Hallux rigidus is an arthritic disorder of the joint located at the base of the big toe (the MTP joint). It causes pain and stiffness in the joint, and with time, it gets increasingly harder to bend the toe. (Hallux refers to the big toe, while rigidus indicates that the toe is rigid and cannot move. )

The Causes

Hallux rigidus may occur as the result of a number of conditions or factors, including:

  • osteoathritis
  • rheumatoid arthritis
  • lupus
  • gout
  • following an MTP joint fracture

The Types of & Symptoms of Hallux Rigidus

  • Grade 1 hallux rigidus is also known as hallux limitus. As this condition develops, there may be limited swelling and tenderness at the first MTP joint. Patients may also experience a reduced range of motion. (Normal first MTP motion is from 90 degrees of upward motion or dorsiflexion to 30 degrees of downward motion or plantar flexion.) However, any x-rays of the first MTP joint may be normal at this stage. 
  • Grade 2 hallux rigidus will also have swelling, stiffness, and tenderness of the first MTP joint. There may be a bony or cartilage prominence on the top (dorsum) of the first MTP joint. X-rays at this stage may reveal small bony spurs at the periphery of the first MTP joint. The cartilage joint space in between the bones of the MTP joint is still relatively preserved. 
  • Grade 3 hallux rigidus will exhibit significant stiffness, tenderness, and spurring at the first MTP joint. X-rays at this stage will display significant spurring, narrowing of the joint space, and sclerosis (hardening) of the bone surrounding the joint.

The Treatment

Treatment for Grade 1 and Grade 2 hallux rigidus is initially conservative. 

  • Anti-inflammatories, ice, and physical therapy may be used to reduce swelling and inflammation, as well as help restore one’s range of motion. 
  • A protective carbon fiber plate may be placed in the shoe to limit the naturally occurring stress on the first MTP joint during push-off while walking.
  • A cortisone and Xylocaine injection in the MTP joint may also be used to reduce inflammation.
  • In early Grade 1 hallux rigidus, and in certain cases of early Grade 2 hallux rigidus, a PRP injection may help as well. 

Should initial conservative treatment fail, or not be an option, surgical care will be the next step in treatment.

  • In cases of Grade 2 hallux rigidus where there are significant spur growths, a cheilectomy (bumpectomy in Greek) may be performed. This is an outpatient procedure performed under general or spinal anesthesia. An incision is made over the top (dorsum) of the first MTP joint; the joint is opened; and all of the spurs are removed. After surgery, a protective boot must be worn by the patient. The patient will also be ordered to avoid all weight-bearing activities for 6 weeks. Early aggressive range of motion therapy of the MTP joint is initiated immediately, and strengthening exercises are initiated after 6 weeks. Risks with this procedure include anesthesia-related risks, wound healing problems, infection, and the increased risk of arthritis.
  • In cases of Grade 3 hallux rigidus, should a patient fail to respond to initial treatment options, an MTP fusion will be needed. This is an outpatient procedure performed under general or spinal anesthesia. The surgery results in fusion or permanent stiffening of the MTP joint. An incision is made on the top (dorsum) of the first MTP joint; the remaining cartilage surface of the MTP joint is removed; and a small plate and screws are inserted to hold the two bones together until healed. Post-operatively, a protective boot is prescribed and patients must avoid all weight-bearing activities for 6 weeks or until the fusion has healed. Risks with this procedure include anesthesia-related risks, wound healing problems, infection, and post-op slow healing or nonhealing of the fusion.