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Hallux Rigidus

Hallux rigidus is a disorder characterized by arthritis of the great toe. The specific joint involved is called the metatarso-phalangeal (“MTP”) joint and is located at the base of the toe.

joint x-ray

joint photo

The cause of hallux rigidus is, in most cases, unknown. While it is a form of osteoarthritis, its occurrence is not limited to middle-aged and elderly individuals. For unknown reasons, hallux rigidus is often seen in younger patients as well. Some have speculated that the alignment of the first metatarsal bone may predispose to this condition. This has not been proven, however, and one scientific study has provided evidence to the contrary.

Patients with hallux rigidus generally have three complaints. First, they note pain at the base of the big toe. The pain is usually a sharp pain or deep aching pain, and is worse when the toe is bent upwards (as when the foot pushes off while walking). Second, patients note stiffness at the MTP joint. The MTP joint usually has 70 – 90 degrees of motion. With hallux rigidus this is decreased, and in some patients there is no motion at all. In fact, the phrase “hallux rigidus” is Latin for “stiff big toe”. Finally, patients with hallux rigidus often notice a

normal motion

Normal joint motion

decreased motion

Decreased joint motion

prominence on the top of the MTP joint. Some mistakenly think of this as a bunion. However, with a bunion the prominence is on the inner side of the joint, not on top. The prominence seen in hallux rigidus is caused by bony spurs, or “osteophytes”, that form as a part of the arthritic process. These spurs can often make it difficult to find comfortable shoes.

spur from outside

Prominence seen on top of foot

bony spur

X-ray of underlying bony spur

Hallux rigidus is divided into three grades depending on severity. With Grade I disease, there is a spur present on top of the joint, but the arthritis in the joint is minimal and on x-ray there is no narrowing of the joint. With Grade II disease, there is arthritis and narrowing of the upper portion of the joint, but this does not involve more than 50% of the joint. Finally, with Grade III disease, there is global arthritis and joint space narrowing.

The initial treatment of hallux rigidus is non-operative. Anti-inflammatory medications are often used initially. These medications should not be taken for long periods of time and are best reserved for patients with mild, intermittent pain. If the bony prominence present and is irritated by shoes, the use of wider shoes or a shoe-stretching device may be helpful. Finally, some patients with hallux rigidus benefit from custom orthotics (shoe inserts). The orthotic usually has a stiff extension built into it. This extends beyond the MTP joint and thereby limits the motion at this joint.

For patients who remain persistently symptomatic despite non-operative treatment, surgery may be necessary. In general, two operations are performed for hallux rigidus. The first operation, formally known as a “cheilectomy”, is performed for milder cases and entails shaving the spur that forms on the top of the joint. This is a day surgery and eliminates the pressure caused by the spurs. In most cases, the motion of the joint is also improved. After surgery, patients may walk on the foot in a post-operative shoe. By three weeks most are back into a sneaker or other wide shoe. In general, formal physical therapy is not necessary, as home stretching exercises suffice.

bony spur

With a cheilectomy the spur is simply shaved off

For more advanced cases of hallux rigidus, it becomes necessary to surgically “fuse” the MTP joint. With fusion surgery, the joint surfaces are surgically roughened with a burr or chisel so that the body is “tricked” into thinking that there is a fracture has occurred. Over the next 6-12 weeks, the body heals the presumed fracture and the two bones become one. Metal screws are used to hold the bones in place while this process occurs. Once the fusion process is complete the arthritic joint is no longer present and pain is relieved.

pre-op view

Pre-operative x-ray with arthritic 1st MTP joint

fused with screws

Post-operative x-ray with joint fused using screws

Beyond cheilectomy and fusion, other procedures such as joint replacement are less commonly used. These procedures are controversial, however, and remain under investigation.