Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Hallux Rigidus


Related Terms

  • Arthrosis
  • First Metatarsophalangeal Joint Arthritis
  • Hallux Limitus

Differential Diagnosis

Specialists

  • Orthopedic (Orthopaedic) Surgeon
  • Podiatrist
  • Rheumatologist

Factors Influencing Duration

Factors that may influence length of disability include the individual's age, whether one or both feet are involved, the stage at which treatment has been initiated, whether the individual has had surgery, the severity of symptoms, and the individual's response to treatment. The individual's basic job requirements and whether work modification is possible also can affect the duration of disability.

Significant loss of joint space and osteophyte formation at the first MTP joint may indicate that articular degeneration has progressed to the point that work requiring prolonged walking is no longer reasonable.

Medical Codes

ICD-9-CM:
735.2 - Hallux Rigidus, Acquired

Overview

Hallux rigidus is a degenerative arthritic condition that affects the large joint at the base of the great toe (metatarsophalangeal joint or MTP joint). When the joint is mildly stiff, the condition is called hallux limitus. When the joint becomes so arthritic that it is very stiff (almost no motion or no motion), it is called hallux rigidus.

The ends of the bones at the MTP joint are covered with cartilage. Hallux rigidus develops when this cartilage begins to wear away (degenerate) and bone rubs against bone. Bone spurs (osteophytes) may form over time, causing pain with toe movement during walking.

Often the cause of hallux rigidus is unknown (idiopathic). The most probable cause of the condition is the tremendous stress placed on this joint during walking. With each step, a force equal to 3 to 4 times the body weight passes through this joint. For some individuals, the condition begins when there is an acute injury to the joint cartilage, such as occurs with a traumatic hyperextension (dorsiflexion injury) to the great toe (turf toe). The injury initiates a degenerative process that may continue for years before symptoms appear. In other individuals, it is thought that chronic, repetitive injury may be the cause. Sometimes hallux rigidus may be secondary to some other medical condition (e.g., gout or infection of the joint); in most individuals, however, no definitive cause can be identified.

Incidence and Prevalence: Hallux rigidus is observed in only 2.2 per 100,000 adolescents, but in individuals aged 60 and over the incidence is 2,000 per 100,000 (Thoradson 227).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Hallux rigidus is fairly common and usually not influenced by age, although it is more common in females. Both feet may be involved (bilateral involvement) in individuals with a family history of hallux rigidus (Coughlin 731). It is believed that minor anatomical differences in the foot may make it more likely that certain individuals develop hallux rigidus, such as having a flat foot (pronated foot) or a relatively long first toe, which may place the first MTP joint at risk for acute or repetitive trauma (Calvo 69).

Sports that involve running or jumping may predispose an individual to hallux rigidus. Trauma to the great toe may be a precursor to the condition.

Source: Medical Disability Advisor



Diagnosis

History: Hallux rigidus develops gradually, so individuals may mistakenly associate it with the activity they were doing when pain was first noticed. Individuals may report pain, intermittent swelling, and stiffness or loss of motion in the joint at the base of the great toe (MTP joint). They generally note that pain is worse during walking or running, because the MTP joint does not have the ability to move enough to allow the foot to roll through with each step.

Physical exam: Physical examination reveals swelling, tenderness, and very restricted motion of the MTP joint. The joint is painful when moved, particularly upward (dorsiflexion). In severe cases, the ability to bend the toe upward may be lost completely. Osteophytes may be felt (palpated) beneath the skin at the top of the MTP joint. The individual may be unable to perform a toe raise (calf raise) without pain.

Tests: X-rays are taken in order to evaluate the full extent of joint degeneration, osteophyte formation on the metatarsal head, and loss of joint space.

Source: Medical Disability Advisor



Treatment

Treatment usually begins with anti-inflammatory medications to control the inflammation and pain associated with the degenerative arthritis. Cortisone injected directly into the affected joint may give temporary relief.

Special shoes that reduce the amount of bending the toe incurs during walking also help lessen symptoms. A rocker-type sole (addition of a metatarsal bar) allows the shoe to take some of the bending force. In some cases, this sole can be combined with a metal brace (steel shank) in the sole to limit its flexibility, thereby reducing painful motion in the MTP joint. Shoes with extra depth and width and those with low heels may help to reduce painful pressure during walking.

Physical therapy that focuses on gentle joint mobilization to improve range of motion, and anti-inflammatory modalities such as ultrasound and electrical stimulation, may decrease pain. Activity modification to avoid extreme positions that place the toe in an extended position (squatting, lunging, toe raises) while weight bearing is important.

If other treatments fail, surgery may be suggested. One procedure called a cheilectomy involves removing bone spurs at the top of the MTP joint so they do not rub together when the toe extends. This procedure permits the toe to bend better and reduces pain with walking. It works best in the early stages when osteoarthritis has not significantly advanced.

Arthroscopic correction of the great toe joint often is effective in relieving symptoms, especially when there are underlying osteochondral lesions or loose bodies within the joint.

Partial removal (resection) of the top part of the joint (partial atherectomy or Valenti technique) may be performed to restore joint range of motion yet preserve joint stability (Harisboure). Cutting away part of the distal joint (proximal phalanx osteotomy or Moberg procedure) decreases compression of the MTP joint and helps restore range of motion.

Replacing the joint with an artificial joint (arthroplasty) similar to that of a knee or hip replacement can relieve pain and preserve joint motion. In this outpatient procedure, one of the joint surfaces is removed and replaced with a plastic, metal, ceramic, or polyethylene surface. However, this approach is controversial, as the artificial joint may not last a lifetime, and the individual will require repeat surgery when it fails.

Another surgical alternative is to remove the MTP joint between the two bones by joining the bones with a metal pin or screw and allowing them to fuse or grow together (arthrodesis). This fusion of the MTP joint alleviates pain but leaves the individual with a joint that no longer moves. Wearing a shoe with a rocker-type sole may improve the gait pattern following a fusion.

Source: Medical Disability Advisor



Prognosis

In the majority of individuals, the joint remains arthritic and stiff and tends not to get much worse. However, in some individuals, the joint becomes progressively stiffer and more painful, requiring further intervention. Conservative treatment with anti-inflammatory medications, activity modification, and special footwear can effectively treat symptoms and yield a good long-term outcome for many individuals.

When symptoms fail to respond to this type of treatment, surgery is required. Cheilectomy and arthrodesis are the most common forms of surgical treatment. The results of surgery are usually good. Research examining pain relief and patient satisfaction comparing arthrodesis with arthroplasty for hallux rigidus showed better long-term results with arthrodesis than with arthroplasty (Frontera).

Source: Medical Disability Advisor



Complications

As with any foot problem, pain may lead to an altered gait. This can place abnormal stress on other parts of the foot, ankle, and knee, creating pain in these joints and eventually causing back pain.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Since pain is worsened by weight-bearing activities, activities such as squatting, walking, lifting, or prolonged periods of standing may be restricted. According to the individual's job requirements, other accommodations (e.g., use of crutches or a cane or a special postoperative shoe) may be needed. Company policy on medication usage should be reviewed to determine if pain medication use is compatible with job safety and function.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Was cause of hallux rigidus determined?
  • Was there a previous injury to the joint cartilage?
  • Were there secondary medical conditions that may have contributed to the development of hallux rigidus? Have these been treated?
  • Does individual participate in a sport that involves running or jumping?
  • Does individual experience pain, intermittent swelling, or stiffness, or loss of motion in the MTP joint?
  • Is pain aggravated during walking or running?
  • Were conditions with symptoms similar to hallux rigidus ruled out?
  • Did x-rays confirm arthritic changes?
  • Were bone spurs present?

Regarding treatment:

  • Was individual given oral anti-inflammatory medications or steroid injections?
  • Was individual supplied with special shoes with a rocker-type sole? Was a metal brace in the sole also used?
  • Did conservative treatments fail to alleviate the condition?
  • Was surgery performed? If so, what type of surgery was necessary? Cheilectomy, arthroscopy, osteotomy, partial arthrotomy, fusion of the MTP joint, or arthroplasty?
  • Was appropriate rehabilitative therapy provided after surgery?

Regarding prognosis:

  • Is individual's employer able to accommodate any necessary restrictions?
  • Does individual have any conditions that may affect ability to recover?
  • Has joint become progressively more stiff and painful?
  • Did pain cause individual to alter gait? Was gait training provided?
  • Has back pain occurred?
  • Is individual wearing appropriate orthopedic shoes?

Source: Medical Disability Advisor



References

Cited

Calvo, A., et al. "The Importance of the Length of the First Metatarsal and the Proximal Phalanx in the Etiopathology of the Hallux Rigidus." Foot and Ankle Surgery 15 2 (2008): 69-74.

Cassidy, C., and V. Chung. "Hand and Wrist Ganglia." Essentials of Physical Medicine and Rehabilitation. Eds. Walter R. Frontera, Julie K. Silver, and Thomas Rizzo. 2nd ed. Philadelphia: Saunders, Elsevier, 2008. 149-154.

Coughlin, Michael J. "Hallux Rigidus: Demographics, Etiology, and Radiographic." Foot & Ankle International 24 10 (2003): 731-743.

Hairsboure, A., et al. "The Valenti Technique in the Treatment of Hallux Rigidus." Revue de Chirurgie Orthopedique et Traumatologique 95 3 (2009): 240-247. PubMed. 22 Jun. 2009 <PMID: 1939491>.

Thoradson, D. B., ed. "Chapter 11: Degenerative Joint Disease/Forefoot Arthritis." Foot and Ankle. 2nd ed. Lippincott, Williams & Wilkins,

Source: Medical Disability Advisor






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