Hallux rigidus

Hallux rigidus

erload Hallux rigidus is a painful condition of the hallux MTP joint characterised by loss of motion, especially in dorsiflexion, and osteophyte formation on the dorsum and sides of the joint ( Figure 41.4 ). Hallux valgus /uni25CF /uni25CF /uni25CF /uni25CF In adults there is often a history of trauma or repetitive microtrauma (sport) but, occasionally , there is a strong family history of the condition. Gout and rheumatological conditions may present in this way . Patients complain of sti ff ness and pain on weight-bearing. The most e ff ective non-operative treatment is provision of a sti ff -soled shoe with a deep toe box or a rocker-soled shoe, which are now available on the high street. The mainstays of surgical management ar e injection/ manipulation, cheilectomy (a radical debridement and exci sion of the part of the joint blocking movement), fusion and interposition arthroplasty (Keller-type procedure or silicone inter position). Prosthetic arthroplasty , with hemi-, total, inter position or spacer arthroplasty , is available but many pr ostheses have been withdrawn because of high failure rates and few series extend bey ond 9 years. Newer prosthetic inserts with claimed joint-preserving capabilities similarly fail to show advantages with regards to pain and have a high revision/reoperation rate but are still preferred by some who wish to retain mobility at MTP1 in the short to medium term. Fusion is for the severely a ff ected and is an e ff ective means of abolishing pain, but a ff ects the biomechanics and some patients are left with intractable pain beneath the sesamoids. A fusion will still usually allow sports participation. Summary box 41.4 Hallux rigidus /uni25CF /uni25CF /uni25CF Sesamoid/sesamoid complex problems Turf toe Acute injuries (turf toe) can be managed non-operatively or surgically depending on the grade of the injury and the occupation of the patient. Grade 4 acute rupture may require surgery . Turf toe is a plantar plate disruption usually from hyper extension injuries at MTP1 and may involve sesamoid fractures. Low-grade injuries can be treated non-operatively Albert Henry Freiberg , Professor of Orthopaedic Surgery , University of Cincinnati, Cincinnati, OH, USA, gave his account of this condition in 1926. Thomas George Morton , 1835–1903, surgeon, Pennsylvania Hospital, Philadelphia, PA, USA, described this condition in 1876. athletes (see Chapter 36 ). Chronic conditions range from stress fracture to avascular necrosis (A VN) and sesamoiditis but are probably all the same phenomenon. Management includes o ffl oading with orthotics, injections of ster oids and, rarely , shaving/excision. Excision surgery car ries a high risk. Lesser toe deformities Hammer, mallet and claw toes are frequent and are usually nonindicative but may be secondary to other deformities in the foot or to underlying neurological disease. Nonoperative treat - ment involves appropriate padding and footwear modification. For symptomatic flexible deformities soft-tissue surgery such as flexor/extensor tenotomies with/without capsulotomy is usually adequate, but for fix ed deformities bony procedures are required such as interposition arthroplasty , fusion or excision arthroplasty . Isolated lesser toe MTP extension/subluxation may result from a ruptured plantar plate at MTP joints and repair tech - niques have evolved recently , but the results ar e moderate at - best and the trend is back to non-operative management where possible. Ultrasound and magnetic resonance imaging (MRI) are now well estab lished for these injuries. - Freiberg’s disease Freiberg’s disease ( Figure 41.5 ) is an ischaemic necrosis of the epiphysis, resulting in pain and swelling of the joint. It will often settle with rest. Reshaping osteotomies are described, or excision of the proximal phalangeal head for severe adult cases with joint destruction. Excision of the whole metatarsal head should never be performed. Morton’s neuroma and metatarsalgia Metatarsalgia usually occurs secondary to joint problems, overload or irritation of a nerve. Morton’s neuroma is a painful -

Bunions affect women more often than men Patients with hallux valgus have inherited a tendency to develop the condition Not all patients need surgery The choice of operation is determined by the severity of the deformity and presence or absence of any arthritis, instability of the joints or hypermobility Hallux rigidus can affect adolescents as well as adults Stiff-soled shoes with a deep toe box are the most comfortable type of shoe Cheilectomy and fusion are the mainstays of surgical treatment Figure 41.5 Freiberg’s disease.

common digital nerve, most commonly between the third and fourth metatarsal heads and the second/third and is usually secondary to other forefoot pathology . The diagnosis is confirmed by ultrasound or MRI. Non operative treatments include advice about footwear, an orthosis (premetatarsal dome) to splay the metatarsal heads or an injection of steroids. Cryotherapy and even alcohol injections have been r eported. Surgery involves resection (the a ff ected toes will be perma nently partly hemi-numb if the nerve is removed) but this is not without risk of patient dissatisfaction, pain and recurrence, with around 5% reporting bad outcomes, often permanent. European colleagues often simply transect the intermetatarsal lig ament instead. Summary box 41.5 Morton’s neuroma /uni25CF /uni25CF /uni25CF Stress fracture This may occur following sport or may be incipient. It usually presents in the forefoot and may mimic Morton’s neuroma or metatarsalgia. An unexplained aetiology might require biochemical or biomechanical evaluation. Forefoot fractures can usually be managed non-operatively . Stress fractures may occur in any bone. Those of the navic ular, talus and tibial sesamoid often present with vague symp tomatology but early diagnosis with MRI and management are essential with immediate o ffl oading and protection with early fixation – if required, urgently – if a full fracture is seen developing. Vague, poor ly defined midfoot pain in an athlete or military recruit mandates urgent scanning and o ffl oading. Follow-up investigation of bone metabolism/density and exclusion of myeloma may be required.

Morton’s neuroma most commonly affects the second or third web space Surgical excision of neuroma is often successful but has a risk of pain syndrome Guided injections form the mainstay of treatment for most

Hallux rigidus

erload Hallux rigidus is a painful condition of the hallux MTP joint characterised by loss of motion, especially in dorsiflexion, and osteophyte formation on the dorsum and sides of the joint ( Figure 41.4 ). Hallux valgus /uni25CF /uni25CF /uni25CF /uni25CF In adults there is often a history of trauma or repetitive microtrauma (sport) but, occasionally , there is a strong family history of the condition. Gout and rheumatological conditions may present in this way . Patients complain of sti ff ness and pain on weight-bearing. The most e ff ective non-operative treatment is provision of a sti ff -soled shoe with a deep toe box or a rocker-soled shoe, which are now available on the high street. The mainstays of surgical management ar e injection/ manipulation, cheilectomy (a radical debridement and exci sion of the part of the joint blocking movement), fusion and interposition arthroplasty (Keller-type procedure or silicone inter position). Prosthetic arthroplasty , with hemi-, total, inter position or spacer arthroplasty , is available but many pr ostheses have been withdrawn because of high failure rates and few series extend bey ond 9 years. Newer prosthetic inserts with claimed joint-preserving capabilities similarly fail to show advantages with regards to pain and have a high revision/reoperation rate but are still preferred by some who wish to retain mobility at MTP1 in the short to medium term. Fusion is for the severely a ff ected and is an e ff ective means of abolishing pain, but a ff ects the biomechanics and some patients are left with intractable pain beneath the sesamoids. A fusion will still usually allow sports participation. Summary box 41.4 Hallux rigidus /uni25CF /uni25CF /uni25CF Sesamoid/sesamoid complex problems Turf toe Acute injuries (turf toe) can be managed non-operatively or surgically depending on the grade of the injury and the occupation of the patient. Grade 4 acute rupture may require surgery . Turf toe is a plantar plate disruption usually from hyper extension injuries at MTP1 and may involve sesamoid fractures. Low-grade injuries can be treated non-operatively Albert Henry Freiberg , Professor of Orthopaedic Surgery , University of Cincinnati, Cincinnati, OH, USA, gave his account of this condition in 1926. Thomas George Morton , 1835–1903, surgeon, Pennsylvania Hospital, Philadelphia, PA, USA, described this condition in 1876. athletes (see Chapter 36 ). Chronic conditions range from stress fracture to avascular necrosis (A VN) and sesamoiditis but are probably all the same phenomenon. Management includes o ffl oading with orthotics, injections of ster oids and, rarely , shaving/excision. Excision surgery car ries a high risk. Lesser toe deformities Hammer, mallet and claw toes are frequent and are usually nonindicative but may be secondary to other deformities in the foot or to underlying neurological disease. Nonoperative treat - ment involves appropriate padding and footwear modification. For symptomatic flexible deformities soft-tissue surgery such as flexor/extensor tenotomies with/without capsulotomy is usually adequate, but for fix ed deformities bony procedures are required such as interposition arthroplasty , fusion or excision arthroplasty . Isolated lesser toe MTP extension/subluxation may result from a ruptured plantar plate at MTP joints and repair tech - niques have evolved recently , but the results ar e moderate at - best and the trend is back to non-operative management where possible. Ultrasound and magnetic resonance imaging (MRI) are now well estab lished for these injuries. - Freiberg’s disease Freiberg’s disease ( Figure 41.5 ) is an ischaemic necrosis of the epiphysis, resulting in pain and swelling of the joint. It will often settle with rest. Reshaping osteotomies are described, or excision of the proximal phalangeal head for severe adult cases with joint destruction. Excision of the whole metatarsal head should never be performed. Morton’s neuroma and metatarsalgia Metatarsalgia usually occurs secondary to joint problems, overload or irritation of a nerve. Morton’s neuroma is a painful -

Bunions affect women more often than men Patients with hallux valgus have inherited a tendency to develop the condition Not all patients need surgery The choice of operation is determined by the severity of the deformity and presence or absence of any arthritis, instability of the joints or hypermobility Hallux rigidus can affect adolescents as well as adults Stiff-soled shoes with a deep toe box are the most comfortable type of shoe Cheilectomy and fusion are the mainstays of surgical treatment Figure 41.5 Freiberg’s disease.

common digital nerve, most commonly between the third and fourth metatarsal heads and the second/third and is usually secondary to other forefoot pathology . The diagnosis is confirmed by ultrasound or MRI. Non operative treatments include advice about footwear, an orthosis (premetatarsal dome) to splay the metatarsal heads or an injection of steroids. Cryotherapy and even alcohol injections have been r eported. Surgery involves resection (the a ff ected toes will be perma nently partly hemi-numb if the nerve is removed) but this is not without risk of patient dissatisfaction, pain and recurrence, with around 5% reporting bad outcomes, often permanent. European colleagues often simply transect the intermetatarsal lig ament instead. Summary box 41.5 Morton’s neuroma /uni25CF /uni25CF /uni25CF Stress fracture This may occur following sport or may be incipient. It usually presents in the forefoot and may mimic Morton’s neuroma or metatarsalgia. An unexplained aetiology might require biochemical or biomechanical evaluation. Forefoot fractures can usually be managed non-operatively . Stress fractures may occur in any bone. Those of the navic ular, talus and tibial sesamoid often present with vague symp tomatology but early diagnosis with MRI and management are essential with immediate o ffl oading and protection with early fixation – if required, urgently – if a full fracture is seen developing. Vague, poor ly defined midfoot pain in an athlete or military recruit mandates urgent scanning and o ffl oading. Follow-up investigation of bone metabolism/density and exclusion of myeloma may be required.

Morton’s neuroma most commonly affects the second or third web space Surgical excision of neuroma is often successful but has a risk of pain syndrome Guided injections form the mainstay of treatment for most

Hallux rigidus

erload Hallux rigidus is a painful condition of the hallux MTP joint characterised by loss of motion, especially in dorsiflexion, and osteophyte formation on the dorsum and sides of the joint ( Figure 41.4 ). Hallux valgus /uni25CF /uni25CF /uni25CF /uni25CF In adults there is often a history of trauma or repetitive microtrauma (sport) but, occasionally , there is a strong family history of the condition. Gout and rheumatological conditions may present in this way . Patients complain of sti ff ness and pain on weight-bearing. The most e ff ective non-operative treatment is provision of a sti ff -soled shoe with a deep toe box or a rocker-soled shoe, which are now available on the high street. The mainstays of surgical management ar e injection/ manipulation, cheilectomy (a radical debridement and exci sion of the part of the joint blocking movement), fusion and interposition arthroplasty (Keller-type procedure or silicone inter position). Prosthetic arthroplasty , with hemi-, total, inter position or spacer arthroplasty , is available but many pr ostheses have been withdrawn because of high failure rates and few series extend bey ond 9 years. Newer prosthetic inserts with claimed joint-preserving capabilities similarly fail to show advantages with regards to pain and have a high revision/reoperation rate but are still preferred by some who wish to retain mobility at MTP1 in the short to medium term. Fusion is for the severely a ff ected and is an e ff ective means of abolishing pain, but a ff ects the biomechanics and some patients are left with intractable pain beneath the sesamoids. A fusion will still usually allow sports participation. Summary box 41.4 Hallux rigidus /uni25CF /uni25CF /uni25CF Sesamoid/sesamoid complex problems Turf toe Acute injuries (turf toe) can be managed non-operatively or surgically depending on the grade of the injury and the occupation of the patient. Grade 4 acute rupture may require surgery . Turf toe is a plantar plate disruption usually from hyper extension injuries at MTP1 and may involve sesamoid fractures. Low-grade injuries can be treated non-operatively Albert Henry Freiberg , Professor of Orthopaedic Surgery , University of Cincinnati, Cincinnati, OH, USA, gave his account of this condition in 1926. Thomas George Morton , 1835–1903, surgeon, Pennsylvania Hospital, Philadelphia, PA, USA, described this condition in 1876. athletes (see Chapter 36 ). Chronic conditions range from stress fracture to avascular necrosis (A VN) and sesamoiditis but are probably all the same phenomenon. Management includes o ffl oading with orthotics, injections of ster oids and, rarely , shaving/excision. Excision surgery car ries a high risk. Lesser toe deformities Hammer, mallet and claw toes are frequent and are usually nonindicative but may be secondary to other deformities in the foot or to underlying neurological disease. Nonoperative treat - ment involves appropriate padding and footwear modification. For symptomatic flexible deformities soft-tissue surgery such as flexor/extensor tenotomies with/without capsulotomy is usually adequate, but for fix ed deformities bony procedures are required such as interposition arthroplasty , fusion or excision arthroplasty . Isolated lesser toe MTP extension/subluxation may result from a ruptured plantar plate at MTP joints and repair tech - niques have evolved recently , but the results ar e moderate at - best and the trend is back to non-operative management where possible. Ultrasound and magnetic resonance imaging (MRI) are now well estab lished for these injuries. - Freiberg’s disease Freiberg’s disease ( Figure 41.5 ) is an ischaemic necrosis of the epiphysis, resulting in pain and swelling of the joint. It will often settle with rest. Reshaping osteotomies are described, or excision of the proximal phalangeal head for severe adult cases with joint destruction. Excision of the whole metatarsal head should never be performed. Morton’s neuroma and metatarsalgia Metatarsalgia usually occurs secondary to joint problems, overload or irritation of a nerve. Morton’s neuroma is a painful -

Bunions affect women more often than men Patients with hallux valgus have inherited a tendency to develop the condition Not all patients need surgery The choice of operation is determined by the severity of the deformity and presence or absence of any arthritis, instability of the joints or hypermobility Hallux rigidus can affect adolescents as well as adults Stiff-soled shoes with a deep toe box are the most comfortable type of shoe Cheilectomy and fusion are the mainstays of surgical treatment Figure 41.5 Freiberg’s disease.

common digital nerve, most commonly between the third and fourth metatarsal heads and the second/third and is usually secondary to other forefoot pathology . The diagnosis is confirmed by ultrasound or MRI. Non operative treatments include advice about footwear, an orthosis (premetatarsal dome) to splay the metatarsal heads or an injection of steroids. Cryotherapy and even alcohol injections have been r eported. Surgery involves resection (the a ff ected toes will be perma nently partly hemi-numb if the nerve is removed) but this is not without risk of patient dissatisfaction, pain and recurrence, with around 5% reporting bad outcomes, often permanent. European colleagues often simply transect the intermetatarsal lig ament instead. Summary box 41.5 Morton’s neuroma /uni25CF /uni25CF /uni25CF Stress fracture This may occur following sport or may be incipient. It usually presents in the forefoot and may mimic Morton’s neuroma or metatarsalgia. An unexplained aetiology might require biochemical or biomechanical evaluation. Forefoot fractures can usually be managed non-operatively . Stress fractures may occur in any bone. Those of the navic ular, talus and tibial sesamoid often present with vague symp tomatology but early diagnosis with MRI and management are essential with immediate o ffl oading and protection with early fixation – if required, urgently – if a full fracture is seen developing. Vague, poor ly defined midfoot pain in an athlete or military recruit mandates urgent scanning and o ffl oading. Follow-up investigation of bone metabolism/density and exclusion of myeloma may be required.

Morton’s neuroma most commonly affects the second or third web space Surgical excision of neuroma is often successful but has a risk of pain syndrome Guided injections form the mainstay of treatment for most