Patient education

Hallux rigidus/limitus involves the 1st metatarso-phalangeal joint. This joint is located at the base of the big toe. Hallux rigidus/limitus causes pain and stiffness in the big toe, and with time it becomes increasingly harder to bend the toe. This is a progressive condition during which the toe’s motion decreases as time goes on. In the early stages, motion of the big toe is only limited, and at this point, the disorder is called hallux limitus.

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As the problem advances, the big toe’s motion gradually decreases until it becomes rigid or frozen. At this point, the disorder is referred to as hallux rigidus. As motion becomes progressively limited, pain increases, especially when the big toe is extended, or pushed up.

Anatomy

The metatarsophalangeal joint is at the base of the big toe. Like all other joints in the body, it is covered with articular cartilage, which is a slick, shiny covering on the end of the bones. If the cartilage is injured, it begins wearing out, or degenerating. The articular surface can wear away until raw bone rubs against raw bone. Bone spurs may form around the joint as part of the arthritic process.

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The spurs, or bony growths, may restrict the motion in the joint, especially the ability of the toe to bend upward when the foot moves forward.

Causes

Chronic and Repetitive Injuries: These can occur to the joint when the big toe repeatedly jams backwards, with force against the joint cartilage. This pressure causes the cartilage to prematurely wear down and tear. Some of the most common causes of this type of injury include frequent wearing of high heel shoes or shoes that are too short, squatting down for long time periods, repeatedly stubbing the big toe, and athletics including running.

Aging: As we age, osteoarthritis sets in and we begin to notice stiffness, swelling, and some pain in all of our joints. One of the most common sites that this occurs in is the big toe joint.

Biomechanics: Excessive pronation causes a person to walk more on the inner border of the foot than is normal. Eventually, this can cause the cartilage to prematurely wear down, resulting in the symptoms of hallux rigidus.
High arched feet may also be a contributing factor. They are usually more rigid than normal resulting in excessive weight on the big toe joint with compression and deterioration of the joint cartilage over time.
An elevated first metatarsal causes the big toe to excessively flex downward or an abnormally long first metatarsal can increase stress on the big toe joint each time the big toe “pushes” us forward. Over time, this results in a thinning and wearing down of the joint cartilage

Symptoms

Early signs and symptoms include: Pain and stiffness in the big toe when you are active, especially as you push-off on the toes when you walk. This is usually aggravated by cold, damp weather. Difficulty with certain activities such as running or squatting is common as well as swelling and inflammation around the joint.

As the disorder progresses, these additional symptoms may develop: Pain, even during rest, difficulty wearing shoes, especially high heels due to the bone spur and stiffness of the big toe joint. A bump, or bone spur like a bunion or callus can develop on the top of the big toe joint. Eventually pain in other parts of the foot may occur as you put weight on other areas, trying to limit the bending of the big toe. You may even experience pain in the hip, knee, or lower back due to changes in the way you walk.

Diagnosis

Physical exam:
In diagnosing hallux rigidus, the doctor will examine your feet and move the toe to determine its range of motion and degree of pain. The structure and biomechanics of the patient’s entire foot is examined. The metatarsal phalangeal joint (big toe joint) is swollen, both dorsally and medially.
On palpation and range of motion crepitation of the joint can be detected.

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X-rays:
X-rays help determine the presence of any bone spurs as well as the degree of degeneration in the joint space and cartilage which enables your doctor to know how much arthritis is present or other abnormalities that may have formed.

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Arthritis of the big toe joint is present with large bone spurs around the joint seen on this X-ray

Treatment

Non-Surgical Treatment

In many cases, early treatment may prevent or postpone the need for surgery in the future. Treatment for mild or moderate cases of hallux rigidus may involve.

Shoe modifications: Shoes with a large toe box put less pressure on your toe. Stiff or rocker-bottom soles may also be recommended. Avoiding high heels, which cause more weight to be transferred to the front of the foot, may be recommended.

Orthotic devices: Custom functional orthotics prescribed by your doctor can be useful in controlling and improving foot function. An orthotic device may reduce symptoms and prevent the worsening of the condition by relieving pressure and redistributing weight from the painful area.

Medications: Oral non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may be recommended to reduce pain and inflammation.

Injection therapy: Injections of corticosteroids may reduce inflammation and pain. Anti-inflammatories may help to decrease pain, but they don’t specifically target the primary mechanical problem contributing to the pain of halllux rigidus.

Physical therapy: Ultrasound therapy or other physical therapy modalities may be undertaken to provide temporary relief.

Conservative treatments for hallux rigidus are often limited because these measures cannot correct the bone deformity. This can only be accomplished with surgery. If conservative treatment fails or the deformity progresses to the point where conservative treatment is no longer a viable option, surgical intervention may be needed.

Surgical Treatment

There are several types of surgery for treatment of hallux rigidus. In choosing the procedure or combination of procedures for your particular case, the surgeon will take into consideration the extent of your deformity based on the x-ray findings, your age, your activity level, and other factors. The length of the recovery period will vary, depending on the person, and the procedure or procedures performed. No surgical procedure can be expected to restore the joint to its normal anatomy and range of motion. The surgical goals are to provide relief of the dorsal impingement and relief of the pain.

Both the traditional and minimally invasive correction techniques are performed at the Coeur d’Alene Foot and Ankle Surgery Center. Because the minimally invasive techniques are less traumatic, and the recovery time shorter, most patients prefer this method of correction.

Traditional Correction of Hallux Rigidus:

Traditional hallux rigidus surgery requires longer incisions at the joint to correct the deformity: Joint debridement, joint implant, or joint fusion (arthrodesis). Arthrodesis is often performed with this type of surgery to relieve the pain. The damaged cartilage is removed and pins, screws, or a plate are used to fix the joint in a permanent position, which means that the patient will not be able to bend the big toe joint at all. Gradually, the bones grow together. This type of surgery means that the patient will not be able to bend the toe at all. For the first few weeks after surgery, the patient has to wear a cast and use crutches. After sufficient healing the patient may need to wear a shoe with a rocker-type sole to improve gait.

Minimally Invasive Correction of Hallux Rigidus:

Dr. Nunez does a minimally invasive ambulatory surgical technique to correct hallux rigidus. Correction of hallux rigidus via the MIS technique involves making a small incision less than 1cm to remove/shave the bony exostosis or bump located along the medial and dorsal sides of the big toe joint to preserve the joint, reduce the pain and increase mobility while achieving a good cosmetic result. The bone spurs that are blocking the joint from normal range of motion are identified and removed from both the bones that make up the joint. The surgeon may perform additional bone reduction to allow more space for greater joint movement. The surgeon may also perform additional bone cuts for the repositioning of the bones that make up the joint to establish more functional alignment and inhibit or slow recurrence of the deformity.

Surgery is performed under Fluoroscopic viewing. Surgeons use instruments specifically developed for these techniques which enable them to do all of the work through these small incisions for the best cosmetic result. The surgeon is able to carefully maneuver around structures adjacent to the deformity in the foot, minimizing trauma which results in reduced swelling, pain, and recovery time. Suturing is also minimal. MIS surgeons are able to rely on a compression dressing and surgical postoperative footwear for stabilization immediately after surgery, eliminating the need for hardware (pins, screws, plates etc) and casting of the foot or crutches. The patient walks immediately after the surgery wearing the surgical shoe/boot. Patients usually experience relief of the original symptoms, even though they experience typical post operative healing pain and swelling. The most commonly performed MIS procedure for hallux rigidus correction at the Coeur d’Alene Foot & Ankle Surgery Center is a modified Reverdin Isham Bunionectomy.

Getting back into regular type shoes depends on rate of healing and amount of swelling, which is very individual. You will have a bulky dressing the first week. Dr. Nunez usually likes to see you back at the clinic after two to three days for redress, if physicality allows, or 5 days after surgery for our out-of-town patients. In one week your dressing is changed to band-aids or bandage strips, a spongy material toe separator and disposable ace bandage type wrap which you yourself change daily. This dressing is worn three to four weeks. No dressing is usually required after this.

Minimally Invasive Hallux Rigidus Surgery – Image Gallery

Preoperative Postoperative
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Preoperative Postoperative
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Surgical Day Visit

Preoperative instructions

Surgeries are performed at the CDA Foot and Ankle Surgery Center and are done with local anesthesia wherein the foot usually stays asleep 4 to 6 hours. A small surgical incision is used which enables the surgeon to use fine specially designed instruments to obtain the best long term pain free, functional and cosmetic results. Often times no sutures are required due to the small incision size. Dr. Nunez also uses a fluoroscope during surgery, enabling him to visualize foot anatomy during surgery in spite of the small incisions. The entire surgery takes approximately 1- 2 hours. This includes viewing a preoperative video and procedure explanation, anesthetic administration, setting up the sterile field, the surgical procedure and postoperative dressing and instructions.

Patients are not required to discontinue their prescription medication unless specifically instructed. There are no restrictions on diet or fluid intake the night before surgery. As recommended by the CDC (Centers for Disease Control), an antibiotic is usually administered at the time of surgery. The patient is given a postoperative pain medication prescription and if appropriate one dose of antibiotic to be taken that evening. Occasionally an RX is also given to the patient for continued antibiotic therapy if necessary according to their medical history.

The dressing must stay dry, clean and intact and is not changed until the first post-operative office visit.
The patient leaves the facility walking with a special surgical boot or shoe. This will be provided for the patient. Crutches or walkers are usually NOT needed.

All minimally invasive surgical techniques are performed in compliance with the Standards of Care published by the Academy of Ambulatory Foot and Ankle Surgery and can be viewed on the U.S Department of Health & Human Services National Guideline Clearinghouse: www.guideline.gov
Academy of Ambulatory Foot and Ankle Surgery. Hallux limitus and Hallux rigidus. Philadelphia (PA): Academy of Ambulatory Foot and Ankle Surgery; 2003.

The Coeur d’Alene Foot and Ankle Surgery Center, is Medicare Certified and an Accredited surgical facility with the Academy of Ambulatory Foot and Ankle Surgery.