lecture 45 shah hallux rigidus
TRANSCRIPT
Hallux Rigidus: Conservative care
Dr.Rajiv ShahFoot & ankle surgeon
‘Foot & ankle orthopaedics’Vadodara, Surat
• Reported in 1887 by Davies-Colley - Hallux Flexus
• Cotterill coined the term Hallux Rigidus
• DuVries in 1959 and Moberg - hallux rigidus is the most common condition to affect the first MTP joint
• Also called as- hallux limitus- dorsal bunion- hallux dolorosus - hallux malleus- metatarsus primus elevatus (MPE)
History
• Painful condition of great toe MTP joint
• Characterized by - Restricted motion (mainly
dorsiflexion)
- Proliferative periarticular
bone formation
Hallux Rigidus
Etiology
Trauma
Intra articular fracture
Single episode Repetitive micro traumas
Crush Injury Acute chondral/
osteochondral injury
Forced hyperextension/plantar flexion injury
Other Etiology
Congenital flattened/squared metatrsal head
Short first metatarsal
Long first metatrsal
Pes planus
Tight intrinsic muscles
Congruent MTP joint
Hindfoot pronation
Metatarsus primus elevatus
Dorsal and dorsolateral
exostosis
Bony ledgeIncreased bulk
around the joint
Constricting footwear Dorsal
exostosis enlargement
Limitation of dorsiflexion
Pain Swelling MTP synovitis
Late Stage
Initial Stage
Symptoms
• Swollen metatarsophalangeal (MTP) joint
• Everted gait
• Numbness develops over medial sensory nerve to the hallux
• Callus develops on lateral heel because of everted gait
• Hyperextension of hallux interphalangeal joint
Signs
• Initial stages - Nonuniform joint space narrowing- Widening and flattening of first
metatarsal head
• Advanced stages - Subchondral cysts and sclerosis of
metatarsal head- Widening of base of proximal
phalanx- Hypertrophy of sesamoids
Radiographic evaluation
Grade 0 Grade I
• Clinical- Only stiffness- Loss of passive motion
• ROM- Dorsiflexion 40-60
• Radiograph- Normal
• Clinical- Occasional pain- Pain at extremes of dorsiflexion
• ROM- Dorsiflexion 30-40 degrees
• Radiograph- Dorsal spur- Min joint narrowing- Min periarticular sclerosis- Minimal flattening of metatarsal head
Grade II Grade III
• Clinical- Nearly constant subjective painsubstantial stiffness pain through out ROM (but not at mid ROM)
• ROM - 10 degrees or less Dorsiflexion
• Radiograph- Grade 2+ substantial narrowing, periarticular changes,>25% joint space involved no dorsal side,sesamoids enlarged
• Clinical- Moderate to severe pain and stiffness- Pain just before maximal dorsiflexion
• ROM- Dorsiflexion 10-30 degrees
• Radiograph- Osteophytes- <25%dorsal joint space involved- Mild to moderate joint narrowing and sclerosis
Grade IV
• Clinical- nearly constant subjective pain andsubstantial stiffness - pain through out ROM+definite oain at mid ROM
• Radiograph- Grade 2+ substantial- narrowing,periarticular changes,>25% joint
space involved no dorsal side,sesamoids enlarged
• ROM 10 - degrees or less Dorsiflexion
Management
Conservative
Surgical
•Cheilectomy•Phalangeal osteotomy•Plantar flexion osteotomy•Arthroplasty•Arthrodesis
Management
Conservative Management
NSAIDs: reduces inflammation & pain due to synovitis
Modification of activities
Neurotropics: if neuritic pain Steroid injections
Conservative methods may be successful even in cases with severe hallux rigidus!
•Morton’s extension•Carbon fibre plate insert•Commercially available inserts•Custom mould inserts
Conservative Management
Tapping
Footwear modifications
Orthotics:To stiffen the fore foot
To offload forefootTo reduce the forefoot/MTP
joint motion
•Stiff insoles•Rocker bottom shoe•Still medial shank•Wide/deep toe box•Low heels
Joint manipulation
Success rate is up to 60%-70%!
That’s all…Thank you all…