Hallux rigidus. Diagnostics & Therapy
Treatment for arthritis in the big toe joint.
Pain during exercise, signs of inflammation in the big toe, reduced mobility: Hallux rigidus increasingly restricts everyday life and quality of life of those who are affected by the disease.
In the early stage, osteoarthritis of the big toe joint often can be treated conservatively. If the cartilage in the joint is severely damaged and symptoms increase, surgery on the big toe becomes necessary. But not always the metatarsophalangeal joint needs to be stiffened. From osteotomy to joint replacement, there are many surgical procedures that allow an effective treatment of hallux rigidus nowadays.
Diagnostics, therapy & treatment of Hallux rigidus.
Diagnostics. How Hallux rigidus is recognized
How is arthritis in the big toe joint identified?
Arthritis in the metatarsophalangeal joint of the big toe is diagnosed based on examination of the joint and x-rays of the foot under stress. If the x-rays reveal evidence of inflammatory joint disease (e.g. rheumatism) or a metabolic disorder (gout), blood tests may also be performed.
Clinical examination of hallux rigidus.
Examination shows a bony upward protrusion of the joint, which is often reddened due to irritation caused by rubbing in the shoe. In some cases, the constant mechanical irritation will also have resulted in the formation of an inflammatory sac of fluid. Mobility is reduced, above all upward movement, and the area around the joint is tender. In the early stages, only significant movement of the toe towards the back of the foot is painful. In the advanced stages, all movements cause pain.
X-rays show the extent to which the joint space is narrowed, as well as revealing developing bone spurs (osteophytes). Around the early stages, only the upper portion of the joint is affected, while the entire joint is affected in the advanced stages. X-rays also reveal evidence of rheumatoid disorders or gout.
Conservative treatment for hallux rigidus.
Treatment without surgery in early stage osteoarthritis.
Non-operative measures can often ease symptoms significantly in the early stages of the disease. The basic aims are reduction of the mechanical loading on the join, local pressure on the bony growths/spurs, joint inflammation and swelling.
These forms of treatment may be used:
- Insoles with stiff shoe soles
The use of insoles with a stiff shoe sole means that the sole of the shoe takes over the heel-to-toe rolling movement of the foot. The big toe does not extend as much during the heel-to-toe movement and therefore avoids the painful part of the movement.
- Rocker soles
Rocker soles are a type of modification made to the soles of shoes. A curved piece of rubber is stuck onto the outer side of the shoe sole. This reduces the flexibility of the sole in the area surrounding the joint at the base of the big toe, while the curved shape makes it easier to transfer weight from the heel to the toe when the shoe is worn.
- Grinding away the space underneath the base of the big toe
This technique has been proven to be especially useful with sport shoes. A square-shaped part of the sole beneath the big toe is ground away here and the empty space is filled with very soft material. The big toe can sink into the soft material during heel-to-toe movement and is not pushed as much into extension.
- Physical therapy
Different exercise techniques can be used to try to improve mobility in the big toe´s metatarsophalangeal joint and simultaneously ease the causes of inflammation. However, it is again impossible to correct the problem causing joint wear and tear using physical therapy.
- Shoes made of soft uppers with space for the big toe
Most of the time, sufficient space in the shoe for the joint at the base of the big toe is enough to clearly relieve symptoms. However, shoes with a large amount of space for the toes do not always correspond with women´s wishes to be fashionable.
- Anti-inflammatory medication
Anti-inflammatory substances (e.g., Diclofenac, Ibuprofen) can have a positive effect on pronounced inflammation in the metatarsophalangeal joint of the big toe. However, long-term intake of this type of medication can lead to liver and kidney damage.
- Products to stimulate cartilage formation
The effectiveness of these products is still scientifically controversial. There are, however, first signs that these products can at least ease pain. It has not been proven though that cartilage has actually formed following either the intake of the appropriate tablets or the injection of these substances into the joint.
Surgical treatment of Hallux rigidus.
Arthroscopy of the first metatarsophalangeal joint.
An arthroscopy of the first metatarsophalangeal joint (joint at the base of the big toe) can often relieve symptoms during the very early stages of the disease. The inflamed synovial membrane and bony growths are removed in this operation. However, as it is not possible to eliminate the cause of wear and tear in the joint, the disease will slowly continue to progress.
Removal of painful bony growths/spurs (cheilectomy).
The removal of bony growths and degenerative changes at the joint can improve mobility and ease symptoms in stage 1 and 2 of the disease. The operation is carried out via a small incision at the ball of the big toe at the metatarsophalangeal joint. Intensive post-operative exercises for the metatarsophalangeal joint are important.
If malalignment is present in addition to joint degeneration, e.g., when the 1st bone of the midfoot is displaced upwards, the malalignment will be corrected in the same operation. In individual cases it is also possible to change the configuration of the joint by tilting the joint surface. The healthier cartilage is then loaded the most while the area with the damaged cartilage is relieved of pressure (e.g., the Morberg operation technique, shortening osteotomy).
The resection arthroplasties (e.g., Keller-Brandes operation technique) frequently conducted in the past have not lead to good long-term results and are currently only being performed on rare occasions. A large proportion of the joint is removed in these operations. The fundamental problem with this type of surgery is that the inside of the big toe is amputated. In particular, the big toe loses a lot of its strength when flexing and can cause considerable problems when walking. As the long-term results are often unsatisfactory, this operation is only carried out in exceptional cases.
When the joint is completely damaged, surgical stiffening of the metatarsophalangeal joint of the big toe is a good option to treat pain and improve the ability to weight-bear. The damaged cartilage is removed in this operation, and the two joint surfaces screwed together. Once the bone is completely healed, the foot can even be loaded during sport without any restrictions. The end joint of the big toe takes over most of the heel-to-toe movement during gait.
To prevent the joint from becoming completely stiff, different approaches are currently being pursued to reconstruct the joint surface, even in advanced stages of the disease. They involve the transplantation of cartilage (e.g., from the knee) or the placement of special membranes in the joint that allegedly facilitate cartilage cell growth. It is impossible to provide a final evaluation of the procedures as comprehensive scientific data on these procedures are not available at this point in time. However, in individual cases it should be carefully weighed-up as to whether a piece of cartilage, e.g., from the knee, should be used to save the joint at the base of the big toe as removal of cartilage from the knee more or less results in significant long-term knee problems in up to 40% of patients.
Artificial joint replacement.
A variety of artificial joints are currently available for the first metatarsophalangeal joint. Even though the different products are consistently reported to have very good short-term treatment results, all long-term results have been unsatisfactory up to this date. Principally speaking, the implantation of a prosthetic at the metatarsophalangeal joint of the big toe is an option. However, the patient must be clearly informed that implantation failure is quite possible over a period of 5 years, meaning that the joint may have to be surgically stiffened at a later stage.
The problem with all joint-conserving procedures (arthroscopy, cheilectomy, corrective osteotomies) is that they cannot eliminate the fundamental problem causing the arthrosis. It is expected that the disease will slowly worsen in all of these cases. The metatarsophalangeal joint of the big toe may then require an arthrodesis and eventually a prosthetic implant at a later stage. The advantage of these procedures is the maintenance of joint mobility. No bridges are removed during corrective osteotomies and cheilectomies, meaning that surgical stiffening or the implantation of a prosthetic is always possible at a later stage. It is technically possible to surgically stiffen the joint following a resection arthroplasty, but the procedure is much more complex than the other operations as the excised bone is replaced with another part bone from the pelvis (iliac crest). If this is not done, the big toe will be too short.
Rehabilitation of hallux rigidus.
The focus of the first post-operative phase is the treatment of post-operative pain and the reduction of swelling using lymphatic drainage. The metatarsophalangeal joint of the big toe is mobilised at an early stage following all procedures except for the surgical stiffening of the joint. Mobilisation treatment can last for a few weeks to several months depending on the restrictions in mobility. If the first metatarsophalangeal joint was stiff before the operation, it is quite possible that a normal range of movement will not be obtainable.
Frequently asked questions & answers.
I would very much like to retain mobility in the metatarsophalangeal joint of my big toe. Is a prosthesis a good treatment option?
There are various artificial replacement joints for the metatarsophalangeal joint of the big toe. Various products have yielded acceptable results in initial studies. However, the long term results to date have always been disappointing. The greater the stress on the joint (e.g. due to sport), the shorter the life of an artificial joint. For active people, a prosthetic metatarsophalangeal joint in the big toe is not a good option as failure within the first five years must be expected in well over 50 % of cases. It is possible that this could change within a few years. However, the body of scientific data currently available is clear.
Can I engage in sports after stiffening of the metatarsophalangeal joint in my big toe?
Once the joint has healed after stiffening (arthrodesis), there is no reason not to engage in sport. There will be limitations in the case of sporting activities requiring a wide range of movement in the metatarsophalangeal joint of the big toe. Examples of such activities include dancing or freestyle climbing. Running is entirely possible, as are mountain climbing, skiing or cycling.
When should surgery be planned for arthritis in the metatarsophalangeal joint of the big toe?
Because none of the interventions really treats the arthritis but rather the symptoms of the arthritis, above all the pain, the decision as to whether surgery is indicated should above all be based on the symptoms. It is the patient who is treated, not the x-ray. Symptoms can often be alleviated by non-surgical treatment. However, if the pain worsens again, the various procedures available for the treatment of different stages of the disorder offer good outcomes in the majority of patients.