Hallux Rigidus-Stiff Big Toe

A condition in which the big toe joint becomes stiff and painful is called “hallux rigidus.”   The big toe joint is important in walking, allowing propulsion or push off.  If one cannot push off the big toe joint properly then compensation occurs.  Patients may shorten their stride, transfer weight to the outside of the foot or lift the leg higher at the hip in order to walk.

Compensation for hallux rigidus is problematic in that compensatory mechanisms involve alterations in gait which lead to other issues.  Shortened stride involves less hip motion and subsequent stiffness about the hip, low back, sacroiliac joints. One may quicken the pace (cadence) to make up for the shortened stride which can lead to fatigue.  The transference of weight to the outside of the foot can lead to ankle sprains, stress fractures in the lessor metatarsals, forefoot pain (metatarsalgia) and iliotibial band syndrome which is pain in the soft tissue over the hip joint.  Increased hip flexion can lead to hip pain or low back pain.

Hallux rigidus is one of the more common conditions we treat at our podiatry office here in San Antonio.  It is a condition that is chronic, becoming more painful and limiting over time. Hallux rigidus is sometimes mistaken for gout.  Gout involves the big toe joint (or other joints) individually becoming hot and red suddenly for a period of about two weeks and is due to excess uric acid in the body.  Uric acid is a breakdown product (waste product) of DNA and RNA which can be elevated because the kidney is not sufficiently eliminating it or because the body makes too much.

Hallux rigidus is a “cousin” of hallux valgus which a a bunion deformity.  Hallux valgus involves a partial dislocation or malposition of the big toe joint in which the joint is crooked, the big toe moving toward  the second toe.  The big toe joint is often straight in hallux rigidus but may appear enlarged or swollen.

Hallux rigidus can be induced via trauma, such as a fracture of the big toe joint that damages the cartilage but is more often a chronic condition that occurs due to years of poor joint alignment and mechanics.  The big toe joint is designed to move downward and “grab” the ground as one pushes off. If the big toe joint fails to do so or moves upward as one pushes off, a jamming occurs at the big toe joint leading to degeneration.

There are four recognized stages of hallux rigidus:

Stage 1 Hallux rigidus – also known as functional hallux rigidus or functional hallux limitus.

This early stage involves mild loss of range of motion in the joint.  One may see joint changes on x-ray which include narrowing of the joint (loss of cartilage thickness), spurring over the top of the joint.  Treatment involves increasing big toe joint (first MTP joint) range of motion by repositioning the first metatarsal downward as one pushes off.  That is best accomplished with a prescription orthotic designed for that purpose.  Such an orthotic may include a forefoot valgus post (external forefoot wedge), reverse Morton's extension (a soft forefoot wedge), a first metatarsal cutout (an orthotic modification designed to allow the big toe joint to drop downward).  Most store bought or over the counter inserts are mainly arch supports.  Arch supports can be helpful but occasionally detrimental because the action of lifting the arch can make it more difficult for the big toe joint to move downward during propulsion.

Stage 2 Hallux rigidus – early structural changes.

Stage two hallux rigidus involves a progression from stage one in which more range of motion is lost and there is more evidence of joint enlargement.  Radiographs may show spurring on top of the joint, increased loss of cartilage as well as flattening of the joint surfaces.  Treatment still involves primarily orthotics but if there is significant spurring on top of the joint, a procedure call “cheilectomy” may be considered.  Cheilectomy involves a shaving of the bone on top of the big toe joint in attempt to increase range of motion and relieve pain.  It is a relatively simple procedure but must be used with caution because an increase in motion on a joint with deteriorated cartilage can, at times, increase joint pain.

Stage 3 Hallux rigidus – significant structural changes.

Stage three hallux rigidus involves more significant joint degeneration and loss of range of motion. Attempts to use an orthotic to increase range of motion are unsuccessful at this stage.  Non-surgical treatment has historically involved use of shoes with a distal rocker sole.  A distal rocker sole is an orthopedic shoe modification that allows the shoe to roll forward without bending of the big toe joint.  Surgical treatment may involve repositioning of the cartilage on the big toe joint in a manner to have the remaining cartilage function where most of the motion is needed.  An implant may be considered. A joint implant is basically a spacer or bushing which takes the place of missing cartilage to re-establish motion of the joint.  It is important not to utilize a cheilectomy at stage 3.

Stage 4 Hallux rigidus – severe loss of range of motion and cartilage at the big toe joint.

Stage 4 hallux rigidus is also known at “end stage” hallux rigidus as there is little effective motion at the first metatarsal-phalangeal joint (big toe joint) and minimal to no cartilage remaining. Two surgical treatments may be used in this stage:
  • Fusion of the first MTP joint.  Fusion eliminates the joint.  The idea is that if there is no joint then there is no pain.
  • Total implant arthroplasty.  This may be considered a joint “replacement” but , in the manner used by Dr. Davis, it is a cartilage “replacement.”

Fusion of the big toe joint vs. implant arthroplasty....which is better? 

There are varying viewpoints on this.  The advocates of fusion state that fusion is “definitive” in eliminating joint pain.  They point out that joint “implants” will eventually wear out requiring a fusion anyway.  There are papers that claim a relatively high success rate.

San Antonio Podiatrist, Dr. Ed Davis, favors implant arthroplasty for the following reasons:
  • Implant arthroplasty allows restoration of near normal function to the big toe joint.
  • Fusion involves an extended healing; fusion can take 8 to 12 weeks to occur.  
  • There is no bone to bone healing with implant arthroplasty; only soft tissue.  Healing may occur in weeks instead of months.
Fusion of the big toe joint may eliminate joint pain but does not restore normal gait, that is one may still need to shorten stride or walk on the side of the foot to push off.
  • Replacement of an implant can be performed depending on the type of implant used and fusion is not a long term sequelae of a worn out implant.
Dr. Davis emphasizes that it is important to establish the stage of hallux rigidus so that the correct treatments can be instituted, that is, treatments that match the stage.



For more information on Hallux Rigidus treatment in the San Antonio, TX area, call Ed Davis, DPM, FACFAS. at (210) 490-3668 today!