hallux limitus

Most authorities states that the big toe requires from 60 to 80 degrees of dorsiflexion in normal gait. Many people can get away with less than that due to compensation mechanisms in their foot function.

For most people the cause of hallux limitus is repetitive micro trauma where the big toe is constantly jamming into the first metatarsal bone. Other causes include direct trauma to the joint, repeated gout attacks to the joint, an excessively short OR long first metatarsal bone and excessive pronation.

In most cases this is a progressive deformity where the patient will relate that the pain initially started as a dull ache which was transient in nature but has progressed to the point where the joint is now painful on a regular basis both in and out of shoes.

Look at the two pictures below. The one on the left is a picture of the dorsal bump. Many times the bump will be red and swollen. The picture to the right is an x-ray coming in from the side of the foot. The yellow arrow shows the excessive bone overgrowth that is occurring on top of the foot. Basically as the patient walks the big toe is unable to fully bend upwards because the toe jams into the bony overgrowth and is prohibited from moving any further upwards.

• Anti-inflammatory medication- short doses over a period of a couple of weeks in an effort to quiet down the inflammation. This should be regarded as a temporary measure and not a long term solution.
• Cortisone injections- may be of use for short and moderate time period relief. Depending on the effectiveness multiple injections can be performed but there is a limit as to how much cortisone can be injected in the same area in a one year period.
• Physical therapy- may also be helpful in reducing the inflammation occurring in the joint. This can be combined with anti-inflammatory medication or cortisone injections.
• Orthotic therapy- an orthotic may help stabilize the joint with the addition of a Morton’s extension. Other times a cutout underneath the big toe joint might create more motion. Most cases of orthotics for hallux limitus require trial and error.
• Shoe modification- many times an extra-depth shoe with a still sole can be helpful in reducing the discomfort.
• Modification of activities- in severe cases the avoidance of certain activities may go a long way to reducing the symptoms.

When conservative measures have failed and the pain is great enough then the patient should consider surgical intervention. Like most medical conditions, not all hallux limitus is the same. Things that have to be addressed are underlying cause of the condition; the type of gait the patient exhibits, the amount of bony overgrowth, the amount of joint destruction, the type of activity the patient would like to resume, the limited or lack of joint motion and of course the amount of pain.

What this means from a surgical standpoint is that many times a patient can get by with just a remodeling of the joint meaning all the bony overgrowth is removed. Additionally, sometimes a wedge of bone will be removed from the top of the first metatarsal in an effort to allow the big toe to bend upwards over the metatarsal. Other times a re-angulation osteotomy (surgical cutting and realigning of bone) may be performed to allow better toe dorsiflexion.

Additionally, if the cartilage is destroyed, many times a joint destructive bunionectomy will be performed or a joint implant will be inserted. Lastly, if the joint is too far gone and cannot be salvaged the joint may actually have to be surgically fused.