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.
Symptoms
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.
Causes
The cause of hallux rigidus is not known; however, there are several risks factors, including a long or elevated first metatarsal 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.
Diagnosis
In many cases, the diagnosis of hallux rigidus can be made with a physical examination. Your foot and ankle orthopedic 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 will 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.
Treatments
Non-surgical management is always the first option for treatment of hallux rigidus. A 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.
Changes in footwear 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 (like Hoka), 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.
Surgery may be required if non-surgical management fails to fully address symptoms. The type of surgery would be determined by the extent of arthritis and deformity of the toe.
Bone Spur Removal (Cheilectomy): 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. The advantages of this procedure are that it maintains stability and motion, and preserves the joint itself.
Joint Fusion (Arthrodesis): Advanced stages of hallux rigidus with severe joint damage are often treated by fusing the big toe joint. 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.
Joint Resurfacing (Cartiva): 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.
The Cartiva technique uses a synthetic cartilage implant plug made out of polyvinyl alcohol as the spacer. The advantages of this procedure are that it requires less bone to be removed and it is typically easier than a failed joint replacement to convert to fusion if it fails. In limited studies, it also has shown to be as effective as fusion in relieving pain, while preserving motion of the joint. This is a newer procedure and additional studies are needed to examine the results over time.
Recovery
The length of recovery depends upon the type of surgery performed, and is shorter for cheilectomy and Cartiva procedures and longer for fusions. 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.
