Hallux Rigidus

What is hallux rigidus?

Hallux rigidus, sometimes called big toe arthritis, is a condition that causes pain and stiffness in the main joint of your big toe. Over time, it can make the joint increasingly difficult, and eventually impossible, to bend.

What are the symptoms of hallux rigidus?

Symptoms usually develop gradually and get worse over time.

• Pain in or around your big toe joint, often worse when walking, running or bending the toe upwards, though it can also happen at rest
• Stiffness, with a reduced ability to bend your big toe upwards
• Swelling and a bony lump (sometimes called a dorsal bunion) on top of the joint, which can rub painfully on your shoes
• Difficulty finding comfortable shoes
• Pain and stiffness that's often worse in cold, damp weather.

As the condition becomes more advanced, you may also notice pain even while resting and changes to the way you walk to avoid bending the joint, which can sometimes lead to pain elsewhere, such as your hip, knee or lower back.

What are the causes of hallux rigidus and who is at risk?

Hallux rigidus is a form of osteoarthritis, the 'wear and tear' type, and often develops without any single obvious cause. Every step you take places a force equal to about twice your body weight through this joint, and this everyday stress can gradually wear down the cartilage that cushions it.

It can also follow an injury, such as stubbing your toe, or repeated stress on the joint from activities like squatting. Unusually long bones in your foot or a foot shape that changes how you walk can also increase your risk and it sometimes runs in families.

Certain health conditions raise your risk too, including rheumatoid arthritis, gout and other conditions that cause joint inflammation. It's more common over the age of 50 and in women and can affect people who are very active on their feet, whether through sport or work.

Are there different types of hallux rigidus?

Hallux rigidus is often described in stages or grades, based on how much movement you've lost in your big toe and how severe your symptoms are. In its early stage, when the toe has only slightly reduced movement, it's sometimes called hallux limitus. As the condition progresses, movement decreases further until the joint may become completely rigid.

How is hallux rigidus diagnosed?

A doctor, podiatrist or foot and ankle surgeon can usually diagnose hallux rigidus by examining your foot and testing how far you can bend your big toe, both upwards and downwards.

An X-ray is often used to confirm the diagnosis, check how much arthritis is present and look for bone spurs or other changes in the joint. Diagnosing it early, before bone spurs develop, generally makes it easier to treat.

How is hallux rigidus treated?

Treatment depends on how severe your symptoms are and most people can manage hallux rigidus without surgery, especially if it's caught early.

Non-surgical options

• footwear changes, such as shoes with a deep toe box, a stiffer sole, or a curved (rocker) sole, which reduce pressure and movement at the joint
• orthotic insoles, which can improve how your foot functions and ease pain
• protective pads over tender areas
• painkillers, such as paracetamol, or anti-inflammatory medicines such as ibuprofen if you are able to take this. (Don't take these for more than 10 days in a row without checking with a doctor)
• ice, such as an ice pack or bag of frozen peas wrapped in a towel, for up to 20 minutes at a time
• losing weight if you're overweight to reduce the stress going through the joint
• steroid injections into the joint which can ease pain and swelling for a while, though they don't treat the underlying arthritis.

A procedure called manipulation, done under general anaesthetic, can also release tightness in the joint to improve movement and reduce pain, often combined with a steroid injection. This isn't a cure, but around half of people get pain relief for up to 2 years.

Surgery

Surgery may be considered if non-surgical treatments haven't helped or your symptoms are significantly affecting your daily life. There are two main operations.

• Cheilectomy, where the surgeon removes the bony lump and any damaged bone from the top of the joint, giving the toe more room to bend. This works well for less severe arthritis.
• Fusion, where the damaged joint surfaces are removed and the two bones are permanently joined together with screws or a plate. This relieves pain reliably but leaves the joint unable to bend, so it's usually reserved for more advanced arthritis, or if a cheilectomy hasn't worked.

Recovery from a cheilectomy is usually quicker: you'll wear a stiff-soled shoe for about 2 weeks, and you should feel the benefit within about 6 weeks, continuing to improve for up to 12 months. Recovery from a fusion takes longer, with a flat-soled shoe worn for 6–8 weeks, and pain and swelling continuing to improve for up to a year.

When should I see a doctor?

See a doctor, podiatrist, or foot and ankle surgeon as soon as you notice new pain, stiffness or swelling in your big toe joint. Diagnosing hallux rigidus early, before bone spurs develop, generally makes it easier to treat.

If you're recovering from cheilectomy or fusion surgery, get medical advice urgently if you notice severe pain, significant swelling, or unusual numbness or tingling in your foot.