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Arthritis of the 1st Metatarso-phalangeal Joint (Hallux Limitus/Rigidus)

One of the more common symptoms of osteoarthritis in the foot is located to the first metatarso-phalangeal joint (Hallux Limitus/Rigidus). Normally, 90% of body weight pushes off this joint during toe off at the end of a gait cycle.  As the arthritic process continues, motion becomes more and more limited, making walking difficult and painful.

Etiology

Hallux Limitus/Rigidus usually occurs in adults between the ages of 30 and older. It may result from previous injury to the joint cartilage or abnormal foot mechanics that increases pressure on the joint. Hallux Limitus is used to describe the disease in its earlier stages and Hallux Rigidus describes the later stages. Other causes may include metabolic bone diseases such as chronic gout and other inflammatory arthritic processes.

Signs and Symptoms

  • Stiffness in the great toe with an inability to dorsiflex or plantarflex the 1st MPJ.
  • An enlargement that develops overlying the joint.
  • Swelling around the joint
  • Pain in the joint when you are active, especially as you push-off on the toes when you walk.

Diagnosis

Inability to move the big toe joint up and down without pain is the early sign of Hallux Limitus.
X-rays of the foot are used to determine the extent of arthritis.

Conservative Treatment

Pain relievers and/or anti-inflammatory medications may help to reduce any swelling and pain. Steroid injection also may be utilized for short-term relief. Wearing a stiff soled shoe with a rocker bottom design or possibly a steel shank or metal brace in the sole may also be of benefit although we feel an orthotic with a correction under the metatarso-phalangeal  joint, reduces the amount of bending of the joint thereby reducing pain.

When there is damage to the cartilage and conservative care has failed, surgical correction may be performed.

Surgical Treatment

Cheilectomy 

This surgery is recommended when the there is mild to moderate damage to the cartilage. The bone spurs as well as part of the joint bone are removed and smoothed out so that the toe can bend easier. The incision is made on top of the foot, a wooden-soled shoe is worn for at least 2 weeks after surgery, and it is usually 3-4 weeks before a soft shoe may be worn. The toe may remain swollen for several months after the surgery. Most patients do experience long-term relief.

Metatarsal Osteotomy

This procedure is recommended when there is limitation of motion secondary to a plantarflexed 1st metatarsal and the cartilage is in relatively good condition.

The procedure involves an osteotomy of the first metatarsal to shorten the bone (creating more joint space) and rotating the cartilage (to allow more motion).

The patient is in a wooden-soled shoe for 2-3 weeks. After that time, the patient is allowed to get into a soft shoe and is sent for physical therapy to help create more flexibility in the joint. They are usually back to reasonable shoes in approximately 8-10 weeks.                  

Arthrodesis (Fusion )

This surgery is a very old orthopedic procedure reserved for severe damage to the cartilage. This is a fusion of the proximal phalanx and 1st metatarsal. This procedure will prevent the toe from ever bending but does relieve the pain in these most severe cases.

Most patients are in a rigid-soled shoe for approximately 3 weeks. Then they are able to get into a softer shoe and after approximately 8-10 weeks may get into their normal shoes.

Arthroplasty (Joint Replacement )

This surgery is recommended to replace the arthrodesis in moderate to severe damage to the joint. This involves removal of the damaged bone and cartilage of one or both surfaces of the joint and replacing them with a metal or plastic implant. We have found that using a titanium implant has proven to be superior to the older designs. The procedure does not require a cast and patients can usually wear a surgical shoe for 2-4 weeks followed by a softer shoe. Patients may then be referred for physical therapy to increase joint motion, and then may return to their own shoes in approximately 2 months.

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