2. Subjective
CC: Pt will generally complain of a “painful big toe.”
HPI:
• Nature: Aching, Dull, Throbbing
• Location: Dorsal 1st MTPJ and within the joint
• Course: Usually gradual and progressive. May
follow an acute traumatic event.
• Aggravating Factors: Shoe gear, WB
• Alleviating Factors: Ice, NSAIDs, Rest
PMH:
• Inflammatory Condition: RA, SLE, Gout
PSH:
• Past 1st MTPJ surgery
Meds/Allergies/SH/FH: Non-contributory ROS: Non-
contributory
4. Imaging - Plain Film Radiographs
AP view:
• Osteophytes at 1st MTPJ
• Osteophytes at hallux IPJ
• Osteophytes at 1st met-cuneiform joint
• Long 1st met
• Irregular Joint Space Narrowing
• Long hallux proximal phalanx
• Square-shaped 1st met head
Lateral view:
• Dorsal flag sign, dorsal lipping
• Elevated 1st met
• Loose bodies (joint mice)
5. Definition of Hallux Limitus:
The proximal phalangeal base is plantarly subluxed upon the first metatarsal head. The
hallux has limited dorsiflexion motion at the first MPJ during propulsion.
There is a decrease in 1st MPJ ROM to < 20 degrees.
Definition of Hallux Rigidus:
Ankylosis of the first MPJ secondary to repetitive trauma during dorsiflexion. < 10 degrees
of dorsiflexion
Definition of Functional Hallux Limitus:
Functional hallux limitus exists when the first MPJ DF ROM is reduced when the forefoot
loads. Stage 1.
Definition of Structural Hallux Limitus:
Structural hallux limitus exists when first MPJ ROM is reduced with the forefoot loaded and
unloaded.
6. Hallux Limitus vs. Hallux Rigidus
• This is a progressive deformity, so what defines rigidus from limitus?
• Bony ankylosis and sesamoid immobilization.
• Functional HL is defined as a decreased PROM with the foot loading and in a neutral position,
and normal PROM when the foot is unloaded. Dannanberg first defined functional HL.
Met Primus Elevatus: Dorsiflexed position of the 1st metatarsal.
• Primary: Structural. Distal segment is dorsiflexed compared to proximal segment.
• Secondary: Global. Due to some extrinsic variable. This can be measured by Meary’s Angle on
a lateral plain film radiograph or using the Seiberg technique comparing the 1st and 2nd
metatarsal positions.
7. What stimulates osteophyte production in and around the joint?
Loss of functional cartilage
Flexor Stabilization of the hallux: Essentially a hammertoe of the hallux with extension at the MTPJ
and plantarflexion at the IPJ.
Axis of rotation of the 1st MTPJ: Normally found in the center of the metatarsal head allowing for a
gliding motion of the hallux up and over the first metatarsal head. In a HL/ HR deformity the axis of
rotation moves distally and plantarly leading to dorsal jamming of the joint.
Compensation Patterns for Lack of Motion
Distal: Hallux IPJ leading to OA and plantar hyperkeratotic lesions
Lateral: Lesser metatarsalgia
Proximal: 1st met-medial cuneiform joint increased motion and OA
Gait patterns: Abductory twist with roll-off; early heel-off; Apropulsive gait
8. AJM Sheet: General HL/HR Information
1st MTPJ ROM
• Normal PROM of the 1st MTPJ is classically
described as 65-75 degrees of dorsiflexion of the
hallux referenced to the weight-bearing surface
(same as 85-95 degrees of dorsiflexion referenced
to the 1st met shaft). Plantarflexion is 30 degrees to
the weight-bearing surface.
• Hetherington contradicts this somewhat by finding
an average ROM of 31degrees of dorsiflexion during
pain-free gait in asymptomatic patients.
9. AJM Sheet:
General HL/HR
Information
HL/HR Etiology
• Many have reported potential causes of HL/HR including Root, Lapidus and Nilsonne:
• Acute Trauma
• Chronic degenerative trauma
• Pes planus with 1st met
• hypermobility
• Long first metatarsal
• Short first metatarsal with hallux gripping
• Met primus elevatus
• Long hallux proximal phalanx
• Iatrogenic
• Compensated varus deformity
• Neuromuscular imbalance
• Plantar contracture
• Spastic conditions
• Square first metatarsal head shape
• No single characteristic has been shown to reliably lead to HL/HR except acute trauma
• Coughlin (FAI 2003) performed a retrospective analysis and seemed to demonstrate that
there are no reliable underlying indicators for development of HL/HR.
10. AJM Sheet:
HL/HR
Classifications
Classification Systems
• Examples of classifications include the
Regnauld, Hanft and KLL.
• Numerous exist; usually in the mild,
moderate, severe format:
• Mild: Mild pain; Normal PROM;
Radiographic evidence of osteophytes
• Moderate: Increasing pain; Decreasing
PROM; Osteophytes and irregular joint
space narrowing on radiograph
• Severe: Increasing pain; Decreasing
PROM; Osteophytes, irregular joint
space narrowing, subchondral sclerosis
on radiograph.
• Rigidus: Increasing pain; Absent
PROM; Sesamoid immobility
