The stiff big toe or hallux rigidus is characterized by limited mobility of the big toe; however, this is just one of the symptoms that lead to the diagnosis of the condition.
Indeed, hallux rigidus is an evolving condition that manifests itself with stiff toe and osteophyte formation, especially on the dorsal surface of the first metatarsal head.
Symptoms gradually develop due to degenerative arthritis of the metatarsal phalanx of the big toe. Pain is caused due to impact on the dorsal osteophyte and also due to inflammation caused by shoe pressure on the proximal osteophytes. In addition, the pain occurs during articular movement, due to the abnormal articular surface that characterizes arthritis.
How often is it observed and which gender does it prefer?
It is the most common cause of arthritis in the big toe and the second most common condition after hallux valgus in the big toe. It is more common in women.
At what age is it observed?
The condition may be diagnosed in adolescence, while in other cases it may be diagnosed in adulthood.
Is there an inheritance factor?
Yes, indeed. It is reported that in up to 80% of cases the disease occurs bilaterally and that in these cases the disease is also present in another family member (positive family history).
What factors can cause the condition?
The exact etiology of the condition is not known. It is commonly thought that the stiff big toe is due to wear and shear forces in the 1st metatarsal joint. Many theories have been formulated regarding the underlying etiology of the condition. Some authors have linked the disorder to sports activities. In this case, the condition is due to acute injuries or the repeated overextension of the 1st metatarsal joint with several years of progressive loosening of the plantar plate and subsequent instability with cartilage injury (turf toe).
At the same time, osteochondritis during childhood (dissecans) has been implicated as a cause of the disease, elevation of the first metatarsal (metatarsus primus elevatus) associated with significant flexion of the big toe during gait and subsequent development of a stiff big toe. The hyperactivity of the 1st metatarsal joint (1st radius) leads to spasm of the flexors and impact of the proximal phalanx to the head of the 1st metatarsal. Particular anatomical differences (such as the elongated first metatarsal) have been suggested to play an important role in the functionality of the 1st metatarsal joint during gait.
What are the symptoms?
The most typical symptom is pain in the upper surface of the big toe in an active middle-aged person. In addition, patients may complain of diffuse pain in the outer anterior surface of the foot, due to increased overload of the outer part of the foot in an attempt not to charge the big toe. The pain is exacerbated by certain activities and certain shoes. There is a correlation between the condition and sports activities including running. However, it is not known if running is a cause of the condition or if it is a contributing factor to the symptoms. Dysesthesia along the inner and dorsal surface of the big toe may be due to pressure from the shoe or due to extension of the medial dorsal cutaneous nerve. Although it is called “stiff” big toe, the patient often does not complain of stiffness and mobility limitations, with the exception of adolescents.
At the same time, pain is often observed on the upper surface of the toe, due to pressure from the protruding osteophyte. Diffuse osteoarthritic pain is experienced later, at more advanced stages of the condition, with significant degenerative lesions. During clinical examination the presence of a painful osteophyte on the upper (dorsal) surface corresponding to the metatarsal joint usually confirms the diagnosis. The dorsal (upward) flexion of the big toe is limited due to periarticular osteophytes and the patient aches during maximal movement of the big toe. Also, pain is experienced on the dorsal surface of the toe during maximal plantar (downward) flexion of the toe and it is probably due to irritation of the long extensor tendon of the big toe, as it passes over the dorsal osteophyte. Pain and cramping throughout the big toe movements indicate advanced osteoarthritis lesions of the metatarsal joint. The patient may present mild claudication due to antalgic gait, and the limited upward movement of the toe (dorsal flexion) can be observed when removing the large toe from the ground during gait.
According to the radiological classification the following stages of the disease are distinguished:\
Mild lesions with preservation of the intra-articular space and a few osteophytes
Moderate lesions, narrowing of the intra-articular space, formation of new bone on the metatarsal head and phalanx with bone sclerosis and bone cysts
Severe lesions with significant narrowing of the intra-articular space, extensive new bone formation and loose bone segments or dorsal bone
In 1999 a different classification system based on the range of motion of the joint combined with radiological and clinical findings was proposed:
Dorsal flexion 40-60o (20% loss of normal movement)
Dorsal flexion 30-40°, dorsal osteophytes and absence of or minimal degenerative lesions
Dorsal flexion 10-30°, mild leveling of the metatarsal joint, mild to moderate joint narrowing (arthritis) or sclerosis and dorsal, lateral and/or medial osteophytes
Dorsal flexion <10°, often plantar flexion <10°, severe degenerative lesions with hypertrophic cysts or erosions or irregular sesamoid bones, persistent moderate or severe pain and pain during maximal joint movements
Rigid joint with loose intra-articular bodies or osteochondral segments and pain throughout the range of motion of the joint
- A) Conservative
The stiff big toe in the early stages is treated conservatively. Painkillers, anti-inflammatory drugs, cold or hot compresses and/or arthritic injections are used to relief pain and reduce stiffness; new footwear avoiding flat shoes and high heels, with spacious curved soles or with special additions to the shoe that limit movement of the first metatarsal joint of the big toe. The most effective is the specially designed insole constructed after a plantogram. Although all of these therapeutic approaches reduce the symptoms, they fail to stop the progression of the disease.
- B) Surgical treatment
When conservative therapy fails, there are various surgical treatments that can be applied. The type of surgical technique will depend on the stage of the disease, the range of mobility of the metatarsal joint of the big toe, the patient’s activity, and the surgeon’s preferences in combination with the patient’s expectations.
- I) Surgical removal of the dorsal osteophyte with or without proximal phalanx osteotomy (Moberg technique)
- II) Metatarsal osteotomy
- IV) Arthrodesis
Dorsallectomy is indicated in patients with mild or moderate osteoarthritic lesions and <50% joint impairment. If there is no satisfactory dorsal flexion of the big toe while maintaining plantar flexion and articular stability. The procedure can be combined with osteotomy of the proximal phalanx.
Capsular interposition arthroplasty offers satisfactory pain relief in selected patients with advanced osteoarthritis. In particular, it is indicated in patients who do not wish to reduce joint mobility with arthrodesis. During surgery, after removal of the damaged cartilage and bone due to arthritis, soft tissue (synovial or tendon) is inserted into the joint to maintain mobility of the joint. However, this procedure is not as reliable and as good in prognosis as arthrodesis.
Excision arthroplasty or the Keller technique has been associated with several potential complications and is generally not recommended.
Arthrodesis of the metatarsal joint is an excellent technique that is indicated in most cases at an advanced stage. In this technique, the damaged cartilage is removed and the bones are joined and fixed together with screws or plates. The main disadvantage is the restriction of the big toe movement.
On the contrary, the benefits of metatarsal osteotomy are theoretical and are not generally recommended for stiff big toe surgery.
Finally, semi-total and total arthroplasty with metallic implants have not been proved to have significant advantages over synovial arthroplasty, and the techniques have many reported complications with early loosening of arthroplasty materials and concomitant failure that requires a second surgery.
Poor peripheral blood circulation of the patient is an absolute contraindication to surgical treatment.
When is it permitted to walk after surgery?
In the case of dorsallectomy and capsular interposition arthroplasty, it is usually recommended that the patient should wear a special shoe and walking should be allowed to charge the foot to the pain threshold for approximately two weeks prior to the gradual return to normal footwear.
In the case of arthrodesis, the patient wears a splint or orthopedic boot for 6 to 8 weeks and walks with partial loading and crutches for 2-3 months.
How satisfactory are the results after surgery?
The results are pretty good. Most patients are capable of exercising, running and wearing the usual footwear without any discomfort. Patients may experience difficulty in wearing high-heeled shoes in the case of arthrodesis.