Hallux rigidus (big-toe arthritis)

What is hallux rigidus?

The big toe joint, where the first metatarsal meets the toe bone, bends upward every time you push off when walking. When the cartilage in that joint wears down, the joint becomes painful and stiff — “rigidus” means rigid — and bone spurs often form on the top of the joint.^[1,2]

It is not fully understood why some people develop it. Contributing factors include foot structure and mechanics, a family history, overuse, injury to the joint, and inflammatory diseases such as rheumatoid arthritis.^[1] Unlike a bunion, in which the toe drifts sideways (see bunions), hallux rigidus is mainly a problem of stiffness and joint wear, although the two can occur together.

Symptoms

• pain and stiffness in the big toe joint with walking, standing, running or squatting
• swelling and a firm bump on top of the joint that rubs on shoes
• pain that can be worse in cold weather
• in later stages, pain at rest, and a change in the way you walk, which can affect the knee and hip^[1]

How it’s evaluated

The examination measures how far the toe bends upward and downward, where the joint is tender, and how you walk. X-rays taken while you stand show how much cartilage space remains, the size of any bone spurs, and other changes. Radiographic grading, along with your symptoms, helps guide treatment.^[1,2]

Non-surgical care

Non-surgical treatment is the first step, particularly in early disease:

• Footwear: shoes with stiff soles and a wide toe box, which reduce bending at the joint.
• Orthotics: custom or stiff inserts that limit bending of the painful joint.
• Anti-inflammatory medicine for those who can take it safely.
• Injections and physical therapy in selected people.^[1,2]

A recent review of conservative management notes that the effectiveness of shoe modifications and insoles is commonly assumed but lacks strong evidence, that injections (corticosteroid or hyaluronic acid) have had varied results, and that roughly half of people treated non-surgically end up having surgery within one to two years.^[3] That doesn’t mean non-surgical care isn’t worth trying. It means expectations should be realistic, and that non-surgical care is best used to keep you comfortable while you decide.

When surgery is considered

Surgery is considered when non-surgical measures no longer control pain well enough.^[1] For the operations in detail, see hallux rigidus surgery. Operations fall into two groups:

• Joint-preserving procedures. A cheilectomy removes the bone spurs on the top of the joint so the toe can bend without pinching; it is used for milder to moderate arthritis and can be done through a small incision.^[4,2] Some surgeons also add a bone cut (osteotomy) to reduce the pressure across the joint.^[2]
• Joint-altering procedures. For advanced arthritis, the joint can be fused (arthrodesis), or its surfaces can be reshaped and a spacer of soft tissue placed between the bones (interpositional arthroplasty).^[2,5]

Fusion removes motion from the joint and aims to give a stable, pain-free big toe. A systematic review of modern fixation techniques for fusion of the big toe joint reported an overall union rate of 95.7% with a mean healing time of about 12 weeks, and a complication rate of 5.8%.^[6] In a systematic review of 16 studies of interpositional arthroplasty in advanced disease, scores improved significantly and toe motion improved after surgery, but the evidence base is limited.^[5]

Which option is best depends on the stage of arthritis, your age and activity, and your goals. For more, see foot and ankle joint fusion and replacement.

When to seek care

Consider an evaluation if your big toe is becoming stiff and painful, if pain limits walking or exercise, if a bump on top of the joint makes shoes uncomfortable, or if you notice you are walking differently to protect the toe. Earlier diagnosis can help delay the need for surgery.^[1]