What is Hallux Rigidus?
Hallux rigidus is the medical name for arthritis of the big toe. It literally means ‘stiffening of the big toe’. It affects the joint base of your first toe called the metatarsophalangeal joint, or MTP joint, and is the most common site of arthritis in the foot.
The pain and stiffness of hallux rigidus leads to difficulty walking and bending the toe. It is a condition caused by the wear and tear of the lubricating cartilage that lines the joint. As the cartilage wears away, the bone becomes scarred and overgrows near the edges, resulting is bony spurs or ‘osteophytes’ that reduce the movement of the toe.
There are a number of effective treatments for hallux rigidus, including pain killers and special footwear or insoles to ease the pain. Surgery is also an option, which include operations such as cheilectomy or joint fusion.
F.A.Q. | Frequently Asked Questions
More Information
Please note that the accuracy of any information provided by external sites is not guaranteed by Orthoanswer. Always discuss your condition with your doctor/health specialist.
- About.com provides lots of information about ankle sprains, instability, treatment options etc. http://orthopedics.about.com/cs/sprainsstrains/a/anklesprain_4.htm
- Pueblo Ankle and Foot Care is an American site that provides brief, easy-to-understand information about many foot and ankle conditions: http://www.puebloankleandfoot.com/conditions/chronic-ankle-instability
References
F. Bonnel, et al., ‘Chronic Ankle Instability: Biomechanics and pathomechanics of ligaments injury and associated lesions’, Orthopaedics and Traumatology: Surgery & Research, Vol 96, Iss. 4, June 2010, pp 424-432.
K. W. Chan, ‘Acute and chronic lateral ankle instability in the athlete’. Bulletin of the NYU Hospital for Joint Diseases, 2011, Vol. 69, Iss. 1, pp 17-26.
PO McKeon PO, et al., ‘Balance training improves function and postural control in those with chronic ankle instability’, Medical Science Sports Exercise, 2008, Vol 40, Iss. 10, pp 1810-1819.
Causes
Hallux rigidus is caused by arthritis in the big toe. This is usually a result of long-term wear and tear over life.
The pain of hallux rigidus is caused by:
- Irritation and inflammation of the joint as cartilage wears away
- The bone directly beneath the cartilage tends to become scarred and may develop holes (‘cysts’) that weaken the bone. This may cause a gradual collapse of the bones against one another.
- In severe cases, rubbing of the bones against one another when cartilage has completely worn away.
The stiffness is caused by the formation of bony spikes around the edge of the joint.
Risk Factors
The reasons why some people develop hallux rigidus and other do not is unclear, however the following are thought to be associated with increased risk:
- A long first toe
- A toe that is abnormally aligned or positioned, of excessively flexible
- Other causes of pain in the big toe, like gout or rheumatoid arthritis are thought to make the development of hallux rigidus in later life more likely.
Investigations
Your doctor or specialist will be able to diagnose hallux rigidus by listening to you, then examining your foot and ordering X-Rays. X-rays are also used to assess the severity of the arthritis in the joint.
When X-Rays are unclear, additional tests may be required to rule out other diseases. This may include blood tests and/or sampling of the joint fluid. These will tell your doctor if you have other forms of arthritis like rheumatoid, gout and pseudogout.
Complications
- Growth of extra bone over the top of the big-toe joint.
- Development of pain and/or deformity in the rest of the foot.
- Sometimes, the abnormal walking pattern that develops to adapt to hallux rigidus causes pain in the knees, hips and/or lower back.
- Numbness and tingling in the foot.
Treatment
In mild-moderate hallux rigidus, pain and difficulty walking can managed through a combination of physical therapy, modified shoes or orthotics and over the counter pain relief, like panadol.
When these methods start to fail, injections directly into the joint are often helpful. Beyond this, there are a number of surgical options available, varying in risk and degree of function maintained post-operatively.
What are the non-surgical options for Hallux Rigidus?
- Medication. Painkillers like panadol and anti-inflammatory medications will help with the pain and inflammation of arthritis. These will therefore help to reduce the discomfort.
- Foot wear. Wearing good shoes can help minimise discomfort from Hallux rigidus. This includes shoes that are wide at the front and are stiff.
- You will know if your shoe is sufficiently stiff if when you hold it in your hands, it is difficult to bend in half.
- Insoles. Insoles are things that you can put in your shoes to either limit the movement of your big toe or provide cushioning around the painful joints in your feet. These will be provided by an Orthotist.
Footwear prescribed by a professional orthotist is invaluable. In some cases these are expensive, however your orthotist may be able to discuss cheaper options, like ready made orthotics rather than custom-made design.
Physical Therapy
A physiotherapist can provide a series of exercises that:
- Strengthen the muscles in your feet and calves
- Correct your walking pattern (‘gait’)
Your physio can also provide significant pain relief.
Manipulation & Injections
Manipulation and injections are procedures that can be performed to help improve flexibility and reduce inflammation in a painful big toe that has arthritis.
The injection and manipulation are performed at the same time. You will need to come into hospital for the day for this procedure which is usually performed under general anaesthetic. Once you are sleep, the Orthopaedic Surgeon will manipulate your big toe to make it more flexible and will inject the joint with a mixture of steroid and local anaesthetic.
After this procedure, you can walk normally straight away (full weight bearing). Occasionally soreness increases for a few days following the procedure before it improves.
This is only effective in people with early or mild arthritis. It may have an effect in reducing pain and improving flexibility in your big toe for months or even years.
What are the surgical options for Hallux rigidus?
There are several types of surgery for the treatment of Hallux Rigidus. These options include:
- Cheilectomy
- Joint fusion (arthrodesis)
What is involved in a Cheilectomy?
Cheilectomy is an operation to remove the extra bone that forms on the top of the big toe joint causing pain and limiting movement.
A small incision is made over the big toe joint. The orthopaedic surgeon will trim away the bony growth that is irritating the joint. The incision is then closed with stitches.
You are encouraged to move the toe as soon as possible to keep the joint flexible. You may however need to wait until the incision wound has healed adequately. This should be discussed with your doctor or surgeon.
For those patients with less severe arthritis there is an 80% chance of this surgery being successful for up to 5 years. If a Cheilectomy fails to improve your condition, a fusion operation may be undertaken at a later date.
For more information, see Cheilectomy.
What is involved in a joint fusion (arthrodesis)?
Fusion operations are used to create stable painless joints. Screws are positioned across the toe joint, keeping it completely stiff and straight. The disadvantage is that all movement at the joint is lost, so that arthrodesis is only recommended when the pain and stiffness is severe. Despite this, arthrodesis is an extremely effective way of relieving pain and facilitating walking.
Like a cheilectomy, an arthrodesis involves a small incision made over the big toe joint. The joint is removed and the bone ends held together with screws and sometimes a plate. The bones then grow and heal around the screws.
After you leave surgery, you will need to discuss with your doctor what kinds of activities you should avoid. This will often include:
- Not wearing high heels
- Avoiding running
Most surgical procedures are performed with a combination of local and general anaesthetic. This combination maximises the chances of returning home the same day following surgery.
You should be able to put weight on your foot as soon as you are comfortable.
For more information, see First Metatarsal Arthrodesis.
Are there any risks associated with these procedures?
Possible complications of surgery include:
- Surgery does not always completely correct hallux rigidus, resulting in residual pain and/or stiffness in the joint.
- Infection. All invasive procedures carry a small risk of infection. These risks are higher if you are a smoker or diabetic, and in fusion operations where screws are used.
- Swelling
- Bleeding and problems with wound healing. These tend to be more common in diabetics, but are fairly rare in hallux rigidus operations.
- Injury to nerves – Numbness or tingling can occur at the wound or in the toe. This is usually temporary but in some it may be permanent.
- Blood clots- Deep vein thrombosis (DVT) or pulmonary embolism (PE) are rare. You will be encouraged to walk around as soon as possible after your surgery to avoid the development of DVT. If you or your family have a history please let us know.
When surgery is complicated or fails, you may need follow-up surgeries.
- Arthrodesis when cheilectomy fails.
- Re-positioning for fusion. Research has shown that 5-10% of cases do not fuse in the exact position intended. This may be due to the position not being achieved during surgery of movement of the bones following surgery. You will not be able to wear high heels following a fusion.
- Removal of screws. Occasionally prominent screws or screws that cause irritation may need to be removed.
- When the bone fails to heal around the screws, revision surgery is required. This is called ‘failed’ fusion. Research has shown that this occurs in approximately 10% of cases but is significantly greater if you smoke.
Seeking Advice
You will probably have suffered from gradually worsening pain and stiffness for some time before you decide to see your doctor. Orthotics and other non-surgical methods will help prevent the progression of disease, so you should try to seek help once you find that over-the-counter pain relief is not enough for you.
If you have diabetes and you notice your hallux rigidus is rubbing against your shoes, you should discuss this with your diabetic foot specialist, GP or diabetes specialist. You may need to see a podiatrist for review of your feet and to avoid ulcers developing over your big toe.
Your Family Doctor (GP)
Your Family Doctor will be able to diagnose and help treat your problem. He or she will be able to
- tell you about your problem
- advise you of the best treatment methods
- prescribe you medications
- and if necessary, refer you to Specialists (Consultants) for further treatment
Prevention
You can help prevent the development of arthritis by
- Wearing comfortable, well-fitting shoes
- Maintaining a healthy weight
- Stopping smoking.