Medically, the big toe is referred to as the hallux. Hallux limitus is a progressive arthritic condition that limits the motion and function of the hallux, usually at the big-toe joint. The big-toe joint is located where the first metatarsal bone and proximal phalanx meet, or at the base where your foot and toes meet. Hallux limitus affects the dorsiflexion (upward) motion, and over time, the condition can worsen and lead to the condition hallux rigidus, or no motion of the big-toe joint at all.
Symptoms of this condition come on slowly. You may notice pain only when you are in motion or when you move the big toe joint. The pain can be mild and temporary or deep, sharp, and chronic. Typically it is a deep, aching type of pain. In some cases, bunions or bone spurs develop at the joint and cause additional pain. When the big toe is not in use, symptoms tend to diminish. Early signs of limited motion are the beginning stages of degenerative arthritis. When arthritis first begins to develop in the joint, a bump or bone exostosis (spur) will typically develop on top of the joint. As the cartilage continues to weaken and break down, pain develops. If left untreated, all symptoms can progressively worsen into the condition known as hallux rigidus.
Symptoms of Hallux Limitus
Symptoms of hallux limitus vary, depending on which stage you are in. Your symptoms may include:
- Pain, especially during weight-bearing movements, but possibly constant and appearing while the foot is at rest or after the shoe has been removed
- Grinding or grating feeling on top of the joint with activity and walking
- Development of bone spur
- Some stiffness and limited motion of the hallux
- Increased pain and stiffness in cold temperatures
- Difficulty wearing shoes, especially high heels, due to increased pressure on the joint
- Difficulty wearing flexible shoes, flip flops, or shoes with poor support
- Feeling of tightness in and around the joint
- Swelling and inflammation of the joint, especially on the top
- Pain in other parts of your body due to the change in your gait
It’s important to know that these symptoms represent the early stages of this condition. Each of these symptoms can progressively worsen until you no longer have movement within the joint. This is the condition known as hallux rigidus. If you are experiencing these symptoms, seek medical attention from your primary physician or a podiatrist.
What Causes Hallux Limitus?
Hallux limitus is caused by one of four things:
- A long first metatarsal bone (or short second metatarsal)
- An elevated first metatarsal bone
In some cases this condition is genetic. Some people are born with a predisposition to conditions such as arthritis and high or low arches, which can lead to foot problems such as hallux limitus and rigidus. Overusing or injuring your big-toe joint can lead to a loss of ability to move it. Repetitive movements and damage to the cartilage that covers the first metatarsal and proximal phalanx can also lead to hallux limitus. Chronic inflammatory diseases such as gout can also cause this condition, as can a traumatic event such as stubbing your toe.
Diagnosing Hallux Limitus
Hallux limitus is a progressive condition that can lead to further problems, including complete loss of motion in the big toe joint. Doctors would much rather see you about this problem while it’s in its early stages, or before bone growths develop. If you are experiencing any of the symptoms listed above, you may want to see a podiatrist or another type of foot doctor as soon as possible for a diagnosis. Your doctor will begin with a physical examination so he or she can determine the range of motion within the joint. Imaging tests such as x-rays and MRIs (magnetic resonance imaging) are often used to determine whether arthritis is present, to see how much the joint has narrowed, and to evaluate the foot’s overall health. Your doctor will also want to ask you about your medical and family history. Your podiatrist will probably do a complete biomechanical and gait exam to determine how it is affecting your gait pattern. The range of motion and quality of motion of the first metatarsal phangeal joint is assessed. Hallux limitus is graded in four stages. Here is a brief description of each stage:
Stage 1: You may feel pain in your joint, but there is no apparent change in your joint’s external appearance. X-rays may not show any changes, and treatment typically involves orthotics such as a dancer’s pad.
Stage 2: You may see an increase in the frequency and duration of pain. X-rays and visual exams may show the appearance of a bump at the top of the joint. Treatment may involve a carbon plate with Morton’s extension, or you may need joint revision.
Stage 3: You will feel pain during all activities, and the bump on the top of your joint will continue to develop and grow larger. X-rays will show the bump, as well as an asymmetrical joint-space narrowing. Treatment typically involves an osteotomy with joint revision.
Stage 4: Also known as hallux rigidus; significant pain accompanies any movement, and the bump has turned into an enlargement of the entire joint. X-rays show the flattening of the joint with multiple bone spurs surrounding the entire joint. Treatment involves fusion, replacing the joint, or a Keller bunionectomy.
Hallux Limitus Treatment
After your diagnosis, your doctor will create a treatment plan based on the severity of your condition. For mild cases, over-the-counter measures such as shoe modifications, custom functional orthotics or prefabricated inserts, physical therapy, and oral anti-inflammatory medications are most commonly used. The PRICE method is also suggested to help reduce symptoms, especially after activities. PRICE stands for Protection, Rest, Ice, Compression and Elevation. For moderate cases, the above options are also used, but additional treatment steps are also employed, such as corticosteroid injections into the joint to reduce inflammation and swelling around the joints. Custom functional orthotics can also be used to reduce the effects of arthritis, reduce pain, and improve function. The goal of all treatment is to stabilize the foot, support the arches, stabilize the big toe, reduce movement of the big toe, and provide shock absorption. For severe cases, surgical intervention may be necessary. Here is a look at some of the top recommended products for non-surgical treatment of hallux limitus:
- A Morton’s extension can be used to relieve forefoot pain. These durable semi-rigid medical devices can be found in podiatry offices, and they are designed to provide support and shift weight away from the big toe to reduce pain. Over-the-counter devices are much softer and do not offer adequate biomechanical control for most patients because of their flexibility and lack of a heel cup.
- Accommodative cushions made of foam work for hallux limitus, since it pads the big toe joint and protects it from painful shoe pressure.
- Turf toe plates limit the range of motion of the great toe joint, which makes this product ideal for treating both hallux limitus and hallux rigidus.
- Athletic or running shoes made especially for over-pronators can provide support. They are less flexible than conventional running shoes, which enables them to limit the motion of the joint.
Talk with your doctor or podiatrist about what products may be available to you and which products you’d like to try before buying them.
Hallux Rigidus Surgery
Surgery is only performed in severe cases, on patients whose condition has progressed into hallux rigidus, or those who have gotten no pain relief from more conservative treatments. Common surgeries may include an arthrodesis (which fuses the joints), or a cheilectomy, which involves removing all scar tissue and bone growths from the joint to allow a wider range of motion. A dorsiflexion wedge can also be placed at the base of the proximal phalanx (the big-toe bone closest to the first metatarsal) to improve range of motion. Additional surgical options may include:
- Arthrotomy: cutting into the joint to repair access
- Keller procedure: removes the base of the big-toe joint, creating a “pseudo joint”
- Osteotomy: the bone is cut to shorten, lengthen, or change the alignment
Surgical procedures such as these usually take place in a hospital or ambulatory surgical center, but they may also be performed in your doctor’s office. Generally, a podiatrist or an orthopedist will perform the surgery. Recovery generally takes eight to sixteen weeks, depending on the type of surgery performed, your activity level, and the severity of your condition.
Questions to Ask Your Doctor
Here are some questions you may want to ask your doctor about hallux limitus:
- How long does it take for the condition to reach hallux rigidus stages?
- Will this problem affect me again when I’m older?
- If the symptoms continue, how long should I wait before scheduling another visit?
- What additional symptoms should I watch for that would indicate treatment is not working?
- How long do you think it will be before I can resume my normal activities?
- Would custom orthotics help?
- What type of shoes would you recommend?