Hallux Limitus

What is hallux limitus?

A big toe (called a hallux) should have 70° -90° of "up" motion (called dorsiflexion) and 20° -25° of down motion (plantarflexion.) It should move freely without any restrictions, clicks, catches or feeling like there is grinding. Foot biomechanics requires that the metatarsal move down in order for the big to move up. In essence the toe ends up on top of the first metatarsal when you raise your big toe.

A joint that has less "up motion" that needed is said to have hallux limitus (pronounced "limit-us"). With hallux limitus patients experience pain when running, walking uphill and eventually just walking. The bone in the big toe is jammed against the metatarsal head, which causes inflammation and pain. Often there is a build up of bone spurs around the head of the metatarsal that you can feel with your finger and rubs in your shoe. This spur (called a flag sign in podiatry-speak) can be seen on an x-ray. If an x-ray is taken with the heel off the ground and the ball of the foot on the ground, the base of the toe bone can be seen to impact the first metatarsal instead of sliding over it. Hallux limitus makes patients shift the weight to the side of the foot and it is not uncommon to see calluses under the lesser metatarsals, especially under the second metatarsal (behind the second toe.)

If the hallux limitus is caused by a build up of bony spurs around the big toe joint, a great improvement can sometimes be made by just cleaning up the joint and removing the spurs. This procedure goes by several names including "simple", "Silver" or "McBride" type bunionectomies depending on the procedures involved. Healing is very rapid after this out-patient procedure. Regular shoes can be worn in 2 weeks and regular activities can start in the third or fourth week after surgery.

Moderate hallux limitus needs any one of several modifications to regular bunion surgeries (see the bunion monograph for a description of these -->  ). My favorite procedure is known as the "Youngswick" modification after Dr. Fred Youngswick of the California College of Podiatric Medicine (my school, rah, rah, rah). Clever man that he is, he suggested taking an extra wedge out of the top of the "V" or chevron bone cut in the first metatarsal head. This will allow the first metatarsal head to move down and back thereby allowing the big toe to move up and over the head and allow easier walking and running. This is a very successful procedure and is commonly done by many podiatric surgeons. Interestingly, it is nearly unknown in the orthopedic community. If you need a Youngswick surgery I will probably suggest doing it at Los Robles Hospital. The power equipment manufacturer has made special double Youngswick blades that help in the performance of this procedure (Thanks Striker!). The Surgery Center does not have these particular blades for this equipment. This procedure required you to be off of your feet for three days and to wear a special post-operative shoe for a month followed by three weeks in an athletic shoe.

Said Jane B. about her Youngswick performed 6 years earlier: "Dr. Zapf provided an alternative to fusing the joint in my large toe which would have left me with a lifetime limp. His method of reconstruction has given me my life back - hiking in the creek bed in Topanga Canyon and gardening on our hilly property is no problem. Thanks Dr. Z"

Jane, you are very welcome. Thank you for your kind comments.

More severe hallux limitus is accompanied by near complete degeneration of the joint with pain with any motion. This might require either of three procedures: a Keller bunionectomy, a Keller bunionectomy with an implant or a joint fusion.

A Keller bunionectomy, named after the civil war surgeon that invented the procedure, involves the removal of the base of the toe bone next to the metatarsal head. In this picture from Mann's textbook the shaded gray areas are the parts that are removed at surgery. There is a portion on the outside of the first metatarsal head and another on the base of the proximal phalanx. It is a joint destructive procedure and designed for those people who want freedom of movement of the joint. The big toe is shorter after the procedure and the joint does not have the same power it had prior to the procedure. Recovery is very quick since only soft tissues need to heal. You can be back in tennis shoes in just two weeks. Unfortunately, transfer of weight to the second metatarsal bone with resultant pain and callus is common. After a Keller people are not nearly as "propulsive" as they were before. Keller bunionectomies are not the procedure of choice for younger active people.

Those who do not want their big toe to shorten after a Keller bunionectomy might elect to have an implant put into the joint. Traditional implants are double stemmed plastic implants with a hinge in the middle. More sophisticated implants are the modular or two-piece. The developers of modular implants claim that they are capable of bearing more weight and allowing more activities than double-stemmed implants. There is some question about the validity of this claim. Nevertheless, if a person under the age of 70 needs an implant, the doctor should look very seriously at the modular variety. The photo here is of a double stem plastic implant. If you look carefully at the spot where the stem meets the body of the implant you will see a dark gray area, These are metal grommets. Research shows that if you use a double stem-implant the grommets seem to help the implant last longer. Double stem plastic implants are nothing more than "spacers" in the joint and no more functional than a Keller bunionectomy. They are designed for people old enough to be non-propulsive (that is their get-up-and-go has up and gone). People who are still active should probably get either a modular implant, as described above, or a "Hemi" as described below.

An alternative to the modular is a metal "hemi" implant that is put in just one side of the joint, usually the toe bone side. These implants have a long track record of helping relieve the pain of hallux limitus and I have found them to work very well. Pictured in this monograph is the one designed by Dr. Lawrence of San Diego. I am very fond of this implant. If you have severe hallux limitus with joint erosions but still have some cartilage left, I will probably suggest this implant. If for some reason that this implant doesn't work out it is easily converted to a total (again, of Dr. Lawrence's design) or even a joint fusion.

An alternative to implants in patients with severe hallux limitus is a surgical fusion of the big toe bone to the first metatarsal. This results in a stiff joint but one quite capable of bearing significant weight. The fusion is done at an angle to allow patients to wear their favorite shoe heel height. For men this would be a ¼ - ½ inches and women 1-1½ inches. In general orthopedic surgeons are fond of fusions and podiatric surgeons are more likely to use an implant. An argument against fusions is that if the motion of the big toe joint is taken away it will have to be taken up by other joints  The net result is the other joints have to work extra hard and may well wear out prematurely.

What is "drilling" of the cartilage?

All of the joints of our body are covered by an articular cartilage that is many times more slippery than ice. It allows our bones to glide over each other. At surgery this cartilage appears a white as snow. If the cartilage is damaged it becomes thin and yellow. Eventually it can flake off leaving raw bone exposed. Joint motion with exposed cartilage is both damaging and painful. If your foot surgeon notices that there are areas where this cartilage is missing, he or she may try to stimulate new cartilage formation. Drilling tiny holes into the exposed bone does the stimulation. Around every small hole your body will grow a little circle of fibrocartilage. Fibrocartilage is not as good as articular cartilage but it is much better than raw exposed bone

A QUESTION FROM AN ALERT READER:

I have 2 x-rays of my big toes, both feet.  The right has no cartilage
at all and in a clinical sense is very painful, limits my walking and
has worsened in the last half year.  The left toe also has the beginning
of this condition and includes a cyst on the bone.

I understand that surgery is a necessary option at this point.  The
Kaiser podiatrist I saw recommends arthrodesis.  The podiatrist I saw in
New York recommends a Keller bunionectomy because it is less invasive
and he feels strongly against the fusion of the joint, partly from
experience and length of recovery time.

My situation is somewhat unusual.  Though I keep a residence in Los
Angeles, I am living and working abroad, returning to L.A.
for the summer.  I would like to do something about
this condition this summer.  Several things are involved.  First, I need
to walk on my return.  I have no car, here and much walking is
necessary for daily life including up and down stairs.  Second, although
I am 62, I also exercise 4-5 times a week, swimming, stationary bike,
weights, etc. and want to be able to continue this activity.

In light of this information, I would appreciate your opinion on both
operations for hallux rigidus.  Also, please explain the healing time
necessary and ambulation prognosis with each, and if possible explain
what transpires in each surgery.  Also, please indicate if you feel there
are other possible options

                            Nancy W.     

Dear Nancy:

I cannot possibly hope to answer your question without examining your feet personally. From your experience with foot surgeons and what I have written you can see the truth that you will get as many opinions as you see doctors. As a rule of toe, go with the doctor you feel comfortable with as long as he or she has the appropriate credentials and experience.

That being said, I am very concerned about your care. Since you do not know the healing times, ambulation prognosis and other possible options I can only assume that you did not have a very thorough and comprehensive visit with your prior doctors. The questions you have are the most basic any surgeon should have answered.  I, like most good podiatrists,  pride myself on my patients agreeing to surgery only after they know all the ramifications.

From the foregoing you can see that I am biased against fusion in a younger person and equally biased against a Keller bunionectomy. Sight unseen I would probably recommend metal "Hemi" implant. The recovery is rather rapid and you should be able to recover and rehabilitate enough to do the things you want to do in 6 to 8 weeks.

I hope this helps.

Dr. Michael Zapf