FOOT

Hallux Rigidus

Hallux Rigidus refers to osteoarthritis of the big toe. The pain and inflammation caused by osteoarthritis gradually over time restricts the movement of the big toe.

This condition is more common in middle aged men and will often present in both big toes.

A bunion may also be present at the same time as hallux rigidus. Treatment is therefore decided by which the more prevalent problem is.

How does it feel?

The big toe will feel stiff and gradually the pain can become quite severe and persistent, especially after standing or walking for any length of time. Symptoms are usually triggered in the ‘push off’ phase of walking which relies on the forefoot and big toe region and puts the toe in a maximally extended position.

However the presentation of hallux rgidus like most arthritic conditions can be unpredictable.

Diagnosis

A physical examination will determine the presence of Hallux Rigidus. Range of motion of the big toe will be very restricted and there maybe an appearance of bony growths on the top aspect of the big toe. An x-ray will show the extent of the deformity, and help the surgeon decide if surgery is necessary.

Diagnosis

Treatment

A combination of the level of pain, radiographic stage of degeneration, the presence of deformity and the chance of success versus the degree of restriction following treatment helps to reach an informed decision as to which of the many therapies will be most appropriate.

Non Surgical (Orthotics):

The principle with orthotic management is to offload the big toe during walking. During normal walking the front part of the foot acts as a rocker, this requires the big toe joint to both extend and take weight. By modifying a normal shoe to add a subtle rocker to the sole at the location of the joint, as well as stiffening the sole here so it doesn't bend, the foot can progress forwards normally with reduced big toe movement and thus reduced pressure through it. The shoe "takes the strain".

Surgical:

Injection/manipulation:

This may be useful in the early stages of arthritis, however the effects are often temporary.

Arthroscopic debridement:

A minimally invasive technique, generally for patients with moderately severe symptoms but lesser degrees of x-ray changes.

Open debridement:

Debridement either by arthroscopic ‘keyhole’ surgery or by the standard ‘open’ procedure involves removal of any loose cartilage within the joint and fine drilling into small areas lacking cartilage. This allows new, though poor quality cartilage, to form in drilled areas. In addition the excess arthritic bone (osteophytes) which form on the top edge of the joint are removed. This should allow an increased range of extension (upwards movement) post-operatively.

Debridement is performed as a day case and a rigid bandage is applied afterwards. A physiotherapist will ensure you are able to mobilise with crutches and generally you are allowed to weight-bear as much as is comfortable. You will return to see the consultant 2 weeks post surgery and you will be instructed on exercises to minimise stiffness. Gradual return to full function will occur.

Kellers/Hamiltons arthroplasty:

A good option in the less mobile, more elderly patient. This involves removal of one side of the painful joint. This stops the pain of the arthritic joint but the big toe sometimes becomes floppy.

Fusion:

The two joint surfaces which are generating the pain due to osteoarthritis are removed and the remaining joint fuses as part of the normal healing process following surgery. The joints are fixated together utilizing screws.

Similar to an ankle fusion, the joints either side from the fused joint can take over some of the original function of the affected joint.

You will need to keep your foot elevated for the first 48 hours. You will be given crutches and generally will be able to weight bear as comfortable (check with your surgeon first). All bandaging will be removed after 2 weeks, however it normally takes 6 weeks before you are able to wear your normal shoes. It will take approximately 6 to 12 weeks for the bones to fuse fully and then there are no restrictions on activity, although you may find due to restricted movement you are limited on the height of heel that you can wear.

Replacement:

Replacement of the big toe has a long though not yet satisfactory history, certainly twenty five years. No previous/established implants have succeeded in being able to maintain movement whilst preserving good mechanical forefoot function and being predictably long lived. However there are still some presentations of hallux rigidus where a replacement may be worth considering. This needs to be fully discussed with your surgeon.

We are currently involved in a multi-centre trial of a new big toe joint replacement.