The most common form of arthritis in the foot is located to the joint behind the great toe. Normally, 90% of body weight pushes off this joint during toe off at the end of a gait 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.
Etiology
Hallux rigidus usually occurs in adults between the ages of 30 and 60. It may result from injury to the joint cartilage or 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 abnormal foot function. 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
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.
We will examine and x-ray the foot to determine the extent of arthritis, and if there are bone spurs or loose, cartilaginous bodies within the joint.
Conservative Treatment
Pain relievers and anti-inflammatory medications may help to reduce the swelling and pain. Heat 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 an extension 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
- Cheilectomy 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 post operative 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.
- Metatarsal OsteotomyThis 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 post operative 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 in 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. We have found that using the new Titanium implants has shown relatively easier stability and compatibility and there no worry with regard to setting off alarms, etc. The procedure does not require a cast and patients can usually wear a surgical shoe for 2-4 weeks, then get into a softer shoe. They are sent for physical therapy to create joint motion, and then may be back to reasonable shoes in approximately 2 months.
- Arthrodesis (Fusion )This surgery is reserved for the most severe damage to the cartilage. This is where the 2 joint bones are fused together with screws or a plate 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 post operative show 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.
Dr. Marc Fink
