Hallux Rigidus

  • Hallux rigidus

    Periodic big toe joint inflammation results in hallux rigidus. It is an arthritic process just as in other joints. Initially it starts as a painless bony "growth" on the top of the big toe. Gradually a 'bony spur' occurs on the worn out joint. It is painful, especially in particular positions of the big toe (especially in higher heels or during "push off" in running when the toe becomes maximally extended). Eventually pain may be present throughout most weight bearing activities or even at rest. Eventually movements of the joint in hallux rigidus can become quite restricted and painful.

    Hallux RigidusHallux Rigidus

    I have hallux valgus; do I also have a hallux rigidus?

    Many times it is possible to have a stiff, destroyed and arthritic big toe along with a hallux valgus. Usually one problem is more than the other. Treatment is determined by the predominant symptom. If bunion is more of the problem then one of the various metatarsal osteotomy like 'scarf' is offered or if arthritic symptoms predominate, then arthroplasty or even excision (Keller's procedure) is the treatment of choice.

    What treatment options are there?

    Non-Operative: Injection/manipulation

    This can be useful in the early stages of arthritis. The effects are often temporary.

    Orthotics

    Are very useful in early disease. The principle with orthotic management is to offload the big toe during walking. During normal walking the front part of the foot acts as a rocker. By modifying a normal shoe to add a subtle rocker to the sole at the location of the joint, and stiffening the sole, so it doesn't bend the foot, great pain relief occurs.

    Orthotics
    Hallux rigidus orthotic
    Orthotics
    Rocker bottom shoe

    Open debridement

    The excess bone and hard osteophytes are removed, generally for patients with moderately severe symptoms but lesser degrees of x-ray changes.

    Keller's/Hamilton's arthroplasty

    This is a good option in the less mobile, more elderly patient. This involves removal of one side of the painful joint. This stops the pain of the arthritic joint but the big toe sometimes becomes floppy. This is acceptable in an elderly patient with limited physical activity.

    Kellers/Hamiltons arthroplasty Kellers/Hamiltons arthroplasty

    Keller's - The involved arthritic joint is removed giving a painless but mobile joint

    Big toe fusion

    Big Toe Fusion
    X ray showing arthritic big toe joint
    Big Toe Fusion
    Fused big toe joint

    In the not too sportive individuals, the big toe can be fused with a plate & screw or wire and screw or only screw. Surprisingly movements are not entirely restricted as the figure below shows.

    Big toe joint replacement

    Replacement
    After fusion of 1st toe
    Replacement
    Surprisingly good function after toe fusion
    Replacement
    X ray after first toe replacement

    Recently big toe joint replacement is also available in India. Function is fully preserved with loss of pain.