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The most common form of arthritis in the foot is located in the area behind the great toe. During normal gait, 90% of your body weight pushes off the big toe joint during the time the foot pushes off for the next step, at the end of the cycle. As the arthritis process continues, motion becomes more and more limited, making walking difficult and painful. In addition, a bone spur may develop on top of the joint, preventing the toe from bending upwards. |
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Etiology
Hallux rigidus usually occurs in adults between the ages of 30 and 60. It may result from injury to the joint cartilage, differences in foot anatomy or foot mechanics that increases pressure on the joint.
The most common cause of this condition is wear and tear on the joint resulting from years of poor foot function. Our bodies are structured to move from one place to another in a very specific manner. Most of us do not function exactly as we should. This is genetic and unless resolved with proper foot orthotics, people walk throughout their adult lives imperfectly. This has a negative effect on many of the joints of the lower extremity, especially the big toe joints. Other causes may include previous trauma, metabolic bone diseases such as gout, and inflammatory arthritic processes.
Signs and Symptoms
- Stiffness in the great toe with an inability to bend it up or down
- An enlargement, like a bunion or callous, that develops on top of the foot
- Swelling around the joint
- Pain in the joint when you are active, especially as you push-off on the toes when you walk.
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Diagnosis
Inability to move the big toe joint up and down without pain is the early sign of Hallux Rigidus. If diagnosed early, this can be treated with conservative care postponing or temporarily avoiding surgery.
Your Podiatrist will examine and x-ray the foot to determine the extent of arthritis and to see if there are bone spurs or loose cartilaginous bodies lying within the joint
Conservative Treatment
Pain relievers and anti-inflammatory medications may help to reduce the swelling and pain. Ice packs may also be of benefit to help reduce pain and swelling for short periods of time. Wearing a stiff soled shoe with a rocker bottom design or possibly a steel shank or metal brace in the sole may also be of benefit. An orthotic with a rocker bottom under the big toe joint reduces the amount of bending of the joint thereby reducing pain.
When there is damage to the cartilage and conservative care has failed surgical correction should be performed.
Surgical Treatment
This surgery is recommended when the there is mild to moderate damage to the cartilage. The bone spurs as well as part of the joint bone are removed and smoothed out so that the toe can bend easier. The incision is made on top of the foot, a wooden-soled shoe is worn for at least 2 weeks after surgery, and it is usually 3-4 weeks before a soft shoe may be worn. The toe may remain swollen for several months after the surgery. Most patients do experience long-term relief.
This procedure is recommended when there is limitation of motion and the cartilage is still in good condition.
This procedure involves making a cut in the long metatarsal bone behind the big toe to shorten the bone (creating more joint space) and rotating the cartilage (to allow more motion). The cut in the bone is fixated with 1 or 2 screws.
The patient is in a wooden-soled shoe for 2-3 weeks. After that time, the patient is allowed to get into a soft shoe and is sent for physical therapy to help create more flexibility in the joint. They are usually back to reasonable shoes in approximately 8-10 weeks.
- Arthroplasty (Joint Replacement )
This surgery is recommended if there is moderate to severe damage to the cartilage. This involves removal of the damaged bone and cartilage of one or both surfaces of the joint and replacing them with a metal or plastic implant. By removing these portions of bone, the appropriate spacing of the joint is restored and allows for reduced pain and increased motion. It has been found that using the new Titanium implant has shown more stability and compatibility and there no worry with regard to setting off airport security alarms, etc. The procedure does not require a cast and patients can usually wear a surgical shoe for 2-4 weeks, and then wear a softer shoe.
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They are sent for physical therapy after the sutures are removed to create joint motion and then may be back to wearing reasonable shoes in approximately 2 months.
This surgery is reserved for the most severe damage to the cartilage. This is where the 2 joint bones are fused together with pins or screws in a permanent fixed position. This procedure will prevent the toe from ever bending again, but does relieve the pain in these most severe cases.
Most patients are in a rigid-soled shoe for approximately 3 weeks. Then they are able to get into a softer shoe and after approximately 8-10 weeks may get into normal-type shoes.
Conclusion
Arthritis of the joint behind the big toe is one of the more common problems seen in a podiatry practice. When recognized in its early stage, conservative treatment usually relieves symptoms. Surgery is considered a last resort treatment for painful arthritis but in experienced hands, will almost always allow the patient to return to pain free gait.
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