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Arthritis of the big toe (Hallux Rigidus / Limitus)

Joints are formed by two bones which are held close together by ligaments and an outer covering known as a joint capsule. In order for the joints to move freely and without pain, the ends of the bones are covered in a softer material called cartilage and the lining of the joint capsule produces an oily substance / fluid called synovial fluid.

In arthritis, the cartilage starts to crack and erode, resulting in bone rubbing on bone. As this is painful, extra bone is laid down at the edges of the joint to try and stop movement and thus symptoms. This is why arthritic joints are often enlarged.

When arthritis affects the big toe, it loses movement, becomes stiff and can cause pain, alter the way you walk and limit the heel height of the shoes you can wear. This condition is known as Hallux Limitus or Rigidus.

What causes Hallux Limitus/Rigidus?

Generally this is due to trauma/injury. Whilst this can be one single event, it can occur over time with low-grade irritation. Most people develop a degree of arthritis at some stage in their life.

There are some conditions (e.g. rheumatoid arthritis, gout) which predispose to arthritis in the joints. These diseases have genetic, autoimmune and inflammatory components and often occur in specific joint patterns (i.e. the number and body site at which they occur).

Are women more likely to get the problem?

It can be more common in women as they tend to wear tighter, narrower shoes with increased heel height. These shoes place a lot of pressure onto the joint and predispose to symptoms. It is common for patients to wear shoes that are too small and this can predispose to the problem. In a study we have performed, 95% of patients were in the wrong size shoes.

Will it get worse?

Arthritis is a progressive condition and will get worse with time. As a result, the joint will become stiffer and more prominent / enlarged. Although the degree of pain is generally related to the extent of arthritis, it does not always get more painful with time. One study reviewed patients who had responded well to the conservative (non surgical) treatment options. After an average of 14 years, whilst the symptoms had not deteriorated, X-rays showed that the arthritis had progressed.

What are the common symptoms?

• Stiffness in the joint
• Enlargement of the joint
• Pain
• Redness around the joint
• Swelling around the joint
• Difficulty in wearing certain shoes
• Difficulty in walking
• Associated deformity
• Tendon / soft tissue irritation or inflammation

How is it recognised?

Clinical examination and a detailed history allow diagnosis. X-rays help to evaluate the degree or type of arthritis within the joint. Sometimes, more sophisticated scans are required.

What can I do to reduce the pain?

• Perform exercises to keep the joint mobile
• Rest the joint when / if it becomes more painful
• Wear good fitting shoes of adequate length
• Avoid high heels
• Wear protective pads
• Pain killers can help to relieve discomfort but should not be taken long term without

seeking professional advice

• Dietary supplements such as Glucosamine and Chondroitin can alleviate symptoms
• Wear stiff soled shoes which tend to be curved towards the toes (rocker sole) rather

like army / walking boots. This reduces stress to the joint

• See a podiatrist

What will a podiatrist do?

If simple measures do not reduce your symptoms, there are other options:

• Advise appropriate shoes
• Advise exercises
• Consider prescribing orthotics /splints
• Arrange a rocker sole modification for your shoes
• Administer a cortisone injection when appropriate
• Administer a hyaluronic acid injection when appropriate
• Recommend physiotherapy when appropriate
• Advise on surgery

The way in which your foot loads during walking can place increased stress on the big toe joint. Special shoe inserts (orthotics) can help to control foot movement. Whilst these are unlikely to resolve established deformity they may help reduce discomfort in the big toe.

Will this cure the problem?

No. Arthritis is a progressive condition and whilst treatment and surgery may help to relieve symptoms and slow progression, the damage that is already done cannot be reversed.

What will happen if I leave this alone?

The arthritis will progress and your symptoms may get worse. However, the degree of discomfort can settle with time although it is likely that you will have periods when the discomfort is worse.

How can I resolve the pain or cure any associated deformity?

Surgery is required to ease the pain and /or correct any associated deformity if the conservative options do not work. The nature of the surgery is dependent the extent of the arthritis.

How does the operation ease the pain?

Essentially, there are two groups of operations for this condition; those that preserve the joint (joint preservation) and those that destroy the joint (joint destructive). The type of procedure that is appropriate for you is determined by the clinical and radiological (X-ray) examination. At times, the final decision is made during the operation (intra-operatively) when the extent of arthritis can be most accurately determined.

Joint preservation procedures

Cheilectomy. This is the most straight forward procedure which involves removing (debriding) the excess bone and generally the upper 1/3 of the joint surface from the head of the 1st metatarsal. This often relieves discomfort when arthritis is mild and can increase joint movement. However, many joints are stiff again after 2 years although symptom relief persists.

Kessel-Bonny. This operation involves the removal of a small wedge of bone from the base of the proximal phalanx in the big toe. This effectively, lifts the big toe off the ground meaning that you can lift your heel further before the toe contacts the ground and uses the available motion in the joint. Some surgeon's feel this also decompresses (opens up) the joint and it is usually performed in conjunction with a cheilectomy.

Decompression osteotomy

This involves shortening the 1st metatarsal, which is often long in this condition. Whilst this can be very successful, the complication rate of transfer pain and stress fractures to the lesser metatarsals (ball of the foot) are relatively high compared to the other operations and this is less commonly performed.

It should be remembered that, whilst these procedures can restore movement and reduce pain, the arthritis can still deteriorate further. Many joints are stiff after 2 years although not necessarily painful.

Joint destructive procedures

Keller's arthroplasty. This involves debriding the joint (cheilectomy) and removing the base of the proximal phalanx of the big toe - effectively removing ½ of the big toe joint. Whilst this is good at relieving pain, the toe will shorten, you will have less control over movement of the toe and you can develop transfer pain / metatarsalgia. Although this is quite a destructive procedure, results are good and the complications are less compared to the other operations.

Joint implant

A range of false joints (implants) are available for the big toe with the advantage of maintaining length and function of the big toe. However, there are also specific risks. The most common implant material and the one that has been used for the longest (therefore we have more long term information) is silicone (silastic). These last, on average, for 10 years. When they start to fail, they can react with the bone and cause bone destruction which means replacing them is often not possible. As a result, they are generally reserved for patients over 60 years old and less than 60% active.

Newer materials such as Ceramic and various metals (i.e. titanium) have been introduced as they have the potential to last longer. Whilst the early results are encouraging, the joint can stiffen following use and they have only been readily available since the 1990's. As a result, we do not have any long term information on their use and they can be considered to be experimental. However, these are appropriate for some people but the available evidence needs to be considered when choosing the most suitable procedure.

Joint fusion

This has been the mainstay procedure for advanced cases of Hallux Rigidus for many years. It involves removing what is left of the joint and fusing (uniting) the two ends of bone together so that the joint is stiff. Many research papers report success in relieving pain. However, the joint will never move again. Fusion alters the way in which you walk, throwing body weight towards the outside of the foot. Pain can develop in the two small bones beneath the joint (sesamoids) or the joint in the middle of the big toe itself. In addition, in a small number of cases the bones do not fuse (non union) requiring a second operation. Many people do not like having a stiff toe and it does affect the heel height of shoe you can wear. However, if you already have a stiff toe that hurts, this may be the best procedure for you.

I have heard it is very painful.

The nature of surgery means that there will be pain and swelling, usually worse the night after surgery. However, with modern anaesthetic techniques and pain killers, this can be well controlled. The level of pain experienced varies greatly from patient to patient with some experiencing no significant discomfort.

Will I have to have a general anaesthetic (be asleep)?

Not if you did not want one. Many of these procedures are performed perfectly safely under local anaesthetic (you are awake). Some patients worry that they may feel pain during the operation but it would not be possible to perform the operation if this were the case.

Will I have to stay in hospital?

No. As long as you were medically fit and have adequate home support, many patients are able to have this type of operation performed as day surgery and go home.

Will I have to have a plaster cast?

Not necessarily. In the majority of cases, newer techniques mean patients do not need a plaster cast and can walk a lot sooner. However, in more severe cases, this may be necessary due to the nature of the operation required for adequate correction. In these instances, you may not be able to walk on the foot for up to 6 weeks.

Are there a lot of complications?

There are risks and complications with all operations and these should be discussed in detail with your specialist. However, with most foot surgery it is important to remember that it is always possible that you may be left with some pain and stiffness and the deformity may reoccur in the future. This is why it is not advisable to have surgery if the deformity is not painful and does not limit your walking. A thorough examination of your foot and general health is important so that these complications can be minimised.

Although every effort is made to reduce complications, these can occur. In addition to the general complications that can occur with foot surgery, there are some specific risks with surgery for Hallux Limitus / Rigidus:

• Continued stiffness (intended with a fusion)
• Deterioration of arthritis and therefore symptoms requiring further surgery
• Failure / rejection of implant material
• Transfer pain (Metatarsalgia)
• Non union for fusions
• You may get discomfort in other parts of your foot during the recovery period. This

generally settles.

When will I be able to walk again and wear shoes?

In the majority of cases, you will able to walk with the aid of crutches within 2-4 days but you will remain somewhat limited for the first 2 weeks.

Some patients are able to return to wider shoes within two weeks with 60% of patients in shoes at 6 weeks and 90% in 8 weeks.

Swelling generally starts to reduce at 6-8 weeks and the foot will be beginning to feel more normal at 3 months although the healing process continues for 1year.

Some patients, undergoing a fusion, require a plaster cast for 3-6 weeks. This will delay the recovery process.

When will I be able to drive again?

When you feel able to perform an emergency stop. This is generally between 4-8 weeks post operatively but you should always check with your insurance company first.

When will I be able to return to work?

If you are able to get a lift and have a job that is not active and you can elevate your foot, you may be able to return after 1-2 weeks. Generally, patients return to work between 4-8 weeks depending on the type of job, activity levels and response to surgery.

When will I be able to return to sport?

Although the healing process continues for up to 1 year, you should be able to return to impact type activity at around 3 months