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Ryan M. Putnam, MD
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Foot & Ankle
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Hallux rigidus is arthritis of the joint at the base of the big toe. It is the most common arthritic condition of the foot, affecting 1 in 40 people over the age of 50. Hallux rigidus tends to affect females more often than males and typically develops in adults over the age of 30.
What are the symptoms of hallux rigidus?
Most patients present with a complaint of pain in the big toe joint while active, especially when pushing off to walk. Often, there also is swelling around the big toe joint or difficulty moving and bending the toe. A bump, like a bunion (hallux valgus) or bone spur, can develop on top of the big toe joint and be aggravated by rubbing against the inside of a shoe.
What causes hallux rigidus?
The cause of hallux rigidus is not known; however, several risks factors have been identified. Risk factors include a long or elevated first foot bone (metatarsal) or other differences in foot anatomy, prior injury to the big toe, and family history. These can lead to excessive wear of the joint, which in turn leads to arthritis.
The big toe joint is called the hallux metatarsal phalangeal or MTP joint. This joint connects the head of the first foot bone (metatarsal) with the base of the first toe bone (proximal phalanx) and the two tiny bones (sesamoids) underneath the metatarsal. Usually the greatest area of wear is at the top of the joint.
How is hallux rigidus diagnosed?
In many cases, the diagnosis of hallux rigidus can be made by physical examination alone. Your doctor examine the MTP joint to see how much you are able to move and where the pain occurs. The doctor also will check your foot for evidence of bone spurs. X-rays may be performed to identify the extent of joint degeneration and to show the location and size of bone spurs. These X-rays are best taken with you standing and putting weight on your foot. MRI and CT scans are rarely necessary.
How is hallux rigidus treated?
Non-surgical management is always the first line treatment for hallux rigidus. A physician may suggest pain relievers and anti-inflammatory medicines and ice or heat packs to reduce pain. Platelet-rich plasma injections and similar injections into the joint are promising but vary in effectiveness.
Changes in footwear may also be suggested. Avoiding thin-soled shoes or higher-heeled shoes can minimize the compression at the top of the joint. Shoes with a stiff sole, curved sole (rocker bottom), or both may also minimize joint pain. You may also benefit from shoe inserts as well as arch supports (orthoses) that limit motion at the MTP joint.
Although these treatments may help decrease the symptoms, they do not stop the condition from progressing.
If pain persists after the above non-surgical treatments, surgical treatments will be considered. The type of surgery would be determined by the extent of arthritis and deformity of the toe.
Bone Spur Removal (Cheilectomy)
For mild to moderate damage, removing some bone and the bone spur on top of the metatarsal and proximal phalanx can be sufficient. This procedure is called a cheilectomy. Removing the bone spur allows more room for the toe to bend up and alleviates pain caused when pushing off the toe. This procedure also can be combined with other bone cuts that change the position of the big toe and further relieve pressure at the top of the joint.
The advantages of this procedure are that it maintains stability and motion, and preserves the joint itself.
Joint Fusion (Arthrodesis)
Advanced stages of hallux rigidus with severe joint damage are often treated by "welding" the big toe joint. This procedure is called arthrodesis or joint fusion. In this procedure, the damaged cartilage is removed and the two bones are fixed together with screws and/or plates to enable them to grow together.
The main advantage of this procedure is that it is a permanent correction to reduce pain. The major disadvantage is that it restricts movement of the big toe, although most patients can still be active.
Joint Resurfacing (Interpositional Arthroplasty)
For the patient with moderate to severe hallux rigidus who wants to avoid loss of motion, an interpositional arthroplasty may be an option. This procedure consists of taking away some of the damaged bone (similar to a cheilectomy) and placing a spacer between the two bones to minimize contact on either side of the joint.
Interpositional arthroplasty is primarily performed in two ways. In one technique, a piece of soft tissue is used as the spacer in an attempt to resurface the joint. This soft tissue can come from your foot, another part of your body, or even prepared cadaver tissue. The operation does preserve some motion but is not as predictable for pain relief.
Alternatively, another technique has been developed that uses a synthetic cartilage implant plug made out of polyvinyl alcohol as the spacer. The advantages of this procedure are that it requires less bone to be removed and it is much easier to convert to fusion if it fails. It also has shown to be as effective as fusion in relieving pain, while preserving motion of the joint. This is a newer procedure; however, current studies have demonstrated good results that appear likely to hold up over time.
Joint Replacement (Arthroplasty)
Arthroplasty, or replacing one or both sides of the joint with metal or plastic parts, is intriguing due to the success of these procedures in the knee and hip. While there are studies that support this technique with particular implants, orthopaedic surgeons are cautious to recommend it at this time due to reports of higher complication rates and unpredictable short- and long-term results. Researchers continue to study this technique and types of implants. Consult with a foot and ankle orthopaedic surgeon for more information.
How long is recovery after surgery?
Recovery depends upon the type of surgery performed. For cheilectomy and interpositional arthroplasty, most surgeons recommend wearing a hard-soled sandal and allowing weightbearing as tolerated for about two weeks before a gradual return to normal footwear. For a fusion or procedure that cuts the bone, the foot may be immobilized with a cast for four to eight weeks, and limited weightbearing may be allowed with crutches for two to three months. You can expect some foot swelling, stiffness, and aching for several months after the procedure, depending on your level of activity.
After recovery, most patients are able to exercise, run,and wear most shoes comfortably. Patients may still find stiff-soled, rocker bottom shoes more comfortable for exercise.
What are the potential complications?
When surgery is warranted, the typical risks of operation apply, including scarring, infection, and failure to relieve symptoms. However, these risks are very infrequent with the above procedures unless there are other factors such as cigarette use or a poor immune system.
Frequently Asked Questions
What type of activity is allowed after fusion surgery?
Most patients are able to return to their usual level of activity, although running and jumping will be more difficult. Wearing a heel higher than one and a half inches may be less comfortable.
The American Orthopaedic Foot & Ankle Society (AOFAS) , https://footcaremd.org/conditions-treatments#conditions
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