Arthritis of the great toe causes pain and stiffness that is called Hallux Rigidus by surgeons (hallux = big toe, rigidus = stiff). Confusingly, podiatrists use a slightly different nomenclature reserving hallux rigidus for severe conditions where the toe is completely rigid. In the early stages, podiatrists refer to the condition as hallux limitus. The condition may affect one or both feet and can occur in isolation or as part of a more generalised arthritis. The condition can present at any age but is more common in middle age onwards.
As the name would suggest, people with hallux rigidus notice the toe getting progressively more stiff and frequently, more painful. There is often a bump on the top of the joint that may cause problems in shoes. Depending on the stage of the problem, the toe may be painful all the time with any movement, or in mider cases, only painful at the extreme of movement.
Diagnosis is made through a combination of clinical assessment and x-rays. The surgeon will assess the range of movement of the joint, whether pain is throughout the range of motion or just the extreme and the condition of the adjacent joints. X-rays are useful to confirm the extent and severity of the problem.
In the earliest stages of the problem it is important to try and keep the toe mobile. Painkillers, supportive shoes such as trainers and keeping active all help. As the condition progresses, keeping the toe mobile may prove increasingly difficult and painful. When this starts to happen symptoms may be controlled by restricting the range of motion of the joint through using stiff soled shoes or special orthotics such as carbon fibre inserts.
Surgery becomes necessary when these conservative treatments are no longer sufficient to alleviate the symptoms. The exact surgery varies on the stage of the problem but will usually take one of 2 forms:
When the pain is felt at the almost only at maximum dorsiflexion and the majority of the joint is healthy, the surgeon may offer a cheilectomy as an option. During this operation the goal is to remove the extra bone (osteophyte) that is restricting the range of motion of the joint along with the worst affected portion of the joint. The aim of the operation is to relieve pain and improve the range of motion. The operation is usually performed as a day case. After the surgery it is important to rest the foot for 2 weeks with elevation. Once the wound has healed the toe is mobilised with the help of the physiotherapists. Even for this, more minor procedure, it is important to realise that it takes quite a long time to get over with full benefit not really being reached until a year post op
- Fusion (1st MTPJ Arthrodesis)
When the majority of the joint is affected or the toe is exceptionally stiff cheilectomy may no longer be appropriate. In this situation the most reliable procedure is an arthrodesis, or fusion, of the joint. In this procedure the joint is removed and the bones held together to allow them to heal into 1 bone. This leaves the inter-phalangeal joint (the one behind the nail) free to move, but permanently stiffens the main toe joint. The aim is to abolish all pain and the operation is extremely successful. The toe is a little short after the operation but because of the pain being abolished, function is usually much better. Depending on the position the toe is fused in, it may be possible to wear a slight heel. The operation is also usually done as a day case. You are able to walk fully weight bearing in special rigid sole shoes from the day of the surgery but it is important that for the first 2 weeks you rest with your foot elevated above the level of your heart. Your wound is checked at 2 weeks and a check x-ray taken at 6. You will need to remain in these shoes when weight bearing for 6 weeks.
As with most foot surgery it will take 3 months to be fair, 6 months to be good and a year to be right.
A newer procedure that some surgeons are offering is a joint replacement. This is a technique that has been tried in the past and at this stage we do not feel the operation is sufficiently reliable or offer any great advantages over a fusion to recommend it. We are keeping a close eye on published results to see if this changes.