Synonyms and Keywords
Big toe pain, dorsal bunion, hallux limitus, hallux rigidus, turf toe.
What is a Functional Hallux Limitus?
“Hallux” is the medical term for the big toe. Functional hallux limitus, then, is the loss of motion to the big toe joint, usually from jamming it during the course of walking or running.
It is also referred to by many doctors as a dorsal bunion for its most characteristic sign — a bump (exostosis) on the top of the joint where bunions are commonly found. Because the big toe is integral to walking through flexing itself upward and pushing off the ground to propel the body forward, a patient with hallux limitus will not have the range of motion in the affected toe to do that, so other joints will need to compensate and consequently putting more strain on the rest of the foot and leg. The continual stiffness and lack of motion lead to an inefficient, awkward gait, as well as increased fatigue and pain.
Then, as the stiff joint undergoes constant trauma from repetitive jamming, the toe bones become stimulated and extra bone growth occurs over the top of the joint, giving rise to the bunion. Eventually, the joint cartilage wears out to cause arthritis, and even less motion and more pain. At the final stage of the condition, known as hallux rigidus, the joint gives out completely and becomes totally immobile. Interestingly, the painful symptoms stop in many cases when/if the joint finally fuses and no longer moves.
In general, hallux limitus is a progressive deformity where the pain initially starts as a dull ache, but develops to into extreme joint pain, especially when the big toe is extended or pushed up, on a regular basis both in and out of shoes.
What Causes a Functional Hallux Limitus?
Hallux limitus can be a result of genetic defects:
- Pronation, a condition in which the foot rolls outward at the ankle, causes a person to put excessive weight and pressure on the big toe and big toe joint when walking. As the big toe joint needs to worker harder to help “push” the body forward on every step, the joint cartilage becomes overly compressed and eventually wear down, leading to hallux limitus.
- Feet with high arches are usually more rigid than normal, so as the person steps forward and puts all of the weight onto the balls of the feet rather than dispersing some to the arch, this forces the bones and joints in the balls of the feet, especially the big toe joint, to bear excessive weight. This deteriorates the joint cartilage in the big toe.
- An elevated first metatarsal (the first long bone in the foot just behind the big toe) causes the big toe to push downward (flex) excessively at every step. When the big toe is in a flexed position and strikes the ground, it is jammed back into its joint cartilage with excessive impact. This thins and wears down the joint cartilage over time.
- An abnormally long OR short first metatarsal will increase stress on the big toe joint each time it “pushes” the person forward. The joint cartilage becomes pinched between the big toe and metatarsal to cause wear and tear. (In most instances you can discern this defect simply by the fact that the big toe appears too long or short as compared with your other toes.)
For most people, the cause of hallux limitus is repetitive stress and/or micro-trauma where the big toe is constantly jamming into the first metamarsal bone. Some of the most common causes for such “overuse” include:
- Frequent wearing of high-heel shoes, or shoes that are too short
- Improper running technique, or running on your toes so your heel does not touch the ground
- Squatting for long periods of time
- Stubbing the big toe
- Dropping a heavy object on your big toe joint
Overuses can lead to a continuous cycle of decreased motion, arthritis, extra bone formation, jamming of the joint and so on.
Other causes for hallux limitus include repeated gout attacks to the joint, and degenerative joint disease (osteoarthritis) due to old age.
Who Gets a Functional Hallux Limitus?
People with pronation, high-arched feet, elevated/long/short first metatarsal are genetically predisposed to hallux limitus. Those engaging in physical sports or activities relying on jumping, running, and change of direction such as basketball, football, soccer, or mountain climbing (due to the uneven surface) have a greater risk than normal. Elderly persons, especially already with decreased range of motion in their leg and feet, must be monitored closely for hallux limitus.
What are the Symptoms of a Functional Hallux Limitus?
The pain of functional hallux limitus is usually associated with any movement of the big toe joint, typically described as a deep ache or sharp pain. If a bone spur develop, there can be pain over the top of the extra bone growth as well. The pain tends to be minor or even nonexistent when there is no weight on the big toe, such as when it’s up in the air or off the ground, sometimes with full range of motion restored. If the condition is present, when you try to pivot forward over the big toe joint, it will not move.
The preliminary signs for functional hallux limitus include:
- A painful and/or swollen base of big toe
- Big toe hurts and feels stiff when your push it upward, as well as when walking, running, squatting, and standing on your toes
- Discomfort in the joint when the weather is damp and cold
- Feeling of “tightness” in and around the toe joint
- Reduced mobility of big toe; walking is difficult and painful
- Swelling and inflammation of the toe joint, especially on the top of the joint
Hallux limitus is graded in four stages and the symptoms vary by stage.
- Stage 1: You experience only vague joint pain. It is often difficult to diagnose at this stage due to the lack of clinical signs, and x-ray will not reveal any problems.
- Stage 2: Pain is a dull ache in the great toe joint that increases with the time spent on your feet, with a mild dorsal exostosis (small bunion) that will show up on x-ray this time.
- Stage 3: You suffer pain with all activities, and cracking and popping of the joint along with sharp pain may occur. X-ray will show a large bunion, and the joint is losing space as cartilage erodes.
- Stage 4: Hallux rigidus or “turf toe,” which makes walking an agonizing chore, and you’ll feel significant pain any time you try to move the joint. On x-ray, the entire joint is enlarged and flattened with a lot of bone spurring around it. The cartilage is completely gone now, so your bones are essentially grinding at each other when you move.
How do You Diagnose a Functional Hallux Limitus?
The easiest way to find out if you have a functional hallux limitus is to see how the big toe and its first joint react to walking on a ground. How easily does the big toe bent back and push off the ground? If you need more force to do that than what you put into the first joint, functional hallux limitus may be present.
Clinical evaluation of the condition involves range-of-motion testing, gait analysis, and thorough history of the pain and symptoms. X-ray is important for investigating the amount of joint narrowing and extra bone spur or formation in the joint.
How do You Treat a Functional Hallux Limitus?
The scope of conservative treatments for functional hallux limitus is narrow. A custom foot orthotic (device designed to correct foot disorders) or support is often used to restore normal motion to the joint during weight bearing. Wider shoe gear and accommodation for the deformity can be used to take the pressure off. Using shoes with stiff soles to limit the amount of motion can be helpful. Cortisone injections into the joint can reduce the inflammation and scar, bringing temporary relief.
Patients suffering pain in the big toe joint that may be due to early arthritis should seek a professional opinion early, since it will limit the need for extensive surgery.
Self-Care at Home
Immediate treatment must be directed toward reducing the inflammation, swelling, and pain in the big toe and its joint. In the early stages of functional hallux limitus, these self-help treatments can be effective:
- Rest the foot by keeping weight off of it. You’re only aggravating and abusing the big toe every time you take a step. It cannot calm down if you don’t stop putting weight on it.
- Wear shoes with a rigid sole (to reduce bending of the big toe), wide and deep toebox (to keep pressure off of the big toe and swollen joint), is relatively flat (to reduce compression of the cartilage in the big toe joint) and of the proper length (to lower the chances of jamming the big toe). Further soften the pressure on the big toe joint by using a gel pad to cushion the ball of the foot.
- Soaking the foot in warm water can help soothe the inflamed and painful big toe joint. The water must be comfortably warm, NOT hot, to avoid skin burns. Soaking for 10-15 minutes two or three times a day is usually recommended. If soaking increases pain, swelling, or inflammation, stop immediately.
- Gentle massage with a topical pain reliever can provide comfort and reduced pain, swelling, and inflammation.
Professional treatment is geared toward addressing the mechanical cause of functional hallux limitus, which includes the following:
- Orthotics to compensate for the flat feet, elevated or long metatarsal.
- Surgery to enable greater motion.
- Medications or injections to decrease pain or inflammation of the joint.
- Possible physical therapy to help reduce inflammation in the joint.
The doctor will choose the most effective method to change or alter the biomechanical issues that is causing problems. For example, if the condition is due to a long first metatarsal, the best treatment will be to shorten it.
The most common surgical procedure for functional hallux limitus is a cheilectomy. In this, the joint is cleaned up of all scar tissue and spurs to enable better range of motion. Recovery is very rapid with this procedure, but may not be a good option if you have severe arthritis. You’ll also undergo physical therapy early after the surgery to get the big toe joint moving as well as prevent scarring and stiffness.
In certain cases, a cheilectomy will also include a cut in the metatarsal bone to shorten and lower the bone to prevent jamming. Recovery is slower as there is a waiting time for the bone cut to heal, but weight bearing is immediate and you can return to full activity in about two months following physical therapy.
In severe cases when there’s a great deal of pain and very little to no motion in the big toe joint, it is surgically fused with another bone. This removes all motion from the joint, but all pain as well. Recovery takes about 6-8 weeks in a boot.
How to Prevent a Functional Hallux Limitus?
The old adage, “An ounce of prevention is worth a pound of cure,” is most apropos when trying to prevent a functional hallux limitus. If this condition is not prevented or treated in the earliest stages, it can lead to debilitating pain and deformities that require surgery for the foot to function normally again.
You must stabilize your feet, maintaining them in a normal (or neutral) position. Don’t let them pronate and roll out. If you have high arches, support them with gel pads or cushions in order to relieve excess pressure on the balls of the feet.
Provide adequate shock absorption for the foot with proper footwear is critical. Your shoes should be wide enough across the ball of the foot and toes, so there is no pressure on the big toe and its joint. The shoes must be long enough to prevent pressure on the tip of the toe. The heel of the shoe should never be higher than 1 inch, and the sole should be rigid to reduce bending of the big toe when walking.