Hallux rigidus (HR) refers to stiffness (rigidus) of the joint at the base of the great toe (hallux). This joint is called the great toe metatarsophalangeal joint (MTPJ). The usual cause of HR is arthritis or wear and tear of the smooth cartilage that lines the joint. HR may be caused by a previous injury or it may be part of a general medical condition e.g. gout. Often the cause is unknown; it just develops, particularly as people get older. It is probably of little surprise that this joint is prone to arthritis as forces up to 2x body weight pass through it during walking.
HR presents with stiffness and pain in the great toe MTPJ. If the symptoms are severe, it may limit walking distance, and compromise work and recreational activities. Bone spurs (osteophytes) develop around the great toe MTPJ and can cause pain by rubbing against tight fitting shoes. To off-load the painful great toe, some people will preferentially walk on the outer border of the foot, causing transfer pain to the lesser toes.
TREATMENT – NON-OPERATIVE
The main aims are to relieve pain and decrease loading and movement through the great toe MTPJ. In it’s mildest form, HR may not need operative treatment with simple lifestyle and activity modifications such as weight loss, helpful. The following can also assist:
A walking aid can help increase mobility when difficulty moving is experienced.
Painkillers and anti-inflammatory medication such as tablets and creams can be prescribed by your doctor to assist in reducing pain.
Footwear and Orthotics
Wearing appropriate footwear and orthotics (stiff insoles or shoes with a rocker-bottom sole) can be helpful. High heels and shoes with a narrow toe box should be avoided.
A cortisone injection may offer relief of inflammation, but as with most treatments, the degree and extent of relief varies from patient to patient. The effect is usually only temporary as well.
TREATMENT – SURGERY
Surgery is considered when the previous measures fail. There are 2 main surgical options to relieve pain and improve quality of life. These include joint cheilectomy (“clean-up”), and arthrodesis or fusion of the MTPJ. The best option for an individual patient depends on many factors including the severity of arthritis, the age and functional demands of the patient, and the presence of arthritis in adjacent joints. The final choice is a joint decision between patient and surgeon.
MTPJ cheilectomy (Clean up)
If the HR is mild to moderate, affecting only the upper part of the joint, this upper portion may be trimmed and the joint washed out. This can provide long lasting pain relief with improved movement of the great toe in the appropriate patient. In 10-20% of patients, the arthritis is progressive and symptoms may return to a point where further procedures may be required. This procedure can generally be undertaken arthroscopically (keyhole) which allows a rapid recovery. Occasionally with large loose pieces of bone in the joint or excessively large bone spurs, an open procedure is required.
MTPJ arthrodesis (Fusion)
This is the ‘gold standard’ procedure for moderate to severe arthritis. The remaining cartilage in the joint is removed, the bones on either side of the joint are fused together and held with screws and a plate. Following recovery, people generally walk normally without a limp. While high-heeled shoes cannot be worn, up to a one inch heeled shoe can be worn if desired. Most social sports can also be undertaken. 95% of patients will experience good pain relief with this procedure. There is a small risk of developing arthritis in the next joint along the big toe but this is rarely troublesome.
SURGERY – RISKS AND COMPLICATIONS
Less than 5-10% will develop a complication that may require further intervention. These include wound-healing problems, infection, damage to nerves and blood vessels, incomplete relief of symptoms, and in the case of arthrodesis, failure of the bones to knit together requiring further surgery.
RECOVERY TIMES (CHEILECTOMY/CLEAN UP)
|Hospital stay||Day surgery|
|Rest and elevation||5-7 days|
|Time off work |
|Foot swelling||4-6 weeks|
RECOVERY TIMES (ARTHRODESIS)
|Hospital stay||Day surgery|
|Rest and elevation||10 days|
|Crutches/frame||Up to 7 days|
|Time off work |
|Foot swelling||12 weeks|
|Result times (Pain relief and function)|
This fact sheet is a brief overview of hallux rigidus (big toe arthritis) produced by our Foot and Ankle Surgeon Dr James Clayton. To make an appointment or enquiry with Dr Clayton or a member of our foot and ankle team, contact 08 8362 7788 or email firstname.lastname@example.org.