Joint, Ligament and Muscle Disorders

Hallux Rigidus (Stiff Big Toe)

Anatomy

Nearly one-fourth of all bones in the human body are in the feet. The foot is a complex, flexible structure that contains bones, joints, and more than 100 muscles, tendons and ligaments, all working together to enable movement and balance. The foot is divided into three sections, the forefoot, the midfoot and the hindfoot. The forefoot has five toes (14 phalanges) and five longer bones (metatarsals). One phalanx of each of the five toes connects to one of the five metatarsals.

The big toe, or great toe (hallux), is made up of two joints. The metatarsophalangeal joint (MTP) is the largest of these, and the closest to the base of the toe, where the first long bone of the foot (metatarsal) meets the first bone of the toe (phalanx). In the MTP joint, as in any joint, the ends of the bones, where they touch, are covered by articular cartilage, a smooth substance that protects the bones and enables the joint to move easily.

Description

Hallux rigidus usually develops in adults between the ages of 30 and 60 years, and occurs most commonly at the base of the big toe, or MTP joint. When articular cartilage in the MTP joint is damaged by wear-and-tear or injury, the raw bone ends can rub together and a spur, or overgrowth, may develop on the top of the bone. This overgrowth prevents the toe from bending adequately, resulting in hallux rigidus, or a stiff big toe. Because the MTP joint must bend with each step, hallux rigidus can make walking painful and difficult.

Symptoms

Common symptoms of hallux rigidus include:

• Pain in the joint—Experienced during activity, especially as you push-off on the toes when walking.
• Swelling—Occurs around the joint.
• A bump develops on top of the foot—Similar to a bunion or callus.
• Stiffness in the big toe—Includes the inability to bend the toe up or down.

Causes

Hallux rigidus may result from an injury to the toe that damages the articular cartilage, or it may be caused from differences in foot anatomy that increase stress on the joint. Why it appears in some people but not others is currently unknown.

Nonsurgical Treatment

Pain relievers and anti-inflammatory medications (NSAIDs) such as ibuprofen may help reduce the swelling and ease the pain. Applying ice packs or taking contrast baths may also help reduce inflammation and control symptoms for a short period of time. Wearing a shoe with a large toe box will lessen the pressure on the toe, and patients typically must give up wearing high heels. Your doctor may recommend that you wear a stiff-soled shoe with a rocker or roller-bottom design, and possibly a shoe with a steel shank or metal brace in the sole. These types of shoes support the foot when walking and reduce bending of the big toe.

Surgery

If nonsurgical treatment does not provide relief for your symptoms, your orthopaedic surgeon may discuss surgical options with you. These may include:

• Cheilectomy—Usually recommended when damage is mild or moderate. An incision is made on the side of the foot to allow removal of bone spurs and a portion of foot bone, giving the toe more room to bend. You will be required to wear a wooden-soled sandal for at least 2 weeks following the procedure. Although the toe and operative site may remain swollen for several months after surgery, most patients do experience long-term relief.
• Arthrodesis—Fusing the bones together (arthrodesis) is often recommended when damage to the cartilage is severe. During surgery, the damaged cartilage is removed and the joint is fixed in a permanent position with the use of pins, screws, or a plate.
• Arthroplasty—Older patients who place few functional demands on their feet may be candidates for joint replacement. During surgery, the joint surfaces are removed and an artificial joint is implanted. This procedure may relieve pain and preserve joint motion.

With any surgery there are some risks, and these vary from person to person. Complications are typically minor, treatable and unlikely to affect your final outcome. Your orthopaedic surgeon will speak to you prior to surgery to explain any potential risks and complications that may be associated with your procedure.