Hallux abductus interphalangeus in normal feet, early-stage hallux limitus, and hallux valgus.

BACKGROUND: Excessive deviation of the distal phalanx in abduction frequently occurs in advanced stages of hallux rigidus but not in hallux valgus. Therefore, theoretically there should be no significant differences in the hallux interphalangeal angle (HIPA) between individuals with normal feet, those with hallux valgus, and those with mild hallux limitus. The objective of the present study was thus to determine if significant differences in HIPA exist in the early stages of hallux valgus or hallux limitus deformities. METHODS: The hallux interphalangeal angle was measured in three groups of participants: a control group with normal feet (45 participants), a hallux valgus group (49 participants), and a hallux limitus group (48 participants). Both of the pathologies were at an early stage. A dorsoplantar radiograph under weightbearing conditions was taken for each individual, and measurements (HIPA and hallux abductus angle [HAA]) were taken using AutoCAD (Autodesk Inc, San Rafael, California) software. Intergroup comparisons of HIPA, and correlations between HIPA, HAA, and hallux dorsiflexion were calculated. RESULTS: The comparisons revealed no significant differences in the values of HIPA between any of the groups (15.2 ± 5.9 degrees in the control group, 15.5 ± 3.9 degrees in the hallux valgus group, and 16.15 ± 4.3 in the hallux limitus group; P  =  0.634). The Pearson correlation coefficients in particular showed no correlation between hallux dorsiflexion, HAA, and HIPA. CONCLUSIONS: For the study participants, there were similar deviations of the distal phalanx of the hallux with respect to the proximal phalanx in normal feet and in feet with the early stages of the hallux limitus and hallux valgus deformities.

[Functional hallux limitus (Fhl): a new explanation for overuse pathologies]. / Hallux limitus fonctionnel: le pied qui fatigue et qui use.

Functional Hallux limitus (Fhl) is still a misconceived and unappreciated clinical entity, being often diagnosed during a clinical examination or a podiatric assessment. In the presence of Fhl, the patient's gait necessitates the unwitting existence of complementary efforts on their part, thus resembling to the gait pattern of someone with elongated foot or feet. The consequences of this dysfunction affect all age groups and manifest themselves in the form of low back pain, impingement, sprain, joint incongruence, or overload tendon and fibro-osseous lesions. An elongated foot gait pattern increases the stress applied to bones and joints and subsequently disrupts equilibrium. The biomechanical changes induced by Fhl mandate a profound reconsideration of our way of thinking and analysis, hence a revision of our reference system. It is indeed a new paradigm shift.

Etiology, pathophysiology, and staging of hallux rigidus.

The condition of hallux limitus is well understood and agreed on as visualized histologically and radiographically. But the historically described pathophysiology and anatomy that predisposes to hallux limitus has been challenged. Numerous investigators have proposed anatomic abnormalities of the foot as a primary cause of this condition, but perhaps trauma is the only unanimously agreed on cause. However, this accounts for only a small percentage of cases. To strive for better treatment outcomes, understanding the pathophysiology, assessing patient risk factors, and recognizing causative agents can better equip the foot and ankle surgeon in managing this condition.

Sesamoid disorders of the first metatarsophalangeal joint.

The sesamoid complex is located centrally and plantar to the first metatarsal head, where they are imbedded within the plantar plate, which transmits 50% of body weight and more than 300% during push-off, is susceptible to numerous pathologies. These pathologies include sesamoiditis, stress fracture, avascular necrosis, osteochondral fractures, and chondromalacia, and are secondary to these large weight-bearing loads. This article discusses sesamoid conditions and their relationship with hallux limitus, and reviews the conditions that predispose the first metatarsophalangeal joint to osteoarthritic changes.

The cheilectomy and its modifications.

Hallux rigidus occurs in 10% of persons aged 20 to 34 years but in as much as 44% of people older than 80 years. Surgical intervention has been suggested for cases of hallux rigidus that have failed using conservative methods. The modified cheilectomy is considered by many the first-line treatment for this disease, given the procedure's inherent ability to eliminate degenerate bone and cartilage and decompress the intra-articular space, while sparing considerable cubic content of bone. Once the cheilectomy has been performed, there remains a sufficient volume of bone to perform a more definitive reconstruction if necessary.

Functional hallux limitus or rigidus caused by a tenodesis effect at the retrotalar pulley: description of the functional stretch test and the simple hoover cord maneuver that releases this tenodesis.

Functional hallux limitus is a loss of metatarsophalangeal joint extension during the second half of the single-support phase, when the weightbearing foot is in maximal dorsiflexion. Functionally, it constitutes a sagittal plane blockade during gait. As a result, the mechanical support and stability mechanisms of the foot are disrupted, with important consequences during gait. Functional hallux limitus is a frequent, though relatively unknown condition that clinicians may overlook when examining patients with complaints that are not limited to their feet, for they can also present other symptoms such as hip, knee and lower-back pain. The purpose of this article is to present a critical review of the literature on functional hallux limitus and to explain a previously described and simple diagnostic test (flexor hallucis longus stretch test) and a physiotherapeutic manipulation (the Hoover cord maneuver) that recovers the dorsiflexion of the hallux releasing the tenodesis effect at the retrotalar pulley, which according to our clinical experience is the main cause of functional hallux limitus. The latter, to the best of our knowledge, has never been described before.

Revisional hallux abducto valgus surgery using tricorrectional bunionectomy.

We present a radiographic analysis of 91 failed hallux abducto valgus surgeries. Patients were categorized by type of postoperative complication: hallux varus, hallux limitus, or recurrent hallux abducto valgus deformities. All deformities were radiographically evaluated preoperatively and after correction using tricorrectional bunionectomy. Analysis of the surgical revisions showed improvement in radiographic parameters, including the intermetatarsal angle, hallux abductus angle, proximal articular set angle, and tibial sesamoid position. We conclude that tricorrectional bunionectomy is a versatile procedure that can be used when addressing a residual deformity after failed hallux abducto valgus surgery.

Nonoperative management of functional hallux limitus in a patient with rheumatoid arthritis.

BACKGROUND AND PURPOSE: Functional hallux limitus (FHL) is a condition that affects motion at the first metatarsophalangeal joint and may lead to abnormal forefoot plantar pressures, pain, and difficulty with ambulation. The purpose of this case report is to describe a patient with rheumatoid arthritis (RA) and FHL who was managed with foot orthoses, footwear, shoe modifications, and patient education. CASE DESCRIPTION: The patient was a 55-year-old woman diagnosed with seropositive RA 10 years previously. Her chief complaint was bilateral foot pain, particularly under the left great toe. Her foot pain had been present for several years, but during the past 5 months it had intensified and interfered with her work performance, activities of daily living, and social life. OUTCOMES: Following 4 sessions of physical therapy over a 6-week time period, the patient reported complete relief of forefoot pain despite no change in medication use or RA disease pathophysiology. She was able to continuously walk for up to 4 hours. Left hallux peak plantar pressures were reduced from 43 N/cm2 to 18 N/cm2 with the foot orthoses. DISCUSSION: Patients with RA who develop FHL may benefit from physical therapist management using semirigid foot orthoses, footwear, shoe modifications, and patient education.

The association of hallux limitus with the accessory navicular.

Hallux limitus is one of the most prevalent, debilitating disorders of the first metatarsophalangeal joint, and it has many proposed etiologies. This article reviews these etiologies, focusing primarily on the pes planus foot. The pes planus foot type is often associated with symptomatic hallux limitus and the accessory navicular. This article discusses this correlation, although a causal relationship has not been proven. The prevalence and classification of the accessory navicular are also discussed. Clinical cases involving symptomatic hallux limitus occurring concomitantly with an accessory navicular are reviewed, including radiographic findings, symptoms, and surgical treatment.

First metatarsophalangeal joint implant as a salvage procedure.

First metatarsophalangeal joint implants are used to correct deformity, to restore or improve motion, and to relieve pain. The authors report on a patient with pain in the first metatarsophalangeal joint that was not relieved by multiple first metatarsophalangeal joint surgical procedures. A two-component first metatarsophalangeal joint titanium implant was successfully used as a salvage procedure to relieve pain and restore foot function following a failed first metatarsophalangeal joint fusion.

The use of osteotomies in the treatment of hallux limitus and hallux rigidus.

Though osteotomies for relief of hallux limitus and rigidus have been around since the earliest surgical corrections, no sound clinical studies have been performed to warrant their use over the standard accepted techniques of cheilectomy and arthrodesis. These operations are surely more technically demanding than such standard procedures, and involve significant increased risk and postoperative immobilization than cheilectomy alone. Sound theories such as metatarsus primus elevatus and excessive metatarsal length contributing to hallux rigidus have never been proven, and no accurate way to diagnose these structural deformities has been proposed. These operations are intriguing and some make clinical sense. It remains to be seen whether the orthopedic community will adopt them based on their merits.