Hallux Rigidus

Plymouth Orthopaedic and Sports Injury Clinic

What is Hallux Rigidus?

Hallux rigidus means stiff big toe. This occurs because the joint at the base of the toe has become arthritic. A joint occurs where two bones meet. They are lined with articular cartilage (the glistening white surface that you see inside a joint of lamb), and this provides a friction free joint, allowing movement. Degenerative joint disease (osteoarthritis) occurs when this lining surface begins to fail. This results in increased friction causing stiffness and pain. In addition extra bone (osteophytes) appears around the joint. This further restricts movement and increases pain, and additionally the osteophytes can rub on shoes.

What causes it?

The exact cause of this condition is unknown. It does not appear to be inherited. It may result form an injury or repetitive stress. The joint involved (first metatarso-phalangeal joint) is subjected to very large loads during walking and running, and so it is no surprise that it is subject to degenerative arthritis

What problems does it cause?

This condition causes pain, particularly when walking or running. The action of bending the toe upwards(dorsiflexion) increases pain, and it is the limitation of this movement that causes stiffness. Stiffness can on occasions limit wearing a high heel. Osteophytes can become very prominent causing sufficient bony swelling to restrict tighter shoes

What can be done for Hallux Rigidus?

General advice

A lot of force goes through the big toe when you walk so losing weight and keeping fit may be of benefit. Finding comfortable shoes with space for the big toes may relieve some of your symptoms. Many patient notice that a rigid soled shoe or walking boot is more comfortable than a soft shoe, and some patients also benefit from rocker bottom type shoes.

Injections

An injection of local anaesthetic and steroid will give temporary relief, but the benefit is usually relatively short lived.

Surgical treatment - Chielectomy

In early hallux Rigidus, removal of osteophytes on top of the joint may free up movement and reduce pain. This is called a Cheilectomy
This procedure is usually performed as a day case, with a small incision on top of the toe.

You can walk immediately after the operation in a special sandal with a dressing on the foot Stitches are removed at 2 weeks and progressive mobilisation encouraged. The foot will remain swollen and stiff for up to 6 weeks.

The aim of the operation is to remove the pain that you experience as you big toe moves upwards. Sadly, not everyone benefits from this procedure, and it is recognised that even when the decision to perform cheilectomy is appropriate, and the operation done well, there is a failure rate in the region of 20%. If Cheilectomy fails then Arthrodesis (fusion) is the next appropriate step.

Surgical treatment - Arthrodesis

In more advanced Hallux Rigidus, or if Cheilectomy has failed, Arthrodesis (fusion) remains the gold standard treatment at this time. It is important to note that many attempts have been made to design joint replacement devices for the first metatarso-phalangeal joint. The failure rate of these designs has sadly been very high. Salvaging a failed joint replacement is very difficult and we cannot recommend joint replacement for this problem at this time.

Fusion involves removing what is left of the lining surface of the joint. The bones are then held together usually with two screws, sometimes supplemented with a small plate. It usually takes six weeks for the bone ends to knit together or fuse. If successful, then the joint becomes solid and therefore pain free.
This is a procedure which is usually performed as a day case with a small incision along your big toe.

Post operative course after Arthrodesis

You can walk immediately after the operation in a special shoe which must be retained for 6 weeks. You will require a dressing change/stitch removal at 2 weeks. You will require an XRay at 6 weeks. At 6 weeks you may have continued swelling but if the XRay is satisfactory, you can progressively mobilise in a normal shoe. Most patients will have recovered by twelve weeks.

After the arthrodesis operation your big toe joint will be permanently stiff. This will affect the way you walk, and it may restrict the ability to wear a high heel. However, most patients can expect very good function following this procedure, because loss of movement is compensated for by movement at other joints.