Hallux rigidus is the medical term used to describe arthritis of the great toe metatarso-phalangeal joint. There are many reasons why arthritis can form here:
• Recurrent minor injuries to the toe that have a cumulative effect over time
• Post-traumatic from previous fracture
• Previous hyper-extension injury or dislocation (turf toe)
• Heredity (inherited shape of the joint is more prone to arthritis)
• Rheumatoid arthritis
One of the hallmarks of great toe arthritis is loss of cartilage in the joint. Cartilage is the white, shiny, slippery material on the ends of the bones that allows them to glide smoothly over each other. In hallux rigidus the cartilage loss can be minor, involving only part of the joint, or complete resulting in “bone-on-bone” arthritis. The severity of the cartilage damage will determine the treatment options.
Another common finding in hallux rigidus is the development of bone spurs on the top of the great toe joint. Bone spurs are an overgrowth of bone near a joint in response to cartilage loss. When these spurs grow large enough they can block the normal motion of a joint and cause pain.
Symptoms of Big Toe Arthritis
Patients with hallux rigidus typically have symptoms located over the top of the great toe joint. These symptoms include:
• Pain with activity
• Swelling of the joint
• Inflammation of the joint
• Stiffness, loss of motion of the great toe joint
• Difficulty wearing shoes that press on the top of the bone spur
• Difficulty wearing heels, narrow shoes
• Irritation of skin over great toe due to shoes rubbing
These symptoms may occur gradually over time or the patient may experience the new symptoms suddenly with no recollection of any injury to the toe. The symptoms can be very mild at first, or they can be so severe that they stop the patient from being able to walk normally or exercise.
Diagnosis of Big Toe Arthritis
The diagnosis of hallux rigidus can usually be made by clinical examination.
• Patient describes typical symptoms
• Bone spurs that can be seen and felt over the top of the toe
• Loss of motion (dorsiflexion) of the great toe joint on examination
• Severe pain with hyper-dorsiflexion of the joint (impingement)
• Tenderness while pressing over the joint
X-rays are used to confirm the diagnosis and to stage the severity of cartilage loss and bone spurs. Cartilage loss appears as narrowing of the space between the two bones of the great toe on X-rays.
In end-stage hallux rigidus there is complete loss of cartilage and the bones are actually touching each other on X-ray. Bone spurs can occur on both sides of the great toe joint. These spurs can grow so large that they block the normal motion of the joint.
There are many conservative treatment options for hallux rigidus:
• Stiffer shoes like cross-trainers or clogs that limit the motion of the painful toe joint
• Wider shoes with a high toe box can decrease pressure on the bone spur
• Orthotic inserts in your shoe that stiffen the great toe joint
• Ice packs can decrease inflammation and swelling of the arthritic joint
• Cortisone injections into the joint
• Anti-inflammatory medications (if permitted by your physician)
In early hallux rigidus, the loss of cartilage occurs primarily on the top third to half of the joint near the bone spur. The remaining cartilage on the bottom of the joint is in good condition.
In these mild cases a simple surgery to remove the bone spur called a chielectomy can be performed. There are multiple benefits from removing the spur:
• Restores nearly normal range of motion to toe joint
• Decreases the prominence over the top of the toe from the spur
• Relieves inflammation and irritation to overlying skin
• May slow the progression of further arthritis
In the more severe stages of hallux rigidus there is little or no cartilage left in the joint. In these cases the best option may be a fusion. A fusion is when the two bones on either side of the joint are made to heal together into one bone surgically. This is usually done using a metal plate and screws to hold the bones together while they heal. Once the joint is fused there will be no motion remaining. However, usually when the arthritis is this severe there is little motion to begin with. The benefits of a successful great toe fusion are:
• Excellent relief from arthritic joint pain because the ends of the bones can no longer rub together
• Excellent correction of alignment of the great toe
• Relief from bone spur on top of great toe rubbing in shoes
• Durable – no limitations on activity level after healed
• Permanent solution – fusion will not wear out or need another surgery later on
For women, wearing a low heel will still be possible.
Patients who have end-stage hallux rigidus but do not want a fusion may consider an interposition arthroplasty. In this procedure the bone spurs are removed similar to a chielectomy and then nearby soft tissues (joint capsule and tendon) are tucked between the surfaces to act as a covering or false joint. Because the joint is not fused, the toe can still move up and down. However, the pain relief is often not as reliable as with a fusion. If the interposition arthroplasty surgery fails the great toe can still be converted to a fusion.
Synthetic Cartilage Implant (Cartiva)
Another surgical procedure is available that can provide pain relief from hallux rigidus without sacrificing motion. In 2016 the FDA approved a new synthetic biomedical device whose properties are similar to normal cartilage.
The synthetic cartilage implant (Cartiva) is a small cylindrical plug which is inserted between the two sides of an arthritic joint providing a durable, low-friction surface for the big toe to move with less pain. Recent research studies have shown that the pain relief between a big toe fusion and the Cartiva implant is comparable, however, the synthetic cartilage implant allows the patient to retain movement in the joint.
Mercy Medical Center was the first hospital in the state of Maryland to perform this surgery.