What are the treatment options for a frozen or restricted hallux metatarsophalangeal joint?

Treatment Options for Frozen/Restricted Hallux Metatarsophalangeal Joint

Metatarsophalangeal joint arthroplasty is the recommended surgical intervention for hallux ulcers with limited range of motion of the first metatarsophalangeal joint when non-surgical offloading interventions have failed. 1

Conservative Management (First-Line Approach)

Conservative treatment should be attempted for 3-6 months before considering surgical options:

• Custom orthotic devices:

  • Provide metatarsal support
  • Redistribute pressure away from affected MTP joint 2

• Footwear modifications:

  • Wide toe box
  • Rocker-bottom soles
  • Low heels 2

• Pain management:

  • NSAIDs
  • Topical analgesics 2

• Physical therapy:

  • Toe and foot strengthening exercises
  • Range of motion exercises
  • Gait training 2

• Joint manipulation and injection:

  • Most effective for early (grade I and II) hallux rigidus
  • Provides symptomatic relief for approximately 6 months in mild cases
  • Limited effectiveness in advanced (grade III) cases 3

• Addressing FHL tendonitis:

  • Treatment focusing on alleviating restricted flexor hallucis longus (FHL) excursion can be beneficial in select cases
  • Non-operative treatment of FHL stenosis results in decreased pain in 75% of cases 4

Surgical Options (When Conservative Treatment Fails)

Joint-Preserving Procedures

1. Cheilectomy:

   • Removal of bone spurs
   • Suitable for early stages of hallux rigidus 5, 6

2. Metatarsal osteotomy:

   • Realigns the metatarsal
   • Reduces pressure on the MTP joint 2

3. FHL release:

   • For cases with confirmed FHL stenosis
   • Surgical release shows decreased pain in 90% of cases 4

Joint-Sacrificing Procedures

1. Metatarsophalangeal joint arthroplasty:

   • Specifically indicated for hallux ulcers with limited range of motion of the first MTP joint
   • Shows small increases in ulcer healing and sustained healing
   • Significant decrease in amputation risk (RR 0.48) 1

2. Metatarsal head (MTH) resection:

   • Indicated when there is persistent pain, limited joint mobility, or evidence of osteomyelitis/infection
   • Particularly useful when infection or osteomyelitis is identified 1, 2

3. Arthrodesis (fusion):

   • Gold standard for end-stage hallux rigidus
   • Despite fusion of a key joint, there is little adverse effect on gait
   • Weight bearing of the first ray can be restored 7

Decision Algorithm Based on Clinical Presentation

1. For early stage hallux rigidus (Grade I-II):

   • Start with conservative management for 3-6 months
   • If unsuccessful, consider cheilectomy or osteotomy

2. For moderate hallux rigidus with limited joint mobility:

   • Consider joint arthroplasty if conservative treatment fails
   • Particularly if hallux ulcers are present 1

3. For advanced hallux rigidus (Grade III) or when infection is present:

   • Consider MTH resection if osteomyelitis or infection is identified
   • Arthrodesis for end-stage disease 1, 7

Important Considerations and Pitfalls

• Pre-surgical vascular assessment is essential, especially in patients with diabetes 2

• Avoid attributing symptoms solely to bone spurs when subluxation may be the primary pain generator 2

• Post-surgical offloading devices are critical to prevent recurrence or new deformities 2

• Consider FHL involvement as a potential cause of hallux MTP pain, especially in athletic individuals 4

• For diabetic patients with hallux ulcers, joint arthroplasty combined with a non-removable offloading device shows better outcomes than offloading devices alone 1