This patient presented in early March with a history of a sudden severely inflamed and painful right 1st MTPJ after a run completed the previous month.
The joint became swollen and stiff after the run, and symptoms have slightly settled. The patient has had a generalised ache in the joint for a few years, but the severe pain is new.
On the X-ray, signs of severe degenerative osteoarthrosis/hallux limitus can be seen, with large dorsal spurring from the first metatarsal and the proximal phalanx. It is this hallux limitus with the marked spurring that would have been the reason for the long-term pain. However, a reason for the recent severed flare-up can also be observed.
I have zoomed into the lateral image to allow you to see the break at the base of the phalangeal spur. He has sustained fracture of the dorsal spur, as can be seen by the black line at the base of the spur, demarcating where the phalangeal spur has hit against the much harder, bigger metatarsal spur, causing it the be avulsed. This has probably happened during the patient’s run.
The immediate treatment is rest and icing with immobilisation of the joint. He may temporarily respond to a post-operative shop or CAM boot if symptoms are severe. This should allow the current “flare-up” to settle. However, the spur rarely reattaches and the hallux limitus will persist.
The patient could try functional orthoses with a permanent Morton’s extension to reduce the dorsiflexion of the joint and hopefully help reduce the amount the spurs hit against each other.
This may help the situation now, but he has quite marked OA/hallux limitus and may benefit from a capsular interpositional arthroplasty to remove the spurring, debulk the joint and allow for a pain-free range of motion. This is my procedure of choice for hallux limitus, as it aims to remove symptoms and reinstate a pain-free range of motion.
Also read:
1st MTPJ cartilage damage
Hallux Limitus / Rigidus
Post-operative wounds
Dislocated 2nd MTPJ
Motion following hallux limitus surgery
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