A comprehensive and narrative review of historical aspects and management of low-grade hallux rigidus: conservative and surgical possibilities

Morphological characteristics of the flexor hallucis longus groove and tendon quality in patients with hallux rigidus: A CT-based study

BACKGROUND

The etiology of hallux rigidus is still unknown and elucidating targeted factors to prevent hallux rigidus or improve treatment outcomes is essential. An association between flexor hallucis longus (FHL) tendon tightness and hallux rigidus development has been suspected; however, the characteristics of the FHL tendon in the hallux rigidus remain unclear. This study aimed to explore the quality of the FHL tendon and the morphological characteristics of the FHL tendon groove at the talus and sustentaculum tali in the pathogenesis of hallux rigidus.

METHODS

Twenty-one feet with hallux rigidus and 15 feet without hallux rigidus were retrospectively reviewed. The ratio of the FHL tendon groove depth to the FHL tendon anteroposterior diameter (groove/tendon ratio), Hounsfield unit (HU) values of the cancellous bone below the FHL tendon groove to those of the navicular (groove HU ratio) were measured using computed tomography at the talus and sustentaculum tali. The ratio of HU values inside the FHL tendon to those inside the tibialis anterior tendon (tendon HU ratio) were measured at the FHL tendon groove of the talus, that of the sustentaculum tali, and below the sesamoids.

RESULTS

The depth of the FHL tendon groove, groove/tendon ratio, and groove HU ratio were significantly larger in the hallux rigidus group; the FHL tendons of the hallux rigidus group were deeply fitted into the FHL groove than those of the control group. The tendon HU ratio was significantly smaller in the hallux rigidus group.

CONCLUSIONS

The FHL tendon in the hallux rigidus can be more constrained at the FHL groove of the talus and sustentaculum tali, and its quality can change compared to that in healthy feet. Tightness of the FHL tendon should be considered when treating hallux rigidus.

LEVEL OF EVIDENCE

Ⅲ.

Effect of different custom-made foot orthotics on foot joint stiffness in individuals with structural hallux limitus: A quasi-experimental study

BACKGROUND

Normal dorsiflexion of the first metatarsophalangeal joint during dynamic activities is critical for effective propulsion. Therapeutic foot orthotics may address the pathomechanical loading and joint kinematics issues faced by this population. This study aims to evaluate the effect of two different types of Custom-made foot orthosis compared to shod condition on the stiffness of the rearfoot, midfoot, and 1st metatarsophalangeal joint during walking in patients with Structural Hallux Limitus.

METHODS

This quasi-experimental study used a repeated-measures design with a single cohort. 24 participants with structural hallux limitus were sampled. Two custom-made Foot Orthotics - a cut-out and an anterior forefoot stabiliser element - were compared under three conditions using minimalist SAGURO neoprene shoes: shod, shod with cut-out custom-made foot orthosis, and shod with anterior forefoot stabiliser element foot orthosis. Kinematic data were captured using a modified Bruening model. We examined the variable stiffness (quantified in Nm/Kg/rad).

FINDINGS

Significant differences were found in dynamic stiffness only between Anterior forefoot stabiliser element custom-made foot orthosis, and the patient shod during the propulsion phase at the 1st Metatarsophalangeal joint (R2 = 0,07 p = 0.027) and a difference of 0,86 Nm/kg/rad. No significant differences were observed for dynamic stiffness in any other phase of the stance period across all conditions.

INTERPRETATION

The Anterior forefoot stabiliser element, in particular, significantly increases the stiffness of the 1st Metatarsophalangeal joint compared to walking shod.

Range of Flexion Improvement in Degenerative Stages of the First Metatarsophalangeal Joint (Hallux rigidus) with Cross-Linked Hyaluronic Acid: A Cadaveric Study

BACKGROUND

Viscosupplementation consists of intraarticular hyaluronic acid injections applied to treat pain and improve joint mobility. The objective of the study was to analyze the improvement of the range of mobility of the first metatarsophalangeal joint with a single dose of cross-linked hyaluronic acid.

METHODS

Ten fresh frozen specimens of feet sectioned below the knee were selected. Before and after the infiltration procedure, the range of flexion was calculated for all specimen's metatarsophalangeal joints. To detect complications due to the procedure, five feet were dissected and five were sectioned with a diamond saw.

RESULTS

The range of the first metatarsophalangeal joint flexion differences between the preoperative and the postoperative period was as follows: (1) 47° (range, 37-51.5) to 58° (range, 49-69.5) degrees of loaded dorsiflexion (p > 0.006); (2) 41° (range, 40-51.5) to 58° (range, 52.5-66.5) degrees of unloaded dorsiflexion (p > 0.009); and (3) 14° (range, 10.5-24.25) to 16° (range, 14.25-28.5) degrees of unloaded plantarflexion (p > 0.083). No injuries of anatomical structures were observed either by anatomical dissection or in the anatomical sections.

CONCLUSIONS

The results obtained in this viscosupplementation study demonstrate the improvement of the range of mobility of the first metatarsophalangeal joint without evidence of extravasation and lesions of the periarticular anatomical structures.

Reviewing Evidence and Patient Outcomes of Cheilectomy for Hallux Rigidus: A Systematic Review and Meta-Analysis

Background: Cheilectomy is a joint-sparing surgery for the treatment of moderate stages of Hallux Rigidus (HR). The purpose of this systematic review was to assess the clinical outcomes, range of motion (ROM), complications, and revision rates associated with cheilectomy. Methods: A literature search of the PubMed, Scopus, and Cochrane databases was performed. PRISMA guidelines were used. Risk of bias was assessed through the Newcastle-Ottawa Scale. Meta-analysis of the clinical outcomes scores was performed. Results: The initial search identified 317 articles, with 16 included. Cheilectomy improved ROM by 51.15% (41.23° to 62.32°), with greater gains in traditional (67.72%) vs. minimally invasive (48.74%) techniques. VAS decreased by 72.61%, more in traditional (79.35%) than minimally invasive (64.97%). AOFAS improved by 33.99%, from 61.83 to 82.85. Complications occurred in 11% (11.68% traditional, 9.73% minimally invasive), with residual pain (7.46%) more common in traditional and nerve injury (3.78%) in minimally invasive procedures. Revision rates were 7.4% overall (6.1% traditional, 8.8% minimally invasive). Conclusions: This procedure showed satisfactory results regardless of whether the traditional or minimally invasive technique is used. Current evidence does not allow for a definitive indication, but careful patient selection is advisable, particularly for mild to moderate cases.

Effect of Custom-Made Foot Orthotics on Multi-Segment Foot Kinematics and Kinetics in Individuals with Structural Hallux Limitus

The first metatarsophalangeal joint (MTPJ) and the first ray are crucial in walking, particularly during propulsion. Limitation in this joint's sagittal plane motion, known as hallux limitus, can cause compensatory movements in other joints. Some studies assessed the impact of various foot orthoses designs on the foot biomechanics; however, a comprehensive understanding is lacking. This study compared the effects of two custom-made foot orthoses (CFOs) on the foot joint kinematics and kinetics in patients with structural hallux limitus (SHL). In this quasi-experimental study, 24 patients with hallux limitus were assessed in three conditions: (i) barefoot, (ii) shod with a cut-out custom foot orthosis (cut-out CFO), and (iii) shod with an anterior forefoot-stabilized element custom foot orthosis (AFSE CFO), fitted into a minimalist neoprene shoe. Multi-segment foot kinematics and kinetics were assessed during the stance phase of the gait. A decrease in ankle and midfoot inversion, as well as in ankle plantarflexion, was found in both orthotic conditions. Regarding the first MTPJ, a greater dorsiflexion was observed with the patient being barefoot compared to both of the conditions under study. From the current finding, it should be concluded that neither of the custom foot orthoses produced the predefined functional effects.

The Role of the Flexor Hallucis Longus in the Treatment of the Painful Hallux Metatarsophalangeal Joint

BACKGROUND

Pain in the hallux metatarsophalangeal joint (MTPJ) is very common, yet the underlying etiology remains unknown. Previous clinical research and biomechanical research has implicated stenosing flexor hallucis longus (FHL) tendonitis as a possible cause. The hypothesis of this study was that treatment solely focusing on alleviating restricted FHL excursion would be beneficial in patients with hallux MTPJ pain.

METHODS

This is a retrospective study of those treated in the Foot & Ankle Division between January 2009, and December 2018, who were diagnosed with FHL tendonitis with associated pain in the hallux MTPJ. Demographics, comorbidities, examination findings, imaging results, pain scores, treatment instituted, and outcome was obtained from the electronic medical record. The primary outcome was the improvement in the pain score (visual analog scale [VAS]). The surgical patients were included if their procedure was solely related to the FHL (posteromedial ankle release ± os trigonum resection). The decision to have surgery was analyzed by univariate and multivariable statistics using demographics, comorbidities, and clinical findings as potential factors (P < .05).

RESULTS

In 75% (59 of 79 feet), nonoperative treatment of FHL stenosis resulted in a decrease in pain scores that the patients felt was satisfactory. The operative group that had an FHL release showed decreased pain in 90% (18 of 20 feet). Multivariable analysis identified the need for immobilization (OR 9.8, 95% CI 1.8-55.2, P = .009), participating in athletics (OR 8.7, 95% CI 1.8-42.2, P = .007), and higher initial VAS (OR 1.7, 95% CI 1.3-2.3, P < .001) as being associated with the decision for surgery.

CONCLUSION

Previous biomechanical studies have suggested that stenosing FHL synovitis can cause increased intraarticular loading in the hallux MTPJ. The current clinical study supports this hypothesis, demonstrating that treatment focused on relieving restricted FHL excursion can ameliorate pain in the hallux MTPJ in select cases.

Hallux Rigidus: Anatomy and Pathology

Hallux rigidus is a common degenerative condition of the hallux metatarsophalangeal joint (MTPJ) characterized by pain, swelling, stiffness, and limited range of motion with characteristic corresponding clinical, physical examination, and radiographic findings. Many historical risks factors including trauma and family history and patient factors including hallux valgus interphalangeus and inflammatory arthropathies have a well-substantiated etiologic role in the disease process. The purpose of this section is to review the normal and pathologic anatomy and biomechanics of the hallux MTPJ while providing an overview of the current understanding and remain debate regarding the disease process.

Long-term outcomes of first metatarsophalangeal hemiarthroplasty for hallux rigidus

Hallux rigidus (HR) is arthritis of the first metatarsophalangeal joint.First metatarsophalangeal joint hemiarthroplasty surgery is one of the treatment options for end stage hallux rigidus.The aim of this study is to evaluate the long-term outcomes of hemiarthroplasty of the first MTPJ with a metallic implant in patients with end-stage HR. Patients who underwent hemiarthroplasty surgery with the diagnosis of HR were included in the study. Self-Administered Foot Evaluation Questionnaire (SAFE-Q) and Foot and Ankle Disability Index (FADI) scores were used in pre-operative and post-operative final follow-ups to evaluate the clinical status of the patients. Post-operative 1st metatarsophalangeal joint range of motion was measured and recorded separately for each patient. The intra-hospital and follow-up complications and revision surgeries of the patients were recorded. Thirty-five patients with a mean follow-up of 8.1 years were included in the study. There was a statistically significant positive change in both FADI and SAFE-Q scores compared to the pre-operative process(p = 0.0001). The average dorsiflexion angle at the final follow-up was 22.0 ± 8.2. Thus, it was determined that the 5-year and 8-year survival rates of patients in this study were 97.1% and 87.8%, respectively. In conclusion, the long-term results show that the use of hemiarthroplasty in the treatment of end-stage HR leads to high patient satisfaction, increased range of motion and a high survival rate.

Polyvinyl Alcohol Hydrogel Hemiarthroplasty of First Metatarsophalangeal Joint Hallux Rigidus

Background Hallux rigidus (HR) is the most common arthritic condition of the foot. Although first metatarsophalangeal joint (MTPJ) arthrodesis has been the historical gold-standard treatment, polyvinyl alcohol (PVA) hydrogel implants have gained popularity as a joint-sparing technique. However, recent studies have shown variable failure rates of PVA hydrogel implants. The purpose of this study was to report the five-year experience with PVA hydrogel implants performed by a single surgeon. Methodology Health records were queried from August 2016 to 2021 for patients who underwent primary PVA hydrogel implant hemiarthroplasty for symptomatic late-stage HR. Patient demographics and postoperative outcomes variables were evaluated. Kaplan-Meier analysis was used to evaluate implant survival. A total of 146 PVA hydrogel implant procedures were performed with a minimum six-month follow-up. Results The majority of patients were female (n = 103, 70.5%), with a mean age of 58.1 (±10.1) years, body mass index of 27.3 (±5.2) kg/m2, and American Society of Anesthesiologists score <3 (n = 131, 89.7%). The majority had stage II or III disease (n = 115, 78.8%). Patients experienced significant improvement in visual analog scale score (p < 0.0001) and hallux dorsiflexion (p = 0.0005). There were 22 (15.1%) complications, including implant subsidence (n = 15, 10.3%), deep infection (n = 6, 4.1%), and hypertrophic ossification (n = 1, 0.7%). Revision surgeries were required in 12.3% (n = 18) of patients at an average of 9.4 (±9.2) months postoperatively. This included nine (6.2%) revision PVA hydrogel implant procedures and nine (6.2%) first MTJP arthrodesis. The one- and two-year survival rates for MTPJ arthrodesis (n = 9) were 95.9% and 86.3%, respectively. Conclusions In the largest single-surgeon series reported, first MTPJ hemiarthroplasty with a PVA hydrogel implant significantly improved pain and hallux dorsiflexion at an average of 14.5 months postoperatively. There was a high two-year survivorship of 86.3% until failure which required first MTPJ arthrodesis. Future studies should be performed to refine the indications for PVA hydrogel implants and identify risk factors.

Assessment and Management of Atraumatic First Metatarsophalangeal Joint Pain

Nontraumatic pain in the first metatarsophalangeal joint is frequent and can be debilitating. The metatarsophalangeal joint complex comprises four articulating surfaces including the first metatarsal, the proximal phalanx, and tibial and fibular sesamoids, which are all contained within a synovial capsule. The most common causes of pain are hallux valgus and hallux rigidus. However, other diagnoses, such as functional hallux limitus, sesamoiditis, gout, and inflammatory autoimmune arthritis, need to be considered as well. A systematic approach is key to accurately diagnose the source of pain, which can sometimes be the result of more than one condition. The most important clinical information to obtain is a focused history, meticulous clinical examination based on understanding the precise anatomy and biomechanics of the first metatarsophalangeal joint, and analysis of the relevant imaging. Each pathology has a different treatment algorithm, as such, understanding the pathoanatomy and biomechanics is important in forming an effective treatment plan.

Morton’s Extension on Hallux Rigidus Pathology

Study design, case-control study: Background, Morton’s extension (ME) is a kind of orthotic that has been used as a conservative treatment of painful hallux rigidus (HR) osteoarthritis, but only their effects on first metatarsophalangeal joint (MPJ) mobility and position in healthy subjects have been studied, but not on its applied pulled tension forces neither in subjects with HR. Objectives: This study sought to understand how ME’s orthotics with three different thicknesses could influence the kinematic first MPJ by measuring hallux dorsiflexion using Jack’s test and a digital algometer with a rigid strip anchored to the iron hook’s extremity and comparing subjects with healthy first MPJ mobility to those with HR. We aimed to clarify whether tension values were different between healthy and HR subjects. Methods: Fifty-eight subjects were selected, of whom thirty were included in the case group according to HR criteria and twenty-eight were included in the control group. A digital algometer (FPX®® 25, Wagner Instruments®®, Greenwich, CT, USA) was used to assess the pulled tension values (kgf) of the first MPJ during Jack’s test. Results: The pulled tension values were highly reliable (ICC > 0.963). There were no statistically significant differences between the pulled tension values for the different ME conditions in the case (p = 0.969) or control (p = 0.718) groups. However, as it’s expected, there were statistically significant differences comparing all pulled tension values between case and control group subjects (p < 0.001). Conclusions: Different ME’s thicknesses had no influence on the pulled effort applied during the dorsiflexion Jack’s test between the healthy and HR groups; therefore, it can be prescribed without joint-care danger. In addition, it is proven that there is greater resistance to performing Jack’s test in the HR group than in the healthy group, regardless of ME’s orthotics. Furthermore, it is shown that the digital algometer device is a valid tool to detect the first MPJ restriction and is more reliable than other tests.

Evaluation of Radiographic Features Including Metatarsus Primus Elevatus in Hallux Rigidus

The etiology of hallux rigidus remains a controversial issue in foot and ankle surgery, i.e., the relationship between metatarsus primus elevatus (MPE) and hallux rigidus. The purpose of this study was to evaluate several radiographic parameters including first metatarsal elevation in patients with hallux rigidus compared to a matched control group. A retrospective case control study was performed including 50 feet, 25 feet with and 25 feet without hallux rigidus. In the patients with hallux rigidus, the first metatarsal was more elevated than in the control group (8.3 ± 1.7 mm vs 3.0 ± 2.0 mm, p < .001) and in 60% of patients with hallux rigidus MPE was diagnosed, compared to zero patients in the control group (p < .001). The lateral 1 to 2 intermetatarsal angle was higher in patients with hallux rigidus (3.6 ± 2.5 vs -0.7 ± 2.8; p < .001). The first metatarsal declination angle was not different between the 2 groups. Intraclass correlation coefficient between 2 observers for measuring the first metatarsal elevation was 0.929 (p < .001). In the current study, increased elevation of the first metatarsal, a higher incidence of MPE and increased lateral 1 to 2 intermetatarsal angle were found in patients with hallux rigidus compared to the control group. These findings support the theory of an association between MPE and hallux rigidus. Further high reliability of first metatarsal elevation measurement was found in our study.

Average 4-Year Outcomes of Distal Oblique First Metatarsal Osteotomy for Stage 1 to 3 Hallux Rigidus

BACKGROUND

Hallux rigidus is the second most frequent pathology of the first ray. Surgical options for degenerative metatarsophalangeal joint disease are either joint destructive or conservative procedures. The hypothesis was that oblique distal shortening osteotomy of the first metatarsal is an effective conservative technique for the management of stage 1 to 3 hallux rigidus.

METHODS

We conducted a retrospective cohort study of 87 feet with Coughlin and Shurnas's stage 1-3 hallux rigidus, operated between 2009 and 2019. The cohort consisted in 72 patients (87 feet) with an average age of 57±9 (30/79) years; 22 of 87 (25.3%) feet had the first metatarsal surgery performed in isolation; 65 of 87 (74.7%) had concomitant forefoot procedures, including 31 of 87 (35.6%) with Akin phalangeal osteotomies and 34 of 87 (39.1%) with Moberg phalangeal osteotomies.We evaluated the American Orthopaedic Foot & Ankle Society (AOFAS) Scale, subjective satisfaction, joint amplitudes, shortening rate, and occurrence of postoperative complications with a mean follow-up of 51 months (16/134).

RESULTS

The AOFAS score increased from 54.2±11.3 (25/70) preoperatively to 92.2±7.8 (62/100) postoperatively (P < .001). Patients reported excellent or good outcome in 95.4% of cases. The 40-point self-reported pain subscale score improved from 19.6 (± 10.0) to 37.4 (± 5.4), P < .001.The overall range of motion increased from 61±21 (20/110) degrees to 69±17 (35/120) degrees (P < .001). The mean first metatarsal shortening rate (SR^po) was 9.6%. Neither the Coughlin grade, the metatarsal index, or the SR^po influenced the AOFAS score. At 6-month follow-up, 15 patients had transfer metatarsalgia compared with 5 at last follow-up without requiring another surgical procedure. The risk was not significantly different according to Coughlin's stage, preoperative metatarsal index, or SR^po.

CONCLUSION

Oblique distal osteotomy of the first metatarsal for stage 1-3 hallux rigidus, often in combination with other first ray procedures, performed well during our follow-up time period, with a high subjective satisfaction rate and few complications.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Hallux valgus associated to osteoarthritis: Clinical-radiological outcomes of modified SERI technique at mid- to long-term follow-up. A retrospective analysis

INTRODUCTION

Treatment of hallux valgus deformity associated with mild or moderate osteoarthritis (OA) is still a topic of debate. In the literature, there are few studies concerning the management of patients affected by this condition. This study aims to report the experience at mid- to long-term results of an original joint-preserving surgical technique.

MATERIALS AND METHODS

Patients affected by mild to moderate hallux valgus deformity and associated to grade 1-2 OA and treated with modified Simple-Effective-Rapid-Inexpensive (SERI) technique from 2008 to 2018 were selected. Inclusion criteria were mild or moderate hallux valgus angle (HVA) <40° and an intermetatarsal angle (IMA) <20° and associated grade 1-2 OA of the first metatarso-phalangeal joint (MTPJ).

RESULTS

128 feet in 120 consecutive patients, undergone modified SERI procedure, have been retrospectively reviewed at a mean follow-up of 5.1 ± 3.8 years (range 2-11). American Orthopaedics Foot Ankle Society (AOFAS) score that was significantly improved from 44.2 ± 13.2 to 88.2 ± 9.6. Pre-operative average HVA and IMA values decreased respectively from 31.6° ± 3.9° to 9.1° ± 4.4° and from 16.2° ± 3.8° to 7.2° ± 3.1°. The average distal metatarsal articular angle (DMAA) value improved from 28.2° ± 6.5° to 7.1° ± 6°. OA of the first MTPJ highlighted a grade 1 in 46 feet and a grade 2 in 82 feet pre-operatively and a grade 0 in 30 feet, grade 1 in 82 feet, and grade 2 in 16 feet at the final follow-up.

CONCLUSIONS

The modifications to the SERI technique could extend the indications to patients affected by hallux valgus with mild to moderate OA. The wider case series and the longer follow-up of this study make us believe this technique is very useful for improving the quality of life in these patients.

LEVEL OF EVIDENCE

IV.

Short-term Efficacy of Ultrasonographic Guidance for Intra-articular Corticosteroid Injection in Hallux Rigidus: A Single-Blind Randomized Controlled Trial

BACKGROUND

Multiple considerations should be taken before standardizing a clinical procedure such as efficacy, safety, or the cost. The aim of this study was to compare the effects of landmark-guided vs ultrasonography-guided intra-articular injection of corticosteroid into the first metatarsophalangeal joint cavity to reduce pain and dysfunction in patients with hallux rigidus.

METHODS

We carried out a single-blind randomized controlled trial with 2 parallel arms in an outpatient clinic affiliated with a medical university. In total, 50 participants (35 women) with the mean (SD) age of 49.8 (10.3) years were randomly allocated to landmark-guided or ultrasonography-guided groups (each n = 25). Each patient received a single intra-articular injection of 40-mg methylprednisolone plus 1 mL lidocaine into the affected first metatarsophalangeal joint. The primary outcome was joint pain and the secondary outcome was the American Orthopaedic Foot & Ankle Society score. We measured the outcomes at baseline and 2 and 6 weeks after the intervention.

RESULTS

Six weeks after the injections, there were no statistically significant differences between the study groups in pain reduction and increase in the American Orthopaedic Foot & Ankle Society scores (P = .131 and .241, respectively). We did not find any complications for the injections in both groups. There were statistically significant changes within each group in pain and the scores for the landmark (P < .001, and P = .007), and ultrasonography groups (both P < .001).

CONCLUSION

Landmark guidance is as effective as ultrasonographic guidance for intra-articular injection in patients with hallux rigidus. A single intra-articular injection of 40 mg methylprednisolone plus 1 mL lidocaine is an efficient and safe therapeutic measure for decreasing joint pain and maintaining its function, at least for 6 weeks.

LEVEL OF EVIDENCE

Level I, high-quality prospective randomized study.

First Metatarsal Phalangeal Joint Arthrodesis without the Use of Hardware after Failed Arthroplasty: A Case Report

Introduction

First metatarsal phalangeal joint (MTPJ) arthroplasty has a high failure rate due to aseptic loosening, which leads to bone loss. The salvage procedure is conversion to an arthrodesis, but bone loss can make obtaining screw fixation difficult. Herein, we report a unique case of revision first-metatarsal arthrodesis without the use of hardware after a failed arthroplasty.

Case Report

A 60-year-old women presented to us with first MTPJ pain in the setting of failed arthroplasty. We performed an arthrodesis; however, intraoperatively, hardware fixation could not be obtained due to bone loss. We utilized allograft bone struts to maintain first ray length and to hold the correct hallux position during arthrodesis maturation.

Conclusion

Bone loss is a frequently encountered problem in revision surgery to a first MTPJ arthrodesis. An arthrodesis can be obtained without the use of hardware in scenarios where bone loss precludes screw fixation.

The efficacy of shoe modifications and foot orthoses in treating patients with hallux rigidus: a comprehensive review of literature

Hallux rigidus (HR) is a degenerative disease of the first metatarsophalangeal (MTP1) joint and affects about 2.5% of people older than 50 years. The real etiology of this condition remains under debate. Clinical symptoms, physical exam, and instrumental evidence are important in assessing and grading the disease. The anatomy of the first metatarsal is unique and its configuration may play a significant role in the HR development. The first approach in the early stages of the disease usually begins with shoe modifications and foot orthoses, designed to limit irritation from the dorsal osteophytes, reducing motion and the mechanical stresses on the joint. To prevent or delay the development of HR, shoes should be sufficiently long, comfortable, with high toe box and broad toe-boxed, and should bear an allowed space for the orthotic device. The ideal orthotic appears to require a 3-mm thickness with a correct stiffness, and also increasing and extending the medial metatarsal arch just proximal to the metatarsal head, raising the first metatarsal and allowing the proximal phalanx to rest in a more plantarflexed position, decompressing the dorsal aspect of the joint. The increased foot pronation moment with medial column overload, when present, should be corrected. In addition, the maximum follow-up found by the analyzed studies was of 14.4 years, so the Authors cannot conclude how long conservative care can keep a patient free from pain and able to perform normal daily activities. However, the use of shoe modifications and foot orthoses may be considered a safe treatment and then should be always offered to patients, before any surgical management. (www.actabiomedica.it)