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A patient, aged 54 years, presented to the office with right foot pain for approximately 10 years. The pain had worsened and the patient was unable to participate in martial arts because of it.
On physical exam, the patient had enlargement of the first metatarsophalangeal (MTP) joint, right greater than the left. The patient had significant pain with passive and limited active range motion at the MTP joint.
The pain improved but was still present after the patient had taken oral nonsteroidal anti-inflammatory medications (NSAIDs).
Anteroposterior (AP) and lateral x-rays of the right foot are shown above.
This case has been brought to you in partnership with the Journal of Orthopedics for Physician Assistants.
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The patient presented with hallux rigidus, or osteoarthritis, of the first MTP joint. Initial treatment should be conservative and focus on reducing pain and improving mobilization.
Nonsurgical recommendations may include NSAIDs, activity modifications, shoe wear modification, custom orthotics, and MTP joint corticosteroid injections.
NSAIDS and corticosteroid injections are used to decrease MTP joint synovitis. Activity modification involves avoiding high impact activities that repetitively put the MTP joint in hyperdorsiflexion.
A custom orthotic or rigid flat plate may be used in shoe wear to help limit dorsiflexion range of motion during ambulation. Shoe wear modification that increases the width and height of the toe box may help patients with exostosis and an enlarged MTP joint, particularly in patients that have more symptoms in shoes than in open toe sandals.
Severe hallux rigidus should initially be treated conservatively as some patients may have minimum symptoms despite end-stage degenerative changes on radiographs.
References
- Miskovsky S. “Hallux rigidus: clinical presentation and management of the stiff great toe.” AAOS Orthopedic Knowledge Online Journal; 2009. 7 (5).
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