Stepping Into Better Health: Overcoming Hallux Limitus

Step­ping Into Bet­ter Health—Over­com­ing Hal­lux Limitus

Orig­i­nal­ly Pub­lished in Race Play Michi­ana August-Sep­tem­ber 2016

Dis­tance run­ning has a way of reveal­ing bio­me­chan­i­cal abnor­mal­i­ties — many times in ways we would nev­er expect. In my first year of med­ical school, I began to see the advan­tages of improv­ing my car­dio­vas­cu­lar fit­ness and took up run­ning 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 ordi­nary from the out­side, with no swelling or red­ness. I pur­chased some over-the-counter inserts and ran the half marathon with no dif­fi­cul­ty. Soon after that, how­ev­er, the whole 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 can­not move through a nor­mal range of motion dur­ing nor­mal ambu­la­tion. Nor­mal gait requires 65 to 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). The name of this par­tic­u­lar joint is called Hal­lux lim­i­tus. This pro­gres­sive con­di­tion can even­tu­al­ly lead to los­ing all motion (Hal­lux rigidus) at the base of the great toe. The x‑ray image below com­pares a nor­mal great toe joint with the full pro­gres­sion of the arthri­tis-asso­ci­at­ed Hal­lux rigidus.

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 sell­ing 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, an extend­ed great toe or a func­tion­al­ly ele­vat­ed first ray. A tight Achilles ten­don can also con­tribute to the flat­ten­ing of your feet, increas­ing the pres­sure on the fore­foot. This joint destruc­tive process can also be be the out­come of an 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.

1. Over-the-counter arch sup­ports are a good start. Com­mer­cial­ly avail­able ​“rock­er bot­tom” shoes can also help relieve a painful great toe joint when walk­ing, but I would not rec­om­mend run­ning in this type of shoe.

2. NSAIDs such as ibupro­fen or Naprox­en can relieve inflam­ma­tion but will not treat the cause. Pro­longed use can also cause many drug inter­ac­tions and poten­tial kid­ney over­load, so cau­tion should be tak­en if need­ed beyond sev­er­al days.

What your podi­a­trist can do:

Hal­lux lim­i­tus is a pro­gres­sive, destruc­tive process clas­si­fied into four stages. Treat­ment depends on the stage of the progression:

Stage 1—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 the Achilles ten­don. This would be done in con­junc­tion with an eval­u­a­tion of shoes and treat­ment of any bio­me­chan­i­cal abnor­mal­i­ties (with orthotics if necessary).

Stage 2 –Struc­tur­al change begins 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 and the pos­si­ble use of pre­scrip­tion anti-inflam­ma­to­ries and cus­tom orthotics may be nec­es­sary to address the bio­me­chan­i­cal cause func­tion­al­ly. Sur­gi­cal inter­ven­tion may be required to restore motion along with con­ser­v­a­tive treat­ment. Such an ear­ly sur­gi­cal inter­ven­tion may pre­serve the joint and pre­vent the need for fusion of the joint later.

Pic­tured are com­par­i­son x‑rays of Hal­lux Lim­i­tus stages 1 – 4, from left to right. Notice the nar­row­ing of the joint and the destruc­tion of the under­ly­ing sesamoid bones, which serve as a ful­crum for propulsion.

Stage 3 –The joint has lit­tle remain­ing motion, and there is sig­nif­i­cant struc­tur­al loss marked by bony build-up around it. 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.

Stage 4 (hal­lux rigidus)–Auto-fusion of the joint has occurred. The joint may not be painful at this point, but the func­tion is com­plete­ly lost. At this point, an accom­moda­tive orthot­ic may be of ben­e­fit, or sur­gi­cal inter­ven­tion may be necessary.

Tell me about the surgery.

Sev­er­al pro­ce­dures are avail­able depend­ing on the sever­i­ty of the con­di­tion. The ulti­mate goal is to reduce the pain and allow you to return to nor­mal activ­i­ty. If sur­gi­cal inter­ven­tion is nec­es­sary, your recov­ery will vary depend­ing on the pro­ce­dure, age, over­all health, etc. How­ev­er, in gen­er­al, you can expect three to six 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 my bone was decom­pressed and the joint remod­eled. This, com­bined with orthotics, allowed me to con­tin­ue run­ning with no recurrence.

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