Have you experienced a painful grinding feeling at the base of your big toe?
Would this pain increase when using your big toe to help you propel yourself forward (eg, when walking and pushing off the ground)?
If yes, then you may be suffering from the degenerative condition hallux rigidus. This condition affects the joint where the toe joins the rest of the foot, and can be an extremely painful and debilitating process that shouldn’t be ignored and can be treated using a variety of options—everything from simple home remedies to surgery.
What Is Hallux Rigidus? Understanding a “Stiff Big Toe”
To break down the term hallux rigidus literally from Latin is ‘stiff toe’ and this is fairly accurate. It is a deterioration of the articular cartilage of the first metatarsophangeal joint (MTP) with resulting bone-on-bone articulation, inflammation, and the development of bony growths (osteophytes), which mechanically obstruct the upward motion of the toe, necessary in normal gait and running, as well as in standing on tiptoes.
Compared to a single injury of a sprain or short-term pain this is a progressing arthritic problem. If left untreated the joint stiffness will progress, and the mobility of the phalango-metatarsal joint decreases gradually, the surrounding soft tissue adapts gradually -often poorly- to compensate for the functional change. Patients may compensate for this loss of mobility by placing more weight on the lateral side of the foot to avoid dorsiflexing the painful joint, which may lead to additional problems in the knees, hips and lumbar spine.
A separate condition which needs to be differentiated from this is hallux valgus – technically a bunion. Hallux valgus has the toe drifting laterally whereas hallux rigidus is limited in its dorsiflexion. Both may be present in the same patient but represent two different structural problems.
Early Signs and Progressive Hallux Rigidus Symptoms
The condition tends not to come to the fore dramatically. The most common symptom experienced is a deep pain and stiffness in the joint of the big toe which tends to become apparent after activity such as walking or running or a day in unsupportive shoes. Some sufferers experience morning stiffness, wherein the joint feels locked or resistant for the first few minutes after arising from bed.
Other than these, some also experience swelling around the joint and sensitivity to cold or damp weather. As hallux rigidus progresses, pain becomes persistent. Bony swelling— osteophyte—may be palpable on dorsal aspect of joint and dorsiflexion is significantly limited.
In advanced cases, joint may be stiff to the point where patient cannot wear normal shoes and gait is affected.
How Hallux Rigidus Is Diagnosed
Diagnosis usually starts with a physical exam. The doctor or podiatrist will manipulate the toe through its range of motion and observe for limitation and painful motion. Weight bearing radiographs are the most common imaging modality.
They demonstrate joint space narrowing, osteophyte formation and the severity of cartilage destruction. Using a grading system from Coughlin and Shurnas (0-4), clinicians can determine the severity of the pathology to better direct management.
Hallux Rigidus vs. Other Big Toe Conditions
Gout can present with nearly the same clinical picture as hallux rigidus with sudden, severe pain and swelling under the first MTP joint. A blood test for uric acid can differentiate the two. Hallux limitus is the same degenerative process but at an earlier stage where the joint motion is decreased but not yet severely limited.
Sesamoiditis, turf toe and stress fractures may also cause similar symptoms; imaging and clinical examination are therefore more important than symptoms alone.
Why Does Hallux Rigidus Happen? Key Causes and Risk Factors
It is the main factor causing the deterioration of the joint. The deterioration of the cartilage due to aging, overuse or injury results in the joint no longer being cushioned and the joint being rough and painful. A history of trauma to the great toe joint no matter how insignificant or insignificant it was, years ago (i.e. the second trauma) can cause faster deterioration of the cartilage.
Genetics also have a real effect on this as if the person has a long first metatarsal and a relative history then it is a definite causative factor.
The Role of Foot Mechanics and Lifestyle
Pathologies such as flat feet and over-pronating which is the excess rotation of the foot forward during gait over time will put abnormal loading through the first metatarsophanegeal joint. Engagement in impact sports, such as running, soccer and ballet dancing, brings forward the onset of this pathology. From a mechanical point of view, work that involves long hours of kneeling or squatting; such as construction work or gardening can increase the loading.
Sharp pointed shoes that squeeze the toes or the opposite; shoes with a completely flat sole with no arch support can also aid this condition.
Associated Conditions and When to Be Concerned
If pain is felt in this joint, though, rheumatoid or psoriatic arthritis may be preferentially attacking the joint, as in these circumstances the arthritis pattern is generally more aggressive and symmetrical, attacking both feet at the same time. If the toes are seen to swell quickly and become hot and red, and the patient begins to experience systemic symptoms such as fatigue, then urgent review should be sought, as these may be signs of an inflammatory arthritis, which will need disease-modifying treatment as well as any mechanical management.
Non-Surgical Treatment Options: Managing Pain and Preserving Motion
The first step will always be conservative treatment, which for many will be a powerful pain relief – especially in the early stages. The aim is not pain relief alone but retarding the progress of the joint degeneration, and preserving as much usable movement as long as possible.
Home Care, Medications and Activity Changes
The measures of rest and ice pack applications are truly the first line during an attack. OTC anti-inflammatory medications such as ibuprofen or naproxen will alleviate the rapid onset of pain, but should not be used as a crutch in the long term. Taking down the high-impact activities such as running (substituted by swimming or cycling) will decrease the repetition of the strain on the joint.
Body weight will directly influence the load to the joints of the foot during each stride.
Footwear, Orthotics and Physical Therapy
Shoes with a stiff, rocker-bottom sole can be truly life changing for many patients. By decreasing the degree of toe dorsiflexion requirement during push-off, they can significantly diminish daily pain. Similar mechanical principles can be applied using custom orthoses with a Morton’s extension-a stiff plate underneath the great toe.
Physical therapy directed at toe mobility, calf flexibility and intrinsic foot strength can maintain range of motion and function.
Surgical Solutions for Hallux Rigidus: What to Expect
Surgical intervention is indicated when conservative care has failed to achieve desired results or if degenerative changes in the joint have become Grade 3 or 4. The appropriate procedure is most often determined by the age and activity level of the patient as well as the remaining joint space.
Cheilectomy and Motion-Preserving Procedures
A cheilectomy is the excision of the bony protuberances which block movement. Usually indicated for Grades 1 and 2 with retained cartilage, it is often used in conjunction with other procedures for pain relief and motion. It generally takes 6-8 weeks to recover and the majority gain good range and pain relief.
It is sometimes combined with procedures aimed at addressing the cause such as cartilage surgery or osteotomies – realignment cuts of the bone.
Arthrodesis and Other Advanced Surgical Options
Joint fusion (arthrodesis): The metatarsophalangeal joint is fused (pinned) together. Movement no longer occurs at the joint. The pain is relieved as there is no longer a painful joint.
Most patients are able to walk in normal footwear and participate in most activities however some find this difficult. Newer joint replacement implants are being introduced for a select group of patients who would prefer to keep some of the motion although the long term durability of these implants is still being evaluated in comparison to the established success of fusion surgery.