What is hallux rigidus?
Hallux rigidus refers to stiffness (rigidus) of the joint at the base of the big toe (hallux) due to arthritis or wear and tear of the smooth lining of the joint. This articulation in the forefoot is called the 1st metatarsophalangeal (MTP) joint. The most common cause of arthritis in this joint is due to trauma or repetitive injury. The natural history of this condition is usually gradual progression over time, but can be asymptomatic.
What are the symptoms of big toe arthritis?
Patients with symptomatic hallux rigidus characteristically describe pain and stiffness of their big toe which is worse on startup and aggravated after prolonged walking or activity. For patients with early or limited arthritis, they may complain of pain which is specifically brought on with push-off on walking, during kneeling when their hallux is extended or with movement of their big toe at the extreme ranges. With progression of the disease, they may also develop a bony prominence over the main knuckle of their hallux, similar to a bunion, which can cause pain from rubbing in footwear.
How can big toe arthritis be managed?
Non-operative management strategies for 1st MTP arthritis include wearing cushioned supportive shoes with a stiff or rocker sole, using a Morton’s extension orthotic, losing and maintaining a healthy weight, activity modification by avoiding activities which aggravate your symptoms and by preferencing low impact-loading activities for exercise/recreation in the long term, such as swimming, cycling and Pilates, simple over-the-counter oral analgesia and/or oral/topical anti-inflammatory medication if not contraindicated as required, and/or an ultrasound-guided intra-articular corticosteroid and local anaesthetic injection to the 1st MTP joint. The aim of this steroid injection is to try neutralise any chronic inflammation and provide pain relief however, this may be temporary only or can be lasting in effect.
What is the surgical treatment for big toe arthritis?
Surgical treatment options for 1st MTP arthritis include a cheilectomy or arthrodesis (fusion) of the joint. A cheilectomy involves excising the overgrown bone or bone spurs (osteophytes) around the joint to help relieve any mechanical block or impingement. The purpose of this joint-preserving procedure is to try improve the range of motion of the joint and is usually reserved for early arthritic disease. The gold standard treatment for hallux rigidus remains a fusion of the 1st MTP joint. This is achieved by excising the arthritic joint, then joining and fixing the metatarsus and proximal phalanx together, typically with compression screws and a plate. The objective of this operation is to convert a stiff painful joint to a stiff pain-free joint once the fusion has healed. Fusing the MTP joint is generally well tolerated and not functionally worse, because the joint is usually already stiff pre-operatively.
What is the recovery after fusion of the big toe?
After your big toe fusion, you can full weight-bear straight away on your operated foot, but will need to wear a flat Darco shoe for up to 12 weeks, after which you can then transition to normal supportive footwear with a stiff sole and wide toe box to accommodate the post-surgical swelling. You can continue to perform your basic daily activities, but should avoid excessive standing/walking and any impact-loading activities through your operated foot for at least 3 months. Once your dressings have been removed after 2 weeks and your wounds are healed, you will be advised to desensitise your surgical scars by massaging your wounds with a moisturising cream/oil. For most patients, it will take 2-3 weeks for your wounds to heal, 4-5 months for your 1st MTP joint fusion to unite, 6-7 months before you feel reasonably comfortable walking in stiff-sole supportive shoes, and at least 12 months for the swelling in your foot to subside and for full recovery to your new baseline level.
What restrictions will I have after fusion of my big toe?
Following an arthrodesis of your 1st MTP joint, you will not be able to wear any shoe with a heel higher than 1-2 centimetres. Once you have recovered from your big toe joint fusion surgery, it is possible that you can return to running and playing sports, but this is not guaranteed and your forefoot will not be as flexible. The plate and screws used to fuse your big toe usually do not need to be removed unless it causes a problem.