint will make your gait inefficient and cause compensation and pain in other areas of the foot and lower extremity, even potentially your knee, hip or back. For normal gait you need good propulsion (moving of your body over your big toe).  This is sometimes referred to as the pre-swing part of gait.  When there is no motion at the big toe we walk on other lesser toes (known as low gear gait) causing pain and discomfort under the ball of the feet resulting in a condition called metatarsalgia. Metatarsalgia can present with many conditions such as joint synovitis, plantar plate pathology, Morton’s neuroma and many more. The joints that commonly can compensate for lack of motion in the big toe joint in lower extremity are your ankle and knee. Hence often we see patients complaining of increase in pain in their ankle when they are diagnosed with hallux limitus and rigidus.

Symptoms:

Hallux limitus and rigidus present with pain in the joint when you are active, especially as you push-off. This can occur with walking or running depending on the severity. You may get swelling and a bump growing on top or around your big toe joint which often can make footwear fitting difficult especially for female footwear. You may also complain of stiffness and inability to bend your big toe up or down.

Causes of Hallux limitus and lack of motion in the big toe:

According to the literature and in our experience as podiatrists the most common cause of hallux limitus/rigidus is trauma or previous injury. Trauma in the form of sprain/strain, stubbing your toe and fractures of the big toe can cause damage to the cartilage and initiate hallux limitus and rigidus. Abnormal foot anatomy when the first metatarsal of the big toe is long and elevated can lead to changes in the way you walk (foot biomechanics) which can contribute to developing hallux limitus / hallux rigidus.  Bad footwear and wearing high heel shoes can increase stress on the cartilage and start the wear and tear process. Other causes are osteoarthritis and systemic arthritis such as gout, rheumatoid arthritis and psoriatic arthritis.

How is hallux limitus/rigidus diagnosed?

On your first visit your podiatrist/podiatric surgeon will take a thorough history and perform physical exam on your foot, lower extremity and gait in order to find out the cause of the problem. X-rays are used to assess the degree of the arthritis present and are used to classify your condition in order to implement a treatment plan. Very rarely other diagnostic studies such as ultrasound, CT scan and MRI are ordered for further diagnosis and evaluation of your big toe joint.

Conservative Treatment Options:

Early diagnosis and treatment of the condition by one of our podiatrists can prevent surgical intervention. Hallux limitus / hallux rigidus can be treated early by conservative measures such as shoe modifications, padding, mobilization and orthotics. Shoes that have a good stiff soled rocker can help you ambulate and help you take off on the big toe joint easier. Customised functional foot orthotics can be used in order to redirect abnormal forces and increase range of motion of the big toe joint. When the condition progresses and becomes more rigid then unfortunately functional orthotics are not successful in alleviating the pain and discomfort. When the big toe becomes stiff and any movement causes pain then you may be prescribed rigid carbon plates in order to limit movement in the big toe joint.

Big toe / sesamoid joint mobilization in early hallux limitus can be very successful treatments. If the big toe becomes stiff then the sesamoids become stiff as well so by mobilising the sesamoids you can potentially improve movement of the big toe (1^st MPJ).  Releasing the triggers or tightness of the intrinsic muscles that functionally make the big toe immobile is done by various myofascial therapy techniques using dry needling and laser therapy.

Other ancillary treatments such as NSAIDS, corticosteroid injections, ultrasound and hyaluronic acid/Durolane injections can be complemented with the above treatments.

Hallux Limitus Surgery Treatment Options in Perth:

Dr Reza Naraghi, a podiatric surgeon can advise you on all options and discuss with you in detail the benefits, risks, advantages and disadvantages of all the above procedure. The goal of the hallux limitus/rigidus surgery is to create a painless, functional foot with good cosmetic results. Dr Naraghi’s extensive training in USA and keeping up to date with latest surgical techniques through workshops, seminars and conferences can assure you the best possible outcome.

Surgical treatment is reserved upon exhausting of all conservative care.  Lower grades of hallux limitus / hallux rigidus can be addressed by cheilectomies (removing the bony spurs around the big toe joint), releasing the sesamoids and decompression osteotomies (cutting the bone) of the first metatarsal or base of the big toe.

Cheilectomy surgery for Hallux limitus:

When performing cheilectomies significant amount of bone is removed from the top and side of the big toe joint in order to allow the motion to increase in the joint. This is reserved for joints that have mostly healthy cartilage intact and the limitation of motion occurs as a result of bony impingement.  The patient will be in post-operative shoe for 3-4 weeks and physical therapy is started during the 2^nd week.

Decompression Osteotomies for Hallux limitus:

Decompression osteotomies are done when the joint is slightly narrowed as a result of minor damage to the cartilage. or when there is an anatomical cause to limitation of motion such as long first metatarsal or when the metatarsal is elevated not allowing the base of the big toe to move upward. These osteotomies can be done at the first metatarsal or base of the big toe joint (base of proximal phalanx). The osteotomies are fixated with screws or staples. Patient will be in post-operative shoe for minimum 4-6 weeks. Early physical therapy in the form of range of motion exercises begin by the end of the 2^nd week.

Joint implant:

Other option for management of hallux limitus is Cartiva implant. Cartiva is an implant that acts as a cushion in the joint. After removing all of the extra bones around the joint cartiva is placed inside the joint so the cartilage on either side of the joint do not rub on each other. The benefit of this is if successful the motion is preserved in the joint. In our experience and based on the experiences of our colleagues internationally when there is higher degree of arthritis is present and significant arthritis of the sesamoid/first metatarsal is present this procedure has higher failure rate.

Hallux Rigidus Surgery Treatment Options in Perth:

When your joint is not salvageable and significant damage is done to the big toe joint’s articular surface then fusion of the big toe joint is required.

Fusion Surgery for Hallux Rigidus:

The joint is fused by removing all of the damaged cartilage.  You may require bone graft to maintain the length of your 1^st metatarsal. By fusing the big toe joint significant stress is transferred to the lesser metatarsals and this further increases when the first ray is significantly shortened as a result of removal of bone on either side of the joint. The fusion site is fixated with screws and or plate and you would be placed in a post-operative shoe or cam walker boot for minimum 6 to 8 weeks. The fusion of the big toe joint ranges from 8 to 12 weeks.  Once there is clinical and radiological confirmation of fusion you would be allowed to wear normal fitting shoes. Early hands-on therapy by a podiatrist or physiotherapist such as ultrasound, bone stimulator and laser therapy are used to reduce swelling and help with the bone healing as early as the 3rd week of post-operative period.

In very rare circumstances when the patient is an elderly and the bone density is not adequate for use of fixation and or fusion then Keller arthroplasty by removing the base of the big toe and interposing of the capsule maybe attempted. Following interpositional arthroplasty, you will be required to be in post op shoe weight bearing for 4 weeks.