The Stiff Big Toe Joint (Hallux Rigidus)
Movement of the big toe joint occurs typically in an up and down plane only (dorsiflexion and plantar flexion). The normal dorsiflexion is approximately 75 degrees and plantar flexion is 25 degrees. When the big toe has limited movement, it is often, but not always, associated with some form of arthritis of the toe. This is referred to as hallux rigidus. Treatment of hallux rigidus often has to be surgical but the joint can be made more comfortable with an appropriate shoe modification.
Hallux limitus is a less severe form of hallux rigidus where there is loss of motion to the big toe, most often to the metatarsophalangeal (MTP) joint.
Arthritis of the big toe joint is present with large bone spurs around the joint seen on the X-ray on figure 1.
There is no cartilage, the joint space has disappeared and there is marked bone spurring around the joint. You can see that the big toe joint on the right has a large bump on it. This is not a bunion, but arthritis (hallux rigidus).
To treat the pain in the big toe joint, the shoes are modified by stiffening the sole, inserting a stiff orthotic arch support in the shoe and sometimes adding a small rocker effect (called a metatarsal bar) which is glued on to the bottom of the sole of the shoe. Thin-soled shoes and high heels aggravate this condition because more stress is placed on the joint, increasing pain.
The surgical treatment for hallux rigidus is determined by the extent of the arthritis and deformity. For the more minor type of hallux rigidus, shaving the bump of the bone on top of the metatarsal is sufficient (a cheilectomy).
As the stiffening of the big toe joint increases a cheilectomy is not sufficient and an additional bone cut may needed on the toe itself (an osteotomy of the phalanx) or an arthrodesis.
For some feet with hallux rigidus, the shaving of the bone on the top of the big toe (the cheilectomy) is not sufficient. An additional bone cut on the toe is made to lift it up slightly from the floor. This improves the upward movement of the toe and makes it easier to wear shoes.
As the arthritis increases, the ability of an osteotomy or cheilectomy to correct the problem, maintain motion, and prevent the arthritis from worsening is very limited. For these patients, either a fusion of the big toe (an arthrodesis) or removal of bone from the joint (an arthroplasty) is performed. The big difference between a fusion and arthroplasty is the movement of the big toe.
The main advantage of a fusion is that it is a permanent correction with elimination of the arthritis and pain. The disadvantage is the restriction of movement of the big toe. Patients are typically able to exercise, run and wear most shoes quite comfortably. Wearing a heel higher than an inch and a half is difficult after fusion of the big toe.
Removal of a bone from the joint (a resection or interposition arthroplasty) shortens the big toe slightly but maintains some movement. This is an effective operation, particularly for individuals who would prefer to have movement of the big toe after this type of surgery. It is not, however, as reliable and predictable as a fusion in terms of recurrent problems with the big toe and push off strength. The decision to perform a fusion or an arthroplasty of the joint is often a matter of patient and physician preference, a decision which is made together.