The Stiff Big Toe Joint (Hallux Rigidus)
Movement of the big toe joint occurs
typically in an up and down plane only (dorsiflexion and plantarflexion).
The normal dorsiflexion is approximately 75 degrees and plantarflexion
is 25 degrees. When the big toe has limited movement, it is often,
but not always, associated with some form of arthritis of the big
toe. This is referred to as hallux rigidus. Treatment of hallux rigidus
often has to be surgical but the joint can be made more comfortable
with an appropriate shoe modification.
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Arthritis of the big toe joint
is present with large bone spurs around the joint seen
on this X-ray. |
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Note the arthritis in the big
toe joint. There is no cartilage, the joint space has
disappeared and there is marked bone spurring around the
joint. You can see that the big toe joint on the right
has a large bump on it. This is not a bunion, but arthritis
(hallux rigidus). |
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To treat the pain in the big toe joint, the shoes are modified by
stiffening the sole, inserting a stiff orthotic arch support in the
shoe and sometimes adding a small rocker effect (called a metatarsal
bar) which is glued on to the bottom of the sole of the shoe. Thin-soled
shoes and high heels aggravate this condition because more stress
is placed on the joint, increasing pain.
The surgical treatment for hallux rigidus is determined by the extent
of the arthritis and deformity. For the more minor type of hallux
rigidus, shaving the bump of the bone on top of the metatarsal is
sufficient (a cheilectomy). As the stiffening of the big toe joint
increases a cheilectomy is not sufficient and an additional bone cut
may needed on the big toe itself, (an osteotomy of the phalanx).
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The cut is being made during
surgery with a small bone chisel. |
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This is the upward range of movement
of the big toe before the bone cuts (on the left), and
after the bone cut (on the right).
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For some feet with hallux rigidus,
the shaving of the bone on the top of the big toe (the
cheilectomy) is not sufficient. An additional bone cut
on the big toe is made to lift it up slightly from the
floor. This improves the upward movement of the toe and
makes it easier to wear shoes.
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As the arthritis increases, the ability of an osteotomy or cheilectomy
to correct the problem, maintain motion, and prevent the arthritis
from worsening is very limited. For these patients, either a fusion
of the big toe (an arthrodesis) or removal of bone from the joint
(an arthroplasty) is performed. The big difference between a fusion
and arthroplasty is the movement of the big toe.
The main advantage of a fusion is that it is a permanent correction
with elimination of the arthritis and pain. The disadvantage is the
restriction of movement of the big toe. Patients are typically able
to exercise, run and wear most shoes quite comfortably. Wearing a
heel higher than an inch and a half is difficult after fusion of the
big toe.
Removal of a bone from the joint (a resection or interposition arthroplasty)
shortens the big toe slightly but maintains some movement. This is
an effective operation, particularly for individuals who would prefer
to have movement of the big toe after this type of surgery. It is
not, however, as reliable and predictable as a fusion in terms of
recurrent problems with the big toe and push off strength. The decision
to perform a fusion or an arthroplasty of the joint is often a matter
of patient and physician preference, a decision which is made together.
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