Stepping into Better Health—Overcoming Hallux Limitus

Posted on Categories Doctors Corner, Podiatry

Distance running has a way of revealing biomechanical abnormalities– many times in ways we’d never expect. In my first year of medical school, I began to see the advantages of improving my cardiovascular fitness and took up running as a means to this end. It didn’t take long to realize the need for appropriate shoes, a better diet and knowing how to dress for the weather in the varying climate of central Iowa. With my first half-marathon only weeks away however, I began to hear a click coming from the base of my great toe, accompanied by a “full-feeling” around the joint. Remarkably, my foot looked quite normal from the outside, with no swelling or redness. I purchased some over the counter inserts and ran the half marathon with no difficulty. Soon thereafter however, the full-feeling became a dull ache…intermittent at first, then all the time.

What is Hallux Limitus?: Hallux (Great toe) Limitus (diminished motion), is a condition in which the great toe is unable to move through a normal range of motion, during normal ambulation. Normal gait requires 65-75 degrees of dorsiflexion (ability to bend upward) at the base of the great toe. Any impairment in the fluid motion of this joint can be considered arthritis (“arthro”—meaning joint, and “itis”—meaning inflammation). In this particular joint however, it’s been given its own name—Hallux Limitus. This is a progressive condition that can eventually lead to the loss of all motion at the base of the great toe, which is called “Hallux Rigidus.”

Below is a comparison of a normal joint (left) compared to hallux rigidus. Note that this is a joint destructive process, and can lead to the full structural/functional loss of the joint itself.

big toe

Clinical signs and symptoms: In its early stages, a person might feel swelling or “a fullness” at the base of the great toe which can progress to pain in the joint as the toe bends to its upper limit. Pain will be aggravated by ambulation that will advance to a burning sensation or dull ache even at rest. At some point, the swelling in the joint will be accompanied by an underlying bony prominence that may be visible through the skin as the joint begins to lose mobility. Eventually, if left untreated, the joint will auto-fuse as it advances from hallux limitus to hallux rigidus.

Why does this happen? There are several biomechanical causes including; flat feet, a long first metatarsal, a long great toe or a functionally elevated first ray. A tight Achilles tendon can also contribute to the flattening of your feet and increasing the pressure at the forefoot.  This joint destructive process could also be the outcome of injury or other inflammatory condition such as gout or rheumatoid arthritis.

What can you do? The key to treating hallux limitus is early intervention prior to the destruction of the joint. Over-the-counter arch supports are a good place to start. There are also commercially available “rocker bottom” shoes available, which can off-load a painful great toe joint when walking, but I would not recommend running in this type of shoe. NSAIDs such as Ibuprofen or Naproxen can relieve the inflammation, but will not treat the cause of the inflammation.

What your podiatrist can do:  Hallux Limitus is progressive, destructive process and has been classified in 4 stages—the fourth being “Hallux Rigidus.” Treatment would be targeting your stage of progression:

Stage I– Pain at the end range of motion, minimal joint changes, and inflammation in the joint. Treatment would target regaining flexibility in the great toe, the bottom of the foot, and Achilles tendon. This would be done in conjunction with evaluation of shoes, combined with treatment of any biomechanical abnormalities (with orthotics if necessary).

Stage II-Structural change is beginning in the joint as it further loses motion. It becomes common for people to walk with their foot pointed outward to compensate for the inability to bend the great toe upward. This may lead to plantar fasciitis or even knee pain. At this point physical therapy may be necessary along with the possible use of prescription anti-inflammatories, and custom orthotics to functionally correct the biomechanical cause. Surgical intervention at this time may be necessary to restore motion along with conservative treatment. Such an early surgical intervention may preserve the joint and prevent the need for a fusion of the joint later. Notice in the picture below, the asymmetrical narrowing, with changes at the lateral joint.

toes

Stage III-There is little remaining motion to the joint with significant structural loss, and marked boney build-up around the joint. Grinding with any attempted joint motion is common along with an increase in pain, swelling and compensatory alterations in gait. Surgical intervention is necessary at this point. Orthotics, physical therapy and rehabilitation, will likely be done after surgery.

footfoot2

Stage IV– Auto-fusion of the joint has occurred. At this point the joint may not be painful, but function is fully lost. The first picture in the article demonstrates this nicely. At this point, an accommodative orthotic may be of benefit, or surgical intervention may be necessary.

Tell me about surgery? Depending on the severity of the condition, there are several procedures available.  The ultimate goal will be to reduce the pain, and have you return to normal activity. If surgical intervention is necessary, your recovery will vary depending on the procedure, your age, health, etc. However, in a general sense, you can expect 3-6 weeks of non-weight bearing (with crutches or a knee scooter), followed by several weeks of rehabilitation to restore your strength and flexibility.

In my case, I underwent surgery in 1997 in which the bone was decompressed and the joint remodeled. This combined with orthotics, have allowed me to continue running throughout these past 20 years with no recurrence.

May the rest of your year be blessed with good health.

Dr. Randall Kline is a board-certified podiatrist specializing in injury, wound and diseases of the foot and lower leg. Contact Allied Bone and Joint at (574) 247-4667 or visit AlliedBoneandJoint.com for more information.

This article was originally published in RacePlayMichianaRacePlayMichiana is the premier local source for all news regarding sports and fitness in the Michiana area. RPM is produced in print and online on a bi-monthly basis.