limitus describes a condition where the hallux (great toe) is limited in
its' range of motion. This limited range of motion results in
jamming of the 1st metatarsal phalangeal joint (1st mpj or great toe
joint). Over time, repetitive jamming will contribute to arthritis
of the great toe joint. The most characteristic sign of hallux
limitus is a bump (exostosis) on top of the head of the 1st metatarsal.
In fact, many doctors also refer to hallux limitus as a dorsal bunion.
Hallux limitus is caused by four contributing factors. These
factors include the following;
1. A long 1st metatarsal.
2. An elevated 1st metatarsal
(metatarsus primus elevatus).
3. An impaction injury of the 1st mpj resulting in an osteochondral defect (OCD) of
4. Systemic diseases that cause injury to the joint such as rheumatoid
arthritis, lupus or gout.
Hallux limitus is graded in four stages;
|Characteristic Findings By Stage Of Hallux Limitus
||External appearance of the joint
||Vague joint pain
||No change evident
||No changes noted
||Dancer's pad or sub 1 cut out in an orthotic
||Increased frequency and duration of pain
||Mild dorsal exostosis
||Dorsal exostosis on lateral x-ray
||Carbon plate with Morton's extension. Possible
||Pain with all activities
||Large dorsal exostosis
||Increased dorsal exostosis. Asymmetrical joint space narrowing
||Youngswick osteotomy with joint revision.
||Significant pain with any range of motion of the
||Enlargement of the entire joint
||Flattening of the joint with prolific spurring surrounding the
||Joint replacement, fusion or Keller bunionectomy
Treatment of Hallux Limitus
Evaluation of the range of motion of the 1st mpj can be performed in two
positions; relaxed and functional. In a relaxed position, with no resistance exerted by the calf,
the 1st mpj shows normal range of motion without pain. In a functional
position, when resistance is applied by the calf, the range of motion of the 1st
mpj changes and hallux limitus can be more appropriately assessed. The
term functional hallux limitus is applied to cases that have normal range of
motion in a relaxed position, but decreased range of motion in a functional
Assessment of hallux limitus requires evaluation of the 1st mpj in
both a relaxed and functional position. Is there crepitus (grating
or cracking) with range of motion? Does the joint catch or pop?
Is there pain with range of motion? Each of these signs can
indicate a certain stage of hallux limitus.
Conservative care of stage 1 hallux limitus may include the use of a
pad or orthotic custom made with a sub 1 cut out pad. These two types
of pads are used
in an attempt to increase the plantarflexion of the 1st metatarsal to improve
range of motion of the 1st mpj. As we progress into more advanced stages
of hallux limitus (2-4), the dancer's pads will no longer be effective. At
this stage, we change treatment to a
stiff insert with a rigid extension called a
Morton's extension. A Morton's extension is used to stiffen the shoe to
decrease painful range of motion. Another short term solution for stage
2-4 is to use a
turf toe strap to limit range of motion.
Injectable cortisone is often used to treat hallux limitus. There is
some debate as to the merit of using cortisone for the treatment of hallux limitus. As noted
above, the majority of cases of hallux limitus are due to aberrations in the
biomechanical properties of the 1st mpj. Therefore, common sense would say
that the most effective method of treatment for hallux limitus would be to
change or alter the biomechanical property that is casing problems. For
instance, if hallux limitus is due to a long first metatarsal, then the optimal
treatment would be to shorten the
first metatarsal. Cortisone cannot treat these biomechanical factors and
therefore must have only a minimal role in the treatment of hallux limitus.
There are a number of common surgical procedures used to correct hallux
limitus. One method of care is a procedure called a cheilectomy.
Cheil means lip and a cheilectomy is a procedure that focuses exclusively on
resection of the dorsal exostosis (the lip) of the 1st metatarsal head. A second
type of surgery for hallux limitus is a metatarsal osteotomy and cheilectomy.
The metatarsal osteotomy, often called a Youngswick's modification of an Austin
bunionectomy, creates an break in the bone that can either shorten or
plantarflex the head of the metatarsal. The osteotomy is important because
it addresses the primary reason for hallux limitus (metarsus primus elevatus and
a long first metatarsal). It should be noted
that there is not universal agreement among doctors as to which of these
procedure is the best solution for hallux limitus.
Many surgeons believe that hallux limitus can be corrected with a simple
cheilectomy. The advantage to performing just a cheilectomy is that a
person will regain some range of motion and be back on their feet relatively
quickly. The disadvantage to performing just the cheilectomy without
osteotomy is that the primary biomechanical reason for hallux limitus will not be addressed.
In time, the dorsal lip will return and arthritis within the joint will
increase. The disadvantage of an osteotomy is that it increases the difficulty of the
surgery and increases healing time.
Cheilectomy and osteotomies are procedures applicable to stage 2 and 3 hallux
limitus. In addition to these procedures, revision of the joint may be
performed to repair or induce regeneration of the cartilage. Transchondral
drilling is a technique used by many doctors to resurface the joint during
surgery. Transchondral drilling means that a fine drill is used to drill
through the hard layer of bone (subchondral bone) just beneath the surface of
the cartilage. Drilling provides access to bone cells in the marrow of the
bone that can become cartilage cells. These cells are known as pleuri-potential
cells and are considered a form of stem cell. Another technique used to resurface
the joint involves the use of a osteochondral graft often referred to as an OAT
procedure or osteo-articular transfer. OAT grafts can be harvested from
other joints (often the knee) to transfer to the damaged cartilage of the 1st
mpj. Synthetic bone
graft material and metallic implants can also be used for joint resurfacing.
Surgical repair of stage 4 hallux limitus again has
disagreement among doctors
as to the best choice of procedure. In stage 4, often referred to as hallux
rigidus, the surface of the joint is so badly damaged that the joint is not
Implant arthroplasty is one choice. Implant arthroplasty involves
resection of the joint and replacement of the joint with an implant. The
advantage of implant arthroplasty is that the implant will maintain the normal
length of the toe and preserve normal range of motion. Another technique
used in stage 4 hallux limitus is
fusion of the 1st mpj. Fusion of the
joint requires a period of non-weight bearing for proper healing. The
disadvantage of 1st mpj healing is that the toe may be shortened due to
resection of the joint. A bone graft may be taken from the hip to
supplement length. Another disadvantage of fusion is permanent stiffness of the 1st
mpj. The last option for stage 4 hallux limitus is a Keller bunionectomy.
A Keller bunionectomy is a procedure where the base of the great toe is resected
and a new joint created using a flap of the joint capsule. This technique
is called an interpositional arthroplasty; interposing the soft tissue to create
a joint. The advantage of a Keller bunionectomy is that it is easy for
patients to get back on their feet. The disadvantage is that the great toe
becomes loose, short and floppy.The following images show the surgical steps
used to correct stage 3 hallux limitus. This procedure is called the
Youngswick modification of an Austin bunionectomy. Image 1 shows the
pre-operative planning with incision line and joint space marked.
Image 2 shows exposure of the dorsal exostosis (also called a dorsal bump or
dorsal bunion). In image 3, we see an oscillating saw resecting the
dorsal exostosis. This procedure is called a cheilectomy. Image
4 shows erosion of the cartilage of the head of the 1st metatarsal (stage 3
chondromalacia). A 1.2 mm pin is Kirschner wire is being used to
perform subchondral drilling. Subchondral drilling can help to restore
damaged cartilage. Image 5 shows the osteotomy of the 1st metatarsal.
A 2 mm wedge is being take from the dorsal aspect of the osteotomy.
The osteotomy is outlined by blue dots. Image 6 shows the completed
osteotomy that has shortened and plantarflexed the 1st metatarsal.
Image seven shows fixation of the osteotomy with a single screw. Image
8 show the improved range of motion post-op. In image 9, the joint
capsule and deep tissue is closed. And image 10 shows final skin
Surgical correction of hallux limitus is performed at a hospital or
outpatient center. The procedure takes approximately 1 hours to
complete. A local anesthetic with sedation or general anesthesia is
used. Patients are able to bear weight on the foot immediately post-op
for limited periods of time. A walking cast will be used for 6 weeks
post-op. Variations in this procedure may include K wire fixation or
absorbable pin fixation.
1st metatarsal phalangeal joint (1st mpj) - the big toe joint. Made
up by the 1st metatarsal bone on the proximal side of the joint and the proximal
phalanx of the hallux on the distal side of the joint.
Bunion - an enlargement of bone at the medial aspect of the
1st metatarsal phalangeal joint.
Distal phalanx - the most distal phalange (bone) of a toe or
finger. Most toes and fingers consist of three phalanges.
Hallux - Refers to the great toe.
Hallux limitus - limitation of the motion of the 1st
metatarsal phalangeal joint (big toe joint)
Hallux rigidus - complete limitation of motion of the 1st
metatarsal phalangeal joint. Also known as stage 4 hallux limitus.
Metatarsus primus elevatus - a fixed elevated position of the
1st metatarsal bone.
Middle phalanx - the middle phalange of a toe or finger.
Most toes and fingers consist of three phalanges.
Phalange - plural for phalanx
Proximal phalanx - the most proximal phalange (singular) of a
toe or finger. Most toes and fingers consist of three phalanges.
The 1st metatarsal bone, one of the five metatarsal bones, is
the medial (inside) of the arch and is about the size of your index
finger. The 1st metatarsal forms the proximal aspect of the 1st metatarsal
phalangeal joint. The distal portion of the joint is compromised of the
base of the proximal phalanx of the hallux.
Normal function of the great toe joint (1st metatarsal phalangeal
joint) requires that the 1st metatarsal bone plantarflex (move down) to allow the
proximal phalanx to ride up (dorsiflex). This hinge action needs to take
place with each step. If the normal range of motion is limited in any way,
jamming of the joint will occur and hallux limitus will ensue. There are
two known biomechanical factors that contribute to the formation of hallux
limitus. Those factors include;
A long 1st metatarsal - the relative length of the 1st
and second metatarsals is very important in understanding the onset of
hallux limitus. To explain the relevance of a long 1st metatarsal,
consider this example; you have two bamboo poles that you hold under your
left and right arms and extend directly out in front of you. The pole on the left is 5
feet long and the pole on the right is 10 feet long. You slowly lower
the poles to the ground and the long (right) pole will hit the ground first,
followed by the shorter pole. Now imagine the two poles as the 1st and
second metatarsals of the left foot or right foot. For effective function of the great toe
joint, the 1st metatarsal has to be that shorter pole. If it is
longer, the normal hinge action will not occur and jamming will ensue.
An elevated 1st metatarsal (metatarsus primus
elevatus)- as previously described, plantarflexion of the 1st metatarsal
is required for the hallux to ride up onto the 1st metatarsal head.
With an elevated 1st metatarsal, the hinge motion is limited and jamming
The symptoms of hallux limitus vary by stage. Stage 1 can
often be difficult to diagnose due to limited overt clinical or radiographic signs of a problem.
For instance, stage 1 shows no x-ray change or dorsal exostosis.
In stage 2 and 3, the symptoms of hallux limitus increase both
in intensity and duration. Pain is a dull ache in the great toe joint that
increases with the time spent on your feet. In the later stages of stage
3, cracking and popping of the joint and sharp pain may occur. These symptoms are due to
the erosion of the cartilage of the 1st mpj. A dorsal bone spur is present
on the top of the joint in stages 2 and 3.
Stage 4, or what is called hallux rigidus, is painful with every
step. The absence of range of motion of the 1st mpj is due to full erosion
of the cartilage within the joint. This erosion results in bone on bone
motion in the joint which produces significant pain. Diffuse enlargement
of the joint is obvious due to arthritis within the joint.
The differential diagnosis for this condition
Sesamoiditis and sesamoid fractures
Products Recommended for Hallux Limitus:
This article was written by Jeffrey A. Oster, DPM and last updated
Additional references include;
Drago, J, Olaf, L,
Jacobs, EM, A comprehensive review of hallux limitus. J. of Foot
Surgery. 23:213-220, 1984
Hanft, JR, Mason, ET,
Landsman, AS, Kashuk, KB, A new radiographic classification of
hallux limitus. J. of Foot and Ankle Surgery, 32(4):397-404, 1993
Shereff, MJ, Baumhauer, JF, Hallux rigidus and osteoarthrosis of the first
metatarsalphalangeal joint. J. of Bone and Joint Surg. 80-A(6):898-908,
Laporta, G, Melillo, T, Olinsky, D X-ray evaluation of hallux abducto valgus deformity, J. Am.
Podiatry Assoc. 64:544-566, 1974
Camasta, C A, Hallux
limitus and hallux rigidus. Clinical examination, radiographic
findings, and natural history. Clin. Podiatr. Med Surg. 13:428-448, 1996
Ronconi, P, Monachino, P, Baleanu, PM, Favilli, G, Distal Oblique Osteotomy of the first
metatarsal for the correction of hallux limitus and rigidus deformity J.
of Foot and Ankle Surg. 39:3 154-160 2000
Lundeen, RO, Rose, JM
Sliding oblique osteotomy for the treatment of hallux valgus associated
with functional hallux limitus, J. Foot and Ankle Surg. 39:3 161-167
Beertema, W, Draijer WF, van Os, JJ, Pilot, P. A retrospective
analysis of surgical treatment in patients with symptomatic hallux rigidus: long
term follow-up. J. Foot and ankle Surg. 45:3 244-251 2006
Was this information
Don't see the answer to your
question? Try one of these resources:
represents a wonderful opportunity to communicate and share information.
It's important to all of us at Myfootshop.com that we communicate in a way
that is most effective for the users of our site. Myfootshop.com follows the
online communication guidelines established by Medem, Inc.
At the conclusion of this article you'll find a number of products that are
recommended by Myfootshop.com to treat this condition. These products have
been hand picked by the medical consulting staff at Myfootshop.com for their
effectiveness and reliability. Should you have any questions regarding the
selection or use of these products please don't hesitate to contact us at
on this page does not constitute the practice of medicine and is offered as
an educational aid. Should you have a medical problem, Myfootshop.com
and their representatives recommend that you seek the help of your physician
or other healthcare professional.
Related Keywords and Search
Shop smart & save!
We comply with the HONcode standard for trustworthy health information: verify here.