Hallux rigidus is a degenerative condition of the first metatarsophalangeal (MTP) joint of the big toe. It may result from a direct injury to the first MTP joint, from differences in foot anatomy or from wear and tear on the MTP joint.
Symptoms are often relieved by using nonsurgical treatment. Shoe modifications and custom orthotic devices can help improve foot function.
Symptoms
Hallux rigidus develops as the cartilage in your big toe joint wears down over time. Each step you take places a force equal to twice your body weight on the first metatarsal bone (the big toe bone). Repeated stress, like that of certain sports or types of work, may put excessive pressure on the big toe joint and cause the cartilage to break down faster than it would in healthy joints. Injury to the big toe, such as a stub or fracture, can also increase your risk of developing hallux rigidus. Inflammatory conditions such as gout and rheumatoid arthritis also can trigger this foot problem.
Symptoms include pain when you press down on the foot with your big toe. You may notice a bump on the top of your big toe joint, which is called a bunion. The symptoms of hallux rigidus are more serious than those of hallux valgus.
Non-surgical treatment for hallux rigidus includes shoe changes, orthotics, activity modification and physical therapy. Over-the-counter anti-inflammatory medications can decrease pain and swelling. Your provider might recommend ice or heat treatments to help relieve pain and stiffness. Intra-articular steroid injections may provide short-term relief. However, these injections can have chondrotoxic side effects. Prolotherapy, or platelet rich plasma injections, have been shown to decrease pain and improve the quality of life for patients with hallux rigidus.
Diagnosis
The diagnosis is usually made by a physical exam. Your doctor will move your big toe and check its range of motion and how much pain it causes. He or she may also recommend x-rays. These can help find the extent of your arthritis and identify bone spurs that have formed.
In early stages of the condition, a procedure called cheilectomy can be performed to remove the arthritic cartilage in the first metatarsophalangeal (MTP) joint and decrease pain. This procedure preserves the MTP joint’s motion and has a low complication rate. However, it doesn’t prevent the progression of hallux rigidus or other problems in the MTP joint.
If cheilectomy doesn’t reduce your symptoms, your doctor may suggest shoe modification, activity modification, and other non-surgical treatment. Oral nonsteroidal anti-inflammatory drugs and steroid injections may help reduce pain. Foot inserts that minimize pressure on the big toe or have a stiff or rocker-bottom sole can also decrease pain and help slow the progression of hallux rigidus.
If your hallux rigidus has progressed to an advanced stage, your doctor may recommend fusing the first MTP joint (called arthrodesis). This procedure eliminates all movement in the big toe’s MTP joint and reduces pain. It’s often used to treat people who participate in high-impact activities or work in occupations that put a lot of stress on the foot.
Treatment
The goal of treatment is to reduce pain and improve function, especially walking. Medications including nonsteroidal anti-inflammatory drugs and injections into the toe joint can decrease pain. Shoes with more room in the toe box can relieve pressure and stress. Foot and ankle specialists at OrthoGeorgia can help you determine the best course of action.
Surgery is an option for those whose symptoms don’t respond to nonsurgical treatment. Surgical techniques can be divided into two categories, joint-sparing and joint-sacrificing. Cheilectomy and Moberg osteotomy are examples of joint-sparing procedures that have shown good results for early stage hallux rigidus. Arthrodesis has long been considered the gold standard in treating advanced hallux rigidus, and newer techniques such as interpositional arthroplasty are showing promise for improved patient outcomes.
During a cheilectomy, the big toe bone spurs are removed in order to increase mobility and reduce pain. Moberg osteotomy also can be used to decompress the big toe joint by reducing the angle between the first metatarsal and great toe. It can be combined with a cheilectomy to treat early stage hallux rigidus and can be converted to an arthrodesis if needed. An interpositional arthroplasty can be done in conjunction with a cheilectomy or arthrodesis to preserve the range of motion at the first MTP joint, and it is particularly effective for those who want to keep doing their favorite activities.
Follow-up
In a normal joint the ends of the bone are covered by cartilage, which allows the bones to glide smoothly over each other. When this cartilage wears away, the bone ends rub together and can cause pain. As the condition progresses, the body lays down additional bone around the joint margins which restricts movement and can eventually obliterate the cartilage completely. This is referred to as hallux rigidus. It is the most common cause of big toe pain.
This condition may be caused by a traumatic injury, a bunion, or from repetitive activities that put repeated stress on the big toe. It is important to identify this condition early because it can become worse over time.
There is an acute need for high quality research in the physiotherapeutic management of hallux rigidus. Studies that examine the effect of manual therapy involving manipulation, stretching exercises, electrical stimulation, shoe modifications and strengthing exercises should be conducted.
A conservative program of management for hallux rigidusx should be implemented consisting of the following: -Great toe flexion mobilizations. -Sesamoid bone mobilization. -Flexor hallucis strengthening. -First metatarsophalangeal (MTP) joint manipulation. This will include a long axis traction of the MTP joint, a MTP flexion stretch and a dorsiflexion rotational maneuver. This should be done in conjunction with other modalities such as ice, electrical stimulation and orthotic devices.