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Hallux rigidus means 'stiff great toe' and was first described in the orthopaedic literature towards the end of the nineteenth century. The degenerative changes can be mild to severe, as can the consequent disability. It affects adults and adolescents and there may or may not be a history of trauma.
The aetiology is unknown. It is thought to relate to 'wear and tear' of the joint through acute, or more usually, chronic repetitive injury. Symptoms result from a degenerative arthropathy of the first metatarsophalangeal (MTP) joint. These degenerative changes are characterised by:
- Loss of cartilage.
- Altered joint mechanics.
Pain and loss of function result from dorsal osteophytes, inflammation and irregularity of joint articular surfaces. As with any degenerative arthropathy the combination of overuse, injury or abnormal joint mechanics may combine to produce stresses and damage to articular cartilage.
One study of 110 patients showed an association between:
- Hallux rigidus and hallux valgus interphalangeus.
- Family history of hallux rigidus and bilateral hallux rigidus.
- Trauma and hallux rigidus (unilateral cases).
There was no association between hallux rigidus and:
- Pes planus.
- Length of the first metatarsal.
- Hallux valgus.
- Metatarsus adductus.
- Hallux rigidus is the most common degenerative disorder of the foot and it is one of the most common causes of forefoot pain[2, 3].
- Most cases are bilateral and many have a family history.
- Women are affected more often than men.
- It most commonly presents after the age of 40 years, although it can occur at young ages.
Presentation is with pain:
- Worse with walking, worse at extremes of dorsiflexion, just before the toe leaves the ground.
- May be worse when wearing particular shoes, particularly those with heels.
- Localised on the dorsal surface of the great toe.
- More diffuse pain in the lateral forefoot (caused by compensatory gait).
- Dysaesthesia caused by compression of the dorsomedial cutaneous nerve (footwear with osteophyte).
- Late diffuse pain of advanced degenerative disease
There may also be stiffness.
There is osteophytic swelling to the dorsum of the first MTP joint, which is usually tender. There is limited first MTP dorsiflexion in particular and also limited plantar flexion. Where presentation is late, there will be pain and crepitus on movement of the joint.
Gait may be affected. There may be limited dorsiflexion as the toe leaves the floor. There may be an antalgic gait.
- Hallux valgus.
- Other forms of arthritis.
- Surgical or traumatic arthropathy.
Plain X-ray reveals the radiographic features of the degenerative changes (see 'Staging', below):
- Flattened metatarsal head.
- Joint space narrowing.
- Subchondral cysts.
Often classified as:
- Mild - maintained joint space, minimal changes.
- Moderate - some narrowing, cysts and sclerosis.
- Severe - severe changes with loose bodies.
A number of classification systems exist, which hinders interpretation of research findings. A 2008 review found the Coughlin and Shurnas classification, which incorporates radiographic features, to be the preferred system.
Coughlin and Shurnas classification
- Grade 0:
- Dorsiflexion 40-60°.
- Normal radiography.
- No pain.
- Grade 1:
- Dorsiflexion 30-40°.
- Dorsal osteophytes.
- Minimal/no other joint changes.
- Grade 2:
- Dorsiflexion 10-30°.
- Mild-to-moderate joint narrowing or sclerosis.
- Grade 3:
- Dorsiflexion less than 10°.
- Severe radiographic changes.
- Constant moderate-to-severe pain at extremities.
- Grade 4:
- Stiff joint.
- Severe changes with loose bodies and osteochondritis dissecans.
- Pain through the entire range of movement.
Non-surgical or conservative approaches
- Analgesics including non-steroidal anti-inflammatory drugs (NSAIDs).
- Strapping of the toe.
- Orthotics to limit extreme dorsiflexion.
- Modification of activities (for example, avoid kneeling/squatting).
- Modification of shoes/shoe choice.
- Physical therapy (limited evidence).
- Injection with sodium hyaluronate may be helpful in early stages; however, evidence is slim.
If there is ongoing pain despite non-surgical interventions, surgery is usually offered. Evidence is poor to help determine the best treatment option. Choice depends on:
- Stage of involvement.
- Degree of limitation of the range of movement.
- Activity levels of the patient.
- Preference of the surgeon and the patient.
A number of procedures may be performed, which may be joint-sparing or otherwise. Options include:
- Various types of osteotomy. A number of different techniques may be used, and aim to be joint-sparing in nature.
- Cheilectomy. Osteophytes are removed, along with some of the dorsal metatarsal head. May be performed in conjunction with osteotomy, such as a proximal phalanx osteotomy. In some cases, minimal destructive surgery is needed and this can be considered a joint-sparing procedure.
- Arthrodesis. This is standard treatment for severe hallux rigidus.
- Arthroplasty. Several types of arthroplasty are available, including interpositional arthroplasty, hemiarthroplasty, resurfacing of the metatarsal head and various types of implants. There are no long-term data about most types of arthroplasty at this time and, therefore, there are no clear evidence-based recommendations about their use.
These depend on the particular treatment used.
This again depends on the severity, patient activity and expectation as well as the particular treatment used. Generally speaking, operative treatments are offered to people in whom non-operative treatments have been ineffective. There are few studies into long-term outcomes.
Further reading and references
Coughlin MJ, Shurnas PS; Hallux rigidus: demographics, etiology, and radiographic assessment. Foot Ankle Int. 2003 Oct24(10):731-43.
Kunnasegaran R, Thevendran G; Hallux Rigidus: Nonoperative Treatment and Orthotics. Foot Ankle Clin. 2015 Sep20(3):401-12. doi: 10.1016/j.fcl.2015.04.003. Epub 2015 Jun 9.
Beeson P, Phillips C, Corr S, et al; Classification systems for hallux rigidus: a review of the literature. Foot Ankle Int. 2008 Apr29(4):407-14. doi: 10.3113/FAI.2008.0407.
Deland JT, Williams BR; Surgical management of hallux rigidus. J Am Acad Orthop Surg. 2012 Jun20(6):347-58. doi: 10.5435/JAAOS-20-06-347.
Polzer H, Polzer S, Brumann M, et al; Hallux rigidus: Joint preserving alternatives to arthrodesis - a review of the literature. World J Orthop. 2014 Jan 185(1):6-13. doi: 10.5312/wjo.v5.i1.6. eCollection 2014 Jan 18.
Zammit GV, Menz HB, Munteanu SE, et al; Interventions for treating osteoarthritis of the big toe joint. Cochrane Database Syst Rev. 2010 Sep 8(9):CD007809. doi: 10.1002/14651858.CD007809.pub2.
Razik A, Sott AH; Cheilectomy for Hallux Rigidus. Foot Ankle Clin. 2016 Sep21(3):451-7. doi: 10.1016/j.fcl.2016.04.006. Epub 2016 May 24.
Hamid KS, Parekh SG; Clinical Presentation and Management of Hallux Rigidus. Foot Ankle Clin. 2015 Sep20(3):391-9. doi: 10.1016/j.fcl.2015.04.002. Epub 2015 Jul 2.
Kline AJ, Hasselman CT; Resurfacing of the Metatarsal Head to Treat Advanced Hallux Rigidus. Foot Ankle Clin. 2015 Sep20(3):451-63. doi: 10.1016/j.fcl.2015.04.007. Epub 2015 Jul 8.
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