Hallux Rigidus

What is it?

It is early arthritis in the big toe joint. Hallux = Big toe - Rigidus = stiff or rigid. Hallux Rigidus may occur in one or both of the feet causing pain, stiffness and swelling of the toe. It is most common in the 30-40 year age group and isn't normally associated with getting arthritis in any other joints.

What causes it?

Usually there is no cause and the toe becomes painful and swollen gradually, sometimes over many years. It maybe hereditary and can run in families.

It can happen after an injury, either stubbing the toe hard many years before or fracturing it or from a 'turf'toe' - when a sportsperson misses their intended target and strikes the ground rather than the ball. This causes damage to the smooth articular cartilage of the toe joint and leads to wear & tear and arthritis of the metatarsophalangeal joint. Sometimes a piece of cartilage may be knocked loose, causing a 'clicking' feeling within the toe, and rarely causing the joint to lock.

Symptoms

The toe joint is swollen and painful, particularly when standing on tip-toe or in high heels. Over time the swelling increases as arthritic spurs or osteophytes form around the joint.

Diagnosis

The degree of arthritis is assessed on clinical examination (degree of stiffness and pain) and with plain xrays. This classifies the arthritis into Grades 1-3 and determines which treatment is the best in your case. Occassionally an MRI is necessary to assess the joint in more detail looking for cartilaginous injuries that can be treated with arthroscopy (keyhole surgery)

Treatment options

The simplest non-surgical measures taken to deal with Hallux Rigidus involve modifying the sole of the shoes to minimise the bending of the joint and therefore the pain. There is now a wide range of footwear almost indistinguishable from normal sports and casual wear that can be used to relive symptoms. In advanced cases, a 'rocker—bottom' shoe may be employed, so the shoe performs the bending that the toe would otherwise do.

If the condition is sufficiently advanced, and non-surgical measures have not relieved the condition, there are several possible options for a surgical solution. If it is a simple osteophyte (bone spur), that is preventing full range of motion within the joint (Grade 1), a simple day operation known as a cheilectomy can be performed, to remove the osteophyte and restore the full range of motion as well as reliving the pain. This is operation is now performed very successfully using minimally invasive surgery. After this procedure, the patient should be able to return to previous sporting activities. (Click here for a link to operation information).

If the arthritis is more advanced, it may not be possible to save the joint and a joint replacement or fusion will be needed to relieve the pain. In joint replacement the most arthritic side of the joint is replaced with a precisely shaped metal replacement - Hemicap. This provides relief of the majority of the pain and maintains some motion in the joint. It has been shown to work for several years...

Five-year results of 1st metatarsal head resurfacing prosthesis (Hemicap) used for the treatment of advanced MTPJ osteoarthritis. Patel A, Tahir M, Syed F, Anand A, Eleftheriou KI, Rosenfeld PF. BOA 2013, Birmingham

In a fusion, the arthritic surface of the joints are removed and the bones (metatarsal and proximal phalanx) are fused together using precision titanium plates and screws. This operation is very successful in relieving pain but will of course stiffen the toe. The interphalangeal joint (the one behind the nail) will be unaffected and still allows upward movement. The fused joint does not normally cause any functional problems with walking or running and most shoes can be worn. (Click here for a link to operation information). There is a 98% chance of successful fusion.

Foot Ankle Int. 2010 Sep;31(9):797-801. doi: 10.3113/FAI.2010.0797.
First metatarsophalangeal arthrodesis using a dorsal plate and a compression screw.
Rosenfeld PF.
Link to paper: http://www.ncbi.nlm.nih.gov/pubmed/20880483