In this article, I describe hallux rigidus and functional hallux limitus from a clinical perspective, as well as from my own experience with the condition, and my recent surgery and postoperative regimen for recovery. My wish is to educate practitioners so that they can potentially recognize budding symptoms in clients and address underlying conditions and causes, perhaps preventing the full onset of this debilitating condition.
Rob McWilliams dancing with the Murray Louis Dance Company (photo by Fritz Lehrer).
From Figures 1a and 1b, the boney deformity and limit to my left foot’s range of motion (ROM) are apparent. The bunion (hallux valgus) is sizeable on the right foot (Figure 1a), but it gives me no pain in any direction of motion. On the left foot, Figure 1b shows that I was unable to hinge in big-toe extension at my first metatarsal-phalangeal (MTP) joint on that side. X-rays revealed it to be a hallux rigidus condition, an obstruction in the joint caused by spur growth limiting toe extension. Note that the shape of the bone spur reaches upwards, not sideways like the bunion on the right foot. This is one of the key identifiers of the condition, as well as ROM testing showing the restrictedness in extension, as in my case.
The Medical Perspective
According to the website of the American College of Foot and Ankle Surgeons:1
Hallux rigidus is actually a form of degenerative arthritis. . . . Many patients confuse hallux rigidus with a bunion, which affects the same joint, but they are very different conditions requiring different treatment. Because hallux rigidus is a progressive condition, the toe’s motion decreases as time goes on. In its earlier stage, when motion of the big toe is only somewhat limited, the condition is called “hallux limitus.” But as the problem advances, the toe’s range of motion gradually decreases until it potentially reaches the end stage of “rigidus,” in which the big toe becomes stiff, or what is sometimes called a “frozen joint.”
Fig 1a Right foot – no pain.
Fig 1b Left foot – pain, extension restriction in big-toe, swelling.
Common causes . . . are faulty function (biomechanics) and structural abnormalities of the foot that can lead to osteoarthritis in the big toe joint. This type of arthritis . . . often develops in people who have defects that change the way their foot and big toe functions. For example, those with fallen arches or excessive pronation . . . of the ankles are susceptible to developing hallux rigidus. In some people, hallux rigidus runs in the family and is a result of inheriting a foot type that is prone to developing this condition. In other cases, it is associated with overuse – especially among people engaged in activities or jobs that increase the stress on the big toe, such as workers who often have to stoop or squat. Hallux rigidus can also result from an injury, such as stubbing your toe. Or it may be caused by inflammatory diseases such as rheumatoid arthritis or gout. . . .
Early signs and symptoms include:
As the disorder gets more serious, additional symptoms may develop, including:
Most of the symptoms listed above can be mimicked by a functional hallux limitus (FHL) condition. This dysfunctional use subverts many normal gait patterns that support healthy alignment, although there is no apparent obstruction in passive toe-extension ROM testing. Dananberg2 shows the compensations in gait that flow from the lack of normal sagittal motion at the MTP joint: cevical flexion; limited ipsilateral shoulder mobility and hip extension; overuse of ipsilateral iliopsoas and contralateral quadratus lumborum and gluteus maximus/iliotibial band complex. I think of this as using these structures to haul the other leg, absent the normal pivot over the MTP joint of the affected leg.
This use pattern sets up a lack of appropriate balance of forces for normal sacroiliac joint closure that, over time, can be a cause of low-back pain. Sacral nutation is necessary for the appropriate force-closure of the sacroiliac joint (SI) joint, and Dananberg shows that in FHL, lack of ipsilateral hip extension and the inability to close the angle between the posterior thigh and the ipsilateral ischial tuberosity in the toe-off part of gait also creates excessive tension in the ipsilateral biceps femoris. This in turn causes holding in the ipsilateral sacrotuberous ligament, blocking sacral nutation on that side.
This description describes my current, post-operative gait very well! Elements of that pattern, especially contralateral QL tightness, have long been present, if masked by other factors in my movement. I got the surgery because I felt that my “world of activity” was shrinking alarmingly quickly: no more walks or hikes, and always needing to plan around a sore foot. As a former professional dancer, I actually had a fair amount of skill in dancing around this deformity, but even that was getting more and more limited, with the pain, and limitation on motion worsening. Concern over long-term problems with SI joint instability, potential back problems, and a desire to better embody and model structural integration (SI) for clients and dance students were some of the factors that led me to get the surgery.
Dananberg’s position is that this functional condition cannot be treated by exercises alone, using the example of treating visual disturbances with eyeglasses. It might be interesting to elicit studies testing the efficacy of SI treatments – including but not limited to work on cervical spine, shoulder girdle, quadratus lumborum, iliopsoas, biceps femoris, interosseous membrane and deep into the MTP joint ligamentous bed – to see if hands-on work coupled with Rolf Movement’s sensory, perceptual, and coordinative work, and appropriate gait concepts, could help correct this.
Analysis from a Full-Body Perspective
By the time I finally went to see a doctor about this, I was assessed at about 5 degrees of passive motion in the joint, and in pain with simple walking for short distances. Kapandji shows normal passive bending in the joint as about 90 degrees, for comparison.3 The pain and decreased ROM was due to a substantial boney spur on the left first metatarsal and a smaller one at the first phalange of the great toe. X-rays also showed practically zero space at the MTP joint, implying a practically total lack of cartilage. The podiatrist gave four options: doing nothing, and dealing with the worsening of pain and stiffness; getting a fusion surgery (installing an appliance to fuse the joint); getting revision surgery that would have left me with a “nubbin” big toe; or getting a Cheilectomy, a procedure to remove the boney spur, hopefully giving me several years of improved ROM. In order for this last strategy to work, I would be required to go though painful rehabilitation work, and my lack of cartilage meant that there would likely be some pain in the joint. I opted for the Cheilectomy, in the hope that I could train the rest of my body to adapt, holistically and fluidly, to the changes.
I believe that my hallux limitus, and later hallux rigidus, condition arose as a combination of an initial turf-toe injury (intense squatting dorsaflexion with full weight into the toe hinge) that was never able to heal properly due to heavy repetitive use as a long-time professional dancer. In addition to this direct source of irritation to the MTP joint, I feel that my use patterns were further complicated by a bad hip injury early in my career: on stage at City Center Theater in New York City, I apparently popped the head of the femur fully out of the socket (and immediately back in!) with a low-pitched, loud noise, different from “cracking” sounds that one might normally experience. (For quite some time afterwards, I was unable to fully lift that leg to the side in a turned-out position. I just figured out how to lift it using increased anteversion in the hip, but with more medial rotation in the thigh. That improved in a relatively short time. It helped that I was twenty-two.) I believe that this led to a strain in the anterior ligaments (which help to hold the pelvis in a functional degree of anterior tilt) and a seemingly permanent laxity there, which appears to have caused me to unconsciously posteriorly tilt my pelvis through that side more than the other. This put even more strain into the toes and forefoot in many frequently performed dance movements that involved rising on the toes and forceful deep squats.
The Surgery and Aftercare
I decided to try visualization work with the toe to begin a process of “re-membering” the foot even before surgery. Basically, this involved imagined movement into a fabulously free toe hinge, accompanied by micromovement through the bones of the feet in all directions. I also decided, in advance, to use all painkillers offered, as studies show that this seems to improve recovery.4 I was supposedly going to be conscious during the procedure; it was done with a nerve-block injection plus Versa, a mood altering narcotic that was supposed to only relax me, but seemed to put me right to sleep. In the first five days of postoperative recovery, I experienced flu-like shivering, which felt to me like a trauma release. I used pain meds for the first three days, mainly to help me sleep in a position that allowed the substantial postoperative swelling to drain (supine, knees and feet raised on pillows).
As time went on, limping with weight only going through the heel gradually progressed into more and more normal motion through the foot in gait. After about three weeks, notable swelling was still there, though a lot less, and I could get into soft slip-on shoes. Physical therapy self-care treatments as instructed by my physician have me working to deeply stretch and distract the joint, working at the ligamentous and joint capsular level.5 (Like treatments received from a Rolfer before I got the surgery had given me a glimpse of the added freedom in my hip, spine, and ankle obtained from freeing the MTP joint by even a very small amount. Unfortunately, it was clear to me at the time that the boney block to normal motion was too great for these treatments to suffice without surgery.) I continue to perform these prescribed “distract and stretch” exercises on an “as tolerated” basis, as they are pretty painful. The podiatrist told me that this was to prevent the stiffening of scar tissue in the ligaments and joint capsules. I can now allow more and more weight through the joint, hopefully moving into a fully normal gait pattern. The postoperative X-ray shows my MTP joint capable, when manipulated by the doctor, of 30 degrees of toe extension with me in a totally unconscious state. This is approximately five times the ROM I had there before the surgery, though far short of the normative 90 degrees in passive bending. It should, however, hopefully improve my walking gait enough for more normal activities, like hiking, and walking with my clients.
At this writing, I am about ten weeks along in my recovery, and it feels slow. I can report that weight-bearing stretching in the joint is just now becoming tolerable – which is a huge improvement, even compared to my condition pre-surgery. Emotionally, I have had to come to grips with the fact that, because I have very little cartilage in my MTP joint, I may never really have a full pain-free gait again, let alone be able to return to a higher-demand use in dance. I realize that my sense of calling as a dancer, teacher, and choreographer intensifies this for me, though it perhaps does not make me unique in this world of avid skiers, runners, and others with physically demanding, and often injurious, pastimes. My preference for dance forms that used a lot of thrust through the toes (modern dance and contemporary ballet) certainly played into my situation. I imagine that someone very involved with post-modern dance (as represented by the likes of Trisha Brown or Yvonne Rainier), contact improvisation, or African dance could also incur a turf to-type injury that could cause this, as opposed to minimal risk for someone whose passion is, say, ballroom dance.
From a philosophical perspective, two things seem to have been the root causes of my long-term MTP joint damage: the basic objectification of my body as a Kunstfigur at the service of dance as an art form, and a general “tough-it-out attitude” common to gainfully employed yet financially poor professional dancers. If I could, I would do over my earlier approach to this, and other dance injuries. I can still hope to find ways to help people in similar circumstances make better, healthier choices. I believe that better and earlier treatments of my turf-toe and hip injuries – rest, manual therapy, rehabilitation, and muscle repatterning (especially in regards to pelvic tilt) – would probably have prevented the degree of tissue damage, bone spur formation, and arthritis at my left MTP joint.
My main goal now is to be able to enjoy walking and hiking again, and continuing the investigation of fuller foot motion and coordination through Rolf Movement work and other forms, such as Chi Walking.6 The latter is a technique that de-emphasizes the toeing-off gesture in favor of a wellsupported forward lean at the ankle, allowing transverse-plane rotation of the shoulders and hips, while de-emphasizing sagittal plane rotation of hip, and of the foot (and ankle) over the MTP joint. Though not allowing the fully upright spiraling undulation movement through the spine/pelvis sagitally and coronally that is considered a hallmark of Ohlgren and Clark’s Natural Walking,7 Chi Walking does potentially activate the “smart spring” necessary for SI-joint force-closure (referred to in Vleeming and Stoeckart’s discussion of gait in a broader article on lumbopelvic stability8). In any case, I know that in teaching dance, demonstrating movements may prove difficult sometimes. I trust my ability to adapt, in movement, while adjusting performance expectations according to the healing and adaptability in my left MTP joint.
The long-term results from the procedure are not to be seen for at least six months afterwards, according to my surgeon. Not all of the “word on the street” is good, as evidenced anecdotally by Internet postings.9 Because I do not have the same condition on the other foot, I should not require surgery there, and I believe this is because my condition was caused by use patterns and as a result of injuries, rather than being an inherited, bilateral issue.
1 . See www.foothealthfacts.org/footankleinfo/hallux-rigidus.htm.
Why I Got Foot Surgery[:]