Hallux Rigidus - Causes, Symptoms, Diagnosis, and Treatment

Introduction

The big toe consists of two joints. The metatarsophalangeal joint is the largest among them. It is formed where the metatarsal (first long bone) in the forefoot meets with the phalanx (first bone of the big toe). This joint is most vulnerable to osteoarthritis. In 1887, Davies-Colley was the first to describe a condition in which the proximal phalanx was plantar flexed in relation to the metatarsal head of the foot, and he referred to this condition as 'hallux flexus.' Later Cotterill gave the term 'hallux rigidus' to describe the painful restriction of movement in the first metatarsophalangeal joint.

What Is Hallux Rigidus?

Hallux rigidus, or stiff big toe, is a form of degenerative arthritis affecting the big toe. It may lead to stiffening joints at the base of the big toe. It is usually seen between the age of 30 and 60 years. However, it affects approximately 2.5 percent of people over the age of 50 years.

The term 'hallux' refers to the big toe, and rigidus denotes the toe is rigid and immobile. This condition affects women more than men. Discomfort due to the pain will make the patient's walking and standing difficult. There is a slight limitation in big toe movement in the early stages. Since it is a progressive condition, toe movement decreases over time. Then the condition is known as hallux limitus. The mobility of the big toe decreases gradually as the condition progresses until it reaches the final stage of stiffening. The resulting immobility is known as a frozen joint.

What Are the Causes of Hallux Rigidus?

Several factors contribute to hallux rigidus, which include:

• Genetics: People with a family history of this condition may inherit this condition which is more likely to develop problems related big toe joint.

• Overuse of Joints: It is common in athletes who stress the joint.

• Injuries: It can occur to the toe due to a sudden hit of the toe over a hard surface.

• Turf Toe: Turf toe condition occurs when a sprain (injury due to a torn or stretched ligament) happens to the big toe's joint.

• Osteoarthritis or Degenerative Joint Disease: It is a chronic medical condition that occurs due to the breakdown of cartilage (a flexible fibrous tissue that cushions the end of the bone) present in the particular joint. This results in stiffness and joint pain.

• Inflammatory Disease: Rheumatoid arthritis (a long-lasting condition that causes joint pain and stiffening) and gout (a condition that causes excessive uric acid crystal buildup in the joints. Uric acid is a normal waste product present in the blood.

• Structural Deformities of the Toe: Flat feet occur due to damage to the arch inside the feet. Arch is the area between the ball of the foot and the heel, and overpronation happens when the foot rolls inwards.

What Are the Symptoms of Hallux Rigidus?

The signs and symptoms of hallux rigidus may vary as the disease progresses. However, the early signs and symptoms include.

• Pain and stiffness during standing and movements like walking and bending.

• Difficulty in certain activities like running or squatting.

• The big toe joint becomes swollen and inflamed.

• Symptoms are aggravated during damp and cold weather.

As the condition advances, other symptoms may also develop, which include the following.

• Pain even during resting.

• Difficulty in wearing shoes due to osteophytes or bone spurs (hard bony bumps or projections that form on the bone edges).

• Changes in the walking pattern. Patients prefer to walk on the foot's outer side, resulting in dull pain in the hip, knee, or lower back.

• Limping (difficulty walking because of the intense pain over the leg) in severe cases.

How Can Hallux Rigidus Be Diagnosed?

Hallux rigidus can be diagnosed with physical examination and imaging tests. In physical examination, healthcare professionals will examine the foot for the exact location of pain and metatarsophalangeal joint to assess the range of movement. They will check how far the toe can be flexed upwards and downwards. They also look for evidence of bone overgrowth or any abnormalities over the toe. Imaging tests like X-rays are advised to find the extent of degeneration of bone. X-rays also help to identify the size and location of bone overgrowth.

MRI (magnetic resonance imaging) and CT (computed tomography) are usually not required in most cases.

How Can Hallux Rigidus Be Treated?

If hallux rigidus is identified in the early stage, it can be managed using non-surgical treatments, which include:

• Appropriate Footwear: Wearing shoes with ample toe space helps to relieve pressure over the toe. High heels should be avoided. A stiff-soled shoe with a bottom roller design may also be recommended. All these types of modifications support the foot during activities and reduce pain.

• Contrast Bath: This uses cold and hot water to relieve the inflammation. Place the foot in cold water for 30 seconds, followed by immersing the foot in hot water for 30 seconds.

• Over-The-Counter Medications: Pain relievers such as NSAIDs (nonsteroidal anti-inflammatory drugs) can be given orally or topically.

• Applying Ice: Ice packs over the affected area temporarily reduce pain and inflammation. Do not place ice packs directly on the skin.

• Injection Therapy: Corticosteroid injections are usually given to control the symptoms.

• Physical Therapy: This therapy will provide temporary relief.

When Is Surgery Needed for Hallux Rigidus?

If the pain and other symptoms are not subsided after non-surgical treatment, the doctor will recommend surgery. The types of surgical treatment include:

• Cheilectomy: This procedure is done in mild to moderate cases of hallux rigidus. It involves the removal of bone overgrowth or part of the bone in the big toe. This allows more space for the toe to bend.

• Osteotomy: This procedure is used in early cases of hallux rigidus. It involves slicing the bone to realign or shortening of the big toe.

• Arthrodesis: This procedure is usually needed in advanced cases of hallux rigidus. It is also known as joint fusion surgery. The surgeon will remove the damaged cartilage, and the two bones will be fixed using screws, plates, and pins. Bones will be fused gradually, resulting in restricted movement. This procedure provides a permanent solution for pain reduction.

• Interpositional Arthroplasty: This procedure is performed in moderate to severe cases of hallux rigidus. It is recommended in younger patients. It is also known as joint resurfacing. It involves the removal of a portion of damaged bone, and a spacer is placed between the bone ends of the joint. This help to minimize the contact, relieves the pain and maintains joint mobility.

• Structural Deformities of the Toe: It involves artificial joint replacement. This procedure replaces joint surfaces with plastic or metal parts.

Conclusion:

Hallux rigidus is a common condition that affects the range of motion. Early diagnosis and treatment help eliminate or postpone surgery requirements in the future. To prevent the onset of the progression of this condition, it is important to maintain a healthy weight, wear supportive and comfortable footwear, and engage in exercise to preserve joint function.