What is Hallux Rigidus?
The term hallux rigidus is used to describe a degenerative arthritic process that causes a functional limitation of motion of the big toe joint, reducing the ability to dorsiflex or move the big toe upward. There is pain and stiffness in the joint. The big toe joint plays a crucial role in normal walking and propulsion. Approximately 50-60 degrees of upward motion (dorsiflexion) is necessary for normal functional gait and less than that will usually result in pain and inhibited ambulation. The body cannot propel forward efficiently when there is limited motion of the big toe causing compensation of other joints and therefore pain. With time the cartilage, which is the material that lays over the surface of each bone of the joint begins to wear, narrowing the joint space causing constant jamming of the joint and therefore limited motion when walking. Arthritis is any amount of damage to the cartilage and it is progressive. An arthritic joint is painful during motion. Upward motion is limited by a mechanical block caused by bone spurs, due to the constant jamming of the joint.
What causes Hallux Rigidus?
The most common cause for hallux rigidus is repetitive microtrauma that injures the cartilage. This occurs with overuse among people involved with activities or jobs like athletes, dancers, construction workers and others that increase the stress on the big toe. Another common cause is trauma that may occur as a result of a single injury such as a fracture or a crush injury. Anatomic variations of the foot are also believed to contribute to the development of hallux rigidus such as a pronated foot (rolling in), a long or elevated first metatarsal, a first metatarsal bone that has too much motion, and a bunion deformity. Systemic conditions such as gout and rheumatoid arthritis can lead to limitation of motion and loss of cartilage in the joint. Treatment options are available once the identifying cause of the joint pain and limitation is determined.
Symptoms of Hallux Rigidus
Patients usually experience insidious onset of activity related pain at the big toe joint and report pain, swelling and stiffness. Swelling and inflammation around the joint can also occur. Limitation of upward motion (dorsiflexion) causes greater difficulty with activities such as running, squatting, and walking up an incline. Wearing high-heeled shoes become difficult because the toe will not bend enough. With time bone spurs (overgrowths) develop, which can lead to irritation from shoe wear. The pressure from the extra bone and shoes over the nerves can cause numbness and shooting pain into the toe. Additional symptoms include clicking or catching with range of motion. Alteration in gait occurs relatively late in the disease process.
Diagnosis of Hallux Rigidus
The diagnosis of hallux rigidus is made by physical examination and plain radiographs. The exam will determine the amount of range of motion present and will reveal any pain. Pain is particularly severe with dorsiflexion or upward movement of the big toe. There is commonly mild swelling and bony prominences associated with the first metatarsophalangeal joint behind the big toe. X-rays will determine how much arthritis and the overall severity of the patient's condition. It will allow the physician to evaluate the joint for bone spurs, decrease in joint space, flattening of joint surfaces, and loose bodies in the joint. X-rays also reveal the cause of hallux limitus as an elongated or elevated first metatarsal.
Treatment of Hallux Rigidus
The sooner this condition is diagnosed, the easier it is to treat. Joints are not able to repair damage on their own. With conservative treatment you are only able to accommodate big toe arthritis. Treatment of mild or moderate cases includes an extra-depth shoe with a deep toe box to accommodate any spurs at the top of the joint. Also a stiff-soled rocker bottom shoe is often helpful allowing less motion of the joint. Oral nonsteroidal anti-inflammatory drugs (NSAIDs), such as Ibuprofen can reduce pain and inflammation. Limiting the activities that cause pain and damage to the joint can help to reduce the painful inflammation and any wear and tear on the joint. Padding can be applied over the prominent bone spur in order to take the pressure off. Corticosteroid injections may also be used to reduce inflammation and pain; however there is a limit to the number of these injections. These injections only provide temporary relief and do not repair the damage in the joint. There is a limit to the number of injections that one can have. Custom orthotics can be used to increase the rigidity along the joint, thus decreasing motion at the big toe joint, minimizing pain with motion and decreases the stress across the joint. Their main function is to decrease the progression of joint damage.
If conservative treatment does not alleviate pain, surgery becomes the next option. There are several options for surgical treatment of hallux rigidus. Dr. Fihman will decide on the appropriate procedure based on the extent of the deformity noted on radiographs, the age of the patient and their activity level. The goal of surgery for hallux limitus is to alleviate pain, return to normal shoes and activities, remove any extra bone, clean out the joint, and promote new cartilage growth when possible.
Cheilectomy is the procedure of choice for patients whose symptoms are the result of impingement of the big toe on the spurs on top of the metatarsal head. The procedure removes scar tissue and spurs from the joint, improving range of motion and relieving pain. Any floating pieces of cartilage or bone is also removed. The patient can ambulate immediately after surgery and is just waiting for the skin to heal.
This is a new revolutionary implant that acts as a replacement for damaged cartilage at the surface of the big toe. It is a man-made synthetic implant that is made of a soft plastic-like substance and salt water. Together these materials form a solid, slippery and durable implant. This implant is placed into the bone in your big toe and provides a new smooth, slippery surface in the joint allowing an increase in range of motion of the joint and eliminating pain. Cartiva will help relieve the pain and stiffness in your big toe caused by warn cartilage. A cheilectomy or cleaning out of the joint is performed and a drill hole is made at the bone at joint level in order to place the implant in. The patient can immediately bear weight in a surgical shoe for 2-3 weeks and then transition into a regular shoe.
A cut is made in the 1st metatarsal to slightly shorten and drop down the head to prevent jamming of the joint. This causes widening of the big toe joint and allows the big toe to easily move on the 1st metatarsal. Any loose pieces of bone are also removed and the joint is cleaned out as well. The cut is fixated with a screw to hold it in its new position. Once the bone heals, the screws are not needed and generally are not removed.
At the end stages of arthritis a joint replacement becomes an option. It is a good option for patients who would like to continue to have motion in the big toe joint, which is important in women who wear heels. Patients are very happy with this procedure because they have movement in their big toe and can return to wearing regular shoes after a few weeks once their skin has healed.
Fusion of the big toe joint eliminates all pain by removing the joint and any motion in the joint. The theory is that if there is no motion than there is no pain. The big toe bone and the 1st metatarsal join together to become one bone. The joint is fused with either a plate or screws. Once the bone heals, the plate of screws do not have to be removed. The post-operative course is non- weightbearing in a cast until the joint has completely fused.