Definition:
Stiffness and pain of the big toe joint is termed Hallux Rigidus or Hallux Limitus. Hallux is the medical term for the big toe and the terms rigidus and limitus describe the extent to which the toe can move.
Typical appearance of forefoot 1 month following surgery for Hallux Limitus
Symptoms:
Symptoms can vary from patient to patient. Most people describe a burning and throbbing pain in their forefoot which may radiate up into the arch. For women, wearing high heel shoes generally aggravates the problem. Additionally, walking and running tend to cause pain. There maybe a noticeable bump on the top of the great to joint with some overling redness. Usually, there is little swelling. Moving the big to joint up usually causes pain.
Patient may experience periods of relatively few symptoms which may last for months at a time, only to be followed by extreme flair ups of pain. The big toe is usually always stiff, even when there are no symptoms.
An easy test patients can perform on their own is to compare the ability of the big toe joint to move upwards. If one side is significantly stiffer then other toe and there is occasional to frequent pain, this is a good sign of Hallux Limitus or Rigidus.
Cause:
Abnormal alignment of the metatarsal bone relative to the proximal phalanx (big toe bone) is the most common underlying factor in developing Hallux Limitus/Rigidus. During a normal stride, whether walking or running, the proximal phalanx must most up and over the metatarsal. In order to do this, the metatarsal bone must be slightly lower then the proximal phalanx. If the metatarsal bone is slightly elevated (or higher) then the proximal phalanx, the big toe cannot move up and over the metatarsal. Instead, a jamming of the joint occurs. Repeated jamming over a period of years leads to degeneration of the joint. Cartilage is worn away and large bone spurs form on the top of the joint. The combination of cartilage loss and bone spurring causes loss of motion of the joint.
Diagnosis:
Diagnosis is usually made via clinical exam and x-rays. Sign and symptoms include:
- Spasms of the overlying tendons
- Inability to move the big toe joint without pain
- Unable to wear high heel shoes without pain in the great to joint
- Unable to run without pain in the big to joint
- Patient must turn their foot slightly sideways when walking to prevent pain
- Painful Bump on the top of the big toe joint
Staging / Classification:
Hallux Limitus/Rigidus in a progressive problem, meaning as time goes on it tends to get worse. There are a defined set of stages to this condition. Each stage generally progress to the next as a function of time. We use the staging system to help determine the best course of treatment.
- Grade 1: Decreased motion to the big toe joint, with or without pain. Recent onset. X-rays show no changes, there are no spurs to the top of the joint.
- Grade 2: Decreased motion, pain is present. A bump is usually present on the top of joint and the X-rays show bone on bone with spurs.
- Grade 3: Very limited range of motion to the big toe joint. A grinding sensation is present when trying to move the joint. Redness and pain with most activities. X-rays show advanced bone on bone changes, minimal cartilage is left within the joint.
- Grade 4: Big toe joint does not move. Pain with activities. X-rays show no joint space, complete loss of cartilage.
Arrows indicate joint collapse. Stage 4
Treatment:
In the early stages on Hallux Limitus/Rigidus, non-surgical care maybe of benefit. This includes custom arch supports to better align the first metatarsal relative to the proximal phalanx. Orthopedic rockerbottom shoes for non-surgical candidates can also be of use. Cortisone injections into the joint can also temporarily alleviate the symptoms. Generally, however, this condition requires surgery. Surgical management falls into two broad categories, preserving the joint or fusing the joint. The surgery is chosen based on the above mentioned staging system.
Joint preserving:
- Chielectomy: remodeling of the joint with removal of the bone spurs and freeing the adhered tissue.
- Shortening osteotomy: Cuts in the metatarsal bone to "decompress" the joint.
Arrow indicates large bone spur
Arrow indicates area of spur removal
Joint Destructive:
- Fusion: Removal of the remaining cartilage, removal of the bone spurs and fusion of the metatarsal to the proximal phalanx. This results in a stiff big toe joint which generally no longer has pain. Patient can usually return to most activities including running and other high impact sports once they are completely healed.
Fusion of joint
- Arthroplasty: removal of the joint with possible implant of an artificial joint. This is usually done for pain relief in patients who are not able to undergo a fusion. Generally return to sporting activity is not possible.