Hallux rigidus refers to arthritis of the metatarso-phalangeal joint (MTPJ) of the great toe – the joint where the toe joins the rest of the foot. Arthritis of this joint classically leads to formation of osteophytes (extra bone spurs around the joint) and flattening of once round articular surfaces, both of which result in stiffness and loss of motion. Loss of motion is this joint is more debilitating than you might imagine, as you rely on up and down movements of the great toe in walking and running. When you step forward, your trailing foot rocks onto the ball of your foot, with the big toe bending up at the MTPJ. If you require more speed, you will then forcefully bend the toe down for a bit of extra push-off. If this joint is painful and stiff, you are forced to walk keeping the forefoot flat, which takes much more energy. The bony spurs that form can also be quite large, and tend to rub on the inside of footwear causing further pain.
What symptoms will I experience if I have hallux rigidus?
The main two symptoms are pain and loss of motion in the MTPJ, which leads to difficulty with footwear, an altered gait, and inability to crouch down on the balls of your feet. As this condition develops slowly, most people have adapted their lifestyle around it, and tend to present only when the condition is quite severe. If you have pain, obvious deformity, stiffness, swelling or loss of motion in your great toe, contact your local doctor for review and request a referral to an orthopaedic surgeon.
How can I confirm if I have hallux rigidus?
If your local doctor suspects this condition, you will be referred for a plain X-ray and orthopaedic opinion. The features that your surgeon will look for are:
- loss of joint space
- osteophytes/bone spurs around the joint
- irregularly shaped joint
- hard, thick (sclerotic) bone under the cartilage
- cysts in the bone
What can I do to manage the symptoms?
Symptom control is the first step, with any pain managed with simple analgesics such as paracetamol or anti-inflammtories like ibuprofen. The stiffness and loss of motion are more problematic, and tend to represent more advanced joint destruction. Physiotherapy and exercises to mobilise the joint have a role early on, but with advancement of disease can cause undue pain. Altering your lifestyle to avoid aggravating stimuli and using stiff sole shoes with a wider toe box can help to limit the symptoms. If you find the pain and lost motion are severely impacting your quality of life, surgery may be required.
What surgical options are available for hallux rigidus?
There are two basic options – joint preserving surgeries, and joint sacrificing surgeries. In joint preserving surgery, the bony spurs and the top part of the joint is removed, allowing the toe to again bend up. This restores the range of motion of the toe at the cost of removing some of the joint, and does nothing to prevent ongoing joint deterioration. In some cases, freeing the joint up can lead to more pain as there is now more movement. For younger people who require a full range of motion, this surgery is an option. For those with lower functional demand or more severe joint destruction, the only surgical option is fusion of the joint. In this operation, the diseased cartilage surfaces are removed, and a plate and screws used to join the metatarsal and proximal phalange together as one bone. By having no movement, the pain is resolved, but at the cost of mobility.
What are the consequences of these operations?
For joint sparing procedures, the motion is restored, but the underlying problem is not altered. The natural course is thus for ongoing deterioration and eventually disease that requires fusion surgery. It may buy a lot of time however, and by preserving the range of motion for longer allow people to function more normally. With successful fusion surgery, the pain is removed, but at the cost of motion. As the two bones unite, there is no motion at the MTPJ. This translates as an inability to stand on the toes, crouch on the ball of your foot, and will lead to a less efficient gait.
Which surgery is right for me?
The choice of procedure depends on the degree of joint destruction, your age and your functional requirements. The treatment will be tailored to give you the best function with the least complications, both short and longer term. For those with severe arthritis, a fusion procedure will give more reliable resolution of pain. For those with mild disease and higher functional requirements, joint preservation surgery is a better short term option. Dr Host will discuss with you the pros and cons of all options, and tailor a treatment to your specific needs. A factor to consider, often more a concern for females, is the type of footwear you would like to wear – if you require footwear with a higher heel, let you doctor know. If a fusion is performed, the position of the fusion can be adjusted to allow for wearing of higher heeled footwear.
How long am I in hospital for if I require surgery?
Though the procedure can be done as day surgery, many choose to remain in hospital overnight to ensure they recover fully and have an effective pain relief strategy in place. You will need to wear a post-operative shoe for 2-6 weeks depending on the operation, and are able to walk only by bearing weight on the heel. A physiotherapist will assess you and provide you with crutches to make mobilisation easier.
How long will it take before I can function normally after surgery?
For a joint mobilisation procedure, the wounds will take 2 weeks to heal, and over the following 4 weeks we expect return of the ability to painlessly bear weight and mobilise. For fusion, bony union will occur over 6 weeks, with a further 6 week period of gradually increasing activity to return to normal function. Though a longer period of recovery, a successful fusion provides a more reliable outcome.
When will I be able to drive after surgery?
If you drive a vehicle with automatic transmission and the surgery is on your left foot, once the wounds have healed you can return to driving. For those requiring both feet to drive or the right foot was operated on, it is recommended to avoid driving until you can safely control the vehicle – 4-6 weeks for joint preserving surgery, and 8-12 weeks for joint fusion.
What should I look out for following surgery?
If you develop any increasing redness or heat in your wound, or have ongoing wound discharge, you should seek review with Dr Host or your local doctor.
If you develop any symptoms such as chest pain or tightness, shortness of breath, or lower limb/calf swelling and pain, you should seek emergency review at your nearest hospital.
Where can I find more information?