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Hallux Rigidus

Hallux rigidus presents as a very painful, stiff great toe. They may complain of a bump on the dorsal aspect, dorsal bunion over the MTP joint and they have a hard time with shoe wear. So what happens here, is there is accumulative trauma to that joint, increased joint stresses and here is an intraoperative picture showing you, here is the articular surface, there is that dorsal osteophyte that they complain about, there is that dorsal bunion that rubs in their show and becomes inflamed. As we said, there is no secondary manifestation, but there is accumulative trauma and increased joint stresses.

There is that articular cartilage lesion in the first metatarsal head that can be quite painful and they need to have that large dorsal osteophyte in joint stiffness, so you need to reduce the inflammation, how do you do that? Well you need to take the stresses off this joint, as you are walking on your foot and you get up on the to the toe walk phase of gait, so you are pushing off with your toes as you go into your next step, there is a lot of contact stress in this joint.

You need to limit this toe from coming up and bumping hard against this articular cartilage lesion here. One way to do that is to put a stiff plate in the shank of the shoe, you stiffen it and you put a rocker bottom on the bottom of the shoe, so instead of having to extend your toe up, you rock off the front of your foot and you decrease the joint stresses here. They also may benefit from high wide toe box shoes for that large dorsal osteophyte.

When I look at someone who presents to me with a foot complaint, I try to break it up into what the primary pathology is, and what are the secondary manifestations that they are coming to me to complain about? The foot is a complex weight bearing surface. There re 28 bones and nearly 60 articulating surfaces, so there are a lot of inter-relationships going on between the different segments of the foot, the hind foot, mid foot and forefoot, and problems in one region can have manifestations elsewhere. So it is very important to recognize what the root cause of the problem is, as well as identifying all the secondary Another concept that I use frequently when I am looking at foot problems, is that the foot should have an axis of balance. That axis of balance runs along the sagittal plane. It goes from the center of the calcaneus, to the center of the midfoot, and runs between the second and third metatarsals in the forefoot. Weight bearing forces are balanced across that access medially and laterally, in fact, minimal muscle activity is required for quiet standing. The muscle forces, or the dynamic forces during the phases.

It needs to be rigid when you’re standing on it, and it needs to be flexible as it strikes to the ground, so it can absorb the shock forces and the weight bearing forces as it strikes the ground. These static restraints such as the ligaments, as they start to weaken and the foot starts to collapse, you start to overwork or atrophy some of the dynamic restraints, the tendons that are trying to stabilize the foot along that axis of balance, and the axis of balance becomes disrupted. I put this slide up here to show you a relatively well aligned foot in this patient. Her left foot is widened out here, but essentially there is the center of her calcaneus and that weight bearing axis runs between the second and third metatarsal. On this side where she has a very severe flat foot, here is her hindfoot, we sort of estimate that here is about the center of the calcaneus, and you see if you draw that straight line, the axis of balance is shifted. Pretty much now all her metatarsals now shifted out laterally, as she is adducting through this talar navicular joint. You can imagine structures over here become lax, both the tendons and the ligaments.