Hallux Rigidus

What is hallux rigidus?

Hallux rigidus means stiff big toe. The reason that the big toe has become stiff is that the big toe joint has become arthritic. An arthritic joint means that the joint is wearing out. 
A joint is made of two bones and the bone ends are covered by articular cartilage.  The articular cartilage is smooth, shiny and slippery and allows the joint to move smoothly. As the joint wears out the movement becomes less smooth and this can cause pain.
In addition, as the joint wears out extra bone appears around the joint .This extra bone limits the amount of movement and this is the cause of the stiffness. The extra bits of bone form lumps which can rub on shoes.

What causes it?

The exact cause of this condition is unknown. It is not an heritable disorder which means that your children are at no specific risk of having this as well. Sometimes this condition can be related to an injury where the joint is injured.  If you get this condition in one big toe it might not happen in the other one.

What problems does it cause?

This condition can be painful. The pain can occur whilst walking but also at rest and at night time. Pain can also occur when the bone ends rub together.
Stiffness - this condition stiffens the big toe and limits the amount of movement upwards that the big toe can move. This has an effect on walking and running. Because the big toe is stiff this will limit the wearing of high-heeled shoes.
Painful lumps - the extra bone that occurs around the joint can form bony hard lumps. These may rub on shoes and this may cause pain.

What can be done for hallux rigidus?

General advice

A lot of force goes through the big toe when you walk so losing weight and keeping fit may be of benefit. Finding comfortable shoes with space for the big toes may relieve some of your symptoms.

Shoe advice

I have many patients with stiff feet and ankles who experience great pain relief from these shoes. Because the shoes have a rocker bottom the shoe moves rather than the foot.
The styles of shoes recommended include Skecher Shape Ups, MBT and Dr Scholl Fitness shoe. The advice is to try lots of types of shoes and find the best suited for you.
It is really important to wear these shoes in gradually over a few weeks. The shoes will change the way you walk and will affect your feet, knees, hips and back. Your legs will ache for a few weeks afterwards but the advice is to persist with the shoes.


Skecher Shape-ups information at www.skechers.com
Skechers Shape-ups
MBT information at www.us.mbt.com

MBT Trainer

Dr Scholl's Fitness exercise trainer information at www.drschollsshoes.com


Scholl fitness shoe

Calf stretch exercises

Some patients with hallux rigidus have tight muscles in the calf. The muscle that is usually tight is the gastrocnemius muscle. This is a muscle which spans across the knee and ankle so that when your knee is bent, the muscle is relaxed. When the knee is straight the muscle is tight. If the gastrocnemius muscle is tight then it will limit the ankle movement upwards when you walk. In this situation there is a greater force taken at the front of your foot. By stretching out this muscle, you may be able to lessen the force on the front of your foot and this may relieve some of your symptoms.

leg stratching exercises

Surgical treatment - Chielectomy

If you have a painful lump and a stiff toe then a procedure to remove the lump and improve the movement at the big toe may help your symptoms. This is a procedure which may be performed as a day case which means that you go home the same day of the operation. The procedure involved a 4 cm incision along your big toe. The extra bits of bone are carefully removed and your joint carefully assessed. Stitches are then inserted into the tissues and a big woolly dressing applied.
You can walk immediately after the operation in a special sandal. You will need a wound inspection at 2 weeks. The foot will remain swollen for up to 6 weeks after the operation but you would then be expected to get back into a normal shoe from 2 weeks.
The aim of the operation is to remove the pain that you experience as you big toe moves upwards. The toe movement may well improve but the arthritic process may still continue. This procedure works in 80% of people.

Surgical treatment - Arthrodesis

If your big toe joint is stiff and painful then an arthrodesis or fusion operation may be performed. Your joint is worn out and is painful when the joint is moved. During a fusion operation the joint is removed and the bone ends fused together so they do not move. Because the joint does not move it is not painful.
This is a procedure which may be performed as a day case which means that you go home the same day of the operation. The procedure involved a 4 cm incision along your big toe. The extra bits of bone are carefully removed and the joint surfaces are prepared. The ends of the bone are then brought together and fixed with metal screws. The skin is then stitched and a big woolly dressing applied.

Post operative course after arthrodesis

You can walk immediately after the operation in a special sandal full weight bearing for 6 weeks. You will require a dressing change / stitch removal at 2 weeks. You will require a check X-Ray at 6 weeks. At 6 weeks you may have continued swelling but should be able to get into a normal shoe.
After the arthrodesis operation your big toe joint will be permanently stiff. The pain of the arthritis will have been reduced. However your walking or gait will change. There may be some difficulty putting shoes or boots on. However most patients adapt to this new way of walking.

Driving after arthrodesis

After 6 weeks when you are walking fully weight bearing you may drive.

Work after arthrodesis

In the first 2 weeks after arthrodesis the foot will be swollen and will need to be elevated. After the stitches have been removed, you may return to a desk based job which will allow you to sit and elevate the foot.

Surgical treatment - Joint Replacement

Joint replacement can be performed for this condition. This involves replacing either half or the entire worn out joint. However I have assessed the data of joint replacement and have come to the conclusion that this procedure does not offer any advantage over an arthrodesis. I hence do not offer this treatment.

Risks of the surgery:

Infection

This is an uncommon complication. Most infections are superficial and may be treated with a short course of antibiotics. If the infection is deep then an admission to hospital and further surgery may be required. This is an uncommon occurrence.

Nerve injury

A small nerve about 1mm in diameter lies just beneath the skin on the inside of the foot. This nerve is vulnerable during the operation but I am trained to find and protect the nerve. Despite these measures the nerve can be injured resulting in numbness along the side of the big toe or a painful nodule on the nerve. Further surgery may be needed.

Pain and swelling

It is not surprising that it may take several weeks or months for your foot to settle down after this extensive surgery. Many patients experience pain and swelling especially in the first few weeks. Rest and high elevation are required to keep these at a minimum.

Failure after chielectomy

Although the success rate of this procedure is good it may not work on every one. There may be pain relief for some time but this may be short lived. If your symptoms continue then an arthrodesis or fusion operation may be necessary.

Deep vein thrombosis and pulmonary embolus

After any lower limb surgery there is a risk of a clot on the leg (deep vein thrombosis) and clot on the lung (pulmonary embolus).  After this procedure you will be mobile and so the risks of these complications are small and prophylaxis is not required. If you have had a previous DVT or PE you may be at increased risk.
A risk assessment will be performed preoperatively. The majority of people undergoing this surgery are at a low risk and do not require any prophylactic medication to reduce the risk of these clots. If your risk is moderate or high prophylactic treatment may be necessary.

Non-union

After a fusion operation the bones may not heal and become solid. This is called a non-union. This has a higher occurrence is people who smoke. If this occurs then a further operation may be required. If you smoke you are at higher risk of this complication. Stopping smoking preoperatively will reduce the risk of this complication.

Alteration in walking and shoe wear after arthrodesis

The arthrodesis is an operation that converts a stiff painful joint into a stiff painless one. Pain will be relieved and this will improve your walking. However the big toe joint will be permanently stiff and this will alter the way you walk. You may encounter difficulty wearing your shoes and these may need to be modified. You may not be able to wear high heeled shoes.