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Hallux Rigidus

Limited and painful movement of the big toe joint.

The degenerative process causes two major problems: pain, and loss of motion of the big toe joint. This can also cause alteration in the way a patient walks, so other parts of the foot, knee, hip and back are frequently affected.

Diagnosis

Diagnosis of hallux rigidus is made by both physical examination of your foot and by x-ray examination. There is a commonly mild swelling and bony prominence associated with the first metatarso - phalangeal joint behind the big toe.

X-ray examination of the foot will reveal the true severity of the condition. It will allow the physician to evaluate the joint for bone spurs, decrease in joint space, flattening of joint surfaces, and loose bodies in the joint. X-rays can also reveal the causes of hallux limitus such as an elongated or elevated first metatarsal.

How can this be treated?

First, you can try symptomatic relief, that is, just making it feel better. Rest, ice, anti-inflammatory medications, steroid injections, physiotherapy, and massage may all help. At least temporarily.

Second, and more importantly long term, you can try to identify the cause of the problem, and attempt to correct this cause. Orthoses (orthotics), for example, can be used to increase what motion still exists in the joint, or if the degeneration is bad enough, both orthoses and special shoe modifications can limit pressure on the spurs, and limit the painful motion that remains in the joint.

The joint can also be treated by the injection of Steroid which reduces the pain from the joint. The final option is to attempt to fix the condition surgically.

What would be done to fix the joint surgically?

Several options exist.

If spurs are present, but the joint doesn't look too worn out, you could simply remove any spur formation that limits motion. This is called a "Cheilectomy" or an "Exostectomy".

These procedures have the advantage of being easy to perform and allowing for quick recovery. Cheilectomies, however, do not do anything to address why the hallux limitus developed. So using this procedure where it is not indicated will tend to create a return of symptoms and may make the patient undergo more surgery in the future. For these reasons, other procedures that attempt to correct the cause may be better choices in the long run, however. For example, if the cause of the condition is an excessively long first metatarsal, a procedure designed to shorten the metatarsal would be considered. Alternatively, the metatarsal may be lowered if it is too high, stabilized if it is too mobile, realigned if it is crooked, recontoured if it is irregular, and so forth.

Range of motion exercises are encouraged afterwards for these procedures, and recuperation is usually quite rapid.

The Keller procedure

The Keller procedure involves removing the base of the big toe joint. As you can see in the illustration to the left, there is a great deal of arthritic changes in the great toe joint.

The Keller procedure involves removing the base of the first toe bone, to remove the arthritic bone surrounding the joint and limiting motion. (See illustration below.)

Usually surrounding soft tissues are positioned between the remaining bone surfaces to prevent further bone-on-bone wear. The Keller procedure is quick-healing, and it increases range of motion tremendously. This helps the patient return to a more normal gait, but the patient loses some push-off power in the toe joint. Future surgery is rarely needed.

The joint could be fused. In other words, instead of removing bone, you attempt to eliminate the joint and allow the two bones to grow together in a fused position. Known as an arthrodesis, the advantage to this is that without motion of the joint, pain is usually resolved. The disadvantages are that this procedure is slow-healing, sometimes requiring months to become solid, and the result is a motionless great toe joint, which can change the way the patient walks. Alterations if shoe gear may be necessary, and other joints frequently begin to become troublesome, as they must make up for the loss of great toe joint motion. It is also somewhat more to reverse if the procedure proves to be problematic.

Which procedure is best?

It depends on each individual case, and on the preferences of both the surgeon and the patient.

Arthrodesis

Removal of the damaged joint surfaces, followed by the insertion of screws, wires, or plates to hold the surfaces together until it heals. Used for patients with severe bunions, severe arthritis, and when other procedures have failed. This is a joint arthrodesis, a fusion of the joint so that is will no longer hurt. It will not move after this procedure.

Joint Replacement

Below is a joint replacement. This allows full range of movement when in place.

  

Other procedures

There are many types of surgery to treat hallux limitus. Each person can have a sligthly different variation of this problem. You will need to book a consultation to discuss your individual needs. Surical procedures vary from small bone cuts to remove the excessive bone growth, a cheilectomy the repostioning of bone shapes, to joint replacement or joint fusion for severe cases