Why I Got Surgery: Hallux Rigidus and Functional Hallux Limitus
By Robert McWilliams, Certified Advanced Rolfer™, Rolf Movement® Practitioner
My reason for describing Hallux Rigidus, and functional Hallux Limitus, is so that practitioners who have no knowledge of these conditions can perhaps recognize budding symptoms, and perhaps discover and address underlying conditions and causes before things deteriorate to the degree that mine did.
The boney deformity and limit to my left foot’s range of motion (ROM) were apparent. The bunion (Hallux Valgus) is sizeable on the right foot but it gives me no pain in any direction of motion. On the left foot, I was unable to hinge in big toe extension at my first metatarsal phalangeal joint (MTP) 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: 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 range-of-motion testing showing the restrictedness in extension, as in my case.
From the Medical Perspective
According to www.foothealthfacts.org, 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.’
Common causes of hallux rigidus are faulty function (biomechanics) and structural abnormalities of the foot that can lead to osteoarthritis in the big toe joint. This type of arthritis – the kind that results from “wear and tear” – 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 (rolling in) 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.(sic)
…Early signs and symptoms include:
Pain and stiffness in the big toe during use (walking, standing, bending, etc.)
Pain and stiffness aggravated by cold, damp weather
Difficulty with certain activities (running, squatting)
Swelling and inflammation around the joint
As the disorder gets more serious, additional symptoms may develop, including:
Pain, even during rest
Difficulty wearing shoes because bone spurs (overgrowths) develop
Dull pain in the hip, knee, or lower back due to changes in the way you walk
Limping (in severe cases)
The site goes on to report recommendations for treatments ranging from painkillers, orthotics and shoe modifications, steroid injections, ultrasound, and surgery.
Most of the symptoms listed above can be mimicked by a “functional Hallux Limitus” (fHL) condition. This dysfunctional use pattern causes many normal gait patterns that support healthy alignment to be subverted, though there is no apparent obstruction in passive toe-extension ROM testing. This condition is eloquently described by Howard Dananberg in “Gait style as an etiology to lower back pain” and “Lower back pain as a gait-related repetitive motion injury”2. He shows the pattern of compensations in gait that flow from the lack of normal sagittal motion at the MTP joint: cervical 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 for 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 (SIJ), 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 contra-lateral 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, the pain, and limitation on motion worsening. Concern over long-term problems with SIJ instability, potential back problems, and a desire to better embody and model structural integration 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. In response to his statements, I feel that it might be interesting to elicit studies testing the efficacy of structural integration 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.
My Toe: 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 comparison2. This 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. My x-rays also showed practically zero space at the MTP joint, implying a practical total lack of cartilage there. Because of these factors, the podiatrist recommended three 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; getting a Cheilectomy, a procedure to remove the boney spur, hopefully giving me several years of improved range of motion. In order for this strategy to work, I would be required to go though painful re-habilitation 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 initially my Hallux Limitus, and later Hallux Rigidus condition arose as a combination of an initial turf-toe (intense squatting dorsaflexion with full weight into the toe hinge) injury 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 pro career. On stage at City Center in New York City I 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. I was 22!) 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 seeming permanent laxity there, which appears to have caused me to unconsciously posteriorly tilt my pelvis through that side more than the other. This, in chain of motion, 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 after-care
Before going in to surgery 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 micro-movement through the bones of the feet in all directions.
I decided, I advance, to use all painkillers offered, as studies show that this seems to improve recovery.3 I slept soundly through the procedure itself, though I was supposedly going to be able to be conscious during it. 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 immediate five days of my post-operative recovery period, 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 post-operative swelling to drain (supine, knees and feet raised on pillows).
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 prescribed to me for post-operative recovery, as instructed to me by my physician, have me working to deeply stretch and distract the joint, working at the ligamentous and joint capsular level. 4 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, however.
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. Over time, I can now allow more and more weight through the joint, hopefully moving into a fully normal gait pattern. The post-operative x-ray shows my MTP joint at 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 10 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 other 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 this, as opposed to, say, ballroom dance. I could imagine, too, 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.
From a philosophical perspective, two things seem to me 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 ‘do over’ my earlier approach to this, and other dance injuries, I would, and 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 re-patterning (especially in regards the 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. I believe that continuing the investigation, through Rolf Movement work and other forms, such as Chi Walking6. This is a technique that de-emphasizes the toeing-off gesture in favor of a well-supported 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 (and delicious) spiraling undulation movement through the spine/pelvis sagitally and coronally, which is considered a hallmark of Gael Ohlgren and David Clark’s “Natural Walking”7, this does potentially activate the “Smart Spring” necessary for SIJ force-closure referred to in Vleeming and Stoeckart’s discussion of gait in a broader article on lumbopelvic stability.8 In any case, I know that in future teaching work, demonstrating dance movements for students 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 6 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 do not believe I will require surgery on the other foot. I believe that this is because my condition was caused by use patterns and as a result of injuries, and is not an inherited, bi-lateral issue. I hope that this article can give Rolfers more information to aid in recognizing, treating and perhaps preventing the full onset of this debilitating condition.
2. See Kapandji, I.A., The Physiology of the Joints, Volume Two, Lower Limb, Churchill Livingstone, 2005 edition, page 196
3. Steen Møiniche, M.D.,* Henrik Kehlet, M.D., D.M.Sc.,† Jørgen Berg Dahl, M.D., D.M.Sc.‡ “A Qualitative and Quantitative Systematic Review of Preemptive Analgesia for Postoperative Pain Relief, The Role of Timing of Analgesia”, Anesthesiology, 96:725– 4, David C. Warltier, M.D., Ph.D., Editor, American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc., 2002
4. Conversation with my podiatrist, and referencing the “Foot Care” handout from Kaiser Permanente
5. Dananberg, HJ, “Gait style as an etiology to lower back pain”, p. 253, Movement, Stability and Lumbopelvic Pain, 2nd Edition, Churchill Livingstone-Elsevier, Vleeming, A, Mooney, V, Stoekhart, R editors; 2007; Dannenberg HJ. “Lower back pain as a gait-related repetitive motion injury”, Vleeming A, Mooney V, Dorman T, Snijders C, Stoeckart R, editors. Movement stability and low back pain. New York: Churchill Livingstone; 1997. p.; 253-67.
6. See http://www.chiwalking.com/ for info on classes, workshops, books and more.
7. Ohlgren, Gael and Clark, David, “Natural Walking”, Rolf Lines Vol. XXIII (Mar.1995)
8. Vleeming, Andry and Stoeckart, Rob, “The role of the pelvic girdle in coupling the spine and the legs: a clinical-anatomical perspective on pelvic stability”, from Movement, Stability and Lumbopelvic Pain, 2nd Edition, p. 131-134, Churchill Livingstone-Elsevier, Vleeming, A, Mooney, V, Stoekhart, R editors; 2007