International Journal of Surgery Case Reports 114 (2024) 109197

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International Journal of Surgery Case Reports

journal homepage: www.elsevier.com/locate/ijscr

Case report

Case study: Gait assessment of a patient with hallux rigidus before and after
plantar modification
Roberto Tedeschi *
Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy

A R T I C L E I N F O A B S T R A C T

Keywords: Introduction and importance: Hallux rigidus (HR) is a degenerative arthritis affecting the first metatarsophalangeal
Case report joint (MTP), leading to pain and functional impairment, particularly during the propulsive phase of walking. The
Baropodometric examination prevalence of HR is about 2.5 % in individuals over 50, but younger individuals can also be affected, as
Hallux limitus
demonstrated in this case.
Insole
Case presentation: We report the case of a 26-year-old patient with a body mass index (BMI) of 20.2, who has been
Motion sensors
suffering from HR for 5 years. The patient presented with walking difficulties, characterized by a limp and
impaired propulsion phase, and pain in the right foot due to HR. A comprehensive gait assessment was conducted
using a baropodometric platform and integrated smartphone motion sensors. Following the diagnosis, a non-
surgical intervention involving the application of a compressed cotton felt foot orthosis at the MTP plantar
area was initiated. This intervention aimed to alleviate pain and improve the functional mobility of the right big
toe. Post-treatment assessments showed an increase in the big toe’s mobility from 0 degrees to 35 degrees, as
measured by a digital goniometer.
Clinical discussion: The application of a soft support, such as compressed cotton felt, at the plantar area of MTP,
demonstrated a potential non-surgical therapeutic approach to improve gait and reduce discomfort in HR
patients.
Conclusion: This case study underscores the potential benefits of plantar modification in the management of HR.

1. Introduction Progression to hallux rigidus is associated with significant to complete

Hallux limitus and its more severe form, hallux rigidus (HR), result
from osteoarthritic degeneration of the first metatarsophalangeal joint
(MTP), leading to swelling, stiffness, pain, and functional limitation [1].
The prevalence of HR is about 2.5 % in individuals over 50, but younger
individuals can also be affected, as demonstrated in this case [2], and is
the primary cause of foot arthritis, with an increasing incidence in the
elderly population [3]. Hallux limitus and hallux rigidus are common
foot conditions that can be highly debilitating. To assess the utility of a
modification to reduce symptoms or improve foot function, some
healthcare professionals, such as podiatrists, occasionally use a piece of
compressed cotton felt as a test. It’s worth noting that, to our knowledge,
there are no examples of using cotton felt in this manner in the medical
literature. Radiographic signs such as joint space narrowing and sub­
chondral sclerosis have been observed in about 10 % of patients aged 20
to 34, suggesting that this condition can begin as early as adulthood [4].
loss of joint function, chronic pain, and a decrease in quality of life [5,6].
In this study, we present the case of a young woman suffering from
persistent pain in the first metatarsophalangeal joint (MTP) of the right
foot, which had been felt over the past five years, and who was even­
tually diagnosed with initial osteoarthritis of the MTP, following a
consultation at the Orthopedic Institute. We also reviewed similar cases
previously reported in the literature [7]. This case highlights the
importance of recognizing that, even at a young age, initial osteoar­
thritis of the MTP may only present as nonspecific foot pain, before
focusing on the affected area. Due to its rarity at such a young age and
the anatomical complexity of the joint, this arthritic condition presents
diagnostic, functional, and rehabilitation challenges [8].
Besides osteoarthritis, HR and HL can stem from various factors,
including an elevated or abnormally long metatarsal joint or first
metatarsal bone, injuries like toe sprains, a fractured toe, or significant
toe stubbing, anatomical variations, and developmental impairments, as

* Alma Mater Studiorum University of Bologna, Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum, Via Zamboni 33, 40126 Bologna,
Italy.
E-mail address: roberto.tedeschi2@unibo.it.

https://doi.org/10.1016/j.ijscr.2023.109197
Received 9 November 2023; Received in revised form 19 December 2023; Accepted 20 December 2023
Available online 24 December 2023
2210-2612/© 2023 The Author. Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY license
(http://creativecommons.org/licenses/by/4.0/).
R. Tedeschi International Journal of Surgery Case Reports 114 (2024) 109197

discussed in a case report. Overuse from activities that continually stress
the toes is also a contributing factor [9].
Compressed cotton felt is available in various thicknesses, with the
most commonly used ranging from 2 mm to 5 mm. In this study, we used
compressed cotton felt with a thickness of 5 mm. The aim of this study
was to evaluate the effectiveness of adjusting a foot orthosis using
compressed cotton felt. We sought to determine if this simple and cost-
effective method could improve functionality and alleviate pain in pa­
tients suffering from hallux rigidus, without having to wait for the
fabrication of a custom orthosis(Table 1). This research is especially
relevant given the lack of information in the literature on this topic.
1.1. Patient information
imaging, appeared to be a small osteophyte. When walking barefoot, a
clinically apparent evasive limp with avoidance of the propulsive phase
was observed. The patient was given a soft compressed cotton (felt)
support to aid the MTP joint, aiming to make walking more functional
and alleviate pain. This type of support is commonly used in podiatry to
temporarily relieve foot overload areas but is seldom used as a trial to
evaluate a future orthopedic orthosis. The literature is lacking in this
area, and this article is the first to evaluate the use of felt as evidence in
this manner. She was assessed using a baropodometric platform
(Figs. 2,3), with and without the soft support, to evaluate the foot’s
pressure parameters. Moreover, thanks to the ‘Health’ application in­
tegrated into Apple smartphones, we were able to automatically monitor
the spatio-temporal walking parameters, such as speed, step length, and
double support, in the days before and after administering the support.

A 26-year-old female, with a body mass index of 20.2, presented to

the Orthopedic Institute with pain in the metatarsophalangeal joint
(MTP1) of the right foot, rated at 6/10 on the NPRS (Numeric Pain
Rating Scale) for over 5 years. The pain did not occur at night but
increased after her activity as a Latin American dancer, and she couldn’t
find any physical posture that would alleviate the pain. She had taken
anti-inflammatories for a short period, but they did not alleviate the
pain. She had no history of fever, trauma, or systemic disease. She had
previously undergone corticosteroid infiltration a year earlier, which
had been beneficial for a few months, and an X-ray (Fig. 1) had
confirmed the initial degeneration of the MTP joint, but she had never
tried manual foot physiotherapy or orthopedic insoles to alleviate the
pain. The clinicians chose X-rays for the initial diagnosis of hallux rig­
idus based on their effectiveness in detecting bony alterations and joint
changes, offering a less invasive and more accessible approach
compared to CT scans. Although CT scans provide more detailed images,
X-rays are often sufficient for an accurate diagnosis of hallux rigidus and
are preferred for their practicality, lower cost, and reduced radiation
exposure. [10–14]. On objective examination, the active movement of
the MTP joint of the big toe showed modest limitation in the sagittal
plane, measured using an analog goniometer (10–15 degrees), but an
increased sensation of pain throughout the foot, measured using the NRS
scale (6–7). The Jack test was performed to passively test the capsular
tissue of the MTP joint, and the Tip Toe Standing test to assess load-
bearing capacity, both of which turned out positive. The “Jack test” is
a passive stress test used to assess the stability of the capsular tissue of
the MTP joint. The “Tip Toe Standing Test” is used to evaluate load-
bearing capacity and involves standing on the ball of the foot to see if
it causes pain or instability in the joint. Often these two tests are per­
formed one after the other; when one or both are positive, there is a
more or less marked difficulty in dorsalizing the first ray, the propulsive
phase of walking is affected by compensatory changes in gait. Unfor­
tunately, the validity of these tests has not been calculated. The Jack test
[15] has an intraclass correlation coefficient (ICC) of 0.997
(0.995–0.999) [8]. On palpation, a palpable mass was found in the
dorsal region of the MTP joint of the right foot, which, according to
1.2. Clinical findings
Upon further diagnostic evaluation, radiographic imaging was also
conducted to assess the structural integrity of the MTP joint. The X-rays
(Fig. 1) revealed initial signs of joint degeneration, corroborating the
clinical findings and adding another layer of diagnostic certainty. No
significant bone deformities or osteophytes were observed, which ruled
out the need for immediate surgical intervention. The radiographic
findings, in conjunction with the clinical tests and patient-reported
outcomes, provided a comprehensive understanding of the condition,
further validating the effectiveness of the soft cotton support (Fig. 4) in
alleviating symptoms and improving joint function. This case study
adheres to the SCARE [16](Surgical Case Report) guidelines for
reporting surgical case studies.
1.3. Timeline
Day 0: Initial presentation of symptoms (Patient reports pain and
stiffness in the right foot MTP joint).
Day 3: Application of plantar support (Custom plantar support is
applied after assessment) (Fig. 4).
Day 5: Assessment of initial response (Initial reduction in pain and
improvement in functionality observed, cotton felt removal).
Day 10: Follow-up via telephone (Patient reports sustained pain re­
lief and comfort from the plantar support).
1.4. Diagnostic assessment
Jack’s Test [15],Tip Toe Standing test [17], Baropodometric Plat­
form [18], Smartphone [19].
The Jack’s Test helps evaluate passive dorsiflexion of the joint, while
the Tip Toe Standing Test provides insights into the patient’s ability to
bear weight on the affected joint. Both contribute to a more compre­
hensive and informed diagnosis.

Table 1
Spatio-temporal parameters of walking measured with smartphone.
Parameter J-2 (October 20, 2022) J-1 (October 21, 2022) J0 (Visit - October 22, 2022) J + 1 (October 23, 2022) J + 2 (October 24, 2022)

Speed (m/s) 5.10 4.75 5.45 5.50 5.00

SD: 1.54 SD: 1.98 SD: 1.27 SD: 1.47 SD: 1.36
SE: 0.68 SE: 0.88 SE: 0.57 SE: 0.65 SE: 0.60
Stride Length (cm) 71.00 61.00 72.00 77.50 75.00
SD: 2.50 SD: 2.00 SD: 2.60 SD: 2.80 SD: 2.70
SE: 1.12 SE: 0.89 SE: 1.16 SE: 1.25 SE: 1.21
Double Support (sec) 28.95 26.30 27.25 29.25 28.06
SD: 1.45 SD: 1.31 SD: 1.36 SD: 1.46 SD: 1.40
SE: 0.65 SE: 0.59 SE: 0.61 SE: 0.65 SE: 0.63
Walking Stability Appropriate Inappropriate Appropriate Appropriate Appropriate

Note: The days are indicated in relation to the visit (J0) when the cotton support was applied. J-2 and J-1 represent the days before the visit without the cotton support,
while J + 1 and J + 2 represent the days after the visit with the cotton support, SD: Standard Deviation, SE: Standard Error.

2
R. Tedeschi
Fig. 1. X-rays foot.
1.5. Therapeutic intervention
The chosen intervention was a non-surgical method involving the
application of compressed cotton support, selected for its conservative
nature suitable for the young patient’s condition of hallux rigidus. The
intervention entailed applying the cotton support to the plantar area of
the foot in a clinical setting. The application was carried out by an
experienced podiatrist, specializing in non-surgical foot treatments.
Recent advancements in computational simulation have shown
promising potential in the field of medical investigation, particularly in
orthopedics. demonstrate Studies [20,21] the efficacy of computational
models in assessing stress and wear in prosthetic joints under various
conditions.
1. Speed (m/s):Before Application (J-2, J-1): The speed was lower
before the visit, averaging 4.925 m/s.
On the Day of Visit (J0): There’s an increase in speed to 5.45 m/s.
After Application (J + 1, J + 2): Post-application, the speed slightly
decreased on J + 2 compared to J + 1, but both values are higher than
the pre-application days.
2. Stride Length (cm): Before Application: The stride length was shorter
before the application, with a noticeable decrease on J-1 (61.00 cm).
On the Day of Visit: It increased to 72.00 cm.
After Application: Post-application, the stride length increased
further, peaking at 77.50 cm on J + 1.
3. Double Support (sec): Before Application: The time spent in double
support was lower before the application.
On the Day of Visit: There was a slight increase to 27.25 s.
After Application: The time increased further on J + 1 and then
slightly decreased on J + 2 but remained higher than pre-application
values.
4. Walking Stability: Before and After Application: Walking stability
was noted as “Appropriate” on all days except for J-1, where it was
“Inappropriate.”
The data reflects changes in walking parameters following the
application of compressed cotton support to the MTP joint. Notably,
there was an improvement in both walking speed and stride length after
the support application. Speed increased from an average of 4.925 m/s
before the visit to 5.45 m/s on the day of the visit and remained higher
post-application. Similarly, stride length showed an increase, reaching
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International Journal of Surgery Case Reports 114 (2024) 109197
its peak the day after the application. The time spent in double support
also increased post-application, indicating a possibly more cautious gait.
Walking stability was generally maintained as ‘Appropriate’ throughout,
with an exception on the day before the visit. These observations suggest
that the compressed cotton support might enhance mobility and comfort
for individuals with MTP1 joint issues.
2. Follow-up and outcomes
After the application of the compressed cotton support under the
head of the 1st metatarsal of the right foot, we reviewed her during the
follow-up about a week later. Her pain was 1/10 on the NPRS scale, and
she was prescribed orthotics with the same modification as the applied
support. A follow-up examination has not yet been conducted.
3. Discussion
Hallux rigidus (HR), characterized by stiffness and pain in the big toe
joint, represents a significant challenge in foot pathology. This condition
arises from wear and tear on the joint over time or due to repetitive
trauma or acute injury [23,24]. The symptoms, predominantly pain and
limited mobility, necessitate an early and accurate diagnosis to prevent
further degeneration and the need for surgical intervention [25].
Our study’s findings regarding the increase in plantar pressures from
120.4 kPa to 125.8 kPa post-treatment align with [26]. This improve­
ment indicates enhanced support in the forefoot, crucial for the effective
management of HR. Despite the limitations of a case report format, our
study provides valuable insight into symptom assessment and the
objective evaluation of joint stability, using methods like the NPRS scale
and a baropodometric platform [27].
The multidisciplinary approach in diagnosing and treating the pa­
tient in our study, especially considering the patient’s young age, em­
phasizes the complexity and necessity of a comprehensive evaluation in
HR cases [28]. The use of smartphone technology for patient follow-up,
particularly in tracking spatiotemporal parameters, is an innovative
aspect of this study. It highlights the potential of modern technology in
enhancing patient care [29].
Interestingly, the application of soft compressed cotton support in
the plantar area of the MTP joint suggests a promising non-surgical
intervention. This approach not only improved foot function but also
limited compensations, raising questions about its mechanism of action
on the accessory joint movements [30]. Our findings, though pre­
liminary, suggest that such interventions could lay the groundwork for
accurate plantar orthosis prescriptions [31].
The slight deterioration in patient outcomes on the second day post-
intervention, potentially due to the material properties of the felt, un­
derlines the need for further research into the durability and long-term
R. Tedeschi
Fig. 2. Dynamic Baropodometric Platform: plantar pressures during walking [22].
efficacy of such treatments.
In conclusion, our study adds to the existing body of knowledge by
using compressed felt as a therapeutic and evaluative tool in HR,
demonstrating the potential of non-surgical approaches. However, more
high-quality studies are necessary to confirm these findings and explore
their generalizability.
The integration of imaging diagnostics, as seen in our case where
radiographic imaging confirmed the initial degeneration of the MTP
joint, plays a crucial role in treatment planning and long-term man­
agement of HR. This comprehensive diagnostic approach is essential for
optimizing patient outcomes in conditions as potentially debilitating as
hallux rigidus.
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International Journal of Surgery Case Reports 114 (2024) 109197
3.1. Evaluation tool validity in our study
• Baropodometric Platform: This tool is established for assessing foot
biomechanics, though its effectiveness depends on precise calibra­
tion and expert interpretation.
• Smartphone Application: The app’s innovative approach offers
convenience, but its validity is contingent on sensor accuracy, which
may not match the precision of traditional clinical tools.
While the plantar support showed positive patient feedback, its
effectiveness needs further validation through controlled trials and
comparison with other treatments. The tools used show promise but
require more extensive validation in future research.
R. Tedeschi International Journal of Surgery Case Reports 114 (2024) 109197

Fig. 3. Dynamic Baropodometric Platform: plantar pressures during walking with support of the 1st MTP of the right foot [22].

3.2. Weaknesses of the case report: limited follow-up
One of the primary weaknesses of our case report is the insufficient
length of follow-up. While the initial outcomes post-intervention
showed promising results, the short-term nature of our observation
period limits our ability to assess the long-term efficacy and sustain­
ability of the treatment. A longer follow-up period would provide
valuable insights into the durability of the therapeutic effects, potential
long-term complications, and the need for ongoing interventions.
3.3. Patient perspective
An important aspect of our case report is the patient’s own
perspective on the treatment received. In this instance, the patient
expressed significant satisfaction with the non-surgical intervention.
They reported a notable reduction in pain and an improvement in foot
functionality, which positively impacted their daily activities and
overall quality of life. This patient feedback underscores the effective­
ness of the treatment from the viewpoint of those directly experiencing
its benefits, adding a crucial dimension to the evaluation of the thera­
peutic intervention.
Ethical approval
Ethical approval is not a requirement at our institution for reporting
individual cases or case series.
Funding
There is no source of funding.

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R. Tedeschi
Fig. 4. Plantar Support Application on Hallux.
CRediT authorship contribution statement
RT contributed to conception and design of the study; RT to data
acquisition, RT to data analysis and interpretation; RT contributed to
draft the manuscript; RT contributed to the critical revision for impor­
tant intellectual content. All authors read and approved the final version
of the manuscript.
Guarantor
Roberto Tedeschi.
Informed consent
The subject signed a standardized informed consent. Ethics com­
mittee: not required.
Consent
Written informed consent was obtained from the patient for publi­
cation of this case report and accompanying images. A copy of the
written consent is available for review by the Editor-in-Chief of this
journal on request.
Declaration of competing interest
As the sole author of this manuscript, I declare that there is no
financial or personal relationship with any individual or organization
that could inappropriately influence or bias the work presented in this
paper. There has been no external funding for this research, and as such,
there are no financial conflicts of interest to report.
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