Archive for December, 2013

Treatment of Hallux Limitus

December 29, 2013

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This is an example of an orthotic with a Kinetic Wedge

When a patient presents with symptoms of hallux limitus, it is important to take into account the severity of their deformity as well as the level of pain and how the pain limits daily activities in order to determine what treatment would be most appropriate. A variety of treatment options can be considered, including both conservative and surgical procedures.

Early stages or minimal discomfort from hallux limitus are often approached using conservative treatments. One popular method of conservative pain control is to take oral nonsteroidal anti-inflammatory drugs (NSAIDs), such as Advil or Motrin. Keep in mind that taking this medication does not cure the condition causing the pain. This method of treatment can be used to treat acute flair-ups of pain and swelling.

Foot orthotics are another conservative option to treat hallux limitus and have been shown to relieve pain better than the use of oral anti-inflamatories alone (1). Examples of custom modifications of orthotics used to treat this condition include the Kinetic Wedge and Morton’s extensions. These specialized foot orthotics can help alleviate pain in the 1st MTPJ. By providing functional correction of deformities with the proper orthotic, 1st MTPJ discomfort can be improved. Foot orthotics are inserted into shoes and can be moved from shoe to shoe.

Physical therapy is also another conservative option that may be of some benefit in early stages of the condition.

Steroid injections can be administered in the doctor’s office. A steroid or cortisone shot is given into and around the joint this may help to relieve pain.  The reduction in swelling and pain from this type of injection may not last long. The injection can be repeated, however since over use of steroid can breakdown tissue there is a limit to the number of injects patients can receive.

If the conservative therapy that has been reviewed does not reduce pain, then surgical intervention may be necessary. The major goals of surgery are to reduce pain and improve daily function. Depending on the nature of the patient’s foot and the degree of joint destruction, other goals could include improving joint motion, recreating a joint space in the 1st MTPJ and reducing deformities of bone.

Operations that are able to preserve the joint involve removing any abnormal bone formations around the joint in order to improve mobility. However, there are instances in later stages of hallux limitus and hallux rigidus where preservation of the joint is not possible. In this case, the joint articulations or cartilage may be removed and replaced by an artificial joint or the joint may require to be permanently locked together also known as joint fusion.

If you believe you are feeling symptoms of hallux limitus or hallux rigidus, it is important to address the pain with your doctor as early as possible. May people that have pain in this area assume that they have a “bunion”.  An earlier and accurate diagnosis opens the possibility of a variety of noninvasive, conservative treatments that can help reduce pain while walking.

References:

1. Shurnas PS. Hallux limitus: etiology, biomechanics and nonoperative treatment. Foot Ankle Clin. 2009 Mar; 14(1):1-8.

Hallux Limitus/Rigidus Part 1

December 16, 2013

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Hallux Limitus/Rigidus Part 1

A 55-year-old male comes into his podiatrist office complaining of pain in the area of his big toe after he finishes his morning walks. He noticed that there is swelling and he has trouble bending his toe because of the pain. He recently noticed a bump at the base of the toe in the area where the big toe bends.  Because of the size of the bump he is starting to have difficulty wearing his running shoes. What could be the cause of his pain?

What are Hallux Limitus and Hallux Rigidus?

The hallux, or big toe, plays an important role in our ability to walk normally. The motion of this toe provides us with pushoff force necessary to lift our foot off of the ground while walking. In order to accomplish this, the hallux normally bends upward (or dorsiflexes) You can see this occur if you lift your heel up while keeping the front of your foot on the ground. In a healthy foot there is a smooth gliding, around 60 degrees of upward motion at the joint where the 1st metatarsal and the big toe bone meets.

Hallux limitus is a condition that describes limited motion of the big toe joint. This limitation in motion is caused by jamming of the big toe into the 1st metatarsal bone, thereby inhibiting the ability to bend the big toe without pain. This condition occurs at the 1st metatarsal-phalangeal joint (1st MTPJ), which is the joint between the hallux and 1st metatarsal. As the hallux and metatarsal move in an abnormal relationship they do not glide they now scrape against each other with uneven and excessive forces.  When this occurs extra bone formations develope, called spurs or osteophytes. These appear in order to disperse the force generated from the friction. Unfortunately, this extra bone leads to more pain and further limitation to the joint motion. The condition can eventually progress to a degenerative arthritic disease called hallux rigidus. At this stage, the motion at the joint approches zero degrees. In a final stage fusion or bone bridging across the joint occurs. Further advancment of this condition can lead to pain in other parts of the lower extremity. This may occur because other muscles, bones and joints will be forced to compensate or function abnormally to make up for the lack of motion of the big toe.

What causes it?

This condition can be caused by a number of factors. Some people have biomechanical abnormalities, such as flat feet, that can lead to imbalances that cause jamming and rubbing of the hallux against the metatarsal. Traumatic events like turf toe injuries or simply accidental injury of the big toe can lead to this condition as well. Wearing shoegear such as high heels can increase the risk of occurrence. Hereditary arthritic conditions, such as rheumatoid arthritis, can also be the inciting factor. Inflammatory joint conditions such as gout can lead to deformity at this joint as well.

Clinical Presentation

Symptoms that generally appear early in the course of hallux limitus are a throbbing, achy pain when moving the big toe and inflammation or swelling at the location of the 1st MTPJ. Cold weather can exacerbate the symptoms. As the disease progresses, the pain may become constant and will be present even when not wearing shoes. A hard ridge of bone may develop on the top of the 1st MTPJ.  A grinding sensation may be felt when the toe is moved up and down this is known as crepitus. It is a sign that the joint cartilage is warning out and now raw bone on one side of the joint is rubbing against the raw bone on the other side.

As this condition progresses the hallux is no longer able to function properly while walking, other structures in the foot and lower extremity are forced to change the way they normally function. This can lead to pain in other joints of the foot or ankle; eventually knee, hip or lower back pain may develop.

Diagnosis

If a patient presents with the symptoms described above, x-ray studies are performed to confirm the diagnosis. These images usually reveal abnormalities in the 1st MTPJ space. There is usually an uneven loss of the joint space compared to the other joints of the same foot.

Small pieces of bone called osteophytes or spurs may also be seen in the joint space, along with thickening of the margins (sclerosis) of the involved bones, both of which are indicative of this arthritic process.

Look for our next installment Hallux limitus/rigidus Part 2: Treatment