Hallux Rigidus Treatment
About Hallux Rigidus
One of the common causes of pain in the foot is arthritis of the great toe. Another name for this is hallux rigidus, which means a stiff great toe.
Hallux rigidus occurs in teenagers up into people in their 80s or 90s. We see it inherited in families from a grandparent to children to grandchildren. Often, we don't know the cause of hallux rigidus, although heredity makes a difference. Injury or trauma can be a cause, too.
The most common cause that we hear about is trauma to the great toe. It may be a single episode but it also can be microtrauma on a repetitive basis. This may take the form of an object falling on a toe but it also may be forced hyperextension of the toe such as in sports activities.
The characteristic of Hallux Rigidus or arthritis is the limitation of the great toe motion. It's interesting that about one in 50 individuals over age 55 develops arthritis of the great toe.
This is a very different condition from bunions in which the great toe deviates towards the lesser toes. A characteristic finding of Hallux Rigidus is a bump or bone spur on the top of the foot right at the joint. This sometimes is the major complaint and people can really have an intolerance of their shoe wear because of pressure against this bump.
These bone spurs or bony enlargements can occur on the top of the great toe but also on either side. As they get larger and larger they restrict motion and sometimes a patient cannot even bring their toe to a neutral position. Because of that, they tend to walk on the outer aspect of their foot. Swelling occurs and pain really occurs often with every step.
When we examine a person with a hallux rigidus, the thing that becomes most obvious is the decreased range of motion. When we feel the foot, we feel that ridge on the upper aspect of the great toe but we feel swelling and thickness that often is very uncomfortable when we push on that area of the great toe.
X-rays are very important as well in defining the problem and they really help us to then understand how severe the problem is and what we can do to bring about successful treatment.
We've developed a grading system of hallux rigidus here in Boise that helps us determine the severity of the disease and also the appropriate treatment. It's very useful to look at this because it will help you understand how severe your disease is.
Hallux Rigidus Treatment
Not everyone needs surgery. It really depends upon the severity of the disease and the severity of the grade that we determine with your x-rays and your examination in the early stages of this disease. There are many things that we can do to help treat hallux rigidus.
Anti-inflammatory medication
Often, anti-inflammatory medication helps to decrease swelling and discomfort. This can often help people to be more active. There are a lot of anti-inflammatories on the market and we'll choose something that's appropriate for you but there are other things besides anti-inflammatories that can be helpful.
Custom insole
Sometimes an insole can be used to restrict the range of motion. Stiffness in the area of the great toe, right beneath that area, can decrease range of motion and decrease pain. Likewise, taping of the great toe can sometimes allow an athlete to continue to be active. Also using a specific shoe that has a stiffer insole such as the extended shank, which can be applied by a shoe repair shop or cobbler shop, can help you to remain active with your sports activities of choice.
Inner-articular injection
On occasion, the inner articular injection of corticosteroids into the great toe joint may relieve pain. This is not done commonly but is an alternative treatment for hallux rigidus, on a rare basis.
Joint clean-out
With a joint clean-out, we remove about 25 to 30 percent of the bone on the top of the metatarsal head which allows us to achieve more motion. A joint clean-out procedure usually allows for improved motion and removes the bony prominence that is uncomfortable, not only with shoewear but with walking. By doing the joint clean-out usually, 40 to 50 degrees of motion can routinely be achieved.
In some preoperative cases, we see that there's only about 20 degrees of upward motion. Following the clean-out we can see right after the procedure is done that we now have probably 60 degrees of motion.
A joint clean-out does not change the amount of disease that is present. It certainly removes the spurs and allows a person to maintain or increase motion and usually reduces pain but it does not change the amount of wear that there is.
In 2004, we followed up on a 20-year period of time in which we did a joint clean-out procedure and we found these patients did very very well. They maintained their motion and very few came back to further surgery but we did not again influence the cause of their arthritis and indeed they still had a worn-out joint on x-ray but they actually performed well with sports activities and activities of daily living.
Joint fusion or Arthodesis
For more severe disease, that is when the joint is a grade-four, there's very little motion there's pain almost with all aspects of the movement of the joint and usually the gait cycle is very abnormal. We sometimes will recommend a fusion or arthrodesis of the joint. In these cases, the join is really obliterated and there is no cartilage left. The choice then, it to do a fusion. Fusion can be accomplished in many different ways. With pins or with screws, we like to use a plate on the top of the foot.
It's very low profile and doesn't seem to bother people after a fusion. Patients actually walk quite well. They just tend to pick their foot up a little earlier. There are some sporting activities that probably aren't well tolerated with a fusion, such as skiing. There are sports activities that are well tolerated such as golf or walking downhill.
It's interesting that approximately 50 percent of our patients can actually get up on their tiptoe after a fusion procedure is accomplished. An 80-year-old woman that's still able to get up on her tiptoes even some 20 years after her fusion procedure.
The mainstay as far as treatment is concerned is a joint clean-out procedure or a fusion procedure.
Rare-case Hallux Rigidus Treatment Options
The Keller Procedure
A Keller procedure is an excision of the joint. It was very popular in the 1950s and 60s but it left people with a very weakened first toe. We do this for only the very sedentary patient who's not very active. Other procedures certainly are preferable.
Joint replacement
Joint replacements are much less popular now than they were ten years ago because of the reaction to the joint itself. We tend to advise a fusion, as opposed to joint replacements.
Metatarsal and phalange incision
Another procedure sometimes recommended is to cut the metatarsal and phalange bones in order to decompress or make room in the joint. Often, there's very little indication for this procedure and tend to rarely recommend it.
Soft tissue replacement
Lastly, a procedure that I'll sometimes do is the placement of some soft tissue in between the two bony surfaces. For someone that really doesn't want a fusion but has severe arthritis, this procedure can be considered, as well.
Arthritis of the great toe is a very common condition and it can really change your lifestyle by making you walk differently, increasing your pain, and even really relegating you to a very sedentary lifestyle. There are many conservative things that can be done early on such as anti-inflammatory medications and shoe modifications.
As time passes and the disease becomes worse, then we sometimes will do a joint clean-out. It burns really no bridges and if it doesn't work or it buys you some time but the disease process continues and time of fusion may be necessary.
The evaluation of hallux rigidus is really very important for our physical examination and the x-ray studies help us to really determine how severe the disease is but your understanding of what's going on is important to us, as well. That's what will determine whether we use some anti-inflammatory pills or shoe modifications or actual surgery. The real key here is to reduce pain, improve activities and let you get back to the things you want to do in everyday life.