What is Hallux Rigidus?
Hallux rigidus, which translates to “stiff toe” from Latin, is a medical condition associated with arthritis in the joint of the big toe. The condition was first explained back in 1881 by Nicoladoni, but it became widely known in 1887 when Davies Colley introduced the term “hallux flexus.” This term was used to describe the particular position in which the toe bends downward in relation to the head of the bone in the foot.
In the same year, the term “hallux rigidus” was introduced by Cotterill to clarify the painful limitation of motion in the big toe joint. In 1931, the term “hallux limitus” was introduced by Hiss. Nowadays, we generally use “hallux limitus” to describe a limitation in the movement range of the big toe joint, and “hallux rigidus” for situations where the joint has almost no movement.
There are different causes for this condition, and numerous treatment options are available. This article aims to review the condition, covering the evaluation and management strategies for each stage of hallux rigidus.
What Causes Hallux Rigidus?
The first joint of our big toe naturally carries about 119% of our body weight with each step we take. Certain foot structures or imbalances can increase this pressure, leading to worsening of arthritis in the big toe, also known as degenerative arthritis.
Several theories have been suggested to explain why this big toe arthritis, or hallux rigidus, happens. Some research suggests that past trauma might strongly relate to arthritis in one big toe, while factors such as family history or being female are commonly linked to arthritis in both big toes.
Other observed causes might include having a flat or V-shaped joint in the toe, an increased angle between the big toe joints, a longer bone in the big toe, or too much flexibility in the first toe joint. Certain foot conditions like in-turned foot, high-arched foot, a bigger angle between the big toe and the second toe, and shoe types have also been suggested as causes, but lack solid proof.
Systemic conditions like gout, rheumatoid arthritis, and other inflammatory conditions, that affect the whole body, could also speed up the joint deterioration and must be considered when looking for the cause of this type of arthritis.
Risk Factors and Frequency for Hallux Rigidus
Hallux rigidus, which is the second most common issue affecting the first MTP joint after a condition called hallux valgus, is quite common in people above 50 years old with foot disorders, affecting 25% of such patients. The condition is even more prevalent at 73% in those with advanced ankle arthritis. While females are twice as likely as males to have hallux rigidus, it is less common in adolescents. However, when adolescents do have it, it is usually linked to osteochondritic lesions.
In a Japanese study conducted in 2021, they found that knee osteoarthritis, gout attacks, and hallux abducto valgus deformities are all connected to the degeneration of the first metatarsophalangeal joint. Furthermore, the data showed that the occurrence of knee osteoarthritis was significantly associated with hallux rigidus.
Signs and Symptoms of Hallux Rigidus
Those suffering from this condition often experience pain, an abnormal walking pattern due to discomfort, and swelling of the joints that can make wearing shoes difficult. A related symptom could be numbness along the inside edge of the big toe, a result of pressure on a certain nerve.
In a physical examination, doctors usually check your foot’s nerve supply and blood flow. A specific symptom may be a ‘Tinel sign’ which shows up when a certain nerve gets squeezed on the inside of your big toe. Often, the joint of your big toe might be tender and swollen, and you may feel bumps on the top of your foot. There is usually a decreased range of motion in your foot, especially when trying to flex your foot upwards. Pain levels can indicate the severity of the condition, with broader wear on the ball of the foot suggesting more serious arthritis. Other tests for pathology could involve experiencing pain when your foot is flexed forcibly upwards or tested with a ‘grind test’.
Some people might have a flat foot or ‘pes planus’, but it hasn’t been strongly linked to this condition. On the other hand, those with high-arched or ‘supinated’ feet are less likely to suffer from this ailment. Skin symptoms could include redness and irritation over a bony bump on the top of your big toe, likely caused by pressure from shoes.
Testing for Hallux Rigidus
To evaluate your foot health, your doctor might order weight-bearing x-ray images taken from different angles, including front-on (anteroposterior), side-on (lateral), and diagonal (oblique) views. However, these standard x-rays do not provide detailed information about cartilage loss. Advanced imaging such as MRI or CT scans are not typically necessary for diagnosing or planning the treatment of this disease. The oblique view is particularly useful for seeing the extent that the space in the joint has become narrower.
One of the methods used to classify the severity of this disease is the Coughlin and Shurnas Clinical Radiographic System. This system provides detailed and specific grading that helps in understanding the disease condition. The grading is as follows:
Grade 0: There’s a 10% to 20% loss of upward (dorsiflexion) movement in the big toe compared to the normal side. X-ray results show normal findings, you don’t experience any pain. However, during physical examination, some stiffness and loss of movement might be noticed.
Grade 1: The big toe movement is limited to 30 to 40°, corresponding to a 20% to 50% loss compared to the normal side. On the x-ray, there might be early signs of bony growth (osteophyte) at the top of the toe joint, moderate narrowing of the joint space, changes in the nearby bone, and some flattening of the ball of the foot (metatarsal head). You might experience mild pain and stiffness, and discomfort at the extreme upward or downward flexion.
Grade 2: The movement of the big toe is restricted to 10 to 30°, or a 50% to 75% loss compared to the normal. The x-ray might show bony growths on various aspects of the toe joint giving a flattened appearance to the metatarsal head. No more than a quarter space of the joint is affected, and mild to moderate narrowing and changes in the bone of the area are also noticeable. You might feel constant moderate to severe pain and stiffness, especially during the maximum upward and downward flexion examination.
Grade 3: Upward movement of the toe is only 10° or less, or a 75% to 100% loss compared to the normal side, and downward movement is also notably less. The x-ray findings are the same as Grade 2 with more narrowing, potential cyst-like changes around the joint, and more than a quarter of the top part of the joint space is involved. The bones near the toe joint might be larger than normal, filled with fluid, or irregular in appearance. You’ll likely experience nearly constant pain and a greater degree of stiffness that’s present at the extremes of movement but doesn’t really bother you in the mid-range of motion.
Grade 4: The movement loss is the same as Grade 3. The x-ray findings are the same as Grade 3. You’ll experience similar symptoms as in Grade 3, but now, there’s significant pain even at the mid-range of the movement.
Treatment Options for Hallux Rigidus
Up to 55% of people with a condition known as ‘hallux rigidus’ – a form of arthiritis that affects the joint at the base of the big toe – can experience significant reduction in pain without needing to resort to surgery. Pain relief can often be achieved with the use of anti-inflammatory drugs, alongside activity modifications like avoiding high impact actions such as running, jumping or using stairs. This may not suit all lifestyles though.
Other methods of pain management can include modifications to footwear and the use of orthotic devices – essentially custom insoles for your shoes. These are designed to alter the way you move, and limit irritation from any bone protrusions, and may offer relief from stress on the joint. Inserts can be made of a range of materials, including carbon fiber or spring steel. Techniques like the Morton’s extension, which involves a rigid insert that goes under the big toe, can help limit upward movement (dorsiflexion) of the toe. Other helpful strategies can include specific shoe styles like shoes with a high toe box to relieve pressure or rocker bottom soles to curb painful toe movement during walking. However, not all patients find these modifications comfortable or easy to adapt to.
When it comes to surgical options, a popular procedure known as ‘cheilectomy’ usually has good results for earlier stages of hallux rigidus, with up to 97% of patients reporting excellent outcomes in terms of pain relief and improved function over a 10-year post-surgery period. Less promising outcomes tend to occur with more severe stages of the condition. The surgery involves making a small cut on the top of the foot and removing about 30% of the part of the foot bone responsible for the problem. If necessary, similar protrusions on the side of the foot can also be removed. The aim is to alleviate the primary source of pain by removing areas where bones are impinging on each other.
The ‘cheilectomy’ can also be conducted via a medial approach, which means approaching the problem via the inner edge of the foot. Having a detailed understanding of the structures in the toe is vital to this approach, in order to avoid damaging nerve branches, for instance. A less invasive version of this surgery that is more conservative in terms of tissue removal can also be performed, and often has promising outcomes. Combination of this minor procedure with use of a scope (arthroscopy) is typically advised to ensure thorough management of the condition.
In more severe cases of hallux rigidus, a surgical procedure known as ‘arthrodesis’ is often the preferred treatment. In this procedure, the joint at the base of the big toe is fused to prevent it from rubbing and causing pain. The success of this procedure is largely based on the accurate positioning of the big toe after surgery.
Other potential surgical interventions include the ‘Keller resection arthroplasty’, where the base of the big toe bone (proximal phalanx) is removed; this is usually recommended for older, less active patients. Artificial joint replacement in the big toe is also an option, but this is generally not recommended for young or active individuals due to concerns with the implant shifting or loosening.
In recent years, a new type of implant made of polyvinyl alcohol hydrogel, which has similar properties to human joint cartilage, has been approved for use in the United States. Early data has shown similar outcomes to that of joint fusion (arthrodesis), but further studies with long-term data are necessary. Interposition arthroplasty, a surgical procedure that involves the addition of a natural or synthetic spacer at the joint, is another alternative. A review of 20 studies found that after a follow-up of roughly 4.5 years, 90% of patients reported significant improvement, with only a small percentage (3.8%) needing further surgery.
What else can Hallux Rigidus be?
In order to distinguish between hallux rigidus (stiff big toe) and other conditions causing pain in the joint connecting the foot and the big toe, various symptoms must be compared and contrasted. These other conditions might include the following:
- Bunions (a swelling on the joint)
- Gout (a form of arthritis)
- Hallux valgus (bunion)
- Infection
- Turf toe (a sprain of the big toe)
In diagnosing hallux rigidus specifically, doctors look for limitations in moving the toe upwards and the formation of bony spurs (osteophytes) at the top of the joint. Turf toe, by comparison, would typically be identified more immediately following a physical injury.
Although hallux rigidus can also make the big toe swollen and painful, blood tests and other lab examinations can help doctors set it apart from conditions like a bacterial infection in the joint (septic first MTP joint) or gout.
What to expect with Hallux Rigidus
The initial approach to treatment should ideally not involve surgery, as it has been found to be quite effective. In a review conducted by Grady and his team involving 772 patients, it was learned that 55% of the patients had good outcomes with just conservative care.
As for surgical treatment, the process known as arthrodesis of the first metatarsophalangeal joint (where a joint between the big toe and foot is surgically fused) is often the best option for those with severe hallux rigidus (a form of arthritis in the big toe). This surgical procedure boasts a success rate of about 90%.
Possible Complications When Diagnosed with Hallux Rigidus
Cheilectomy, a type of surgery for the foot, won’t necessarily stop the progress of an existing disease. Evidence shows that 7% to 9% of people who undergo this surgery may need another procedure called arthrodesis within 10 years. However, if a cheilectomy fails, it doesn’t interfere with the possibility of additional surgery.
According to a comprehensive review by Stevens and his team, around 6.6% of patients who had arthrodesis experienced either nonunion (the broken bone failing to heal), or delayed union (the bone taking longer than usual to heal). They also found that about 20% of patients had asymptomatic nonunion, which means that although the bone didn’t heal, it didn’t cause symptoms or require treatment.
There can be other complications, which include:
- Necessity to remove surgical hardware
- Stiffness of the joint
- Pain in the ball of the foot (metatarsalgia)
Specific complications tied to a procedure known as Keller resection arthroplasty include an upward bending (cock-up) deformity of the big toe, weakness when pushing off while walking, and transferring metatarsalgia.
Lastly, complications can occur related to arthroplasty, another type of surgery. The most common complications, found in about 26% of cases, are due to problems with the surgical implant, with main issues being the implant becoming loose. This can lead to instability and pain when walking.
Recovery from Hallux Rigidus
It’s common after surgeries like foot bone trims (cheilectomies), bone cuts (osteotomies), and installments of artificial body parts (implants), for patients to be allowed to walk immediately, but with the help of a special surgical shoe. However, after a surgery where the big toe joint (first MTP joint) is fused, patients need to avoid putting any weight on it for 4 to 8 weeks.
Currently, there are no specific recovery exercise guidelines after this kind of surgery. However, a recent study from the Department of Kinesiology of VA found that the tiny muscles in our foot (intrinsic muscles) tend to get smaller and weaker after a first big toe joint fusion. This suggests that patients might find it helpful to follow a recovery program including exercises that strengthen these muscles.
Preventing Hallux Rigidus
Hallux rigidus is a term that describes a condition where the big toe becomes stiff because of arthritis. While the exact cause isn’t completely known, this stiff toe is often connected to previous injuries in cases where only one toe is affected. It’s also more common in women and seen in both toes if there’s a family history of the condition. However, it’s important to know that wearing shoes does not lead to this condition.
Modifying your shoes or using special shoe inserts known as orthotic devices, may help the foot work better and slow down worsening of the toe’s shape. Other treatments that don’t involve surgery include taking anti-inflammatory drugs orally, getting steroid injections, and going through physical therapy. Over half of the patients experience satisfactory relief from pain using these non-surgical treatments. But in more severe cases where the toe is very stiff, surgery may be required.
