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Hallux Rigidus

In the simplest of terms, Hallux Rigidus is arthritis affecting the big toe joint.   It starts with a limitation of motion in the joint at the base of the big toe. Over time, the joint gets damaged and leads to degenerative joint disease (DJD) which is a kind of wear-and-tear arthritis. With hallux rigidus the big toe joint becomes progressively stiffer and more painful.

Symptoms of Hallux Rigidus

Will Hallux Rigidus Get Worse?

Diagnosis of a Hallux Rigidus

Treatment of Hallux Rigidus

Surgery to correct Hallux Rigidus

Is Hallux Rigidus the same as a Bunion?

Symptoms of Hallux Rigidus

You might be developing hallux rigidus if you have any of theses signs and symptoms:

- Pain in the big toe joint (worsens with walking, standing, bending, kneeling)

- Pain gets worse as weather turns cold

- You find it hard to participate in some activities (such as running, kneeling, squatting, bending the big toe)

- Pain in the joint, even at rest

- You notice swelling or redness around the joint

- A hard bump or knot on the top of the foot (that makes it painful to wear shoes)

- Stiffness and soreness in the big toe joint (that makes it hard to wear high heels or cowboy boots)

- Limping or changes in the way that you walk

Will Hallux Rigidus Get Worse?

Hallux rigidus is progressive.  Once it starts, it will worsen over time unless treated correctly. The biomechanics that lead to the jamming within the joint will never just go away on their own. In addition, the continued jamming in the joint will cause continual destruction of the cartilage.  The articular cartilage will not grow back.  It is an irreplaceable resource.

 Over time your body begins to try to adapt to all of the joint destruction. Gradually bone spurs develop around the joint to try and decrease the painful motion within the joint.  This unfortunately leads to even more jamming and joint damage. The shape of the metatarsal bone with start to flatten out and change shape.  In essence, the longer you wait to seek treatment, the more difficult it becomes to preserve you joint and the important biomechanics of the big toe joint.

Diagnosis of a Hallux Rigidus

When you suspect you have a a painful big toe joint with hallux rigidus, your foot doctor should begin by taking a complete history of your condition to make sure that he has the full story. A physical exam will also be performed to determine the condition of the big toe joint, evaluate how much motion is restricted, note any associated deformities, and evaluate the unique biomechanics of your foot. X-rays are usually performed on the first visit as well to look for any loss of cartilage, joint destruction and bone spurring.

arthritis in the big toe joint on xray by San Francisco Podiatrist

These tests are usually sufficient for your foot surgeon to get an idea of the treatment that will be required. In some cases, it may be necessary to get an MRI or CT scan to determine how much damage has been done to the cartilage. The results of all of these tests can usually be explained on the first visit. In this way,  you can get a full understand of how hallux rigidus begins, what you can do to treat the problem, and which treatment will be most helpful in your case.

bone spurs in big toe joint as seen on xray by San Francisco Podiatrist 

Treatment of Hallux Rigidus

In general, the treatment for hallux rigidus depends on the amount of joint damage.  In short, the earlier it is treated, the better.

Early cases of hallux rigidus often have absolutely no damage to the cartilage in the great toe joint.  This of course, is good.  All that needs to be done is correct the faulty biomechanics that are cause the limited motion.  By freeing up the big to joint and restoring normal motion, you can expect t avoid any of the later problems typically associated with degenerative arthritis.

In these cases, icing and anti-inflammatory medications (such as ibuprophen and other NSAIDs) can calm down any irritation. In some cases injection may be used to control joint inflammation.  Supplements such as glucosamine-chondroitin sulfate contained in Joint Juice can also help. A custom orthotic or insert in the shoe can be prescribed to increase motion in the great toe joint and restore more normal foot biomechanics. In such cases the prognosis is usually good and surgery can be avoided.

Moderate cases of hallux rigidus may show some loss of joint space and bone spurring on Xray. There is usually some pain and limitation in the joint that needs to be addressed.  But not all of these cases will need surgery. It should always be the goal to get you back to your desired activities without surgery, if possible.

In these cases, non-surgical treatments will be tried first.  If there is no improvement, you and your surgeon might consider correcting the problem, before more destruction takes place.

Advanced cases of hallux rigidus usually show several changes in the joint on X-Ray. There is often joint space narrowing (which signifies loss of the cartilage), cysts (or holes) in the bone, bone spurring (osteophytosis) and even flattening of the metatarsal bone.  But even with these changes, it does not mean that all of these cases will need surgery. It all depends on the activity level and expectations of the patient. Sometimes stiffer shoes and non-surgical treatments are all that is required to allow pain-free walking.

Surgery to correct Hallux Rigidus

In general, the surgeries for hallux rigidus depend on the amount of joint damage.  Basicaly there are two classes: “joint preserving” or “joint destructive.”

Joint Preservation Surgery

Maintaining normal foot function by preserving your natural biomechanics is preferable. Whenever there is limited damage of the joint, the goal of surgery is to “clean up the joint.” Bone spurs are removed, loose cartilage is taken out, and abnormal adhesions are freed in order to restore motion.  Sometimes, a procedure (called an osteotomy) is performed to decompress and realign the joint. After surgery, the motion of the joint is restored allowing you to return to your favorite activities without pain.

Joint Destruction Surgery

If treatment is delayed for too long, there may be irreparable damage to the joint. In this case the goal of surgery is to decrease pain by removing the painful joint.  This can be accomplished in three ways.

            • Arthroplasty

               (removing a portion of the joint only)

            • Joint Implant Surgery

               (replacing one or both joint surfaces with a metal or plastic implant)

            • Joint Fusion

Arthroplasty surgery is simple and heals relatively quickly but most effective in patients that are not very active.  Sometimes the toe can drift in one direction or another.

Joint implant surgery can preserve more normal motion in the foot.  The drawback is that sometimes the implant breaks down over time.  Some research indicates that if performed in the wrong patient, there is a high failure rate.  It is important to make sure that your surgeon is familiar with all of your activities and has performed a thorough biomechanical and gait exam before considering you for implant surgery. Click here to view a short video on Big Toe Joint Implant Surgery created by San Francisco Foot Surgeon Dr. Segler. WARNING: this video contains graphic surgical images from actual foot surgery

In joint fusion (also called arthrodesis) the cartilage is removed, screws are placed across the joint and the two bones grow together, much in the same way that a fractured or broken bone heals.  Once it is all healed, the joint is gone, so there is no more painful motion. The trade-off is stiffness. Fusing the big toe joint has a high success rate, but it makes it very difficult to wear shoes with different heel heights. 

Advances in Hallux Limitus Surgery

We are currently developing exciting new surgical treatments to help avoid the historically destructive procedures that have been performed for more advanced cases of hallux limitus. This exciting research has the potential to bring a higher quality of life to those suffering from halux rigidus.

Recovery from Hallux Limitus Surgery

Provided that all goes well, you should be back to activity fairly quickly after surgery. Most of these procedures are “outpatient surgery” performed at an ambulatory surgery center.  You should expect to be able to go home about one to two hours after the surgery.  There is typically no overnight hospital stay associated with hallux rigidus surgery.

If you have joint preservation surgery, you may be able to walk in a protective post-operative shoe or surgical boot. If you have joint destructive surgery, the recovery can be more extensive. In many cases, you will need crutches for six to eight weeks after surgery.

Keep in mind that hallux rigidus is always treatable, and the sooner it is treated, the easier it will be for both you and your surgeon to get back to the activities you love...faster.

Is Hallux Rigidus the same as a Bunion?

Bunions and hallux rigidus are both conditions affecting the great toe joint.  They also both can involve pain, destruction of the cartilage in the joint and bone spurring. However, these two conditions are opposite problems. 

A bunion develops when there is instability in the foot. Faulty biomechanics lead to joint instability and the big toe drift toward the second toe (laterally), while the first metatarsal bone drifts away from the second toe (medially).

Hallux rigidus develops because there are faulty biomechanics that leads to rigidity (hence the name) in the great toe joint. Because motion in the joint is limited and restricted, the big toe joint jams every time you take a step.

Over time, the cartilage becomes damage and worn away. Bone spurs start to develop. The spurring blocks motion further.  Sometimes it can even be felt as a lump on the top of the foot at the base of the big toe. 

In contrast, any bone spurring related to a bunion happens on the inside of the foot (medially) at the big toe joint where it may rub against the inside of the shoe.

While both bunions and hallux rigidus can be corrected surgically, they are caused by very different problems.  Those who are prone to bunions typically have low arches, flat feet and a “pronated” foot type. Those who develop hallux rigidus tend to have higher arches and a “supinated” foot type.

 

Dr. Christopher Segler is a San Francisco Podiatrist and Foot Surgeon. He has a special interest in Hallux Rigidus and wrote the chapter on Hallux Rigidus in the "Handbook of Podiatric Sports Medicine." He also published an article in the "Journal of Ambulatory Surgery" which teaches other foot surgeons how to use the same methods he uses to minimize pain after foot surgery. His podiatry practice is based in the San Francisco Bay Area. 

 

 

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