London Foot Surgery Specialists in Hallux Rigidus (big toe arthritis) Operation

Hallux Rigidus - Arthritis in the Big Toe


What is hallux rigidus? Hallux rigidus is arthritis of the main joint of the big toe in the ball of the foot. It is a wearing out of the joint surfaces. It is called "hallux rigidus" because its main feature is stiffness ("rigidus") of the big toe ("hallux"). Some people get stiffness in this joint with little or no obvious arthritis - this is called "hallux limitus" because the toe has limited movement but is not absolutely stiff. Sometimes only the upper part of the joint is affected and the rest of the joint is all right. In other people the whole joint is worn out. What causes it? In most people there is no definite cause - it just develops. Probably the main reason why this joint is particularly subject to wearing out is that it is under tremendous stress in walking. With each step, a force equal to twice your body weight passes through this very small joint. In a few people it may be caused by an injury or another medical problem such as gout or an infection in the joint. There are a lot of theories about why the joint becomes arthritic but as yet none of them seem very helpful in treatment or prevention of the condition. What problems does it cause? The commonest problems are: Pain in the big toe around the joint. In some people the pain is present whenever they walk or even at rest, but in others it only occurs when they turn the big toe up as far as it will go Stiffness of the big toe. the ability to turn the big toe upwards is lost, although it can usually be turned downwards. Sometimes it gets so stiff it points downwards and cannot be laid flat on the floor A bony bump ("osteophyte" or "dorsal bunion") may develop on top of the joint. This is your body’s natural response to the worn joint. The bump may rub on the shoes. In some people this is their only problem. Because of the painful big toe some people tend to walk on the side of the foot. This may produce pain in the ball of the foot or down its outside border. Sometimes the joint wears down more on the outer side, towards the lesser toes, than on the inner side. This may make the toe tilt towards the second toe, and the toes may rub together. Why have I got this condition in my twenties? It is well known that hallux rigidus may begin early in life, even in the teens. We don't know why this happens. Fortunately, the chances are that your toe will not get progressively worse, and (apart from your other big toe) you are not much more likely to get arthritis in other joints, such as your hips and knees, than anyone else. What will happen - will I be crippled by this condition? Research shows that although the joint remains arthritic and stiff, it tends not to get much worse in the majority of people. Even after 20 years the joint was much the same as it had been when the people who were studied first went to the doctor. However, in about 20-25% the joint becomes progressively more stiff or painful and treatment may be required. Is there anything I can do to stop it getting worse? - Orthotics/Insoles to help improve big toe joint function have shown to help. - In some cases surgery to align the big toe joint can also help to improve big toe joint function and reduce the chance of long term joint deterioration What can be done about hallux rigidus? Because the joint is usually most painful when the toe is bent upwards during walking, it sometimes helps to stiffen the sole of your shoe so that it does not bend while walking. If you do this, you may need a small "rocker bar" on the sole of your shoe so that you can rock over this while walking instead of bending your toe up. This can be done for you by an orthotist or podiatrist. One disadvantage of this treatment is that the stiff insole may push your osteophyte up against the shoe. If the toe remains very painful, it may be worth injecting some steroid (cortisone) mixed with local anaesthetic into the joint. This reduces the inflammation inside the joint. The injection can usually be given in the outpatient clinic, although sometimes you may have to come into hospital as a day patient. The toe may be painful for a few days after the injection and any improvement has usually occurred by a week. If your toe is improved by an injection the effect may last for a few days, weeks or months; occasionally the improvement seems to be permanent. There are also newer natural occuring substances such as ostenil (Hyaluronic Acid). That can help lubricate the joint in the early stages. Can an operation help? If none of the above operations helps, an operation may be useful. You would need to discuss this with an foot and ankle surgeon. There are several common operations for hallux rigidus. If only the upper part of the joint is involved: The upper part of the joint can be trimmed out and the joint washed out. This operation is called a cheilectomy. Most people who have a cheilectomy get less pain and a useful improvement. In about 75% this improvement is permanent. The others develop worsening of the arthritis over the following years and some will eventually need another operation. Either as a separate operation or at the same time as a cheilectomy, the bone in the base of your great toe (proximal phalanx) may be reshaped to make the most of the movement you have left. If the whole joint is involved, there are three main options, depending on the age and activity of the patient: • In young fit people, especially those doing heavy jobs, a fusion of the joint would be recommended. This removes the painful joint and stiffens it completely. 95% of people will get rid of their pain. However, the toe is stiffer than before and the choice of shoes is more limited. A few people will go on to get arthritis of the small joint in the middle of the toe after a fusion, but this is not usually troublesome. • There are a number of ways to replace the arthritic toe joint. A plastic ("silastic") replacement is the simplest, and useful for older people who don’t ask too much of their feet. However, it can wear out badly and be difficult to sort out if it does. Complete joint replacements made from metal, plastic or ceramic are promising but still experimental. They offer pain relief with some movement, but we don’t know how long they last or whether they are really any better than a fusion. • The simplest operation is simply to cut out the arthritic joint (Keller’s procedure) and leave the toe a little floppy. This can be quite successful in people who walk very little. However, in the more active person the toe may become deformed and pain tends to develop in the ball of the foot because of the weak big toe.

What is hallux rigidus?

Hallux rigidus is arthritis of the main joint of the big toe in the ball of the foot. It is a wearing out of the joint surfaces. It is called "hallux rigidus" because its main feature is stiffness ("rigidus") of the big toe ("hallux"). Some people get stiffness in this joint with little or no obvious arthritis - this is called "hallux limitus" because the toe has limited movement but is not absolutely stiff.

Sometimes only the upper part of the joint is affected and the rest of the joint is all right. In other people the whole joint is worn out.
What causes it?
In most people there is no definite cause - it just develops. Probably the main reason why this joint is particularly subject to wearing out is that it is under tremendous stress in walking. With each step, a force equal to twice your body weight passes through this very small joint.

In a few people it may be caused by an injury or another medical problem such as gout or an infection in the joint. There are a lot of theories about why the joint becomes arthritic but as yet none of them seem very helpful in treatment or prevention of the condition.

What problems does it cause?
The commonest problems are:
Pain in the big toe around the joint. In some people the pain is present whenever they walk or even at rest, but in others it only occurs when they turn the big toe up as far as it will go
Stiffness of the big toe. the ability to turn the big toe upwards is lost, although it can usually be turned downwards. Sometimes it gets so stiff it points downwards and cannot be laid flat on the floor

A bony bump ("osteophyte" or "dorsal bunion") may develop on top of the joint. This is your body’s natural response to the worn joint. The bump may rub on the shoes. In some people this is their only problem.

Because of the painful big toe some people tend to walk on the side of the foot. This may produce pain in the ball of the foot or down its outside border.

Sometimes the joint wears down more on the outer side, towards the lesser toes, than on the inner side. This may make the toe tilt towards the second toe, and the toes may rub together.

Why have I got this condition in my twenties?
It is well known that hallux rigidus may begin early in life, even in the teens. We don't know why this happens.

Fortunately, the chances are that your toe will not get progressively worse, and (apart from your other big toe) you are not much more likely to get arthritis in other joints, such as your hips and knees, than anyone else.

What will happen - will I be crippled by this condition?
Research shows that although the joint remains arthritic and stiff, it tends not to get much worse in the majority of people. Even after 20 years the joint was much the same as it had been when the people who were studied first went to the doctor.
However, in about 20-25% the joint becomes progressively more stiff or painful and treatment may be required.

Is there anything I can do to stop it getting worse?

- Orthotics/Insoles to help improve big toe joint function have shown to help.

- In some cases surgery to align the big toe joint can also help to improve big toe joint function and reduce the chance of long term joint deterioration

What can be done about hallux rigidus?
Because the joint is usually most painful when the toe is bent upwards during walking, it sometimes helps to stiffen the sole of your shoe so that it does not bend while walking. If you do this, you may need a small "rocker bar" on the sole of your shoe so that you can rock over this while walking instead of bending your toe up. This can be done for you by an orthotist or podiatrist. One disadvantage of this treatment is that the stiff insole may push your osteophyte up against the shoe.

If the toe remains very painful, it may be worth injecting some steroid (cortisone) mixed with local anaesthetic into the joint. This reduces the inflammation inside the joint. The injection can usually be given in the outpatient clinic, although sometimes you may have to come into hospital as a day patient. The toe may be painful for a few days after the injection and any improvement has usually occurred by a week. If your toe is improved by an injection the effect may last for a few days, weeks or months; occasionally the improvement seems to be permanent.

There are also newer natural occuring substances such as ostenil (Hyaluronic Acid). That can help lubricate the joint in the early stages.

Can an operation help?
If none of the above operations helps, an operation may be useful. You would need to discuss this with an foot and ankle surgeon. There are several common operations for hallux rigidus.
If only the upper part of the joint is involved:

The upper part of the joint can be trimmed out and the joint washed out. This operation is called a cheilectomy. Most people who have a cheilectomy get less pain and a useful improvement. In about 75% this improvement is permanent. The others develop worsening of the arthritis over the following years and some will eventually need another operation.

Either as a separate operation or at the same time as a cheilectomy, the bone in the base of your great toe (proximal phalanx) may be reshaped to make the most of the movement you have left.

If the whole joint is involved, there are three main options, depending on the age and activity of the patient:

• In young fit people, especially those doing heavy jobs, a fusion of the joint would be recommended. This removes the painful joint and stiffens it completely. 95% of people will get rid of their pain. However, the toe is stiffer than before and the choice of shoes is more limited. A few people will go on to get arthritis of the small joint in the middle of the toe after a fusion, but this is not usually troublesome.

• There are a number of ways to replace the arthritic toe joint. A plastic ("silastic") replacement is the simplest, and useful for older people who don’t ask too much of their feet. However, it can wear out badly and be difficult to sort out if it does. Complete joint replacements made from metal, plastic or ceramic are promising but still experimental. They offer pain relief with some movement, but we don’t know how long they last or whether they are really any better than a fusion.

• The simplest operation is simply to cut out the arthritic joint (Keller’s procedure) and leave the toe a little floppy. This can be quite successful in people who walk very little. However, in the more active person the toe may become deformed and pain tends to develop in the ball of the foot because of the weak big toe.

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Hallux Rigidus - Arthritis in the Big Toe