Hallux rigidus is arthritis of the joint at the base of the big toe. It is the most common arthritic condition of the foot, affecting 1 in 40 people over the age of 50 and typically developing in those over age 30. Big toe arthritis tends to affect women more than men.
The big toe joint is called the hallux metatarsal phalangeal (MTP) joint. This joint connects the head of the first foot bone (metatarsal) with the base of the first toe bone (proximal phalanx) and the two tiny bones (sesamoids) underneath the metatarsal.
Usually the greatest area of wear is at the top of the joint.
Most patients feel pain in the big toe joint while active, especially when pushing off to walk. Often, there is swelling around the big toe joint or difficulty moving and bending the toe. A bump, like a bunion or bone spur, can develop on top of the big toe joint and be aggravated by rubbing against the inside of a shoe.
The cause of hallux rigidus is not known; however, there are several risks factors, including a long or elevated first foot bone or other differences in foot anatomy, prior injury to the big toe, and family history. These can lead to excessive wear of the joint, which in turn leads to arthritis.
The foot of a patient with big toe arthritis. Notice the bump is on the top of the foot, in contrast with a bunion bump, which is on the inside of the foot.
In many cases, hallux rigidus can be diagnosed with a physical examination. Your foot and ankle orthopaedic surgeon will examine the MTP joint to see how much you are able to move and where the pain occurs. Your surgeon also will check your foot for evidence of bone spurs. X-rays may be taken to identify the extent of joint degeneration and to show the location and size of bone spurs. These X-rays are best done with you standing and putting weight on your foot. MRI and CT scans usually aren’t needed.
Non-surgical management is always the first option for treatment of hallux rigidus. Your physician may suggest pain relievers and anti-inflammatory medicines and ice or heat packs to reduce pain. Platelet-rich plasma injections and similar injections into the joint are promising but vary in effectiveness.
Changing shoes also may help. Avoiding thin-soled or higher-heeled shoes can minimize the pressure at the top of the joint. Shoes with a stiff sole, curved sole (rocker bottom), or both also may minimize joint pain. Shoe inserts as well as arch supports that limit motion at the MTP joint also can help.
Although these treatments may decrease the symptoms, they do not stop the condition from worsening.
If non-surgical treatments do not relive the pain, your doctor may recommend surgery. The type of surgery would be determined by the extent of arthritis and deformity of the toe.
For mild to moderate damage, removing some bone and the bone spur on top of the foot and big toe can be sufficient. This procedure is called a cheilectomy. Removing the bone spur allows more room for the toe to bend up and relieves pain caused when pushing off the toe. This procedure also can be combined with other bone cuts that change the position of the big toe and further relieve pressure at the top of the joint.
The advantages of this procedure are that it maintains stability and motion, and preserves the joint itself. Most patients can participate in physically strenuous activity such as running without pain.
Advanced stages of hallux rigidus with severe joint damage are often treated by "welding" the big toe joint. This procedure is called arthrodesis or joint fusion. In this procedure, the damaged cartilage is removed and the two bones are fixed together with screws and/or plates so they can grow together.
The main advantage of this procedure is that it is a permanent correction to reduce pain. The major disadvantage is that it restricts movement of the big toe, although most patients can still be active.
For the patient with moderate to severe hallux rigidus who wants to avoid loss of motion, an interpositional arthroplasty may be an option. This procedure removes some of the damaged bone (similar to a cheilectomy) and places a spacer between the two bones to minimize contact on either side of the joint.
In a common interpositional arthroplasty technique, a piece of soft tissue is used as the spacer in an attempt to resurface the joint. This soft tissue can come from your foot, another part of your body, or even prepared cadaver tissue. The operation does preserve some motion but is not as predictable for pain relief and may not restore the normal mechanics of the joint.
Arthroplasty, or replacing one or both sides of the joint with metal or plastic parts, is intriguing due to the success orthopaedic surgeons have demonstrated with these procedures in the knee, hip, ankle, and other joints. Orthopaedic surgeons are cautious to recommend it at this time due to reports of higher complication rates, unpredictable short- and long-term results, as well as difficulty with salvage procedures should the joint replacement fail. Consult with your foot and ankle orthopaedic surgeon for more information.
The length of recovery depends upon the type of surgery performed. For cheilectomy and interpositional arthroplasty, most surgeons recommend wearing a hard-soled sandal and allowing weightbearing as tolerated for about two weeks before a gradual return to normal footwear. For a fusion or procedure that cuts the bone, the foot may be in a cast or boot for 4-8 weeks, and limited weightbearing may be allowed for 2-3 months. You can expect some foot swelling, stiffness, and aching for several months after the procedure, depending on your level of activity.
After recovery, most patients are able to exercise, run, and wear most shoes comfortably. Running and jumping may be more difficult for patients undergoing fusion surgery and is not recommended after joint replacement. Patients may still find stiff-soled, rocker bottom shoes more comfortable for exercise.
Any surgery has risks, including scarring, infection, and failure to relieve symptoms. However, these risks are very infrequent with the above procedures unless there are other factors such as cigarette use or a poor immune system. Consult with your foot and ankle orthopaedic surgeon for specifics in your situation.
Yes. In many cases, symptoms improve with shoe modifications, NSAIDs, corticosteroid injections, and physical therapy.
Shoes with a wide toe box and stiff or rocker soles help reduce pressure and relieve pain.
No. While both affect the big toe, a bunion causes a bump on the inside of the toe, while hallux rigidus involves joint stiffness and pain on the top.
Arthrodesis (fusion) has the most reliable long-term results for pain relief but limits toe mobility.
Recovery can range from 2 weeks (cheilectomy) to several months (fusion or osteotomy), depending on the procedure.
Contributors/Reviewers: F. Ray Nickel, MD; Jeff Feinblatt, MD
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