Hallux Rigidus: Causes, Diagnosis and Treatment
Hallux rigidus is a condition that results in limitation of movement at the metatarso-phalangeal joint (ball joint) of the great toe.
Before reading on it would be good to first understand the anatomy of the foot (skip this if you already done so).
It is caused by a start in the destruction of the cartilage of great toe, this leads to irritation of the synovium (a membrane lining the joint). The irritated synovium becomes inflamed. This inflammation leads to further cartilage destruction and osteophyte (excess bone also called bone spur) formation. This ultimately causes arthritis of the joint and limitation in movement.
- trauma to the joint
- osteochondritis dessicans (degeneration or injury to cartilage)
- abnormally long first ray (1st metatarsal)
- pronation or rotation deformity of the foot
- rheumatoid arthritis
- pain and swelling in the 1st metatarso-phalangeal joint
- inability to extend the great toe (pull it up)
- difficulty in walking and running; pain in the push off during stepping
- tenderness over the joint
- later on there may be pain in the other toes (these toes are over burdened because due to pain in the great toe your body places more weight on these toes bypassing the great toe)
- painful calluses may form in the foot
Diagnosis is confirmed by x rays of the foot. Typical changes of osteoarthritis are seen in the x rays.
- decrease in joint space due to destruction of the cartilage
- formation of bone spurs (osteophytes)
- alteration in bone density (increased density just under the cartilage and decreased density else where)
Treatment of hallux rigidus can be of two types non-operative and operative.
Initially all patients are advised non-operative treatment that consists of
- proper education about the condition with emphasis on its non seriousness
- to use proper foot wear (use a wide toe box shoe and to avoid high heels that can aggravate the pain)
- anti-inflammatory medication and ice to reduce the pain and swelling
- injections of steroid (too many injections should be avoided as steroid can increase the destruction of the joint; maximum 1 or 2 injections should be used)
- you may be advised to use a rocker bottom or stiff sole shoe (this shoe decreases the movement of the 1st metatarso-phalangeal joint and hence reducing the pain too)
If the above treatment fails to provide relief from pain then surgery should be considered.
Surgery depends on the grade of the hallux rigidus.
Grading according to Hattrup and Johnson (1988)
- Grade 1 - bony spur formation is mild and joint space is maintained
- Grade 2 - bony spur formation is moderate and joint space is decreased with increase in density of bone beneath the cartilage
- Grade 3 - bony spur formation is severe and joint space is markedly diminished
Surgical procedure used in grade 1 an 2 is cheilectomy.
- in this procedure all the bone spurs are removed that are limiting motion of the joint; surgery takes 30 to 40 minutes
- movement in the joint improves and pain decreases
Surgical procedure used in grade 3 is arthrodesis.
- in this procedure the joint is fused in a proper position.
- pain in the joint is now no more, but there is no movement too
Frequently Asked Questions
When is non-operative treatment successful?
The earlier the treatment is started after symptoms appear the more are the chances of success with non-operative treatment.
How long does it take to recover after cheilectomy surgery?
Walking is allowed as soon as pain is tolerable (usually 10 to 18 hours after surgery). Complete recovery can take three months.
Can the disease recur after this operation?
Yes it can, if the arthritic process continues in the joint.
As my joint is already rigid won't fusion (arthrodesis) increase my symptoms and make walking more difficult?
Before surgery you have a rigid and painful joint after surgery you will have a rigid and painless joint. Absence of pain will make walking more easy.
What about joint replacement?
Joint replacement has been tried for hallux rigidus but because of the many complications and poor long term results it is not recommended.
I hope the information provided was helpful. If you have any query you can ask me at the contact me page.
This page was last updated on 23th June 2009.
Other causes of foot pain...
Tarsal Tunnel Syndrome
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