Hallux Rigidus treatments and symptoms

What is it?

Hallux rigidus is arthritis of the big toe (called hallux), particularly the joint between the metatarsal and the phalanx. Arthritis is defined by as wear and tear to the cartilage, which is the white tissue covering the bone in joints. Cartilage loss is irreversible. It gradually causes the joint to stiffen and triggers rapid changes to its mobility (it becomes rigid). The progression of the disease is characterised by the development of growths or bony spurs around the joint (= osteophytes). This results in mechanical conflicts among these growths or spurs or, when they are large, a direct conflict with the shoe. Three types of discomfort occur with this condition: loss of mobility, joint pain and the development of osteophytes.

Fig. 1

Normal hallux
The joint is covered by cartilage
Fig. 2

Hallux rigidus
Destruction of the surface of the joint and development of osteophytes at its periphery

Although joint pain due to the loss of cartilaginous cover is only experienced at a very late stage, the development of osteophytes rapidly causes a problem. In fact, the mobility of the joint depends on the congruence of its two surfaces, namely a hemisphere articulating with a cup. Osteophytes inevitably cause conflict, particularly with dorsiflexion (extension) movements of the toe.

Fig. 1

Normal hallux
Complete mobility
Fig. 2

Hallux rigidus
Conflict between the phalanx and the osteophyte, blocking the movement

Clinical presentation

Usually, the mobility of the big toe is considerably reduced and it may be painful when mobilised or in dorsiflexion, when the phalanx comes into conflict with the osteophyte.

When the size of the osteophyte is large, it causes a direct friction with the shoe, which is extremely incapacitating.

When should you consult a specialist?

Decreased mobility is not usually a reason for consultation. If considerable pain is experienced during movements or when putting on shoes it is advisable to see a specialist.

The clinical examination is completed by a radiological assessment to locate the position of the osteophytes and to determine the degree of severity of the condition.

Non-surgical treatment

As the pain is mainly due to the movement of the big toe, the treatment is to limit movement to the maximum extent possible. This may be achieved using rigid plantar support or by wearing shoes with an insole that allows the foot to move smoothly. Comfortable shoes will be encouraged, limiting the painful direct pressure on the osteophyte.

Taking anti-inflammatory drugs can provide temporary relief from pain. However, most of these treatments have a limited effect.
Surgical treatment

When conservative treatment is inadequate, surgery should be offered.

Several options are available depending on the degree of cartilage damage and the development of the osteophytes.

When the wear and tear to the cartilage is low or moderate and the main problem involves the osteophytes and the conflicts they entail, a simple excision can produce excellent results.

This technique, called cheilectomy, is typically performed by an open excision of the bony spurs. We prefer to perform this surgery percutaneously, meaning the size of the incision is 1 mm which facilitates the post-surgical recovery. This kind of surgery is sometimes completed by a procedure on the bone at the level of the phalanx, to further enhance the dorsiflexion mobility (osteotomy of the phalanx).

Cheilectomy: ablation of the excess bone (osteophyte) and its conflict

It is important to note that this technique does not alter the surface of the cartilage. Arthritis, and therefore the wear of the joint, progresses independently. This surgical procedure resolves the problem of the conflict related to the osteophytes and restores a certain amount of mobility to the big toe. It offers a temporary release from the pain, but it is sometimes sufficient to delay the final blocking of the joint (= arthrodesis) for many years. In fact, all joints are surrounded by a hard envelope, called a capsule, which is subject to tension from the osteophytes and increases the pressure on the joint. After a cheilectomy, this pressure is reduced and the constraints on the joint diminished.

When the injury to the cartilage is too significant, the preferred surgery is the final blocking of the joint. This procedure, called arthrodesis, consists of excising the remaining cartilage, placing the two bones into contact and fixing them with a plate or two screws. Contrary to popular opinion, the blocking of the joint has few repercussions on the quality of life and most patients can resume sport after healing (75-95% according to the sport). Wearing high heels can be a problem, but patients had usually stopped wearing such footwear prior to surgery, due to the loss of mobility caused by the arthritis.

Arthrodesis with a plate

Arthrodesis with screws

As is the case with the hip, ankle or knee, joint replacements can be proposed for patients with advanced arthritis. The joint is replaced with a synthetic implant. The results obtained vary from one case to case and revision surgery, in the event of failure, can be complex. For this reason, arthrodesis is the preferred option for cases of severe arthritis, as it is extremely well tolerated and offers more reproducible results. However, a prosthesis remains a viable alternative.
Post-surgical follow up

When surgery involves a simple excision of the osteophytes (cheilectomy), walking is allowed immediately with comfortable shoes. Physical activities or driving can resume as soon as the pain allows. Sick leave will last from 2 to 6 weeks, depending on the post-surgical discomfort and type of professional activity.

After an arthrodesis, weight-bearing walking is permitted immediately, protected by a special shoe for six weeks. A stick may be used solely for comfort purposes.

Driving can resume after six weeks. When only one foot has been operated on, driving is allowed after a shorter time, on condition the car is an automatic one.

Returning to work is not possible for 3 weeks to 3 months, depending on the profession (sedentary or more active job, whether standing up or not, etc.).

In terms of sport, swimming or riding a bike can start after 8 weeks; running or contact sports will require up to a minimum of 3 months.
Risks and complications
Besides the possible complications after any type of surgery (thrombosis, infection <1%, algodystrophy <1%), it is recognised that the treatment of hallux rigidus involves the following risks and complications:
- Recurrence of joint pain or osteophytes in the case of a simple cheilectomy. Arthritis is not changed by this surgery, and its natural progression will determine the progression of pain.
- Non-consolidation of the arthrodesis (pseudarthrosis). This possible complication requires revision surgery.
- Nerve damage (usually temporary and regressive)
- Persistence of swelling (oedema). Normal during the first 2-3 months, it may persist longer in some cases.