Hallux Rigidus 1 PDF

HALLUX RIGIDUS 1 Jarrod Smith, DPM, FACFAS Assistant Professor LEARNING OBJECTIVES Differentiate anatomical and functional causes of hallux rigidus/limitus Demonstrate knowledge of the radiographic findings of hallux rigidus/limitus Demonstrate knowledge of the Drago, Oloff & Jacobs classification o...

HALLUX RIGIDUS 1 Jarrod Smith, DPM, FACFAS Assistant Professor LEARNING OBJECTIVES Differentiate anatomical and functional causes of hallux rigidus/limitus Demonstrate knowledge of the radiographic findings of hallux rigidus/limitus Demonstrate knowledge of the Drago, Oloff & Jacobs classification of hallux rigidus Identify the stages of hallux limitus/rigidus Demonstrate knowledge and describe the surgical treatment of hallux limitus/rigidus based on the stage st Normal 1 MTPJ ROM Ginglymoarthrodial joint Ginglymus joint à Hinge joint A) Rolling motion for the first 20-30° of hallux dorsiflexion Arthrodial joint à Sliding B) First ray plantarflexion changes the motion to a sliding motion for the remainder of propulsion C) Compression occurs at end range of motion Normal ROM = 65 – 75° st Normal 1 MTPJ ROM 1st metatarsal head is shaped like a cam which aids: I. II. III. IV. Rolling Sliding Sliding Compression st Normal 1 MTPJ ROM st Normal 1 MTPJ ROM Requirements First ray plantarflexion STJ supination Normal parabola (2nd met longer than 1st) Normal intrinsic/extrinsic muscle function Normal sesamoid function Intact proximal phalangeal base (Windlass) Intact plantar aponeurosis (Windlass) Medial Column Stabilization Plantarflexion of the 1st ray is dependent on the pull of the peroneus longus tendon Medial Column Stabilization Plantarflexion of the 1st ray is dependent on the pull of the peroneus longus tendon The wedge-shape of the middle and lateral cuneiforms result in a key stone effect within the medial cuneiform and cuboid Medial Column Stabilization Plantarflexion of the 1st ray is dependent on the pull of the peroneus longus tendon The wedge-shape of the middle and lateral cuneiforms result in a key stone effect within the medial cuneiform and cuboid This stabilizes the lesser tarsus and allows the first ray to plantarflex First Ray Plantarflexion This stabilizes the lesser tarsus and allows the first ray to plantarflex Hallux Rigidus Definition - A progressive disorder of the first MTP joint, characterized by a diminished ROM and degenerative alterations of the joint. Hallux Rigidus Definition - A progressive disorder of the first MTP joint, characterized by a diminished ROM and degenerative alterations of the joint. If any of the requirements for normal 1st MTPJ ROM is not met, the result is usually first ray elevation Hallux Rigidus Elevation of the first metatarsal (metatarsus primus elevatus) causes the proximal phalanx of the hallux to sublux plantarly (hallux equinus/flexus). Because some movement is generally available the term hallux limitus is used. Only 25-30° are possible without 1st ray plantarflexion. Hallux Rigidus Windlass mechanism Heel lift with ankle plantarflexion will dorsiflex the 1st MTPJ Tightening of the plantar fascia Raises the arch Resists elongation of the foot Shortens the foot Assists in resupinating the subtalar joint Hallux Rigidus Windlass mechanism function is blocked by any force the drives the first ray up The first ray is prevented from plantarflexing The hallux cannot dorsiflex Plantar fascia tension still increases, however, this results in increased 1st MTPJ compression Hallux Rigidus Etiologies of hallux limitus/rigidus: Functional (biomechanical) causes Pronation 1st ray hypermobility Weak peroneus longus All lead to first ray dorsiflexion and subsequent “jamming” of the dorsal aspect of the MTP joint Hallux Rigidus Etiologies of hallux limitus/rigidus: Functional (biomechanical) causes High heels Increasing heel height reduces 1st MTPJ dorsiflexion A 1-inch heel reduce dorsiflexion by 20° Each additional inch decreases dorsiflexion by 14° A 2-inch heel will decrease 1st MTPJ ROM by 34° meaning you will need 100° of dorsiflexion if we need 65° to propel forward Hallux Rigidus Etiologies of hallux limitus/rigidus: Structural causes Immobilization of the 1st ray (in dorsiflexion) Congenital metatarsus primus elevatus Congenital long first metatarsal/short 2nd metatarsal Arthritis of the 1st TMTJ (decreased ROM) Rigid flatfoot deformity Hallux Rigidus Etiologies of hallux limitus/rigidus: Iatrogenic à Previous surgery Unintentional first ray elevation with HAV correction This is why you most likely will never intentionally dorsiflex the first metatarsal head with HAV correction Hallux Rigidus Etiologies of hallux limitus/rigidus: Trauma TMTJ arthritis MTPJ arthritis Turf-toe Malunion of a 1st metatarsal fracture (healed in elevatus) Systemic arthridities (gout, RA) Hallux Rigidus Common clinical findings: Pain Limited motion at the 1st MTPJ Dorsal bump on the 1st metatarsal head Dorsal bunion Hypermobility of the hallux IPJ Plantar callus at the IPJ Metatarsus primus elevatus Metatarsalgia à lateral dumping Hallux Rigidus Radiographic findings: Dorsal osteophytic formation 1st metatarsal head (flag sign) Base of the proximal phalanx Metatarsus primus elevates Hallux equinus 1st MTP joint space narrowing Flattening of the 1st metatarsal head Subchondral sclerosis Pronatory changes in the foot Functional vs Structural Functional hallux limitus (flexible) Decreased hallux dorsiflexion only when the forefoot is loaded Responds well to orthotic management (functional orthosis) Raise the arch up, allow the 1st ray to plantarflex, thus unblocking the windlass mechanism, and allowing hallux dorsiflexion Functional hallux limitus can develop into a structural hallux rigidus Functional vs Structural Structural hallux rigidus (fixed) Decreased hallux dorsiflexion with the forefoot loaded and unloaded Orthotics have limited utility Hallux Rigidus Treatment Options: Conservative treatment Functional Treatment Orthotic management Physical therapy PL strengthening Joint mobilization Adjunct Treatment à limited utility without functional treatment NSAIDs Injections Orthotic Management Goals of treatment Increased ROM of the 1st MTPJ by correcting the biomechanics Plantarflex the first metatarsal Raise the arch = increase metatarsal declination Reverse Morton’s extension Decrease the ROM of a painful 1st MTPJ = mimic a fusion Dorsiflex the hallux Morton’s extension Orthotic Casting Start with subtalar joint in neutral position Lock the midtarsal joint by applying a dorsiflexory force to the 4/5th met heads Hold the STJ in neutral with the midtarsal joint locked with one hand & plantarflex the first ray with the other Plantarflexing the first ray to remove supinatus/forefoot varus is critical to first ray function Reverse Morton’s Extension Allows the first ray to plantarflex more (if able) Increases ROM of the 1st MTPJ Morton’s Extension Dorsiflexes the hallux Decreases ROM of the 1st MTPJ Hallux Rigidus Surgical Treatment Options: Joint salvage procedures Joint destructive procedures Goal is to keep what remains of the joint and get it to function better Usually, can be revised to a joint destructive procedure Not considered definitive Destroys the joint Considered definitive, however, not all are Before we can get into surgery…we must classify!!! Drago, Oloff, & Jacobs Classification Drago, Oloff, & Jacobs Classification Stage I: Functional Limitus Limited dorsiflexion with weightbearing but normal ROM with non-weight-bearing Little/no degenerative changes Biomechanical derangement (pronation) 1st ray insufficiency Metatarsus primus elevatus Hallux equinus Hyperextension hallux IPJ Treatment: Joint-Salvage procedure Drago, Oloff, & Jacobs Classification Stage I: Functional Limitus Limited dorsiflexion with weightbearing but normal ROM with non-weight-bearing Little/no degenerative changes Biomechanical derangement (pronation) 1st ray insufficiency Metatarsus primus elevatus Hallux equinus Hyperextension hallux IPJ Treatment: Joint-Salvage procedure Drago, Oloff, & Jacobs Classification Stage 2: Adaptation Flattening of the first metatarsal head Osteochondral defect Pain on end ROM Limited passive ROM Small dorsal exostosis Subchondral sclerosis Periarticular lipping of the first metatarsal head, proximal phalanx, & sesamoids Treatment: Joint-Salvage procedure Drago, Oloff, & Jacobs Classification Stage 2: Adaptation Flattening of the first metatarsal head Osteochondral defect Pain on end ROM Limited passive ROM Small dorsal exostosis Subchondral sclerosis Periarticular lipping of the first metatarsal head, proximal phalanx, & sesamoids Treatment: Joint-Salvage procedure Drago, Oloff, & Jacobs Classification Stage 3: Deterioration Severe flattening of the first metatarsal head Dorsal osteophytosis Asymmetric joint space narrowing Degeneration of articular cartilage Crepitus Subchondral cystic formation Pain on full ROM Treatment: Joint-Salvage or Joint-Destructive procedure Drago, Oloff, & Jacobs Classification Stage 3: Deterioration Severe flattening of the first metatarsal head Dorsal osteophytosis Asymmetric joint space narrowing Degeneration of articular cartilage Crepitus Subchondral cystic formation Pain on full ROM Treatment: Joint-Salvage or Joint-Destructive procedure Drago, Oloff, & Jacobs Classification Stage 4: Anklylosis Obliteration of joint space Exuberant dorsal osteophytosis w/ loose bodies < 10° ROM Degeneration of articular cartilage Deformity/Malalignment Total ankylosis may occur Treatment: Joint-Destructive procedure Drago, Oloff, & Jacobs Classification Stage 4: Anklylosis Obliteration of joint space Exuberant dorsal osteophytosis w/ loose bodies < 10° ROM Degeneration of articular cartilage Deformity/Malalignment Total ankylosis may occur Treatment: Joint-Destructive procedure Treatment Algorithm