What is hallux rigidus?
'Hallux' refers to the big toe and 'rigidus' suggests a rigid toe. However, this is not always a correct term for this condition as movement may be available but is reduced.
Hallux rigidus is occasionally confused with a bunion, or hallux valgus, as it is often associated, as part of the degenerative process (wear and tear), with new bone formation over the big toe. However, the bone bump is normally over the toe joint, not on the side as in bunion/hallux valgus deformity. The thinning/wear and tear of the joint may cause the toe to lean towards the other toes, further confusing this with hallux valgus deformity.
What is the cause of hallux rigidus?
Often there is no definite cause: as with other joints the big toe is subject to wear and tear and cartilage becomes progressively thinned and damaged. Past injury, such as a sprained or broken toe, can lead to early wear and tear. Hallux rigidus can also be secondary to gout or other inflammatory conditions that can cause damage to the joint.
Biomechanics: The foot primes itself to bear weight onto the great toe and to allow the toe to move. Certain foot types may predispose to early jamming of the big toe and wear and tear.
Common presenting problems
Although some people may have a stiff big toe without pain, the main presenting complaint is pain and stiffness. This can be a problem in certain occupations such as tiling or carpet laying where kneeling causes pain as the big toe is required to bend. It can also interfere with exercise such as yoga or pilates or even push ups - essentially any activity that requires movement of the big toe. Having a stiff big toe changes the way one loads the foot and can also give rise to pain in other areas of the foot and lower limb.
Footwear can be limited as the bone bump that forms over the toe joint can result in irritation of the overlying skin causing pain and limiting footwear choices. The stiff big toe also limits the heel height you can wear.
Treatment
Your podiatrist or podiatric surgeon can advise you on non-surgical as well as surgical ways of managing this condition.
Non-surgical
Footwear
Wearing shoes with a deep toe box will prevent irritation of the skin overlying the bone lump over the toe. Avoid thin-soled flexible shoes and wear a low-heeled shoe with a firm stiff sole. This is likely to help because if your shoe does not bend this will help protect/limit painful movement of your big toe.
Orthotics
Orthotics/insoles may be of some benefit by off-loading the big toe joint reducing the stress. These can also be used to reduce the flexibility of shoes.
Rocker soles or bars
Rocker soles or rocker bars added to your shoes will help you roll off your big toe, preventing painful movement.
Anaesthetic injections
If the toe is very painful injecting a long-acting anaesthetic with steroid is likely to improve this. This can be given in clinic and occasionally either ultrasound or x-ray is used to guide the needle into the joint. However, the length of time that you benefit from this treatment can vary.
Surgical
If the pain continues despite conservative management, surgery may be considered. There are a number of procedures possible dependent upon the symptoms you present with, the severity of the wear and tear within the joint and the amount of movement that remains.
Cheilectomy
In the early stages, where impingement pain occurs over the big toe on walking as you load your big toe, a Cheilectomy may be possible. This involves removing the upper part of the joint that jams together causing a bone block to movement and pain. If carried out at the right stage the majority of patients have less pain. Other procedures that involve realigning the big toe joint to help to further improve movement and function of your big toe may be possible.
However because of the wear and tear within the big toe joint there are limitations to these procedures and you may require a further operation in the future.
Joint replacement or fusion
With more advanced wear and tear and painful stiff toe other options are joint replacement or fusion of the big toe joint. Fusion of the big toe joint in majority of patients stops pain as this completely stiffens the toe. The positioning of the fused toe is critical to allow walking and running and wearing a heel.
If you do not want fusion you have the option for joint replacement; however, depending on a number of factors, this may not be appropriate. There is a risk of failure of the implant and on-going pain and stiffness of the big toe.
Deciding on your treatment
Your podiatric surgeon will discuss your options in a shared decision-making process taking into account your presenting symptoms, your age, activity level, occupation and medical history, and will request the imaging required. Your podiatric surgeon will help you to make an informed decision as to what is best for you.
Podiatrists and podiatric surgeons are registered with the Health and Care Professions Council (HCPC). You can check your professional is registered here.