Significant history/Physical symptoms

First metarsophalangeal (MTP) Joint Dysfunction can be characterised by pain around the joint and associated structures, deformity of the joint position, or by reduced range of movement at the first MTP joint, which can be either structural or functional

Functional Hallux Limitus (FnHL) 

Jacks Test (or the Hubscher maneuver) is a clinical test used to estimate the integrity of the windlass mechanism of the foot.

Video of Jacks test (Hubscher Maneuver)

Hallux Limitus / Hallux Rigidus

A dorsal exostosis is characteristic and is caused by proliferation of disease and flexion of the first MTP Joint. Dorsal flexion becomes limited and painful with/without crepitus. Pain can result from an isolated traumatic event but is more frequently associated with repetitive micro trauma or idiopathic arthritis. Increased activities/occupational demands that require extension of the first MTP Joint can be a contributing factor.

• Painful 1st MTP joint
• 1st MTP joint stiffness
• Pain increases with activity/ aggravated by shoes
• Dorsal exostosis
• Inter Phalangeal Joint (IPJ) Hyperextension
• +/- Abnormal ROM 1st MTP joint.
• Central metatarsalgia
• IPJ plantar callus

Radiographic Findings

• Progressive degenerative changes at 1st MTP joint.
• Loss of joint space
• Dorsal osteophytes
• Subchondrial cyst
• Articular flattening

Sesamoid Disorders

Significant History/Physical symptoms

• +/- History of Trauma
• Acute or Insidious onset
• Isolated problem or associated with other 1st MTP joint pathology
• Associated foot deformity
• +/- Swelling, effusion, dislocation, crepitus, erythema, warmth.
• Pain on 1st MPJ ROM/ propulsion
• Localised pain with weight-bearing
• Pain with maximal dorsiflexion
• Pain/ loss of strength on testing plantarflexion
• Pain on direct palpation of sesamoid

Hallux Abducto Valgus

Significant history/physical symptoms

Hallux abducto valgus (HAV) is the most common deformity of the first metatarsophalangeal (MTP) joint. Although research evidence into the cause of HAV are equivocal, the aetiology appears multifactorial—familial history, female gender, occupational foot stress, and an oval or curved MTP joint articular surface have all been partially correlated.

HAV is common, being found in around 2% of children aged nine to ten and in up to 50% of adults, with around 17% of cases becoming symptomatic.

Common progressive deformity of the forefoot characterised by medial deviation of the first metatarsal plus lateral deviation and rotation of the hallux.

HAV has been linked with long term footwear use but the hypothesis that high heels causes HAV is not supported.

Relationship between excessive foot pronation and hallux valgus is inconclusive.

Can be classified using the Manchester Scale.

• Painful “bunion”
  • Progressive deformity
  • Aggravated by footwear
• Medial prominence – “bunion”
• Deviation of hallux towards midline of foot
• +/- abnormal Range of motion 1^st MTP Joint
• Medial bursitis
• Widening of forefoot
• Neuritic “bunion” pain
• Family history
• 2^nd hammer toe

Radiographic findings

Radiographs are not recommended for evaluation of HAV. Radiographs should be restricted to those conditions that are progressing to surgery and should only be carried out as part of any pre-operative assessment

• Medial prominence 1^st metatarsal head
• +/- joint space abnormality
• > HA angle/ >intermetatarsal angle
• Lateral displacement of sesamoids
• Rotation of Hallux

The first line intervention should focus on educating the patient about the condition, and prescribing therapies that can be self-administered by the patient.

Leaflets should be given to patients to reinforce verbal advice and links to NHS website resources where available. Leaflet on Hallux Limitus/Rigidus

Initial Patient Directed Treatment Options

• Advise weight loss if appropriate
  • Signposting to activities which may promote weight loss link exit/parallel pathways
  • Referral to Weight Management Service if BMI greater than 30.
  • NHS Choices - Lose weight
  • Leisure Pathway
• Activity modification and management advice
• Analgesia & Non-Steroidal Anti Inflammatory Drugs as appropriate.
  • See guidance on good practice for analgesia advice. 
• PEACE and LOVE (Protect, Elevate, Avoid anti-inflammatory modalities, Compress, Educate, Load, Optimisation, Vascularisation and Exercise)
• Footwear Advice
• Give leaflet to reinforce verbal advice - NHSGGC Footwear advice leaflet 
• Alternative Shoe Lacing Options
• Heel Raise
  • These should be given bilaterally so as to avoid Leg Length Discrepancy 
• Exercise Prescription
  • Both specific plantar fascia and Achilles tendon stretches should be used

Non evidenced treatments

The following treatments are not supported by high quality evidence therefore they should not be considered as a treatment option for patients unless all other evidenced treatments have been tried unsuccessfully and there is clear clinical justification as to why these treatments are being used.

• Stretching
• Acupuncture
• Low Level Laser Therapy LLLT
  • Some limited evidence but more research needed to determine optimum dosage to provide a significant effect
• Therapeutic Ultrasound
  • Minimal benefit and no conclusion on effective dosage parameters 

Biomechanical assessment and prescription of Foot Orthosis

• Address biomechanical deficit if indicated by assessment
• Off the shelf or custom made insoles should be prescribed dependant on the severity of biomechanical deficit
• The orthotic prescription should be decided by the clinician, who should describe the prescription in detail in the patient records
• It is worth noting that passive dorsiflexion of less than 10 degrees has limited success with orthotic management.
• Footwear Adaptations -Rigid sole/ rocker bottom
• Prescription Footwear (HAV)
  • Accommodate deformity and reduce pressure on skin

Corticosteroid Injection

Radiographic findings

Radiographs are recommended for evaluation of Hallux Limitus / Rigidus but should be restricted to those conditions that are progressing to surgery and should only be carried out as part of any pre-operative assessment.

Radiographs are not recommended for evaluation of HAV. Radiographs should be restricted to those conditions that are progressing to surgery and should only be carried out as part of any pre-operative assessment.

One reason for referring to the orthopaedic department is for a surgical opinion. This is not a guarantee that surgery is the correct option for your patient so it’s important that this is not the expectation given to the patient by the referring clinician.

It is important that the patient has the option of a surgical opinion if this may be an appropriate treatment option for them so that they can discuss what is involved in surgery and make an informed decision.

Common conditions which are operated on include, hallux valgus, hallux rigidus, Morton’s neuroma, lesser toe issues, tendon pathology and degenerative changes of the joints of the foot and ankle.

The indications for surgery include persistent pain, worsening symptoms, significant limited mobility or failure of conservative therapy.

Foot and ankle surgery is generally successful with many of the common foot operations achieving 85% success rate, however complications can occur and will be considered as part of the decision making process for surgery.

Remember to exhaust all conservative means ie: orthotics, footwear advice , physiotherapy, pain relief medication , if appropriate steroid injections, before considering surgical opinion.

Further investigation

The other reason for referral to Orthopaedics is for “Further Investigations”. 

MRI and CT are helpful and can be arranged within orthopaedics as appropriate – if your patient does not have a clear diagnosis or there is a concern about a diagnosis and as above, struggling with symptoms, referral on to orthopaedics is appropriate

Things to consider before referring for further investigation are the severity of the symptoms and whether there are odd/suspicious symptoms making it difficult to make a clear diagnosis.

Things to consider before referring to orthopaedics:

Before referring to orthopaedics ensure the following:

Vascular status – palpable pulses (for surgery)

Patient is happy to attend for further review, possible further investigation and possible surgery as an outcome.

Conservative means have been attempted.

This is a referral guide however please do not hesitate to contact your local ESP Orthopaedic clinician if you are unsure whether to refer. 

The majority of the papers included here are level 1 or level 2 evidence, however other papers have been included to allow for further reading around the subject. Articles are listed in Harvard format.

Coughlin, M.J. and Shurnas, P.S., 2003. Hallux rigidus: grading and long-term results of operative treatment. JBJS, 85(11), pp.2072-2088.
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Durrant, B. and Chockalingam, N., 2009. Functional Hallux LimitusA Review. Journal of the American Podiatric Medical Association, 99(3), pp.236-243.
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Glasoe, W.M., Yack, H.J. and Saltzman, C.L., 1999. Anatomy and biomechanics of the first ray. Physical therapy, 79(9), pp.854-859.
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Gordillo-Fernández, L.M., Ortiz-romero, M., Valero-Salas, J., Salcini-Macías, J.L., Benhamu-Benhamu, S., García-de-la-Peña, R. and Cervera-Marin, J.A., 2016. Effect by custom-made foot orthoses with added support under the first metatarso-phalangeal joint in hallux limitus patients: Improving on first metatarso-phalangeal joint extension. Prosthetics and Orthotics International, 40(6), pp.668-674.
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Grady JF, Axe TM, Zager EJ, Sheldon LA. A retrospective analysis of 772 patients with hallux limitus. Journal of the American Podiatric Medical Association. 2002 Feb;92(2):102-8.
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Jarvis, H.L., Nester, C.J., Jones, R.K., Williams, A. and Bowden, P.D., 2012. Inter-assessor reliability of practice based biomechanical assessment of the foot and ankle. Journal of foot and ankle research, 5(1), p.14.
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Lawrence, H. 2011 ‘’Evidence-based Medicine (EMB) and Orthotic Therapy’’ Podiatry Management March 97-101
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Menz, H.B., Auhl, M., Tan, J.M., Levinger, P., Roddy, E. and Munteanu, S.E., 2017. Predictors of response to prefabricated foot orthoses or rocker-sole footwear in individuals with first metatarsophalangeal joint osteoarthritis. BMC musculoskeletal disorders, 18(1), p.185.
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Murley, G.S., Landorf, K.B. and Menz, H.B., 2010. Do foot orthoses change lower limb muscle activity in flat-arched feet towards a pattern observed in normal-arched feet?. Clinical Biomechanics, 25(7), pp.728-736.
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Nawoczenski, D.A., 1999. Nonoperative and operative intervention for hallux rigidus. Journal of Orthopaedic & Sports Physical Therapy, 29(12), pp.727-735.
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Roukis, T.S., Scherer, P.R. and Anderson, C.F., 1996. Position of the first ray and motion of the first metatarsophalangeal joint. Journal of the American Podiatric Medical Association, 86(11), pp.538-546.
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Sammarco, V.J. and Nichols, R., 2005. Orthotic management for disorders of the hallux. Foot and ankle clinics, 10(1), pp.191-209.
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Schnirring-Judge, M. and Hehemann, D., 2011. The cheilectomy and its modifications. Clinics in Podiatric Medicine and Surgery, 28(2), pp.305-327.
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Shrader, J.A. and Siegel, K.L., 2003. Nonoperative management of functional hallux limitus in a patient with rheumatoid arthritis. Physical therapy, 83(9), pp.831-843.
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Solan, M.C., Calder, J.D.F. and Bendall, S.P., 2001. Manipulation and injection for hallux rigidus: is it worthwhile?. The Journal of bone and joint surgery. British volume, 83(5), pp.706-708.
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Vanore, J.V., Christensen, J.C., Kravitz, S.R., Schuberth, J.M., Thomas, J.L., Weil, L.S., Zlotoff, H.J. and Couture, S.D., 2003. Diagnosis and treatment of first metatarsophalangeal joint disorders. Section 2: hallux rigidus. The Journal of Foot and Ankle Surgery, 42(3), pp.124-136.
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