Anteroposterior radiograph of a 46-year-old woman shows loss of joint space at the metatarsophalangeal (MTP) joint and large dorsal osteophytes.
Lateral radiograph of the patient’s affected foot.
A 46-year-old woman presents with a several-month history of pain in the left great toe. She enjoys running and has started to notice severe pain after running a few miles. She denies prior injury to the toe or history of gout. On examination, she has significant pain over the dorsal metatarsophalangeal (MTP) joint and decreased dorsiflexion motion compared with the contralateral side. The patient has significant MTP joint arthritis, and a rigid shoe with a larger toe box is recommended. However, she decides she would rather consider a surgical procedure that would allow her to continue running.
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The patient has an arthritic metatarsophalangeal (MTP) joint. Anteroposterior and lateral radiographs show loss of joint space at the MTP joint and large dorsal osteophytes.
Arthritis at the MTP joint is known as hallux rigidus and is the most common form of arthritis in the foot. Typical presentation includes an insidious onset of great toe pain, decreased dorsiflexion, and increased bulk of the MTP joint. Patients often have large dorsal osteophytes that cause impingement and pain with dorsiflexion of the toe. As the osteophytes enlarge and the toe bulk increases, certain types of shoes may no longer fit. Initial diagnostic workup should include standing anteroposterior and lateral radiographs.1,2
A trial of conservative treatment is recommended initially, although it is often unsuccessful. Conservative treatment includes nonsteroidal anti-inflammatory drugs and modified shoes with a rigid sole and wide toe box. Intra-articular injections may be used for temporarily relief. However, relief is often brief, particularly in those with advanced disease, and surgical treatment is often required for long-lasting relief.
Dorsal cheilectomy is a procedure that removes approximately 30% of the dorsal metatarsal head. Cheilectomy preserves the existing joint and allows improved joint motion and stability, compared with other surgical procedures.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).
- Deland JT, Williams BR. Surgical management of hallux rigidus. J Am Acad Orthop Surg. 2012;20(6):347-358.
- Mann RA. Disorders of the first metatarsophalangeal joint. J Am Acad Orthop Surg. 1995;3(1):34-43.