Lesson

Hallux rigidus

Hallux rigidus is a disabling degenerative disease of the first metatarsophalangeal joint. In football, the disease arises from the repetitive dorsiflexion/jamming of the foot’s first row. The normal ROM of the big toe includes 45 degrees flexion and 70 degrees extension. Football players with clinical pain and stiffness at the base of the MTP joint following injury can develop progressive degenerative arthritis. Together with trauma, systemic arthropathies, hyperpronation, an elevated metatarsal, poor footwear and an unusually long first metatarsal can also initiate degenerative changes.

 

History

The football player complains of pain, swelling and decreased motion over the big toe. There is usually no trauma, or a minimal amount, involved. It may be bilateral in some cases.

 

Examination

Palpating the great toe during passive ROM may reveal areas of combined crepitus and loss of motion. There may also be palpable osteophytes – especially over the dorsum of the MTPJ.

 

Investigation

The diagnosis is made by obtaining an x-ray showing joint space narrowing, osteophytes and metatarsal head flattening. Ankylosis of the joint may also occur, but is usually present at a later stage of the disease. When there are minimal plain film findings, an MRI may document a more isolated chondral lesion.

Click on the following images to view examples of hallux rigidis.

  • 1st MTPJ Osteoarthritis

    OA can lead to hallux rigidus (left great toe).

  • Chondral Injury 1st MTPJ

    Chondral loss with subchondral oedema involving the 1st MTPJ

  • Functional hallux limitis

    This can be demonstrated by stabilising the plantar surface of the MTPJ and attempting to extend the hallux

Treatment

Adjustments to the football shoe, inlays and podiatric modifications (to limit the motion of the first metatarsophalangeal joint) are the initial preferred type of treatment in football players with hallux rigidus. Oral NSAIDs or intermediate-acting steroid intra-articular injections can help to relieve the synovial joint inflammation. When conservative treatment fails, most players are treated surgically with a cheilectomy that removes the dorsal joint impingement of bone and soft tissue. Other surgical options available are dorsiflexion osteotomy of the proximal phalanx, decompression osteotomy and arthrodesis.

Conservative treatment aims at restoring the motion of the joint and strength of the intrinsic foot muscles. After cheilectomy, the football player is allowed to weight-bear as tolerated in a protective rigid postoperative shoe. After about ten weeks after the operation, running can be initiated but caution needs to be taken that the shoes can accommodate any occurring post-operative swelling. This swelling may persist for six to nine months after surgery.17,32