Arthritis of Big Toe joint
Hallux rigidus is a painful condition involving the big toe joint of the foot. “Hallux” refers to the big toe and “rigidus” refers to limitation of motion or stiffness of the big toe joint. Hallux rigidus simply refers to arthritis of the big toe joint of the foot.
The first metatarsalphalangeal joint or “big toe joint” plays a very important role in our normal foot motion. The big toe joint helps create stability of the foot during walking and is very important during the propulsive phase of walking. The three phases of the weight bearing cycle of our walking gait include: heel contact, midstance and propulsion. During propulsion the foot is preparing to lift the heel bone prior to initiating the non weight bearing portion of the gait cycle. The active lifting of the heel off of the ground initiates the propulsive phase of walking. As the heel lifts off of the ground the big toe joint must extend a minimum of 70 degrees from the weight bearing surface of the ground during normal walking. If the motion is less than 70 degrees as seen in hallux rigidus the big toe joint during propulsion develops abnormal stresses that over time can develop painful arthritis.
Arthritis of the big toe joint clinically is seen as the development of pain that is generally described as “achy” or sharp and “pinching” in nature. Radiographs of the big toe joint show bone spurring, joint space narrowing with the progressive wearing away of the joint cartilage as well as increase bone density at the joint related to chronic abnormal stresses occurring at the joint.
Men and women generally beginning as early as the third to fourth decade of life can experience this painful foot problem. Shoes play a limited roll in the development of the problem but certainly have some influence upon the conservative treatment options available. The cause of the big toe joint arthritis is related to abnormal walking mechanics occurring during the “midstance” phase of the walking cycle. During midstance the foot is going through complex motion called pronation and supination. The pronated foot is a very flexible foot position that can accommodate abnormal walking surfaces while the supinated foot is a rigid state that prepares the foot to transfer the weight bearing pressures of the body into the swing portion of the walking cycle. Between the midstance and propulsive portion of the walking cycle the foot normally moves from a pronated position into a supinated position in preparation of lifting the foot off of the ground as it enters the swing phase of the gait cycle. People who develop hallux rigidus generally stay in a pronated foot position as the heel lifts off of the ground. This pronated position increases abnormal pressures in the big toe joint and over time can lead to the development of hallux rigidus.
Conservative treatment of hallux rigidus is designed at relieving the abnormal stresses in the excessively pronated foot by the use of an orthotic device that will allow a more normal transition between the pronated unstable foot and the supinated stable foot. A customized orthotic is an essential therapy to reposition the abnormally pronated foot into a more supinated foot position at heel lift. Shoe selection is also important with the need to purchase a shoe that has adequate room in the ball of the foot as well as a shoe that helps support the foot by decreasing abnormal foot pronation as well as one that accommodates a customized orthotic. The use of ant inflammatory medications including the non steroidal anti-inflammatory medications including ibuprofen and naproxen tend to provide limited help. The selective use of cortisone injection into the painful big toe joint if the shoe and orthotic therapies are incorporated can be a useful tool in pain reduction.
If the pain related to hallux rigidus is not relieved by conservative measures and the pain has affected the quality of life to a degree that is very limiting surgical correction may be warranted.
Surgical care is designed to relieve pain by relieving the abnormal stresses at the painful arthritic joint. There are generally three surgical approaches for the relief of pain related to arthritis of the big toe joint. The surgical decision making is based on the type of pain, quality of motion and the radiographic findings. Someone who has severe arthritis as compared to someone who has minimal to moderate painful arthritis will require different surgical procedures. The main take home message is that it is better to do surgery “sooner” rather than “later” when it comes to hallux rigidus after the failure of conservative therapies.
The first surgical option includes surgically removing the bony spurring and “cleaning” up the joint. This surgical removal of bone spurring or “exostectomy-chielectomy” is generally not recommended because it does nothing to improve the functional motion of the big toe joint which is limited in hallux rigidus. These surgical procedures are generally reserved for people who have limited expected activity after the surgical procedure. The overall length of pain relief for active patients pursuing this surgical procedure is usually within five years.
The second surgical option includes surgically removing the bony spurring and “cleaning” up the joint with the additional a creating an osteotomy or bone cut to shorten the length of the first metatarsal bone. This “decompressive” first metatarsal osteotomy improves the motion of the joint to near normal. Despite the fact that cartilage that is worn away in arthritis can not be repaired this joint decompressive first metatarsal osteotomy improves motion, decreases pain and tends to provide long term pain relief for the mild to moderately arthritic joint.
The third surgical option is reserved for the end stage arthritic big toe joint that does not have enough cartilage to be salvaged. These joint destructive surgical procedures include implanting a synthetic toe joint, implant arthroplasty with the resection of the joint without implanting a synthetic toe joint as well as joint fusion that incorporates the removal of all of the cartilage and placing screws or a plate across the joint to create a permanently stiff toe joint. These joint destructive surgical techniques all have there advantages and disadvantages with the decision of surgical approach based on the specific clinical picture.
If surgical correction is pursued based on quality of the pain and failure of conservative options the decompressive first metatarsal osteotomy generally has the greatest long term satisfaction. The old adage of “come back to my office when you can’t stand the pain” should not be followed because the degree of pain often times relates to the severity of the developed arthritis. If the hallux rigidus is severe it will lead to a joint destructive procedure rather than the decompressive procedure which is a joint preserving surgical procedure.
The goal of conservative and surgical care in the treatment of hallux rigidus is to improved quality of life with the reduction of pain during normal walking in the big toe joint.