May 2018

PERSPECTIVE: Podiatry

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By Jay Segel, DPM

Dr. Segel is in private podiatry practice in Martha’s Vineyard, Massachusetts, and Director of Applied Podiatric Biomechanics at Noraxon USA. He is also a podiatric advisor and member of the medical education staff at Orthotic Holdings Inc.

LER: Dr Segel, what is the most common problem you see in patients who were previously active but who have had to curtail activity.

JS: The most common foot issues I see clinically are hallux limitus, and the more advanced stage of this disorder, hallux rigidus. This progressive biomechanical deformity of the forefoot is characterized by a decreased range of motion at the first metatarsophalangeal joint, often accompanied by flattening of the metatarsal head and arthritic, osteophytic lipping about the narrowed joint space, which is seen best on radiography.

I describe the first metatarsophalangeal joint as the quality-of-life joint, because although a compromised joint won’t kill you, it leads to a downward spiral of limited activity that translates to fewer walks on the beach–or anywhere else for that matter.

LER: What are the risk factors for developing hallux rigidus?

JS: Although a metabolic disease such as gout can be the primary cause of hallux limitus/rigidus, it is most often associated with joint wear and tear from repetitive microtrauma, and from macrotraumatic events, such as direct impact, crushing injury, or status post local surgical intervention. Poorly fitting shoes that provide inadequate length, width, and depth are prime contributors, as are overuse and rigid foot. Clinically, I find it is the walking biomechanics that drives this condition to worsen.

Sports that put extra stress on the first metatarsophalangeal joint, such as football, basketball, and soccer, and sports that require squatting, such as the catcher’s position in baseball, also can set the stage for injury.

LER:  What does the patient experience with this condition?

JS: Hallux rigidus is typically not even on the patient’s radar or treated until early symptoms turn into debilitating pain and frank observable bone deformation, yet it is easily discoverable on physical exam. Patients will often present with localized stiffness and sharp pain on ambulation, reproducible on dorsiflexion. A foot lacking available motion to perform propulsion results in gait alteration, both spatial and temporal. This can be seen clearly on computer-aided gait analysis, which will demonstrate early toe-off, shortened step length, excessive pronation, and foot abduction to avoid extension of that compromised joint.

LER:  What is your approach to confirming the diagnosis?

JS: The diagnosis is typically obvious on visualization and palpation. The optimal range of motion for fluid movement is 45° of dorsiflexion according to Physiopedia though there is debate on normative values. Clinically, I see gait affected with less than 30° of upward motion. The Coughlin and Shurnas grading system suggests that the dividing line between hallux limitus and rigidus is greater or less than 10° of dorsiflexion, respectively.  Hallux rigidus also shows a marked decrease in plantar flexion as well.

LER: What is your approach to treatment?

JS: In my practice I am able to visualize the compromised joint in motion via diagnostic ultrasound, and using this modality, I distract the joint with pressure just a bit beyond resistance, then dorsiflex the first metatarsophalangeal joint to ascertain whether the joint is likely to respond to rehabilitation. The science behind the program is taken from the principal that 2 bones in space have no reason to interact but for the integument that contains them and the several forms of connective tissue that make those 2 bones a workable unit. We know that soft tissue has elasticity, and we can use the natural makeup of tendons and ligaments to expand and loosen, increasing range of motion and functionality while relieving pain and problematic gait accommodation. It is fair to note that the prognosis, with treatment, is better for hallux limitus than hallux rigidus, as early diagnosis and treatment usually yield better results.

Over the past 35 years, I have had great success applying a conservative protocol for treatment of arthritic hallux disorders:

  • counseling the patient to use footwear of ample length, width, toe box depth, and minimal heel raise
  • use of orthoses, based on physical examination and computer-aided gait analysis data
  • use of topical analgesic as needed
  • weekly physical therapy, including ultrasound therapy, manual therapy, joint mobilization, distraction, and light percussion
  • home exercise, including toe extensions, towel pick-ups, and painting the alphabet in water with each foot.

Surgical intervention should be considered if no meaningful improvement is realized after 9 months to 1 year of conservative therapy.  Surgical procedures often include cheilectomy, implants and fusion. Cheilectomy appears to be the first choice surgical procedure and in the early stages of disease has an approximately 87% initial success rate, with about a 9% revision rate, perhaps leading to joint fusion as a salvage procedure when cheilectomy fails. These success rates decrease and revision rates increase with stage four conditions and over time. The success rates with this conservative therapy program are better than 93% and outweigh, in my opinion, the risks of surgery, pre- and postoperative testing and rehabilitation, and joint and tissue assault after iatrogenic trauma. What is really rewarding is that patients exhibit increased functionality from the very first treatment, with results lasting longer as treatment series progresses. I find I get great compliance and patient response.

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