Now that the basics of movement have been established through the three previous posts We Are Just a bunch of moving parts, The Core, and The Hinge, let us move into actual conditions that develop due to the breakdown of normal, developmental movement patterns we learned when we learned how to walk. For those of you who haven’t read them yet, please click on the above links before reading on as the prior articles lay the groundwork for the rest of this article.
What is Arthritis?
Arthritis is a general statement of a joint that doesn’t function as it was supposed to and either develops inflammation, loss of cartilage and/or bone spurs. It does NOT imply pain, as many people often think. It also does not imply that eventually pain will develop! Again, it’s a general statement of a condition, and not about symptoms. Symptoms however, can, and do often develop. When joints aren’t moving as they should AND begin to break down, then there will be ramifications. The result is not only dysfunction to that particular joint, but also ALL of the other joints in the body that depend on the normal function of the particular joint that is breaking down. That is why it’s so crucial to understand the relationship between the foot and the rest of the body when arthritis in the foot is identified.
Why the big toe?
Hallux is the medical name for the great (big) toe. Limitus refers to any limitation in motion. So the term Hallux limitus means limitation of the motion in the great toe joint. This also happens to be a progressive disorder. If there are reasons for joint mobility to be limited, and they are never addressed, then the limitations of motion will only progress (worsen) over time. When the motion becomes almost completely (or completely) limited, it’s referred to as Hallux Rigidus (rigid great toe joint). The main reason why this happens in this particular joint is that the 1st metatarsal phalangeal joint (1st MTPJ, big toe joint) is structurally and functionally designed to be the main stabilizer of the foot. When motion is limited in the ankle joint, the motion through the 1st MTPJ (big toe joint) becomes blocked out and the other, smaller, stabilizers of the foot engage, thereby limiting motion of the ankle even more (see last blog on The Hinge). If forward momentum was able to stop at the exact moment the joint needs to bend but couldn’t, there wouldn’t be any problem at all. However, it is impossible nor expected to stop forward motion due to a joint not doing its job. Therefore, motion occurs against the will of the joint and thus the degenerative process begins.
Mechanics of Hallux Limitus:
As we’ve learned in the prior articles, proper mechanics (proper movement) is dependent on the harmony that exists with the movements our body’s make. It either works flawlessly, or it doesn’t. Most people who are reading this and old enough to follow along should understand this. Due to many years of being forced to sit in chairs as school kids and being forced to wear shoes that constrain our feet, our adult movement has no choice but to be flawed. Therefore, we will not be using all of our joints in the most efficient and effective manner possible. When the foot is fixed against the ground, and our body passes over that grounded foot, our foot is forced to react. Again, our foot and all the joints and muscles are either going to react properly, or not. When you have Hallux Limitus or Rigidus, it means the reaction is improper.
As the foot hits the ground, it usually does so striking the heel first. Due to the improper functioning of our body mechanics (see prior posts), our heels typically land in front of our bodies center line of posture. As we continue to move our body forward, the midfoot and then forefoot (ball of foot just behind the toes) load onto the ground as weight transfers from heel to toe. Once the foot is fully loaded, it’s time for the body to pass over that foot. In normal situations, the ankle is able to bend over a stable foot and forward movement occurs without compensation in the foot. With Hallux Limitus/Rigidus, the ankle does not bend as it should despite the forward movement of the body. Motion is thus forced through whatever joint(s) in the foot that have the ability to move. This is somewhere in the midfoot and can be seen in Figure 1 below as marked by the vertical yellow arrow labelled Functional “Ankle” Joint.
The ankle joint (labelled) is where the motion should have taken place. With the forward motion occurring through the wrong joints, it creates a loss of stability through the (medial) column of the foot as depicted by the broken line through the X ray. In a stable foot, you can draw a line that runs through these bones. At this precise moment in the gait cycle, the body is passing over the foot and ready to move in front of the foot. Due to the midfoot bending instead of the ankle, the 1st metatarsal shifts upward relative to both the hindfoot (behind the “functional ankle joint”) and the great toe which is still fixed against the ground. This is seen also in Figure 1 with the yellow arrow that is pointing upward under the 1st metatarsal head. As the body continues its forward movement, the joint is now out of position to function properly! Yet, forward movement still occurs, and as a result, it is forced through the great toe joint, often resulting in jamming of the great toe joint and forcing the next joint up the chain (the interphalangeal joint of the great toe) to bend instead. The changes that occur over time can be seen by looking at the foot (All examples seen in Figure 2A & 2B):
Hallux limitus only on right foot. Hallux limitus AND bunion on left foot. Note the removal of the left great toenail due to nail problems secondary to limited motion of hallux. Notice redness on top of right foot and top/side of left, classic presentations.
Notice great toe curling upwards towards tip due to lack of motion at great toe joint. Bump seen on top/side of left great toe joint is visible on the left foot (closer image). Bump seen at top of joint on right consistent with hallux limitus.
- A big toe that curls up towards the end (sometimes causing small holes to be worn into the top material on sneakers and shoes).
- Ingrown toenails from increased ground reactive pressure being forced through the end of the toe (the nail is the only structure that can resist this force, and does so by naturally curling over time – often starting in adolescence).
- Enlargement over the great toe joint that often becomes red from shoe pressure.
The common compensations that are extended to the body and not necessarily seen, but felt, are:
- Low Back Pain.
- Tension headaches and/or neck and shoulder stiffness.
- Narrowing of the joint space in the great toe joint (Figure 3).
- It often is uneven (asymmetric) due to loss or thinning of cartilage. Cartilage isn’t seen on X ray and therefore when there isn’t cartilage present, the bones will appear closer together (thus the expression “bone on bone” often used in advanced cases of arthritis – whether hallux limitus or elsewhere in the body).
- Enlargement of bone/spurring on the top of the metatarsal (Figure 4).
- Enlargement of bone/spurring at the top base of the great toe.
- Spurs of bone, broken spurs of bone and loose fragments of bone (Figure 5).
Additionally, these are most commonly asymmetric findings (seen on one side more than another side of your body), and therefore, the problems will be magnified on one side of the body more than the other. The low back pain, even sciatica, will be commonly seen on the same side as the foot problem and the shoulder and neck stiffness will vary. A good test is to look at your feet and see if they look different or are shaped differently. Ever wonder why? Adaptations over time, that’s why!
Lastly, the changes that would be seen on X ray are as follows:
Figure 5: Loose Joint Bodies/Joint Mice
Is it a Bunion?
A lot of patients are sent to me with concern about having a bunion. When people see a bump of bone on the big toe joint, it’s often referred to as a bunion. There is a fairly large list of problems that can lead to a bump on that area of the foot other than bunions (and arthritis):
- Ganglion cysts, gout, synovial cysts, bursitis, infection in some instances
Of course, there is always the possibility of having both arthritis/hallux limitus AND a bunion. That is most common. As a rule of thumb, the great toe moving sideways towards the other toes with the bump sticking out to the side is the classic bunion. If the toe is straight when comparing it to the other toes, and the bump of bone is on the top of the joint, then it’s Arthritis (hallux limitus or rigidus). When the toe is somewhat moving towards the other toes and the bump of bone is not exactly on the side of the foot, and not exactly on the top, but somewhere between the two locations, then it is considered an Arthritic Bunion (Figure 6 and Figure 2A).
Of course, given what you now know about “moving parts,” when that joint isn’t properly aligned and forced to do a job, it will not last as long or will deteriorate. That is the essence of arthritis and that will certainly happen with all bunions at some point in time. The cartilage will only hold up so long before it starts wearing out and it becomes the arthritic condition we have been describing.
Does it Hurt?
Not always!! This was introduced in the first heading in the paper, “What is Arthritis.” This is one of the more difficult concepts to deliver to patients in our symptom-driven society. We are raised in a society that mostly believes if they can’t feel something, or see something, then it isn’t a problem. Likewise, they find it equally hard to understand when they are given the diagnosis of “arthritis,” how it is possible when they haven’t felt pain. The key is that arthritis does NOT equal pain. There are many types of arthritis with many causes and end-results, but very few are always painful. Hallux limitus/rigidus is a type of Osteoarthritis, also considered a “wear and tear” type of arthritis. In other words, it is not systemic like Rheumatoid Arthritis, and therefore is something we’ve done to ourselves rather than what our bodies have done to us. When patients have symptoms related to the arthritis, it’s much easier to understand their own diagnosis of arthritis as it would make sense given the symptoms. When Arthritis is diagnosed without symptoms, it is important to realize that the condition is describing what is happening, not what is being felt.
What to Do?
If there are symptoms being felt, they need to be addressed. It must be determined if the pain is coming from the joint or the bump of bone. It’s also important to recognize areas of compensation, both in the foot and outside the foot. The great toe joint is a key joint for proper movement. If the joint doesn’t bend enough, then what other parts of the foot and body are becoming stressed? How advanced is the degenerative process? Are there spurs or loose/broken fragments of bone and cartilage present? All of this can and should be evaluated in a thorough examination with X rays and gait analysis, though neither are required to make the diagnosis necessarily.
Other factors that are significant and must be addressed relate to lifestyle and day to day activity. Jobs that require bending, kneeling and stooping (electricians, childcare workers, gardeners, for example) lead to over-stressing the great toe joint. If that individual has an arthritic joint, it’s more likely to be symptomatic. Do the shoes fit properly, where are the seams and how are they laced?
When I discuss treatment options with patients, it obviously depends on all of these factors and more. Treating symptoms is very important, and has to be the first step. That means, eliminate everything possible that leads to those symptoms. Whether it’s daily routine or something worn, if it’s causing pain, then it needs to be changed in some way. For some, more rigid shoes are a solution, while in others, minimalist footwear is preferred. Custom orthotic devices are often helpful. These devices, when properly made and implemented, help eliminate painful joint motion by either functionally increasing the available range of motion (by improving the position of the joint as described in the technical description above) or by eliminating the painful motion altogether. Each can allow dramatic improvements in symptoms. Shoes must fit properly, period! If the foot is being squeezed in any way, then the joint will not be allowed to function properly, and therefore, its motion will be limited.
In cases where the arthritis and symptoms are advanced, surgical treatment is often necessary. Options surgically include cleaning up the joint and bone spurring; termed a Cheilectomy procedure (Figure 7).
Figure 7: Cheilectomy (this is a post-operative x-ray from Figure 4)
Osteotomies, which are bone cutting and shifting procedures, are done to re-position the joint and allow the joint to function properly while preserving motion (Figure 8).
Figure 8: Post Op Osteotomy
In advanced cases, what is called Stage 4 or end stage Hallux Rigidus, the joint can be fused together in order to eliminate all motion (Figure 9).
Figure 9: Post Op Fusion
When it gets to this stage, the lack of motion isn’t what creates symptoms. What limited motion that occurs is what creates symptoms. Therefore, eliminating that small amount of painful motion is curative and allows patients to increase activity significantly, though shoe fitting and other tasks that are dependent on toe bending will be limited.
Two other surgical options that are utilized in end stage cases, or in the less active, mostly elderly population, are Joint Implants/Replacement and the Keller Bunionectomy. In the former, a silicone or titanium joint (or part of the joint) is used to replace one half or the whole of the joint. Due to the forces placed through the great toe joint (compression, tension, and sheer), implants often fail in this particular joint. As such, if they ever need to be removed, the end result is something usually very difficult to repair and requires a lengthy recovery process. For this reason, it is not a procedure I perform. The Keller Bunionectomy (Figure 10) is the alternative where rather than just cleaning up the joint, moving the joint or fusing the joint, the goal is to eliminate the joint, such is done with the replacement. The difference being that nothing is placed in its stead. The great toe/hallux will be weakened somewhat, but the arthritis is removed and the pain and deformity typically resolved with a far easier recovery than one of the prior procedures.
Figure 10: Pre and Post-Operative Keller Bunionectomy
There are many other treatments available for this condition, some old and some new. Technology will continue to advance including injections of materials aimed at helping the body regenerate new cartilage, surgical application of synthetic materials to help recreate new cartilage in addition to vitamin supplementation. All of these can play a role and work for some, but none have been shown to be cure-all for the masses. In the end, if the parts aren’t moving right, then the joint will break down, regardless of whatever magic is sprinkled on it.