"Due to severity of joint destruction at this
stage [3], surgical solutions may become an
attractive choice."
to attempt to allow for full ROM at the first
MTPJ. Shoegear for this patient would include a
shoe with a high toe box, which will also prevent
direct contact between the dorsal osteophyte and
the shoe and a stiff, commercial rocker-style sole,
particularly if the first ray cutout increases pain at
the joint. motion and be substituted for adding a rigid
shank to the shoe [13] . This rigid beam decreases
the motion available at the arthritic hallux joint
and reduces the pain that is experienced with
motion. This orthotic modification can allow the
patient to ambulate comfortably without pain or
compensation.
Stage 2: Stage 3:
In stage two there is a more dramatic loss
in dorsiflexion at the first MTPJ (10° to
30° of dorsiflexion remaining), which can
make ambulation both difficult and painful.
Radiographically, we again see dorsal osteophytes.
However, they will be more extensive than in
stage one, and there will be a further decrease
in joint space. While this stage still represents
a structural hallux limitus, the severity of joint
destruction at this point in the progression of
the disorder necessitates a different approach
to treatment than the previous stages. Instead
of attempting to increase motion, which would
continue to cause the patient pain, we would
like to limit the remaining motion available
at the joint. The goal of this intervention is to
control pain. In order to do this, we recommend
implementing a neutral position orthotic
device with a rigid shank shoe and a rocker
sole. A modification of the Morton’s extension
used in structurally-elevated first metatarsals
can be incorporated into the orthotic. A rigid
continuation of the medial shell of the orthotic
that extends to the distal hallux can restrict In stage three, nearly all motion in the first
MTPJ has been lost (less than 10° of dorsiflexion
remaining), and movement of the joint to end
range causes the patient significant pain. Joint
space narrowing is substantial, and the sesamoids
may be affected. This stage would correspond
to a hallux rigidus, by definition. The most
effective conservative treatment at this point is to
reduce all motion at the osteoarthritic joint and
completely immobilize the first MTPJ. This can
be accomplished with a rigid-shank shoe with a
custom-made rocker sole to match the patient’s
angle and speed of ambulation. The apex of
the rocker sole should be just proximal to the
metatarsal heads in order to mimic the normal
characteristics of the foot’s movement. Depending
on the stride length, the angle of the rocker may
require the addition of a thicker sole on both
shoes. Even if pathology is only on one side, it is
often helpful to add rockers to both shoes to even
out the patient’s gait and prevent symptoms from
developing on the asymptomatic side. Due to
severity of joint destruction at this stage, surgical
solutions may become an attractive choice.
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