The great toe joint is a small joint, but its normal function and
ability to dorsiflex (bend upwards as in the photo on the right) is
essential to normal foot function.
Unfortunately, it is possible for an abnormal limitation of great toe
joint function to develop. Indeed, this is a common condition seen
in podiatric practice. This is the topic of this web page.
Stiff big toe joints may be known by different
names. When motion is limited, the condition is called
When the motion is completely gone, the condition is called
When a patient has a bony bump on
the top of the big toe joint, the condition is sometimes called a
(See picture to the left.) Dorsal bunions, a type of arthritis,
can be one of the more common causes of hallux limitus or hallux
creates this condition?
All joints consist of two bones
coming together, to form the joint. The joint surfaces on each bone are
covered with a slick, glistening, pearly-white surface called cartilage. The
type of cartilage on a joint surface is known as articular
When limitation of normal function occurs, however,
arthritis begins to develop. So Hallux Limitus and Hallux Rigidus can be
thought of as arthritic conditions, or at least pre-arthritic.
Degenerative arthritis is a
condition where the joint surface, the articular cartilage, begins to wear out. The causes for this
are many, some of the most common of which include:
An elevated first
metatarsal This is the case in the
picture above. As you can see, the affected bone sits higher up than
the adjacent bone, and this makes the motion of dorsiflexion
more difficult. This is best viewed with a "Weight Bearing
Lateral" X-ray, a side view of the foot when the patient is standing.
first metatarsal is the case
where the first metatarsal bone may look like it's in a normal position, but
it is unstable, lifting excessively relative to the other metatarsals in
stance. This judgement is usually made clinically, although there are
some specialty X-ray views that may be helpful.
The first metatarsal may be
too long. Normally, the 1st
met should be slightly shorter than the 2nd, so as the body weight is
transferred forward, the bone may plantarflex (or drop) relative to the 2nd
metatarsal. But if the 1st metatarsal is longer than the 2nd
metatarsal, the bone tends to elevate relative to the 2nd metatarsal in the
"toe off" portion of gait, causing jamming of the joint, and MTP
joint degeneration (hallux limitus). As an example of this, put your
four fingers (minus your thumb) on a table. Notice that your middle
finger is the longest finger. Now lift the heel of your hand,
maintaining your fingertips on the table. If you look at your fingers
from the medial side, you should see that the shaft of the second finger
tends to drop below the shaft of the third. This is how the
metatarsals should move. Now, do the same thing with just your 3rd,
4th and 5th fingers, (not the thumb or 2nd finger). Pretend that the
3rd finger is a longer-than-normal 1st metatarsal, and the 4th finger is the
relatively shorter 2nd metatarsal. Now as you lift the heel of your
hand you should see that the 3rd finger elevates relative to the 4th finger.
In the foot this will tend to cause hallux limitus. A simple
weight-bearing AP (also known as a DP) x-ray will reveal whether this is the
case. (Non-weight-bearing films are less accurate.)
The first bone in the big toe (the proximal
phalanx) may be too long. This can apply a retrograde force through the
joint, which may cause hallux limitus. Again, an AP (DP) film should
help you discern this.
Excessive pronation may
destabilize the great toe joint. If the foot pronates (or flattens)
excessively, there is an increase in pressure under the first
metatarsal as the foot rolls in. This force may be considered as an upward
pressure from the floor on the inside of the weight-bearing portion of the
foot. This pressure beneath the first metatarsal can cause it to
elevate, resulting in hypermobility, hallux limitus or hallux rigidus.
Irregular bone contours
can also cause a limitation of joint motion. This is where abnormal bony bumps
begin to exert friction on each other
Irregular joint alignment may
lead to abnormal strain on the joint and wear on the bony surfaces, possibly
leading to diminished motion.
The presence of loose fragments of
bone in or near the joint may
also limit motion. Loose fragments are known as "osteophytes",
or more colloquially, as "joint mice".
Improper sesamoid function can
also adversely affect joint function. (Sesamoids are the two small
bones beneath the 1st metatarsophalangeal joint and are integral to normal
function of this joint.)
Improper muscle or tendon function may
also lead to a poorly-functioning joint, either directly causing a
limitation of motion, or doing so secondarily by leading to the formation of
joint wear and arthritis.
Scar tissue may
also bind down the joint, thereby limiting motion.
a joint may destroy bony and soft tissues, create arthritis and scar tissue
and lead to hallux limitus or rigidus.
Primary Arthritis is
the type of arthritis that causes joint wear, as opposed to the type of
arthritis that develops from abnormal motion. Some forms of arthritis
may directly damage the metatarsophalangeal joint and create hallux
Excessive pressure from a shoe with a tight toe
box may create hallux limitus by creating abnormal, excessive, and chronic
High-heeled shoes tend
to create hyperextension of the great toe joint, thereby altering function
and leading to hallux limitus.
Acute trauma to the joint,
such as dropping something on the joint or kicking something may cause a
sudden, acute trauma to the joint, leading to arthritis and loss of joint
Abnormal biomechanics (abnormal function of the
joint) may lead to abnormal
joint wear, arthritis, and hallux limitus.
Genetic causes are
also thought to be involved in the development of this condition. This
is because metatarsal length, structure, position and function are factors
that tend to be inherited.
First, as a result of some cause,
the cartilage begins to wear, and the joint surface loses its lustre. It
glistens less and loses its slick feel. This is the beginning of
The next step is where the joint
begins to change from a pearly-white color to a dull-grey. Sometimes
holes or depressions develop in that surface, as the cartilage wears
through. Joint motion diminishes, and pain tends to develop.
As the condition progresses, the
cartilage is worn away, and all that remains is the two raw bone surfaces
rubbing together. Because bones can't function well without the
cartilage between them, joint motion worsens, and the bones become more
and more misshapen. The joint surface tends to flatten on each side of
the joint, and projections of bone know as "spurs" develop. At
this stage, motion of the joint is usually quite limited, and most patients
experience a significant amount of pain, and the way the patient walks,
the "gait", begins to become altered.
Eventually, the motion gets so bad
that the two bones can fuse together, completely obliterating what was once a
symptoms does arthritis cause?
The degenerative process causes two
major problems: pain, and loss of motion of the big toe joint.
This can also cause alteration in the way a patient walks, so other parts of
the foot, knee, hip and back are frequently affected.
can a patient be certain this is the condition?
In most cases, the diagnosis is
apparent on physical examination alone. But X-rays help us understand
the extent of the joint degeneration and bone malformation.
How can this
First, you can try symptomatic
relief, that is, just making it feel better. Rest, ice,
anti-inflammatory medications, steroid injections, physiotherapy, and massage may
all help. At least temporarily.
Second, and more importantly long term, you can try to
identify the cause of the problem, and attempt to correct this cause.
for example, can be used to increase
what motion still exists in the joint, or if the degeneration is bad enough, both
orthoses and special shoe modifications can limit pressure on the
spurs, and limit the painful motion that remains in the
The third option is to attempt
to fix the condition surgically.
be done to fix the joint surgically?
Several options exist.
These procedures have the advantage of being easy to
perform and allowing for quick recovery. Cheilectomies,
however, do not do anything to address why the hallux limitus
developed. So using this procedure where it is not indicated will tend
to create a return of symptoms and may make the patient undergo more surgery
in the future. It can also create scar tissue on the top of the joint,
which would also tend to inhibit motion.
For these reasons, other procedures that attempt to
correct the cause may be better choices in the long run, however. For
example, if the cause of the condition is an excessively long first
metatarsal, a procedure designed to shorten the metatarsal would be
considered. Alternatively, the metatarsal may be lowered if it is too
high, stabilized if it is too mobile, realigned if it is crooked,
recontoured if it is irregular, and so forth. There are many more
procedures that may be considered than the average patient would
Range of motion exercises are
encouraged afterwards for these procedures, and recuperation is usually quite rapid.
Procedure This procedure
involves a pie-shaped piece of bone being removed from the big toe to
allow the toe to "dorsiflex" or bend up. In the right
applications it may allow the patient to roll forward off the bent
toe, without causing excessive painful bending the big toe
to the Bonney-Kessel, the Waterman involves a pie-shaped wedge of bone cut
to be made in the first
metatarsal instead of the big toe. It is classically done in the
"head" of the first metatarsal bone, behind the big toe
Lambrinudi procedure basically consists of a long, pie-shaped wedge of
bone to be made in the shaft of the bone. When the
triangular-shaped piece is removed, the bone is able to
"plantarflex," or drop.
Giannistras consists of a Z-shaped bone cut when viewed from the top of
the bone. This cut allows the metatarsal to be lowered and
shortened as necessary to help the joint function. It is typically
held in place with two screws. It is less stable than other
procedures, but allows for substantial correction in severe
Kalish Procedure or
Offset V Procedure
This procedure is similar to the Lambrinudi except that it involves an
interlocking "V" shaped into the bone cut (when viewed from
the side). This interlocking "V" cut allows for more
stability in the bone cut and allows for quicker ambulation
by a California podiatrist named Dr. Fred Youngswick, this common modification to the
Austin Procedure allows the surgeon to shorten and drop the metatarsal head, in
cases where arthritis and limitation of motion is developing at the great
To allow the head of the bone
to be raised or lowered, there is the Reverdin-Green-Laird-Todd
procedure. In this procedure a triangular-shaped wedge is removed both
from the top and from the side. This procedure allows one to correct a
bunion in three dimensions. An example is demonstrated with the x-ray
on the right.
When the joint is terribly
worn and more conservative procedures are not sufficient, you sometimes need
to give up the idea of salvaging the joint, and perform a
joint-destructive procedure. Several possible such procedures exist.
A false joint, or
could be put in. Years ago, these false joints were metal.
Then surgeons moved towards using plastic. Today, metal is being
used more and more once again.
When performed correctly, this procedure can
restore good motion. The disadvantage is that the implant can
irritate the bones, and the implants tend not to last forever.
Other surgery down the road to remove or replace the implant is common.
Part of the joint could be
removed in a procedure known as a
procedure involves removing the base of the big toe joint.
As you can see in the illustration to the left, there is a great
deal of arthritic changes in the great toe joint.
The Keller procedure involves removing the
base of the first toe bone, to remove the arthritic bone
surrounding the joint and limiting motion. (See illustration
Usually surrounding soft
tissues are positioned between the remaining bone surfaces to prevent
further bone-on-bone wear.
Keller procedure is quick-healing, and it increases range of
motion tremendously. This helps the patient return to a
more normal gait, but the patient loses some push-off power in
the toe joint. Future surgery is rarely needed.
could be fused. In other words, instead of removing bone, you
attempt to eliminate the joint and allow the two bones to grow together in
a fused position. Known as an
the advantage to this is that without motion of the joint, pain
is usually resolved. The disadvantages are that this procedure is
slow-healing, sometimes requiring months to become solid, and the result is a motionless great toe joint,
which can change the way the patient walks.
Alterations if shoe gear may be necessary, and other joints
frequently begin to become troublesome, as they must make up for the loss
of great toe joint motion. It is also somewhat more to
reverse if the procedure proves to be problematic.
For more information on procedures
that may be chosen for hallux rigidus and limitus, you may wish to visit our
web page on
surgeries, as some of the procedures described there may be
chosen for this type of abnormality.
Which procedure is best?
It depends on each individual case, and
on the preferences of both the surgeon and the patient.
What kind of
anaesthesia would be
used for these procedures?
Any type of anaesthesia may
be used--general, spinal, or local. In most cases, local
anaesthesia is preferred, as it is safer, easier on the patient,
and less painful afterward.