Hallux rigidus is a complex condition that affects the first metatarsophalangeal joint, manifesting as painful osteoarthritis and progressive limitation of movement. It is essential for podiatrists to understand this condition in order to provide appropriate treatment and improve the quality of life of patients. This comprehensive guide explores the pathologic aspects, causes, diagnostic methods, and treatment options of hallux rigidus.
Pathology of hallux rigidus
Hallux rigidus is characterized by double metatarsophalangeal and metatarsosesamoid osteoarthritis, with osteophytic formations and progressive ankylosing that affects the three articular planes: the metatarsal head, the phalangeal base, and the sesamoids. The integuments and the capsule are also affected, causing dystrophic and inflammatory disorders.
The lesions observed in hallux rigidus are dominated by ischemic osteoporosis, marked by rarefaction and thinning of the bone trabeculae, as well as widening of the medullary spaces. This process is accompanied by bone remodeling, with linear repair (fibromatosis of the medullary spaces and thickening of the bone trabeculae) and nodular repair (appearance of osteogenic nodules). Cartilaginous lesions, often caused by microtrauma and internal hyperpressure, lead to multiple ulcerations and endochondral ossification.
Etiopathogenesis of hallux rigidus
The causes of hallux rigidus can be varied, although some remain poorly defined. Several factors can contribute to its development:
1. Osteoporosis
Hallux rigidus can appear following prolonged joint immobilization, caused by foot trauma, a joint fracture, or a tibiotarsal sprain. This immobilization osteoporosis, of the algoneurodystrophic type, is often a triggering factor.
2. Microtraumas
Repetitive microtraumas, particularly due to wearing unsuitable shoes, can cause the appearance of hallux rigidus. The Egyptian or square foot, where the end of the big toe is directly exposed to shocks in the shoe, is particularly vulnerable. Additionally, static foot disorders, such as pes cavus or pes planus, can cause excess pressure on the first metatarsophalangeal joint, exacerbating the condition.
3. General pathologies
Certain systemic diseases, such as generalized osteoarthritis, acute arthritis, rheumatoid arthritis, or gouty rheumatism, can also cause hallux rigidus.
Diagnosis of hallux rigidus
The diagnosis of hallux rigidus is based on a combination of clinical and radiological examinations, allowing the disease to be classified into several stages according to severity.
Clinical diagnosis
Hallux rigidus presents in three clinical stages:
- Stage I: Characterized by acute or subacute pain on dorsiflexion of the first toe, with limitation of movement.
- Stage II: This stage corresponds to established osteoarthritis, with variable pain, ranging from tingling at rest to intense pain when walking. The first toe takes on a "barquette" appearance, and joint stiffness becomes more pronounced.
- Stage III: This is the stage of ankylosis, where the joint becomes an ossified block, with very limited mobility. Pain is present both in forced dorsiflexion and during pressure, often accompanied by dorsal joint hypertrophy making it difficult to put on shoes.
Radiological diagnosis
Weight-bearing X-rays allow us to visualize the stages of hallux rigidus:
- Stage I: Absence of significant bone remodeling, slight narrowing of the joint space and early dorsal exostosis.
- Stage II: Tight narrowing of the joint space with bony condensation, flattening of the articular surfaces, and sesamoid hypertrophy.
- Stage III: Disappearance of the joint space, complete osteoarticular remodeling, and marked osteophytosis dorsally.
Treatment of hallux rigidus
Treatment for hallux rigidus can be medical or surgical, depending on the stage of the disease and the severity of symptoms.
Medical treatment
Conservative treatment is mainly palliative. It includes the use of analgesics, anti-inflammatories, and possibly infiltrations to relieve pain. Podiatric orthoses, such as subcapital blades, can be used to limit the use of dorsiflexion of the toe. Wearing suitable shoes, with a wide fit and flat heels, is also recommended.
Surgical treatment
Surgical treatment aims either to relieve pain or to restore joint function. Surgical techniques vary depending on the stage of the disease:
- Stage I and II: Conservative surgical procedures, such as metatarsal head trimming, phalangeal osteotomy or metatarsal lowering osteotomy, may be proposed to limit the progression of osteoarthritis and preserve joint mobility.
- Stage III: For more advanced cases, metatarsophalangeal arthrodesis is often preferred, as it offers a long-lasting solution by eliminating pain while stabilizing the joint.
- Stage IV: Complete ankylosis of the joint usually requires arthrodesis to restore good support of the first toe and improve the patient's quality of life.
Prevention and long-term monitoring
Prevention of hallux rigidus is mainly based on early detection of risk factors and adequate management of static foot disorders. Wearing suitable shoes, with good support and sufficient space for the toes, is essential to prevent the onset of this pathology. Particular attention should be paid to patients with a history of foot trauma or rheumatic pathologies.
Follow-up of patients treated for hallux rigidus is crucial to assess the effectiveness of treatment and adjust care if necessary. In cases where arthrodesis has been performed, regular monitoring is necessary to ensure proper healing and maintenance of the functional position of the toe.
Finally, educating patients about the importance of foot care and adopting good footwear practices can help prevent recurrences and maintain a good quality of life in the long term.
