A 35-year-old man complains of right great toe pain for several months. He is very active and enjoys running. On examination, he has pain and limited dorsiflexion of the first metatarsophalangeal (MTP) joint. Pain is felt with passive hyperdorsiflexion, but otherwise range of motion of the toe is nonpainful. Anteroposterior and lateral radiographs of the right foot show hallux rigidus (Figures 1 and 2).
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Hallux rigidus (1st MTP arthritis) is the most common arthritic condition of the foot. Risk factors include previous trauma to the foot and a family history. It is thought that previous trauma to the toe, such as stubbing the toe, may injure the articular cartilage leading to the development of arthritis. Hallux rigidus occurs bilaterally in 95% of patients. The most common symptom is increased pain when pushing off with the great toe or forced dorsiflexion. On exam, patients will likely have decreased dorsiflexion and pain with motion at the MTP joint. Decreased dorsiflexion is a result of a dorsal osteophyte at the first metatarsal head best seen on lateral radiograph.1,2
Nonoperative treatment starts with activity modifications, NSAIDs, and a stiff-soled shoe or foot plate to limit MTP joint motion. A wide toe box may take the pressure off a painful dorsal osteophyte. A corticosteroid injection into the MTP joint may provide short-term relief. Surgical treatments include cheilectomy, cheilectomy and phalangeal osteotomy, arthrodesis, and arthroplasty. Cheilectomy involves removing 30% of the dorsal metatarsal head articulation to improve dorsiflexion and prevent dorsal impingement. Cheilectomy is the least invasive surgical procedure and is usually reserved for active patients who complain of pain primarily during the toe-off phase of gait. When MTP joint arthritis becomes severe, an arthrodesis or arthroplasty may be indicated.1,2
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA).
- Shereff MJ, Baumhauer JF. Hallux rigidus and osteoarthrosis of the first metatarsophalangeal joint. J Bone Joint Surg Am. 1998;80:898-908.
- Deland JD, Williams BR. Surgical management of hallux rigidus. J Am Acad Orthop Surg. 2012;20:347-358.