Big Toe Arthritis - Hallux Rigidus (Stiff Big Toes)

What is Hallux Rigidus?

Hallux Rigidus essentially involves stiffening or locking up of the big toe joint due to an ongoing arthritic process in the joint. The joint cartilage wears down resulting in pain in the big toe joint, stiffness and limited movement.

It affects both men and women equally but can be exacerbated by previous trauma. Often patients present with a stiff big toe or Hallux Rigidus deformity and pain within the big toe joint. An injury to the joint may predispose a person to Hallux Rigidus. It is not unusual for patients to have stubbed the toe, or someone else may have stood on their big toe many years ago. Initially, a patient may have had some temporary pain they did not think much of at that time. However, over time the joint becomes stiffer and painful.

Hallux Rigidus Symptoms

• Pain and stiffness: These are common symptoms of Hallux Rigidus. Pain and stiffness can be more prevalent during activities such as walking, standing or pushing off while running as they engage the big toe joint. The stiffness in the big toe joint can limit range of motion.
• Limited Range of Motion: The range of motion of the big toe becomes limited, particularly during dorsiflexion (bending the toe upward).
• Swelling: Inflammation and swelling may occur around the affected joint, contributing to pain and discomfort.
• Difficulty Walking: As the condition progresses, activities that involve bending the big toe become more challenging, this may alter your gait to compensate for the pain and stiffness.
• Bone spurs: Over time, the MTP joint in the big toe may develop a bony prominence or enlargement, known as an osteophyte. This can also contribute to a visible deformity of the first MTP joint.

Hallux Rigidus Diagnosis:

• Physical examination: Your specialist will examine your foot and the big toe. They will look for signs of swelling, redness or deformity. The range of motion in the big toe joint will be assessed for pain and stiffness.
• Medical history: Your foot and ankle specialist will request information about your symptoms, such as location and triggers of the pain.
• X-rays: An X-ray is commonly used to assess the bones and joints. It is important to assess a big joint deformity with the use of an X-ray to confirm whether there are osteophytes present, or any other abnormalities.
• MRI or CT scan: A magnetic resonance imaging (MRI) or computed tomography (CT) may be suggested in order to provide a more detailed imaging assessment.
• Gait analysis: An assessment of how you walk, called a gait analysis, may be carried out to ascertain how Hallux Rigidus is affecting your biomechanics.
• Arthrocentesis: Where the joint is aspirated using a syringe or needle to remove fluid. The fluid can be analysed by a pathologist to confirm presence of inflammatory cells, crystals (such as in gout or pseudogout), infection and other abnormalities.

Surgical Management of Hallux Rigidus.

Cheilectomy:

This procedure can be performed using minimally invasive surgery or a small open incision. This is usually reserved for mild to moderate osteoarthritis of the big toe or Hallux Rigidus, where only the bony enlargement over the top of the first metatarsal causes pain in shoes and impingement, and restricts joint extension. The procedure is very simple in that it can be performed via keyhole method through a small 3 to 4 mm incision made on top of the toe. A small bur is used to remove the bone spur and a camera may be inserted to the joint to ensure that everything is removed.

The patients will need to rest for 48 hours and then they can start walking again. Only a small plaster dressing on the wound will be present after the first 48 hours and they can transition into trainers. Typically, you may not be able to go back to sports for three to four weeks but normal walking will be allowed after the first 48 hours.

Arthrodesis (Fusion of the big toe joint):

This is the gold standard in advanced or significant osteoarthritis of the big toe joint, where most of the motion has already been lost in the big toe joint and there is very little viable cartilage. Patients who are suitable for the fusion procedure often do not walk properly through the big toe joint and walk only using the outside of the foot, resulting in pain in the hips or the knees, this is known as low gear walking.

A fusion procedure is very successful in that it improves the loading of the foot so that you can walk through the stiff big toe joint pain-free. This allows normal gait and studies have shown that this in the long-term prevents other problems that could be associated with the painful big toe joint.

Typically, a 5-6 cm incision is placed on top of the toe and a screw or a plate is used to fuse the joint. Two weeks of complete rest with no more than 10 minutes an hour followed by using a boot or increasing activity carefully in the shoe to 15 to 20 minutes for the next four weeks until bone healing happens at six weeks. Sports may resume after approximately six to eight weeks gently and running may take a little longer.

Implant arthroplasty:

This is essentially a big toe joint replacement. It is suitable for the elderly patients who require very little ambulation, no long distance walking or hiking. It is not suitable for younger patients or patients with high activity demands, such as sports. Those patients are better suited for a fusion procedure. However, this is a straightforward procedure that allows quick recovery and return to shoes at approximately two weeks, once the swelling has settled. You can walk on the operated foot after the first 72 hours.

Joint implants for big toe joint have not proven successful in very active and young patient groups. The multi-dimensional demands of the joint are different to other larger joints and therefore they tend to fail in high demand patients.

Osteotomy:

Osteotomy of the big toe involves realigning of the metatarsal bone or the big toe to improve the range of motion in the joint. This is a rare procedure used where healthy cartilage is present but joint position does not allow range of motion in the big toe joint. This is the least used procedure and works well when there is very little, if any, cartilage damage.

Frequently Asked Questions

How common is Hallux Rigidus?

Hallux Rigidus has been reported with the prevalence of 2.5% of the population, which means that 1 in 40 people will develop osteoarthritis of the big toe joint through their lifetime. It presents equally in men and women and can be related to trauma or genetics.

What does Hallux Rigidus surgery involve?

Hallux Rigidus surgery involves either shaving down of the bone which is known as a cheilectomy procedure or fusion of the big toe joint which stops any movement and therefore results pain in the big toe joint. These are the most common procedures followed by a possible joint replacement or realignment of bones.

What are the Hallux Rigidus risk factors?

The risk factors for developing Hallux Rigidus can include mechanical problems such as flatfoot or short or long first metatarsal bone. Further genetics of developing osteoarthritis due to early wear and tear or previous history or trauma can exacerbate the problem. Wearing inappropriate or tight footwear can also result in Hallux Rigidus.

What is the best treatment for Hallux Rigidus?

Treatment for Hallux Rigidus depends on the severity of the symptoms and duration of the problem. In the first stages you may be able to use a rigid-soled shoe or an orthotic insole device to try to protect the movement in the joint. Should that not settle then an injection into the joint of either hyaluronic acid or steroid can help alleviate pain in the joint at least in the short-term but if conservative care fails then surgery is the only way of treating Hallux Rigidus and it is well known that fusion procedure has been present for more than 40 years with high success rates in approximately 97% of patients.

How long does it take to recover from Hallux Rigidus surgery?

Recovery from Hallux Rigidus surgery depends on the type of procedure. Most procedures will involve a period of two weeks of rest and then careful mobilisation until bone healing occurs at six to eight weeks. However, the minimally invasive cheilectomy procedure does allow an initial recovery period of 48 to 72 hours where you are resting and then returning back to most activities except for sports which may take three to four weeks.

Can you get rid of Hallux Rigidus?

Hallux Rigidus is an irreversible process in that the cartilage is worn down over time and this cannot be regenerated. The progression of the disease or correction or replacement of the joint problem can be achieved by surgery.