Hallux Limitus

Hallux 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 the joint.
4. Systemic diseases that cause injury to the joint such as rheumatoid arthritis, lupus or gout.

Hallux limitus is graded in four stages;

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 position.

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 dancer's 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 salvageable. 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.

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 located on 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;

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 should include;

Arthritis

Gout

Pseudogout

Septic arthritis

Sesamoiditis and sesamoid fractures

• Gout

• Bunion

• Turf Toe

• Foot and Ankle Surgery

• Foot and Ankle Anatomy

This article was written by Jeffrey A. Oster, DPM and last updated 2/8/13.

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, 1998

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