Hallux rigidus remains one of the most controversial topics facing foot and ankle specialists on a daily basis. Although many theories as to the etiology of hallux rigidus have been discussed, only trauma and systemic arthritides can definitively be associated with the development of the condition. The biomechanical contributions to the development of hallux rigidus have never been scientifically proven, and several conditions, such as etatarsal primus elevatus, have come into question re: even existing as a pathology.

Classification System

The lack of understanding as to the etiology of hallux rigidus is accompanied by a lack of consensus on the proper treatments for this difficult problem. I have found that a four-stage classification system has works best for me. It combines both clinical and radiographic findings and helps my thought process towards developing a treatment plan for my hallux rigidus patients.

Figure 1

Figure 2

Figure 3

The biomechanical contributions to the development of hallux rigidus have never been scientifically proven.

Stage 1

It is rare to see patients during the very earliest stage of hallux rigidus because there are few or no symptoms. When symptoms do exist, however, they are usually minimal and transient. They are commonly brought on by excessive activity, poor shoe gear, or usually a combination of the two. Clinically, there may be associated edema of the first metatarsal phalangeal joint, slight dorsal medial first metatarsal head prominence and a slight decrease in 1st MPJ range of motion that may or may not elicit pain. Radiographically, one might see first metatarsal elevatus, hallux equinus, peri-articular subchondral sclerosis, minimal dorsal osteophytosis and minimal 1st metatarsal head flattening. Treatment for this stage is almost always accomplished nonoperatively. Symptomatic reduction of the pain and swelling can be accomplished through oral anti-inflammatory medications, icing, reduction of activity, and an isolated corticosteroid injection. Mechanical changes such as shoe modifications and functional orthotic devices can provide additional and more sustained benefits. Some have discussed the benefits of surgically intervening at this stage to prevent further degenerative changes by changing the position of the metatarsal and creating a better position for the 1st MPJ complex.

Figure 4

Figure 5

Figure 6

Figure 7

Figure 8

Stage 2

Patients often start to present with complaints in stage 2 hallux rigidus. Patients may complain of pain and swelling at the "big toe joint," pain into the big toe, pain to the bump at the top of the big toe joint and more. The pain is usually associated with shoes that either do not properly support the foot or do not provide enough space for the developing bone spur formation. Excessive activities often correlate with increasing pain in these patients. Clinically, there is usually some edema surrounding the MPJ, and dorsal medial spur proliferation. There is associated pain with normal dorsiflexion/plantarflexion range of motion as well as axial rotation of the 1st MPJ. There will be some reduction of motion. There may be pain to the dorsal spur formation, with deep palpation to the dorsal lateral aspect of the 1st MPJ. Radiographically, one will appreciate moderate dorsal osteophytosis, moderate 1st metatarsal head flattening, minimal joint space narrowing, lateral 1st MPJ exostosis. There may be sesamoid hypertrophy, and subchondral cyst formation.

Conservative treatments are no different from those of stage 1.

Surgery at this stage is where some controversies begin. Many will advocate the use of osteotomies at this stage to change mechanics and stresses of the 1st MPJ. Shortening, rotational and displacement osteotomies to decompress and reorient the jointhave been advocated. No good studies, however, have been published showing moderate to long-term success with these procedures. The literature has shown that cheilectomy is an effective, predictable and technically easy procedure to perform, with long - term studies showing high patient satisfactions.

Patients often start to present with complaints in stage 2 hallux rigidus.

Figure 9A

Figure 9B

Figure 10

Figure 11

Stage 3 is the most controversial stage in the surgical management of hallux rigidus.

Stage 3

Stage 3 hallux rigidus is associated with increasing symptoms and problems . Along with the common symptoms of pain, swelling, compensatory symptoms, and inabilities to perform desired activities, patients may complain that they can not fit into desired shoe gear because of bone spur formation around the joint. There will likely be notable dorsal medial spur formation and edema of the joint. There will be significant pain with attempted range of motion of the 1st MPJ, with reduced total motion. There may be pain with both dorsiflexion and plantar flexion . Crepitus will likely be appreciated with range of motion. There will likely be associated pain to the dorsal prominence as well as to the joint itself. Radiographically, there will be severe dorsal osteophytosis, irregular joint space narrowing, sesamoid hypertrophy, subchondral cysts and loose intra-articular bone, often at the dorsal aspect of the proximal phalanx base.

Complaints may range from severe pain with any activity to no pain except for shoe gear irritation

Figure 12A

Figure 12B

Figure 13A

Figure 13B

Patients respond to conservative care much less frequently in this stage than in the previous two stages and often necessitate operative care. Stage 3 is the most controversial stage in the surgical management of hallux rigidus. As with stage 2, many advocate the use of osteotomies for stage 3 disease. It has been shown, however,that osteotomies are not overwhelmingly successful in situations where there is greater than 50% cartilage erosion of the 1st metatarsal head, which is very common in this stage.

Many DPM's advocate the use of proximal phalanx base arthroplasty with insertion of a hemi-titanium implant. Several different designs are currently available, but none have been on the market long enough to assess their long term efficacy. Cheilectomy has been advocated in this group of patients as a joint-sparing alternative. Arthrodesis is also a consideration in this group, providing a definitive long-term solution.

Figure 14A

Figure 14B

Figure 14C

Figure 14D

In stage 4 a lack of pain will likely be due to a near total ankylosis of the joint that has eliminated all painful motion.

Grade 4

Grade 4 hallux rigidus is the end stage arthrosis. Patients will have severely enlarged areas of the 1st MPJ due to the significant exostoses formation. Complaints may range from severe pain with any activity to no pain except for shoe gear irritation. A lack of pain will likely be due to a near total ankylosis of the joint that has eliminated all painful motion. Clinically, there will be very little, if any, range of motion of the 1st MPJ. When motion is available, it will be severely painful. Loose fragments may be palpated around the joint.

There will be associated edema from the severely degenerative joint. Radiographically, there will be severe dorsal osteophytosis, an absent joint space and sesamoid fusion. Conservative options are usually only successful in patients with near total ankylosis. Shoe modifications to accommodate the bulkiness of the 1st MPJ may be successful. Anti-inflammatory medications and cortisone injections may provide temporary relief to these patients.

Figure 15

Total joint arthroplasty with insertion of a total joint implant is another option in this group.

Surgically, arthrodesis of the 1st MPJ is the mainstay of treatment for these patients. It has been well studied and has stood the test of time in this group. Newer fixation options and techniques have facilitated this procedure and seem to allow patients a quicker and more predictable outcome. Total joint arthroplasty with insertion of a total joint implant is another option in this group. Hinged-silastic total first MPJ implants with or without grommets are commonly used in the older population with stage 4 disease. Improvements in silastic products and the addition of grommets have made this option very attractive in the right patient in recent years. Two component 1st MPJ implants have historically failed and the more recent entries into the market have not seemed to fare much better with a complete absence of literature to support their use.