Hallux Limitus – Arthritis of the Great Toe Joint (Big Toe Arthritis

The medical term for the big toe is “Hallux.” Hallux Limitus then is the loss of motion to the big toe joint. The big toe should have a normal range of upward (dorsiflexion) motion of 50 to 90 degrees for normal function. The big toe is an integral part of gait and the propulsion of the body forward when it flexes upward and pushes off the ground. With limited motion, the big toe will not propel the body forward and other joints of the body will need to compensate, putting more strain through the rest of the foot and lower extremity. This will lead to an inefficient gait pattern and increased fatigue and pain. Over time, the decrease in motion will lend to jamming of the joint. As the joint undergoes constant trauma in this way the bones become stimulated and extra bone growth occurs over the top of the joint. Eventually the joint cartilage will become eroded leading to arthritis (degenerative joint disease) and even less motion and more pain. The pain then is really caused by the remaining amount of motion. Now that the joint has become arthritic, any motion will cause increased pain.

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Picture showing the normal amount of dorsiflexion for the big toe joint. Picture showing the normal amount of dorsiflexion in the big toe joint during gait.
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Picture showing a big toe joint with limited dorsiflexion motion.
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Picture showing normal big toe joint. Picture showing arthritis of the big toe joint.
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Picture showing the inside of the big toe joint. Notice the missing cartilage on the head of the first metatarsal.

Symptoms:

The pain is usually associated with any movement of the big toe joint. Patients will describe a deep achy to sharp pain with use of the joint. If a bone spur develops, there can be pain over the top of the extra bone growth as well. There is usually limited to no pain when there is no weight on the big toe.

Causes:

Hallux limitus can be as a result of genetics or overuse. If there is a genetic predisposition to limited motion in the joint, the eventual arthritis will cause pain and decreased function. Other patients will develop arthritis in the joint from trauma and or overuse injuries. This arthritis then will lead to limited motion and pain and decreased function. This becomes a continuous cycle of decreased motion, arthritis, extra bone formation, jamming of the joint and so on.

Diagnosis:

Clinical evaluation involves range of motion testing, gait analysis and thorough history of the pain and symptoms. X-ray evaluation is important to investigate the amount of joint narrowing and extra bone (spur) formation in the joint.

Treatment:

The scope of conservative treatments for hallux limitus is narrow. Wider shoe gear and accommodation for the deformity can be used to take the pressure off the area. Using stiff soled shoes to limit the amount of motion can be helpful. Custom molded orthotics can take some pressure off the big toe and redistribute the forces of the ground through the rest of the foot. Injections of catabolic steroid (cortisone) into the joint can reduce the inflammation and scar tissue. This type of injection often brings temporary relief. Several injections over many weeks of a normal joint fluid substitute (sodium hyaluronate) can increase the lubrication of the joint, often decreasing pain. In most cases surgery will be warranted.

The most common surgical procedure is a cheilectomy. In this case, the joint is cleaned up of all scar tissue and spurs to allow for better motion. Recovery is very rapid with this procedure, but may not be a good option for severe arthritis cases. Physical therapy is used very early after surgery to get the great toe joint moving and prevent scarring and stiffness.

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Pre-operative x-ray of Hallux Limitus and arthritis with bone spur.
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Post-operative x-ray of Hallux Limitus and arthritis with removal of bone spur and repair and salvage of the joint.

In certain cases, a cheilectomy will be combined with a cut in the metatarsal bone to shorten and lower the bone to prevent jamming. Recovery is somewhat slower than with plain cheilectomy as there is a waiting time for the bone cut to heal. Weight bearing is immediate and the patient returns to full activity at about two months. Physical therapy is often used to decrease stiffness and pain after surgery.

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Pre-operative hallux limitus with limited joint destruction but poor alignment. Elevated 1st metatarsal noted with spur formation causing jamming and pain in the great toe joint.
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Post-operative x-ray showing joint realignment and mild decompression shortening to correct stiffness and pain. Lateral x-ray showing dropping of the 1st metatarsal head for realignment and correction of spurs and joint jamming.

In certain cases, the 1st metatarsal bone leading to the great toe joint is so elevated and loose that correction needs to address the laxity of the metatarsal. This is performed by bringing the 1st metatarsal to the ground and fusing the 1st metatarsal to the 1st cunieform in the midfoot. This is a non-essential joint for normal walking and the added support in the midfoot helps to decrease arch collapse and helps with normal position of the foot. After the 1st metatarsal is re-aligned, the great toe joint is cleaned up of scar and spur formation. In the appropriate patient, this procedure is an excellent long term correction option and truly deals with the problem of an elevated 1st metatarsal and jamming of the great toe at the source of the problem.

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X-ray showing arthritis and jamming of the great toe from an elevated 1st metatarsal. Lateral x-ray showing severely elevated 1st metatarsal with jamming at the great toe joint.
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Post-operative x-ray showing re-alignment of the 1st metatarsal with fusion of the midfoot. Not the joint clean-up and spur removal at the great toe joint. Post-operative x-ray showing re-alignment of the 1st metatarsal and clean up of the great toe joint removing spurs and allowing movement of the great toe with corrected arch alignment.

In severe cases, the great toe joint is fused. This removes all motion from the joint, but also removes all pain from the great toe joint. This procedure is reserved for severe cases with a great deal of pain and limited to no motion of the great toe joint prior to surgery. Recovery is 6 to 8 weeks in a boot with limited weight on the foot. Patients are mostly very happy with the outcome from fusion of the great toe as there is no more pain and they can return to their full activity.

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Pre-operative x-ray of Hallux Limitus and arthritis of the big toe joint. Post-operative x-ray with fusion of the big toe joint with plate and screw fixation.
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Pre-operative x-ray of Hallux Limitus and arthritis of the big toe joint. Post operative x-ray with fusion of the big toe joint with screw fixation.

By replacing half the joint with this titanium implant joint mobility can be maintained and often increased without sacrificing the joint. Thereby, decreasing pain and improving function.

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Pre-operative x-ray of Hallux Limitus and arthritis of the big toe joint.
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Picture of the implant placed into the big toe during surgery.
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Post-operative x-ray of the partial big toe joint replacement.

The main advice for patients suffering with pain in the great toe joint that may be due to early arthritis is to seek an option early. This will allow the best options and limit the need for extensive surgery.