Hallux Rigidus and 'Turf Toe"

Hallux Rigidus

Arthritis is a common cause of pain and stiffness of the big toe joint (1st MTPJ). Hallux = big toe and Rigidus = rigid or stiff. It may affect one or both feet but it is not normally associated with generalised arthritis throughout the body. It usually occurs in the 30's to 40's age group but can affect a wider age-range. It often occurs spontaneously (without a history of injury).

One of the first symptoms is stiffness of the big toe joint - usually bending the toe upwards is difficult (dorsi-flexion) and walking may be painful as foot 'pushes-off" from the ground. There may be a bump on top of the joint which can cause problems with rubbing on shoes (dorsal osteophyte). In the early stages, the actual joint may be well preserved and it is just the dorsal osteophyte that causes the limited movement and pain. The next joint along the big toe (intephalangeal joint behind the nail) is usually unaffected.

How is it diagnosed

Examination will assess the limitation in the range of motion and the dorsal osteophyte. The degree of underlying arthritis can be evaluated with x-rays.

What is the treatment

The simplest measures can be to modify shoe-wear and stiffening the sole of the shoe under the 1st MTPJ. In advanced cases, placing a carbon-fibre 'rocker-bottom" in the sole of the shoe may allow the shoe to do the bending that the big toe joint used to, thereby alleviating pain.

When is surgery necessary

If it is just a dorsal osteophyte that is preventing the toe from bending upwards, this can be removed by a simple operation carried out as a day-case procedure (cheilectomy). The purpose of the operation is to improve the range of motion, relieve pain and allow a return to previous sporting activities. Cheilectomy may also be performed during the early stages of arthritis. (Click here for a link to operation information)

When the arthritis is more advanced it may not be possible to save the joint. In this case it may be necessary to fuse the joint. This operation removes the arthritic joint surface and fuses the metatarsal and proximal phalangeal bones together using a small plate and screws. The interphalangeal joint (behind the nail) is left unaffected. The purpose of the operation is to leave a stiff but pain-free joint. The fused joint does not normally cause problems with walking or shoe-wear. Ladies often prefer the joint fused with the toe slightly elevated so that a healed shoe may be worn comfortably. (Click here for a link to operation information)

Replacement of the joint is a newer technique which may be considered in patients who really do not wish to lose range of movement at the 1st MTPJ. Some published results are promising but it is early days and careful selection and evaluation of patients is required before they may be considered suitable to undergo 1st MTPJ replacement.

Turf-Toe

An acutely painful and stiff big toe may occur in young sportsmen / sportswomen after an injury - classically this may be caused by the toe striking the ground rather than a ball. This may cause damage to the smooth articular cartilage of the big toe joint leading to acute pain and stiffness. Occasionally a piece of loose cartilage may cause a clicking feeling within the joint causing it to 'lock".

An x-ray may reveal a small fracture to the joint surface and an MRI scan may be helpful to show whether a there is loose fragment of articular cartilage within the joint. Such a loose fragment may be removed during a simple operation carried out as a day-case procedure. The purpose of such an operation is to relieve symptoms and prevent further damage to the joint. With the advent of new instruments it is now possible to perform the operation by the minimally-invasive technique of MTPJ arthroscopy. (This technique is shown above and the photograph on the right demonstrates the view inside the joint).