Big Toe Arthritis
What Is Hallux Rigidus?
'Hallux' refers to the big toe, while "rigidus" indicates that the toe is rigid and cannot move. Hallux rigidus is actually a form of degenerative arthritis.
This disorder can be very troubling and even disabling, since we use the big toe whenever we walk, stoop down, climb up, or even stand. Many patients confuse hallux rigidus with a bunion, which affects the same joint, but they are very different conditions requiring different treatment.
What Causes Hallux rigidus?
There are a lot of theories about why the joint becomes arthritic but as yet none of them seem very helpful in treatment or prevention of the condition.
In most people there is no definite cause - it just develops. Probably the main reason why this joint is particularly subject to wearing out is that it is under tremendous stress in walking. With each step, a force equal to twice your body weight passes through this very small joint.
In some people, hallux rigidus runs in the family and is a result of inheriting a foot type that is prone to developing this condition. In other cases, it is associated with overuse or an injury, such as stubbing your toe. It may be caused by inflammatory diseases such as rheumatoid arthritis or gout. Your foot and ankle surgeon can determine the cause of your hallux rigidus and recommend the best treatment.
What are the Symptoms?
The commonest problem is pain in the big toe joint. As the disorder gets more serious, additional symptoms may develop, including:
- Pain, even during rest
- Difficulty wearing shoes because bone spurs (overgrowths) develop
- Dull pain in the hip, knee, or lower back due to changes in the way you walk
- Limping (in severe cases)
How is it Diagnosed?
The sooner this condition is diagnosed, the easier it is to treat. Therefore, the best time to see a foot and ankle surgeon is when you first notice symptoms. If you wait until bone spurs develop, your condition is likely to be more difficult to manage.
In diagnosing hallux rigidus, the surgeon will examine your feet and move the toe to determine its range of motion. X-rays help determine how much arthritis is present as well as to evaluate any bone spurs or other abnormalities that may have formed.
What is the Non-Surgical Treatment?
In many cases, early treatment may prevent or postpone the need for surgery in the future. Treatment for mild or moderate cases of hallux rigidus may include:
- Shoe modifications. Shoes with a large toe box put less pressure on your toe. Stiff or rocker-bottom soles may also be recommended.
- Orthotic devices. Custom orthotic devices may improve foot function.
- Medications. Oral nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may be recommended to reduce pain and inflammation.
- Injection therapy. Injections of corticosteroids may reduce inflammation and pain.
- Physical therapy. Ultrasound therapy or other physical therapy modalities may be undertaken to provide temporary relief.
When Is Surgery Needed?
In some cases, surgery is the only way to eliminate or reduce pain. There are several types of surgery for treatment of hallux rigidus. In selecting the procedure or combination of procedures for your particular case, the foot and ankle surgeon will take into consideration the extent of your deformity based on the x-ray findings, your age, your activity level, and other factors. The length of the recovery period will vary, depending on the procedure or procedures performed.
What are the types of surgery available?
If only the upper part of the joint is involved, the upper part of the joint can be trimmed out and the joint washed out. This operation is called a cheilectomy. Most people who have a cheilectomy get less pain and a useful improvement. In about 75% this improvement is permanent. The others develop worsening of the arthritis over the following years and some will eventually need another operation.
If the whole joint is involved, there are three main options, depending on the age and activity of the patient:
In young fit people, especially those doing heavy jobs, a fusion of the joint would be recommended. This removes the painful joint and stiffens it completely. 95% of people will get rid of their pain. However, the toe is stiffer than before and the choice of shoes is more limited. A few people will go on to get arthritis of the small joint in the middle of the toe after a fusion, but this is not usually troublesome.
In certain circumstances, it may be appropriate to consider a replacement joint. There are a number of joint replacements available, although they are only appropriate in certain patients. As with all joint replacements, there are risks with the procedure. In particular there is a risk that the new joint may loosen or wear out, in which case a more complex procedure may be necessary. This will, of course, be discussed with you by your surgeon.