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Hallux Rigidus (Stiff Big Toe) Q&A

Mr Rajiv Limaye is a Consultant Orthopaedic and Trauma Surgeon at BMI Woodlands Hospital, with over 20 years of surgical experience, he specialises in dealing with disorders of the foot and ankle. Here Mr Limaye answers questions on the second most common condition affecting the big toe – hallux rigidus (stiff big toe).

What is hallux rigidus?

"Hallux rigidus" means stiff big toe, and this is the main symptom of the condition. It is a form of arthritis of the metatarsophalangeal joint, which is the joint where your big toe joins your foot.

Hallux rigidus is the second most common condition affecting the big toe, after bunions. It most commonly affects people between the ages of 30 and 60, with the condition being much more common in women.

What are the symptoms of hallux rigidus?

  • Pain and stiffness of the big toe
  • Increased pain when walking
  • Swelling around the joint
  • A bump, like a bunion, often occurring on the top of the toe, around the joint.

What causes a stiff big toe?

The exact cause of the condition is not known.
It usually occurs due to wear and tear of the joint and can be more common in people who have had an active job, or have put a lot of stress across the joint (for example during sport).
Some cases run in families.
Other conditions, such as rheumatoid arthritis or gout can result in hallux rigidus.

How is it diagnosed?

An examination of your foot by a specialist will give an idea about the amount of movement at the joint in your toe, compared to what is normal.
X-rays can give more information to help diagnose hallux rigidus, as well as showing how severe the disease is; this will help to guide the treatment choices offered to you.

How is it treated?

Treatment is guided by how severe your symptoms are, as well as the examination and X-ray findings.

There are some measures you can take to improve your symptoms, these include:

  • Wearing shoes which are wide enough for your toes and avoiding high heels
  • Shoes with stiff soles may help reduce the amount of movement, and therefore the amount of pain in your big toe
  • Reducing activities that put a lot of strain through the joint, for example running
  • Taking regular pain killers.
  • If these measures are not helpful, and your symptoms continue to be severe, surgery may be necessary.

What surgical options are available?

This mainly depends on how severe your condition is.
In mild to moderate cases, an operation called chilectomy may help. This involves shaving down the abnormal bone and washing out the joint to improve symptoms and give the toe more room to bend.

Some patients permanently improve following chilectomy. In others, the symptoms gradually return over time and require further surgery.

For severe cases, there are two main surgical options available. Traditionally, the only option for patients with severe disease was to fuse the joint of the big toe; a process known as arthrodesis. This involves removing the damaged joint surface and fixing the 2 bones together with a plate or screws so they eventually fuse together.

More recently, joint replacements have been developed (like a hip or knee replacement) for the big toe.

What are the benefits of surgery?

Both joint replacement and fusion aim to improve the pain in your big toe 

Fusing the joint has been shown to be a good operation for pain relief, but it does mean that you will no longer have any movement in your big toe, which some patients find problematic.

After a fusion operation you will need to be in a plaster or a special shoe until the bones heal together, usually around 6 weeks.

Joint replacement has the benefit of improving pain, but also allows patients to keep some movement in the joint of their toe.

The healing process with joint replacement can also be shorter, and does not require a cast after the surgery. For this reason, more foot and ankle specialists are performing joint replacements in some of their patients with hallux rigidus.

What are the risks of Joint Replacement?

There are some complications that can happen with any operation, these include:

  • Pain
  • Infection
  • Bleeding from the wound
  • Wound infection
  • Scar
  • Blood clots

There are further complications that are involved particularly with this operation:

  • Damage to nearby structures (nerves, blood vessels)
  • Pain in the ball of the foot
  • Loss of movement of the big toe
  • Symptoms returning
  • Implants becoming loose or wearing out.
  • Severe pain, stiffness and swelling, known as complex regional pain syndrome (rare).

Is joint replacement safe?

There have been many different types of big toe joint replacements developed over the years to treat a stiff big toe.
Early types of joint replacement often only lasted for a short time before patients needed another operation.

There has been a lot of research performed to improve our understanding of what makes joint replacement for hallux rigidus successful.

Following this research, newer joint replacements have shown much better results compared to the initial implants used.
Due to continued improvement in patient outcomes, the National Institute for Health and Care Excellence (NICE) have recognised that joint replacement is a safe an effective procedure for certain patients with hallux rigidus.

There are many different types of joint replacement available in the UK; this often depends on the choice of the individual foot and ankle specialist.

One implant which is being used more and more in the UK and Europe is called Roto-glide™. Roto-glide has a particular design which allows it to cope with the forces through the joint and has shown excellent outcomes It has been in use in the UK since 2002. There are several studies showing excellent medium and long term results with this particular implant. There is a large group of patients in the UK who continue to be followed-up, to help us understand how patients progress after many years.

What is the recovery like after joint replacement?

Recovery times vary from patient to patient; the exact management will also depend on your surgeon. Usually, patients are usually able to go home the same day, or the day after surgery.  When you are discharged you will need to wear a special shoe to protect your foot for the first few weeks while you walk. You will need to keep your foot raised to help with the swelling. 

It can take up to six months for the swelling to completely resolve. Normally, patients require the special shoe for 2 weeks, and then can start to wear their own footwear if the swelling has settled sufficiently. Depending on your job, patients often return to work after 6-12 weeks. 

How long will the implant last?

It is difficult to predict exactly how long the joint replacement will last. This depends on many of factors, including:

  • Age
  • How severe your hallux rigidus was, and any other problems with your foot
  • Activity level
  • Type of implant used

Surgeons using the Roto-glide™ implant (mentioned above) are currently looking at patients who have had their joint replacement in place for up to 15 years and will be publishing their results later in the year.

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