Introduction

Hallux rigidus is arthritis of the joint at the base of the big toe (first metatarso-phalangeal joint). It is called “Hallux rigidus” because its main feature is stiffness (rigidus) of the big toe (Hallux).

The most common cause of Hallux Rigidus is osteoarthritis, general known as wear and tear of the joint.  The main reason why this joint is particularly prone to wear and tear, is that it is under tremendous stress during walking. In some people it may follow an injury, infection, or inflammatory joint disease (such as rheumatoid arthritis).

Hallux rigidus can cause pain and stiffness around the joint. It can also result in a bony bump that may rub on the shoes.

Sometimes only the upper part (dorsal aspect) of the joint is affected and the rest of the joint is preserved. In other people the whole joint is worn out.

Treatment

Medications

Simple analgesics such as Paracetamol can be used if the pain is bad and interferes with activities of daily living. If this does not work, stronger analgesics or anti-inflammatory medicines can be used.

Shoes

Because the joint is usually most painful when the toe is bent upwards during walking, it sometimes helps to stiffen the sole of the shoe so that it does not bend while walking. A rocker bottom shoe is helpful to allow the foot to rock over while walking instead of bending the toe. This can be done by an orthotist or podiatrist.

Steroid injection

An injection of steroid and local anaesthetic into the joint may be useful. This reduces the inflammation inside the joint. The toe may be painful for a few days after the injection. If the injection improves the pain, the effect may last for a few days, weeks or months.

Surgery

Operations performed for hallux rigidus are removal of the spur/bump (cheilectomy), fusion (arthrodesis) of the first metatarso-phalangeal joint or interposition (Cartiva)

Cheilectomy involves trimming of the upper part of the joint. This is helpful if only the upper part of the joint is affected. Most people obtain pain relief and better movement in the joint. The arthritis however can worsen over time and some will eventually require further surgery.

Fusion (arthrodesis) of the first metatarso-phalangeal joint involves stiffening of the joint at the base of the big toe. 95% of people will obtain relief of their pain. However, the toe will be stiffer than before surgery and the choice of shoes is more limited, heels of only up to 2 cm can be worn.

Cartiva is a newer device that replaces part of the damaged cartilage in the joint, this aims to remove pain but keep movement. This a newer technique and the long term outcomes are not yet known, in the event of problems this can be converted to a fusion.

Before Surgery

Anti-inflammatory medications such as Aspirin, Brufen, Voltaren, etc. should be stopped 10 days before surgery.  If you are taking any blood thinners, for example, Warfarin, Plavix or Iscover, stopping these should be discussed with your surgeon.  It is ideal if smoking can be ceased prior to surgery.  

It is also advisable to prepare circumstances at home prior to your surgery, as there will be a period of recovery and rehabilitation following your surgery.  Arranging for family and friends to assist you in the home setting is highly recommended. You should ensure that there is adequate clearance in the home to enable you to use a crutches or walking frame.

It is important that you organise family and friends to assist you with transport, as you will not be able to drive for at least 8 weeks. 

After Surgery

You will be in a bandage and require a post-operative shoe for up to 6 weeks.  Your mobility will be limited by swelling and discomfort.  It is important that you rest in between walking to allow the pain and swelling to settle.  At home, initially walking is kept to a minimum.  You will require assistance with household chores such as cooking and cleaning. 

After 6 weeks the dressings are removed, it may take another 2 weeks to be comfortable in closed shoes.

Driving is not allowed when in the post-operative shoe, but may be resumed when comfortable, particularly when you are able to brake in an emergency, usually at the 8 week mark following surgery.

Returning to work can be dependent upon the activities of your employment, but is usually resumed at anywhere between 6 weeks and 3 months following surgery. 

Running is not recommended after fusion of the first metatarso-phalangeal joint.

Risks of Surgery

Risks include infection, wound healing problems (especially in those patients who smoke, have diabetes or vascular disease), failure to fuse (non-union), which may require the fusion surgery to be repeated.  Surgery may not completely remove pain or deformity.  Rarely, nerves and blood vessels can be damaged leading to numbness or loss of a toe (amputation))