Understanding Hallux Limitus / Rigidus: A Conservative Approach For Each Stage of Joint Destruction
Figure 1: Here one can see a forefoot rocker bottom shoe that
clinicians can use to help treat stage 3 and 4 hallux rigidus.
be used, as the clinical picture of each patient will
be different. However, it provides a guideline upon
which to base the patient’s overall therapy.
Stage 0:
In this stage there is no radiographic evidence of
joint destruction, and the patient does not experience
pain during full ROM. However, there is some joint
stiffness present, and only 40° to 60° of dorsiflexion
is allowed upon examination. This stage most closely
represents functional hallux limitus. Our goal for
patients in this stage is to increase the motion at
the first MTPJ and attempt to return this individual
to their full potential ROM. In order to do this,
we would suggest the use of a neutral position foot
orthosis (NPFO) with a first ray cutout to allow for
normal plantarflexion of the first metatarsal during
propulsion. It is imperative to facilitate utilization
of all of the cartilage covering the metatarsal
head. When the proximal phalanx begins to lose
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articulation with the dorsal metatarsal head it can
lead to cartilage atrophy and faster progression of the
deformity. Standard footwear can be utilized in this
stage, however, rocker-style sole designs may provide
additional relief.
Stage 1:
In stage one of the classification system, only
30° to 40° of dorsiflexion is available for the
hallux to dorsiflex passively. Furthermore, we
begin to see dorsal spurring radiographically with
minimal narrowing of the joint space. The patient
consequently begins to experience slight pain,
but usually only at end range of motion, and not
consistently. These clinical and radiographic findings
correspond to early structural hallux limitus. The
goal of treatment should be to increase motion at
the great toe joint, before shifting our focus to pain
reduction. With less than half of the motion lost at
the joint, a first ray cutout will once again be useful