Hallux rigidus is a form of osteoarthritis in the 1st metatarsophalangeal (big toe) joint. The main symptom is stiffness and inflexibility of the big toe – which is reflected in its name “hallux rigidus” which translates to “rigid big toe”.
It is a fairly common condition and affects 1 in 40 of those aged over the age of 50 years old (Razik and Sott, 2016).
Symptoms of Hallux Rigidus
Hallux rigidus symptoms include:
- Pain in the big toe joint – particularly when bending the big toe back as far as it can go. There may be pain with certain activities such as walking and running. In more advanced stages, the pain may also be present at rest.
- Loss of motion of the big toe joint – particularly with big toe extension.
- Swelling around the big toe joint and potentially bony bumps (known as osteophytes) that may develop on top of the big toe joint in more advanced stages of the condition.
Causes of Hallux Rigidus
The majority of hallux rigidus cases have no clear cause. It is understood that the big toe joint experiences a lot of stress when walking and this may be what causes an increase in osteoarthritic changes. The big toe joint absorbs force that is double your body weight with every step you take (Kunnasegaran et al, 2015).
Other certain factors that can increase your risk of developing hallux rigidus, include:
- Previous injury to the big toe – including previous sprains to the big toe, including turf toe.
- Nearly two-thirds of those with hallux rigidus will have a family history (Lam et al, 2017).
- Females are twice as likely to develop the condition compared to males (Kunnasegaran et al, 2015).
Hallux rigidus affects the 1st metatarsophalangeal (MTP) joint. This joint is known as a condyloid joint and allows the big toe to flex, extend, abduct, adduct and circumduct. It is formed by the head of the first metatarsal and the base of the first proximal phalange. The joint is covered by articular cartilage which helps the joint glide easier. As the articular cartilage wears away, this leads to the joint space narrowing and the two bones rubbing together resulting in osteophytes (bony spurs).
How to diagnose
During your physiotherapy appointment, your clinician will take a detailed history, and examine your big toe and biomechanics. An X-ray can show any joint space narrowing, osteophytes or bone abnormalities.
Hallux rigidus is more likely to respond positively to conservative treatment in the early stages.
Conservative treatment includes:
- Appropriate footwear.
Wearing a shoe with a stiff sole will limit the toe from bending back when walking. Rocker shoes such as the Hoka trainers, allow you to roll over rather than push through the big toe. It’s important to wear shoes that have plenty of room for your forefoot and toes and to avoid wearing high heels or pointy shoes.
- Shoe modification.
Inserting pads into your shoes to limit big toe extension or wearing customised orthotic insoles to improve foot function and reduce stress on the toe joint.
- Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen can reduce pain and inflammation.
- Manual therapy and exercises to reduce stiffness and pain in the big toe joint. As well as increasing strength in the foot.
- Weight loss may help if you are overweight, as this will result in less stress going through the big toe joint.
If symptoms do not improve with physiotherapy, you may want to consider an ultrasound-guided steroid injection. This is where corticosteroid is injected into the 1st MTP joint under ultrasound guidance. This can be helpful in reducing pain and inflammation within the big toe, however, it is important to note that the positive effects are only temporary and the length of time varies between each person.
Hyaluronic acid injection
A small dose of hyaluronic acid (HA) is injected into the big toe joint under ultrasound guidance. HA acts as a lubricant within the joint to reduce friction and allow the joint to move smoothly. HA injections can be an effective way to reduce pain at rest and during walking for those with hallux rigidus (Pons et al, 2007). It is sometimes possible to have a steroid injection and HA injection at the same time to maximise benefits of both types of injections.
Those who do not respond to the above treatment interventions and have more advanced stages of hallux rigidus, may want to consider surgery.
Kunnasegaran, R. and Thevendran, G.(2015) Hallux Rigidus`; Nonoperative Treatment and Orthotics. Foot and Ankle Clinics. 20 (3) pp.401-412.
Lam, A., Chan, J., Surace, M. and Vulcano,E. (2017) Hallux rigidus: How do I approach it? World Journal of Orthopaedics. 8(5). Pp.364-371.
Pons, M., Alvarez, F. and Solana, J., Viladot, R. and Luisa, V. (2007) Sodium Hyaluronate in the Treatment of Hallux Rigidus. A single-blind randomzied study.
Foot and Ankle International Journal. 28(1) pp. 38-42.
Razik, A. and Sott,A. (2016) Cheilectomy for Hallux Rigidus. Foot Ankle Clinics. 21(3). Pp. 451-457.
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