Editor’s note: Given the frequency with which arthritic conditions present in the lower extremity and requests from our readers for articles on managing lower extremity manifestations of arthritis, we proudly introduce this new column on “Lower Extremity Arthritis.” The column, which will appear on a semi-regular basis, will discuss the diagnosis and treatment of lower extremity complications, as well as clinical scenarios that may warrant referral to podiatrists.

Hallux limitus is one of the most common degenerative arthritic conditions clinicians see in the foot and ankle. Patients with hallux limitus have painful, limited range of motion in the sagittal plane at the first metatarsophalangeal joint (MPJ). To allow for normal gait, the range of motion of the first MPJ should be approximately 65 to 75 degrees. Anything less than 65 degrees at this joint usually requires some form of compensation during the gait cycle.

There are two forms of hallux limitus. With structural hallux limitus, there is limitation of range of motion regardless of weightbearing. With functional hallux limitus, limitation of range of motion only occurs during weightbearing.

The exact etiology of hallux limitus is unknown. However, there is a host of factors that can contribute solely and in conjunction with the condition. These factors include: a condition called metatarsus primus elevatus (an elevated first metatarsal when compared to the lesser metatarsals); a long first metatarsal; a hypermobile first metatarsal; osteochondritis dissecans; soft tissue and sesamoidal constraints around the first MPJ; and trauma at the joint. Due to the wide range of etiologies that may contribute to hallux limitus, there is no significant predilection among race, age or gender.

Key Insights On The Clinical Presentation
Clinicians can use several grading systems, based upon radiographic and clinical findings, to aid in the diagnosis and treatment of hallux limitus. (See “An Overview Of Diagnostic Staging For Hallux Limitus”) Clinically, patients will present with pain at the hallux with or without footwear. Some footwear, especially higher heels, will aggravate the condition by creating strain at the joint and fixing the hallux in dorsiflexion for an extended amount of time. The patient’s pain will usually progress with increased ambulation and can be correlated to his or her level of activity. Women typically tend to present more symptomatically with hallux limitus. This is not to say that women are more prone than men to developing hallux limitus but do tend to be more symptomatic secondary to footwear choices.

Many patients will present with “bump” pain to the top of the joint created by dorsal exostoses at the first metatarsal head as shown below.

Some patients will also present with “bump” pain to the top of the joint, which is created by a dorsal exostoses at the first metatarsal head. Certain footwear may further aggravate this bump. Also be aware that these patients may experience radiating, tingling or burning pain. This is caused by the medial dorsal cutaneous nerve impinging on the dorsal exostoses due to the anatomical pathway of the nerve.

At times, patients will also present with painful hyperkeratotic lesions on the plantar aspect of their feet. The most common lesion is usually at the plantar aspect of the hallux interphalangeal joint. Due to limited dorsiflexion available at the first MPJ, the foot compensates by dorsiflexing or hyperextending at the hallux interphalangeal joint during the stage of gait cycle known as propulsion. This hyperextension causes increased plantar pressure at the hallux interphalangeal joint and leads to the resulting painful lesion.

What About Conservative Treatment Options?
Treatment options vary depending on the severity of a patient’s condition. In the early stages of hallux limitus, our goal as practitioners is to reduce the pain and inflammation through conservative means. Conservative options include intraarticular and periarticular cortisone injections, oral NSAIDs, physical therapy, shoe modifications and orthoses. Physical therapy of the first MPJ — via the manipulation and reduction of the periarticular soft tissue contractures — can increase mobilization of the joint.

Orthoses that have cutouts or extensions at the first MPJ allow for increased plantarflexion at the joint and are especially useful in patients with a functional limitus. A “rocker bottom” shoe or a shoe with a metatarsal bar will also allow for less strain at the joint during propulsion.

Painful hyperkeratotic lesions on the plantar aspect of a patient’s feet may be present in cases of hallux limitus. The most common lesion is usually at the plantar aspect of the hallux interphalangeal joint.

Exploring Surgical Options For Severe Cases Of Hallux Limitus
For the more severe cases of hallux limitus, one may need to consider referral of the patient to explore possible surgical options, which are dependent on the patient’s age, pain and level of activity. The five surgical options currently available are cheilectomy, arthrodesis, corrective osteotomies, arthroplasties and joint implants.

Cheilectomies are the most common procedures for hallux limitus, especially in the early stages when the patient is only complaining of “bump” pain. This involves resecting an adequate amount of bone dorsally to increase dorsiflexion at the joint. However, this does not address any structural deformities of the first metatarsal. In many cases, cheilectomies will give your patient relief for many years but an additional procedure may be required if the original etiology was not addressed and the deformity recurs.

Arthrodesis of the joint is currently the standard of care for the latter stages of hallux limitus. In these stages, there is significant degenerative disease and the joint is unsalvageable. The arthrodesis procedure involves resecting all osteophytes, denuding all articular cartilage and fixing the hallux in a dorsiflexed position by utilizing screws or plates. Many outcome studies have suggested high patient satisfaction with fusion of the first MPJ. However, those patients studied tend to be older, less active and with significant disease at the joint. Arthrodesis does not seem to be a suggested option in younger, more athletic patients.

Corrective osteotomies of the first metatarsal as well as the proximal phalanx can address the underlining etiology. By performing a decompression osteotomy, one can shorten the first metatarsal or the proximal phalanx to allow for more space within the joint. Enclavement of the proximal phalanx can also serve to decompress the joint. A surgeon would resect the base of the proximal phalanx, reshape the resected base and seat it into the medullary canal of the proximal phalanx. This also serves to remove the tension of the flexor hallucis brevis, and attachments of the abductor and adductor hallucis tendons at the joint.

When it comes to metatarsus primus elevatus, a plantaflexory osteotomy can theoretically allow a relaxation of the flexor tendons plantarly and increases the vector force of the extensor tendon pull at the first MPJ. For a hypermobile first ray, some studies have suggested fusion of the first metatarsocuneiform joint. Studies have suggested that increasing the lever arm decompresses the joint. Additionally, wedge resections during fusion can aid in plantarflexing and repositioning the first metatarsal.

In the past, arthroplasties of the first MPJ involved completely resecting the base of the proximal phalanx. Surgeons generally reserved this procedure for the elderly population or those who were inactive.
By removing the base completely, the joint space increases but it also creates a shortened and unstable hallux. Other methods now include interpositional arthroplasties, in which one will resect a small portion of the first metatarsal head. The surgeon will anchor soft tissue — such as the joint capsule, a portion of the extensor hood or a cartilaginous/tendinous substitute — as a spacer within the joint to facilitate motion. Surgeons can perform interpositional arthroplasties in younger patients since there is less bone resection and because it is more stable than resecting the proximal phalangeal base.

An Overview Of Diagnostic Staging For Hallux Limitus

There are many new implants designed every year for the first MPJ. These implants include total joint implants or “hemi-implants.” However, there are few long-term studies on the effectiveness and longevity of the implants. For many practitioners, the hesitancy in placing implants into the first MPJ stems from the unproven longevity of most implants as well as the amount of bone resection required to insert them. Note that if a surgeon needs to remove an implant for any reason, the amount of bone loss at the first ray can be dramatic.

In Conclusion
Hallux limitus is a common complaint in the lower extremity. Patients will present to you with vague pain to the hallux. Due to the progressive nature of this condition, it is important to recognize and treat the symptoms early and conservatively. Many patients are highly active and pain-free when clinicians treat them with pharmacological antiinflammatory intervention, physical therapy and orthoses. However, if conservative measures fail, there are many surgical options available.