Reliability Study of Diagnostic Tests for Functional Hallux Limitus.

BACKGROUND: Functional hallux limitus (FHL) refers to dorsiflexion hallux mobility limitation when the first metatarsal head is under loading conditions but not in the unloaded state. The goal of the study was to evaluate 3 common manual tests (Buell, Dananberg, and Jack tests) for assessing first metatarsophalangeal joint (MPJ) mobility and determining the normal values needed to detect FHL, and clarify the signs and symptoms associated with this pathology. METHODS: Forty-four subjects were included in this reliability study. Subjects were divided into healthy control (non-FHL) and FHL groups according to the Buell first MPJ limitation values in addition to signs and symptoms derived from the literature. In both groups, we measured the mobility in the Buell, Dananberg, and Jack tests using a goniometer; their intraclass correlation coefficients (ICCs), sensitivities, and specificity indexes were also calculated. RESULTS: All techniques showed high reliability across measurement trials with ICCs ranging from 0.928 to 0.999. The optimal mobility grades for predicting FHL were 68.6 ± 3.7 degrees, 21 ± 5.9 degrees, and 25.5 ± 6.5 degrees (mean±SD) (P < .05) for the Buell, Dananberg, and Jack tests, respectively. CONCLUSION: Normal and limited mobility values were established for assessing FHL using each technique. The sensitivity and specificity data were perfect for the Dananberg and Jack tests, thus identifying these tests as specific and valid tools for use in FHL diagnosis. Pinch callus was the sign most associated with FHL. LEVEL OF EVIDENCE: Level II, comparative series.

The Role of Plantar Fascia Tightness in Hallux Limitus: A Biomechanical Analysis.

Restriction of greater toe dorsiflexion without degeneration of the first metatarsophalangeal joint is defined as hallux limitus. We assume that in hallux limitus the limitation of greater toe dorsiflexion takes place in the terminal stance phase because of massive tightening of the calf and plantar structures. The current study investigated the role of a tight plantar fascial structure in impairing dorsiflexion of the greater toe. For the purpose of the study, 7 lower limbs from Thiel-fixated human cadavers were evaluated. To simulate double-limb standing stance, the tibia and fibula were mounted on a materials testing machine and constantly loaded with 350N. Additionally, the tendons of the specimens were loaded using a custom-made system. The plantar fascia was fixed to a clamp and tensioned using a threaded bar. Four different tensile forces were then applied to the plantar fascia (approximately 100, 200, 300, and 350 N) and the extension of the first toe was measured. The results show a significant positive correlation between the decrease in extension of the hallux and the tension applied to the plantar fascia reaching a maximum mean decrease of 4.2° (117% compared with the untightened situation) for an applied tension of 364N.

Clinical improvement in functional hallux limitus using a cut-out orthosis.

BACKGROUND: Functional hallux limitus (FHL) has been implicated in the development of metatarsophalangeal joint osteoarthritis. OBJECTIVES: To determine whether cut-out orthosis treatment increases plantarflexion of the first metatarsal by increasing its declination angle. STUDY DESIGN: Cross-sectional study. METHODS: A total of 46 female volunteers with an average age of 25.66 ± 5.70 years (range: 19-42 years) and FHL participated in the study. We assessed the degrees of movement of the first metatarsal and proximal phalanx bones at the first metatarsophalangeal joint without and while wearing the cut-out orthosis using the 3Space Fastrak® via sensors. RESULTS: The movement of the plantarflexión declination angle of the first metatarsal bone was higher using the orthosis 29.84° ± 5.98° versus without orthosis 27.69° ± 5.91° (p < 0.031°). Use of sandals may have minimized the magnitude of movement changes associated with orthosis versus non-orthosis use. CONCLUSION: The cut-out orthosis demonstrated a beneficial effect on non-fixed first metatarsophalangeal and metatarsal cuneiform joints affected by FHL, significantly increasing the declination of the metatarsal angle. Furthermore, use of the cut-out orthosis significantly reduced adduction movement of the first metatarsal bone in the transverse plane. CLINICAL RELEVANCE: The cut-out orthosis demonstrated a beneficial effect on non-fixed first metatarsophalangeal and metatarsal cuneiform joints affected by FHL, significantly increasing the declination of the metatarsal angle. Furthermore, use of the cut-out orthosis significantly reduced adduction movement of the first metatarsal bone in the transverse plane.

Effect by custom-made foot orthoses with added support under the first metatarso-phalangeal joint in hallux limitus patients: Improving on first metatarso-phalangeal joint extension.

BACKGROUND: Hallux limitus is one of the most common disorders affecting foot biomechanics. Custom-made foot orthoses can improve the function of the first metatarso-phalangeal joint. OBJECTIVES: The objective underlying this study was to test whether custom-made foot orthoses increased the range of mobility of metatarso-phalangeal joint in patients with hallux limitus. STUDY DESIGN: Randomized, double-blinded, and clinical trial. METHODS: The study consisted of 20 participants (40 feet) diagnosed with hallux limitus. A control group and an experimental group both wore the same custom-made foot orthoses and, in the experimental group, a support element under the first metatarso-phalangeal joint was added to the orthoses. Two measurements were made with both groups: the relaxed position of the first metatarso-phalangeal joint and the maximum extension of the hallux. These measurements were made before first placing the foot orthoses and 6 months after application of the treatment. RESULTS: In the experimental group, the results showed an improvement of 4.5° in the relaxed position and 22.2° in the maximum extension being statistically significant (p < 0.001) for both measurements. CONCLUSION: Custom-made foot orthoses with added support under the first metatarso-phalangeal joint were proved to be an effective treatment to restore functionality of this joint in hallux limitus patients. CLINICAL RELEVANCE: Limitation of hallux movement in the joints propulsive phase of gait negatively affects the biomechanics of the lower extremity, causing changes in the rest of the joins. The use of foot orthoses designed in this study restores range of motion of the first metatarso-phalangeal joint.

An assessment of hallux limitus in university basketball players compared with noncompetitive individuals.

BACKGROUND: Injuries of the first metatarsophalangeal joint have lately been receiving attention from researchers owing to the important functions of this joint. However, most of the studies of turf toe injuries have focused on sports played on artificial turf. METHODS: This study compared the range of motion of the first metatarsophalangeal joint in collegiate basketball players (n = 123) and noncompetitive individuals (n = 123). RESULTS: A statistically significant difference (P < .001) in range of motion was found between the two groups. The difference between the two sample means was 21.35°. CONCLUSIONS: With hallux rigidus being a potential sequela of repeated turf toe injuries, it seems likely that subacute turf toe injuries occur in basketball players, leading to degenerative changes that result in hallux limitus.

Severity of pronation and classification of first metatarsophalangeal joint dorsiflexion increases the validity of the Hubscher Manoeuvre for the diagnosis of functional hallux limitus.

BACKGROUND: Functional hallux limitus (FHL) is diagnosed with a static test known as the Hubscher Manoeuvre, the validity of which has been previously questioned. OBJECTIVES: To investigate the validity of this Manoeuvre and whether introducing severity of pronation as a second concurrent test would increase this validity. METHOD: 30 participants with a hallux dorsiflexion <12° were divided into 2 equal groups, depending on their severity of pronation according to the Foot Posture Index. A single video camera, placed perpendicular to the plane of motion of the 1st MPJ, captured its movement, from which the angle of maximum dorsiflexion of this joint was measured. RESULTS: 10 males and 20 females, aged 18-56 years (mean 28 yrs, SD ± 12.1 yrs) participated. There was no significant relationship between non-weight bearing and dynamic maximum dorsiflexion (p=0.160), and between weight bearing and dynamic maximum dorsiflexion (p=0.865). A significant relationship between 1st MPJ dynamic maximum dorsiflexion and severity of pronation (p=0.004) was found. CONCLUSIONS: None of the participants exhibited a complete lack of hallux dorsiflexion. A positive Hubscher Manoeuvre test, on its own, is not a good indicator of limited 1st MPJ dorsiflexion during dynamic motion. However, as pronation increases, 1st MPJ maximum dorsiflexion during gait decreases.

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.

Hallux interphalangeal joint range of motion in feet with and without limited first metatarsophalangeal joint dorsiflexion.

BACKGROUND: This work was designed to assess the degree of correlation between hallux interphalangeal joint and first metatarsophalangeal joint dorsiflexion and to compare the mobility of the hallux interphalangeal joint between participants with and without limited first metatarsophalangeal joint dorsiflexion (hallux limitus). METHODS: Dorsiflexion of the hallux interphalangeal joint was measured in 60 normal feet and in 60 feet with hallux limitus to find correlations with first metatarsophalangeal joint dorsiflexion with the Spearman correlation coefficient and a simple linear regression equation. In addition, movement of the hallux interphalangeal joint was compared between normal and hallux limitus feet with the Mann-Whitney U test. RESULTS: Significant differences were found between the groups in mean ± SD interphalangeal joint dorsiflexion (control group: 1.17° ± 2.50° ; hallux limitus group: 10.65° ± 8.24° ; P < .001). A significant inverse correlation was found between first metatarsophalangeal joint dorsiflexion and hallux interphalangeal joint dorsiflexion (ρ = -0.766, P < .001), and the regression equation from which predictions could be made is the following: hallux interphalangeal joint dorsiflexion = 27.17 - 0.381 × first metatarsophalangeal joint dorsiflexion. CONCLUSIONS: Hallux interphalangeal joint dorsiflexion was greater in feet with hallux limitus than in normal feet. There was a strong inverse correlation between first metatarsophalangeal joint dorsiflexion and hallux interphalangeal joint dorsiflexion.

Hallux limitus and its relationship with the internal rotational pattern of the lower limb.

BACKGROUND: The aims of this study were to determine whether individuals with mild hallux limitus show a diminished capacity of internal rotation of the lower limb compared with those without hallux limitus and whether individuals with mild hallux limitus show an increased foot progression angle. METHODS: In 80 study participants (35 with normal feet and 45 with mild hallux limitus), the capacity of internal rotation of the lower limb (internal rotational pattern), hallux dorsiflexion, and the foot progression angle were measured. The values for internal rotational pattern and foot progression angle were compared between the two study groups, and the correlations between these variables were studied. RESULTS: The capacity of internal rotation of the lower limb was significantly lesser in patients with mild hallux limitus (P < .0001). There was no significant difference in foot progression angle between the two groups (P = .115). The Spearman correlation coefficient was 0.638 (P < .0001) for the relationship between internal rotational pattern and hallux dorsiflexion. CONCLUSIONS: Patients with mild hallux limitus had a lesser capacity of internal rotation of the lower extremity than did individuals in the control group. The more limited the internal rotational pattern of the lower limb, the more limited was hallux dorsiflexion. The foot progression angle was similar in both groups.

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.

Evaluation and biomechanics of the first ray in the patient with limited motion.

Adequate first ray function is essential to healthy human gait. Controversies still exist about aspects of human structure and function and many newer answers and theories have been proposed by a new generation of experts. Examples include the sagittal plane facilitation, tissue stress, and preferred movement pathway theories. This article also presents a summary of how to provide a thorough, detailed, and accurate first ray examination on the individual with limited motion. This article explores functional first ray mechanics in both a theoretic and biomechanical perspective, as well as a practical, hands-on examination perspective.

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.

Structural factors associated with hallux limitus/rigidus: a systematic review of case control studies.

STUDY DESIGN: Systematic review of case control studies. OBJECTIVES: To identify and analyze demographic and structural factors associated with hallux limitus/rigidus. METHODS: A literature search was conducted across several electronic databases (Medline, EMBASE, CINAHL, and PubMed) using the following terms: hallux limitus, hallux rigidus, metatarsophalangeal joint, and big toe. Methodological quality of included studies was evaluated using the Quality Index. To evaluate the magnitude of differences between cases and controls, odds ratios were calculated for dichotomous variables and effect sizes (Cohen d) were calculated for continuous variables. RESULTS: The methodological quality of the 7 included studies was moderate, with Quality Index scores ranging from 6 to 11 out of a possible score of 14. The overall mean age for the case group was 44.8 years (mean range, 23.4-54.9 years) and for the control group was 39.6 years (mean range, 23.4-58.8 years). There was a similar distribution of males and females across case and control groups. All studies used plain film radiography to assess foot structure. Cases were found to have a dorsiflexed first metatarsal relative to the second metatarsal, a plantar flexed forefoot on the rearfoot, reduced first metatarsophalangeal joint range of motion, a longer proximal phalanx, distal phalanx, medial sesamoid, and lateral sesamoid, and a wider first metatarsal and proximal phalanx. Measures of foot posture and arch height were not found to substantially differ between cases and controls. CONCLUSIONS: This review of case control studies indicates that several variables pertaining to the structure of the first metatarsophalangeal joint may be associated with hallux limitus/rigidus. These findings have implications for the conservative and surgical treatment of the condition.

Dynamic splinting for runner's toe: a case report with gait analysis.

We present a case report of runner's hallux limitus and the effect of dynamic splinting in reducing contracture as measured by gait analysis. After 4 months of treatment with dynamic splinting, the patient regained 45 degrees in active range of motion, and the gait analysis showed significant and beneficial changes.

Functional hallux limitus: a review.

Functional hallux limitus is defined as a functional inability of the proximal phalanx of the hallux to extend on the first metatarsal head during gait. The theory concerning this anomaly and the altered gait characteristics that may result appears to have influenced the understanding of sagittal plane podiatric biomechanics. Although there is an increase in the body of evidence to support the proposed gait alterations, a detailed review suggests the need for further work. The aim of this article is to review the functional hallux limitus literature and its reported effects on gait. Furthermore, we explore some of the key and inherent problems with obtaining accurate data for joint motion measurement in the foot. With evidence-based practice now at the forefront of both clinical and academic practice, it is imperative to review the literature that underpins a particular commonly held or historical belief, in order to substantiate and validate subsequent diagnoses and treatments provided in light of this information. This is also true to advance the understanding of a particular anomaly or pathology and to inform so as to facilitate the provision of better care to patients.

Analysis of dynamic angle of gait and radiographic features in subjects with hallux abducto valgus and hallux limitus.

BACKGROUND: Hallux abducto valgus and hallux limitus are two commonly encountered foot deformities causing altered structure and function of the first metatarsophalangeal joint and subsequent compensatory mechanisms. This study was undertaken to determine the relationships between these two deformities and transverse plane position of the foot, or angle of gait, and several radiographic angular and linear parameters with established reliability. METHODS: A convenience sample of 23 subjects with hallux abducto valgus, 22 subjects with hallux limitus, and 20 control subjects was used. Radiographic parameters were standardized weightbearing views and included lateral stressed dorsiflexion of the first metatarsophalangeal joint, composite, dorsoplantar, and lateral views. Angle of gait was obtained from powdered footprints recorded on paper. Two left and two right footprints identified on each trial were used to calculate angle of gait. RESULTS: The findings of the study suggest that an association between angle of gait and the presence of hallux abducto valgus or hallux limitus does not exist. Possible explanations may relate to the large variability of normal angle of gait, the need to identify factors extrinsic to the foot capable of affecting transverse plane orientation of the foot, and the addition of information relating to symptoms. CONCLUSIONS: In this study, the presence of hallux abducto valgus or hallux limitus did not correspond to an association with a particular angle of gait. Length and elevation of the first metatarsal were associated in subjects with hallux abducto valgus and hallux limitus.

Effects of hallux limitus on plantar foot pressure and foot kinematics during walking.

The effects of hallux limitus on plantar foot pressure and foot kinematics have received limited attention in the literature. Therefore, a study was conducted to assess the effects of limited first metatarsophalangeal joint mobility on plantar foot pressure. It was equally important to identify detection criteria based on plantar pressures and metatarsophalangeal joint kinematics, enabling differentiation between subjects affected by hallux limitus and people with normal hallux function. To further our understanding of the relation between midtarsal collapse and hallux limitus, kinematic variables relating to midtarsal pronation were also included in the study. Two populations of 19 subjects each, one with hallux limitus and the other free of functional abnormalities, were asked to walk at their preferred speed while plantar foot pressures were recorded along with three-dimensional foot kinematics. The presence of hallux limitus, structural or functional, caused peak plantar pressure under the hallux to build up significantly more and at a faster rate than under the first metatarsal head. Additional discriminators for hallux limitus were peak dorsiflexion of the first metatarsophalangeal joint, time to this peak value, peak pressure ratios of the first metatarsal head and the more lateral metatarsal heads, and time to maximal pressure under the fourth and fifth metatarsal heads. Finally, in approximately 20% of the subjects, with and without hallux limitus, midtarsal pronation occurred after heel lift, validating the claim that retrograde midtarsal pronation does occur.

Functional hallux limitus and lesser-metatarsal overload.

The implications of functional hallux limitus for lesser-metatarsal overload are discussed. A new method of treating functional hallux limitus is proposed, and three case histories are reviewed showing adequate resolution of symptoms using the proposed method of treatment. A proposed mechanism for the development of functional hallux limitus is discussed, and different methods of identification are illustrated.

The relationship between hallux dorsiflexion and ankle joint complex frontal plane kinematics: a preliminary study.

BACKGROUND: It has been suggested that the function of the first metatarsophalangeal joint may be related to the motion of the ankle joint complex. OBJECTIVE: This study explored the relationship between ankle joint complex and first metatarsophalangeal joint motion during gait in a group of 14 who demonstrated clinically limited passive hallux dorsiflexion in quiet standing (cases), and 15 matched controls. METHOD: An electromagnetic tracking system was used to measure the ankle joint complex frontal plane motion and first metatarsophalangeal joint sagittal plane motion during gait, in both cases and controls. The case group was then evaluated further to investigate the effect of an orthosis on first metatarsophalangeal joint motion. FINDINGS: The correlation between maximum ankle joint complex eversion and maximum first metatarsophalangeal joint dorsiflexion during gait was r=0.471. Within the case group, maximum rearfoot eversion was reduced following the application of the orthoses, but there was no change in sagittal first metatarsophalangeal joint rotations. INTERPRETATION: The relationship between maximum ankle joint complex eversion and first metatarsophalangeal joint dorsiflexion kinematics found in this study was moderate, and decreasing maximum ankle joint complex eversion with an orthosis did not result in any increase in first metatarsophalangeal joint dorsiflexion during gait in patients with functional first metatarsophalangeal joint limitation. These results do not support the assumption that ankle joint complex eversion influences first metatarsophalangeal joint motion substantially.