Review

Authors: Chul Hyun Park, Min Cheol Chang

Forefoot disorders are often seen in clinical practice. Forefoot deformity and pain can deteriorate gait function and decrease quality of life. This review presents common forefoot disorders and conservative treatment using an insole or orthosis. Metatarsalgia is a painful foot condition affecting the metatarsal (MT) region of the foot. A MT pad, MT bar, or forefoot cushion can be used to alleviate MT pain. Hallux valgus is a deformity characterized by medial deviation of the first MT and lateral deviation of the hallux. A toe spreader, valgus splint, and bunion shield are commonly applied to patients with hallux valgus. Hallux limitus and hallux rigidus refer to painful limitations of dorsiflexion of the first metatarsophalangeal joint. A kinetic wedge foot orthosis or rocker sole can help relieve symptoms from hallux limitus or rigidus. Hammer, claw, and mallet toes are sagittal plane deformities of the lesser toes. Toe sleeve or padding can be applied over high-pressure areas in the proximal or distal interphalangeal joints or under the MT heads. An MT off-loading insole can also be used to alleviate symptoms following lesser toe deformities. Morton's neuroma is a benign neuroma of an intermetatarsal plantar nerve that leads to a painful condition affecting the MT area. The MT bar, the plantar pad, or a more cushioned insole would be useful. In addition, patients with any of the above various forefoot disorders should avoid tight-fitting or high-heeled shoes. Applying an insole or orthosis and wearing proper shoes can be beneficial for managing forefoot disorders.

PubMed: 31620619
DOI: 10.12701/yujm.2019.00185

Review

Authors: Bryant Ho, Judith Baumhauer

An estimated 40% of the US population have foot problems.Of all patients aged over 50 years, 2.5% report degenerative arthritis of the first metatarsophalangeal (MTP) joint, termed 'hallux rigidus'. First MTP osteoarthritis is the most common arthritic condition in the foot.Progression of great toe arthritis is associated with pain and loss of motion. Non-surgical intervention begins with shoe modifications and orthotics designed to limit MTP motion.In patients with mild arthritis, operative procedures focus on removing excess osteophytes (cheilectomy) to prevent dorsal impingement with or without a concomitant osteotomy (Moberg) to improve or shift range of motion into a less painful arc.In patients with more advanced arthritis, operative management has centred on arthrodesis of the first MTP joint.A recent Level 1 study shows excellent function and pain relief with a small hydrogel hemi-implant into the metatarsal headMultiple joint-sparing procedures such as joint arthroplasty or resurfacing have been described with inconsistent results. Cite this article: EFORT Open Rev 2017;2:13-20. DOI: 10.1302/2058-5241.2.160031.

PubMed: 28607766
DOI: 10.1302/2058-5241.2.160031

Review

Authors: T Bauer

Percutaneous methods can be used to perform many surgical procedures on the soft tissues and bones of the forefoot, thereby providing treatment options for all the disorders and deformities seen at this site. Theoretical advantages of percutaneous surgery include lower morbidity rates and faster recovery with immediate weight bearing. Disadvantages are the requirement for specific equipment, specific requirements for post-operative management, and lengthy learning curve. At present, percutaneous hallux valgus correction is mainly achieved with chevron osteotomy of the first metatarsal, for which internal fixation and a minimally invasive approach (2 cm incision) seem reliable and reproducible. This procedure is currently the focus of research and evaluation. Percutaneous surgery for hallux rigidus is simple and provides similar outcomes to those of open surgery. Lateral metatarsal malalignment and toe deformities are good indications for percutaneous treatment, which produces results similar to those of conventional surgery with lower morbidity rates. Finally, fifth ray abnormalities are currently the ideal indication for percutaneous surgery, given the simplicity of the procedure and post-operative course, high reliability, and very low rate of iatrogenic complications. The most commonly performed percutaneous techniques are described herein, with their current indications, main outcomes, and recent developments.

Topics: Bandages; Endoscopy; Exostoses; Fluoroscopy; Forefoot, Human; Hallux Rigidus; Hallux Valgus; Humans; Learning Curve; Metatarsal Bones; Metatarsalgia; Metatarsophalangeal Joint; Osteotomy; Postoperative Care; Surgery, Computer-Assisted; Surgical Equipment; Surgical Instruments; Toe Phalanges; Treatment Outcome; Weight-Bearing

PubMed: 24412043
DOI: 10.1016/j.otsr.2013.06.017

Review

Authors: Nicoline Kirk Bro, Jeppe Lange, Jesper F Kabel...

This review summarises the present knowledge of diagnosing and treating hallux rigidus in Denmark. Hallux rigidus is a degenerative disease of the first metatarsophalangeal joint. The pathology of the joint can be visualised on standing radiograph of the foot. If conservative treatment measures fail to provide adequate pain relief, surgery will be an option for most patients. Several procedures are adequate for the treatment of hallux rigidus, and especially surgery show good or excellent results for most patients.

Topics: Follow-Up Studies; Hallux Rigidus; Humans; Metatarsophalangeal Joint; Radiography

PubMed: 33491644
DOI: No ID Found

Authors: James W Brantingham, Timothy G Wood

Hallux rigidus is a common problem of the first metatarsophalangeal joint and is particularly common in the 31-69 year old age group. Loss of articular cartilage narrowing of joint space and formation of periarticular osteophytes are present and increase over time, often leading to palpable osteophyte formation. The authors suggest that a diagnosis of hallux rigidus be made if at least 4 of the following are present at the big toe: pain, stiffness, palpable exostosis, positive X-ray findings, positive axial grind test, occasional synovitis, decreased motion on motion palpation (particularly dorsiflexion). This case study follows a 36-year-old male professional tennis player over a 7 year period under various forms of management including orthopaedic, physical therapy and chiropractic care. Initial surgery provided some relief, subsequent physiotherapy did not significantly reduce the patient's pain while chiropractic manipulation and mobilization on two separate occasions provided marked reduction in pain scores. NSAID usage and "punching out" his shoes also provided some relief. There is a reasonable possibility that general foot and big toe mobilization and the Brantingham "protective" big toe manipulation may reduce the pain of hallux rigidus. A randomized-controlled study should be done to ascertain the efficacy of such a treatment protocol.

PubMed: 19674557
DOI: 10.1016/S0899-3467(07)60025-1

Review

Authors: Michael R Anderson, Bryant S Ho, Judith F Baumhauer...

Arthritis of the first metatarsophalangeal (MTP) joint, hallux rigid, is a common and disabling source of foot pain in the adult population. Hallux rigidus is characterized by diseased cartilage and large, periarticular osteophytes that result in a stiff, painful joint. Activity modification, sensible shoes, orthotics, anti-inflammatory medications and occasional intra-articular steroid injections can be attempted to alleviate the discomfort associated with hallux rigidus. A number of surgical options exist for the treatment of recalcitrant hallux rigidus. Cheilectomy is a useful treatment for dorsal impingement pain seen in mild hallux rigidus. A new polyvinyl alcohol hemi-arthroplasty implant has shown promising early and midterm results in the treatment of advanced hallux rigidus; however, arthrodesis of the first MTP joint remains the gold standard treatment for advanced hallux rigidus because of unpredictable outcomes after early-generation joint replacement implants.

PubMed: 37506124
DOI: 10.1177/24730114231188123

Review

Authors: Philip J York, Frank B Wydra, Kenneth J Hunt...

PURPOSE OF REVIEW

Injuries to the great toe are common in athletes. While most are managed nonoperatively and allow return to sports activity, some great toe injuries are highly problematic and can impact function. The purpose of this review is to highlight several specific injuries and disease processes involving the hallux and to detail current recommendations and management options in order to help raise suspicion for injuries that can result in long-term dysfunction.

RECENT FINDINGS

Toe injuries have been found to represent nearly 10% of injuries presenting to fracture clinics. While most injuries can be treated nonsurgically, there are a number of specific injuries that require a high index of suspicion, careful management, and in some cases, surgical intervention. Injuries detailed in this review include turf toe, traumatic bunion, and hallux and sesamoid fractures. Additional pathologies that are covered include sesamoiditis and sesamoid avascular necrosis as well as hallux rigidus. Appropriate workup and current treatment recommendations are discussed. Injuries to the hallux can result in long-term pain and disability if not properly diagnosed and treated. A high index of suspicion is required.

PubMed: 28124292
DOI: 10.1007/s12178-017-9390-y

Authors: Francesco Di Caprio, Massimiliano Mosca, Francesco Ceccarelli...

BACKGROUND AND AIM OF THE WORK

Hallux rigidus represents a surgical challenge, with a multitude of possible surgical options, but with no ideal procedures.  The propose of this paper was to review the actual knowledge on the operative techniques, paying particular attention to the evolution of interposition arthroplasties, as an alternative to arthrodesis and prosthesis in the advanced stages of the disease.

METHODS

A comprehensive literature PubMed search was performed, and the actual literature regarding hallux rigidus was overviewed. The operative and nonoperative options for HR were described. Studies on interposition arthroplasty were classified by publication year, summarizing the operative technique, results and complications.

RESULTS

Among the various techniques for interposition arthroplasty, the Modified Oblique Keller Interposition Arthtoplasty (MOKCIA) showed the lower complication rate. It does not sacrifice the insertion of the flexor halluces brevis, maintaining the stability, length and strength of the big toe.

CONCLUSIONS

Although long-term randomized controlled trials are lacking for interposition arthroplasties, the reported results are comparable to the other alternatives for the treatment of end-stage hallux rigidus, making this technique a valid alternative also in the young active patient, without precluding other end-stage procedures in case of failure. Based on the current knowledge, a treatment algorithm was developed, according to the Coughlin classification.

Topics: Humans; Hallux Rigidus; Metatarsophalangeal Joint; Treatment Outcome; Arthroplasty; Algorithms

PubMed: 36300241
DOI: 10.23750/abm.v93i5.12811

Review

Authors: Kenichiro Nakajima

In 1927, Cochrane noted that elastic resistance to dorsiflexion of the hallux was retained after the cheilectomy or dorsiflexion osteotomy of the metatarsal head and speculated that the shortening and tightness of the soft tissues below the first metatarsophalangeal joint would be the etiology of hallux rigidus. He devised a novel surgery in which the plantar tissues were divided using a plantar approach and reported good results in 12 patients with the disappearance of elastic resistance during dorsiflexion and with no recurrence. Although he identified the etiology of hallux rigidus and developed a revolutionary surgery that directly addressed the etiology, this approach has not yet been seen in current surgeries. Therefore, we hypothesized that current surgeries for hallux rigidus lack rationality regarding etiology and aimed to critically review joint-preserving surgeries based on etiology. First, we summarized the literature on proposed causes and explained how the condition progresses from shortened, tightened plantar soft tissues. We then reviewed joint-preserving surgeries in terms of etiology and treatment efficacy and finally mentioned the arthroscopic Cochrane procedure as a promising option.

PubMed: 40095556
DOI: 10.3390/jcm14051595