Orthopedics-Online

Hallux rigidus

Synonyms in a broader sense

Hallux non extensus
Hallux limitus
Arthrosis of the metatarsophalangeal joint of the big toe
Stiffening of the metatarsophalangeal joint of the big toe

definition

Of the Hallux rigidus is a wear-related disease of the metatarsophalangeal joint of the big toe (arthrosis). The consequences are restricted mobility and pain. If left untreated, this leads to the stiffening of the Metatarsophalangeal joint. Occasionally, pre-stages of this disease are also called Hallux limitus designated.

Gender distribution and frequency

Of a Hallux rigidus mostly men are affected. Of the primary hallux rigidus often occurs unilaterally. The disease occurs in all ages and often begins in adolescence.

root cause

Arthrosis of the metatarsophalangeal joint of the big toe and thus the development of Hallux Rigidus develops slowly over the years. Normal sporting activities usually do not favor the development of osteoarthritis. However, injuries can lead to cartilage damage and thus to osteoarthritis. Hallux Rigidus disease in most people is likely due to congenital poor cartilage. Other possible causes are deformities of the metatarsophalangeal joint of the big toe, e.g. hallux valgus - misalignment of the big toe and metabolic disorders such as gout.

Symptoms of hallux rigidus

The wear and tear caused by wear and tear results in a painful restriction of movement of the metatarsophalangeal joint of the big toe. Rolling is painfully restricted, and the resilience for longer walking distances is considerably reduced.
In the initial phase of the disease, the big toe usually remains sufficiently flexible (soles), but the much more important stretch ability (back of the foot) for the rolling process decreases more and more until, in the worst case, the big toe stiffens in the base joint in a flexed position. An overstretching in the end joint still results in a low rollability.

Due to the painful unrolling as the disease progresses, the gait pattern also changes.There is a gentle gait, and sometimes a limp on the affected side. A rolling over the outer edge of the foot can often be seen, sometimes with an internal rotation of the entire foot. The toe stand can no longer be demonstrated painlessly, climbing stairs and going uphill are very painful.
When looking at the foot, a thickened metatarsophalangeal joint is often noticeable. The joint is tender on pressure, partly red and overheated. Mobility is painfully restricted and rubbing can be felt when moving.

You can also find more on the subject under Hallux rigidus symptoms

Pain in hallux rigidus

Hallux rigidus pain is a sign of overloading and destruction of the joint. Usually they are typically expressed in the form of a sharp pain in the area of the ball of the big toe. Especially with runners, the pain may initially only appear after exercise or, for example, during a run.
If, in the course of the disease, there is swelling, overstimulation and misalignment in the entire area of the forefoot, the pain usually occurs continuously.
It is important to always clarify other joints as well. Pain in the big toe can also be caused by a misalignment in the knee or hip. Especially when all of these joints are painful, you should look for exactly where the cause and the effect are.

Hallux Rigidus pain can be aggravated by a number of factors. In addition to the strain, cold weather or tight footwear can also increase the pain. If the disease is advanced, any load on the foot, including standing or normal walking, is perceived as painful.
Since the pain can occur more and more frequently in the course of the illness, it is also important to take action against the pain as early as possible. In addition to conservative and surgical therapies, painkillers can be used here to reduce the pain but also the inflammation. Devil's claw and hyaluronic acid injections into the affected joint are also said to alleviate the pain.

Often the pain causes a vicious circle. The pain causes the joint to move even less. While this alleviates the pain, it also leads to further stiffening and increased bad posture. So if normal movement is no longer possible due to the pain, better pain therapy or surgery should be urgently considered.
Over a longer period of time, the incorrect posture can otherwise lead to consequential damage to other joints or, for example, to the outside of the foot, as this area is usually more stressed in order to reduce the pressure on the big toe.

If the pain is ignored for too long, a number of secondary problems can arise. However, the various forms of therapy, surgery at the latest, are usually a good way of reducing pain in the long term.

Read more on the topic: Pain in hallux rigidus

Therapy of hallux rigidus

When treating hallux rigidus, a distinction is made between conservative and surgical therapy.

Further information can be found here: Therapy of Hallux rigidus

Conservative therapy

Should an underlying disease, e.g. osteoarthritis is based on gout disease, this should be treated first.
Initially and in the early stages of osteoarthritis, the mobility of the metatarsophalangeal joint of the big toe can be improved or maintained for a certain time through independent manual therapy with traction and displacement of the distal phalanx (demonstration by the physiotherapist)

Shoe supply for hallux rigidus

Due to the painful stiffening, which is particularly noticeable when the forefoot rolls, the big toe joint must be relieved.
Correspondingly, rigid inserts, e.g. made of metal, made to measure. A ball roll under the (front) shoe can also provide relief so that the rolling work is kept away from the metatarsophalangeal joint of the big toe. To this end, the sole of the shoe itself must be stiffened. Alternatively, a Rigidus spring insert can be prescribed.

Read more on the topic:

Treatment of Hallux rigidus with a spring insert
Insoles in hallux rigidus

Therapy with natural remedies

Natural remedies, especially devil's claw should be mentioned here. The devil's claw can be used alone for mild pain and to support the existing therapy for more severe pain. The devil's claw is said to reduce the symptoms of osteoarthritis of the big toe.
The therapy of hallux rigidus can be supported by homeopathic medicines. Various homeopathic medicines can alleviate symptoms in osteoarthritis therapy.

You can find out more about this topic at: Osteoarthritis and homeopathy

Therapy with hyaluronic acid

Hyaluronic acid is a natural component of cartilage that is particularly responsible for its elastic properties. Depending on the degree of osteoarthritis, an injection of hyaluronic acid into the metatarsophalangeal joint of the big toe can improve the pain and movement situation.

More on this under our topic: hyaluronic acid

Insole treatment for hallux rigidus

Insoles are used in various ways in the therapy of Hallux Rigidus. On the one hand, they are part of the conservative therapy used. It's mostly about the To minimize stress on the foot or the Reduce pain.
Insoles can reduce problems that arise during training, especially for runners. In general, the deposits in the early stage are aimed at further wear of the joint. There are special insoles for this, for example Carbon sole necessary. With a stiff sole and special padding in the area of the balls of the feet, these reduce the stress on the Big toe joint acts.

There are also special Hallux Rigidus shoes in which the insoles are already firmly integrated into the shoe. Also a very wide shoe at the front, which gives the toes plenty of room to move, can reduce the strain on the metatarsophalangeal joint.
Also within the Splint therapy are mostly used as a supplement. However, this is usually about Soft footbed insolesdesigned to alleviate the stress on the neighboring toe joints.
As a rule, insert therapy, as part of conservative treatment with a Pain therapy and physical therapy can be added. As a rule, the insoles can help to postpone surgical treatment. Due to the reduced stress on the affected joint, the occurrence of Inflammatory response prevented or at least less.
This not only causes less pain, but also the Wear and tear of the cartilage becomes less.

However, surgery is often necessary in the long term. As with all medical insoles, it is important to have the insole or the shoe precisely adjusted becomes. The insoles not only serve to reduce the problems in the area of the big toe. Even the neighboring joints, like knee- or hip joint are spared by improving the axis position.
For another, deposits are made too after an operation prescribed to compensate for a changed foot position, they are often only used on the non-operated foot. In addition to improving the axis position and foot posture, insoles on the operated foot lead to a Decrease in pain after the operation. The other foot usually receives an insert in order to harmonize the axes of the two feet again.

Read more detailed information on this topic at: Insoles for hallux rigidus

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Splints in a hallux rigidus

In the case of hallux rigidus, a splint initially has the effect of immobilization. This will reduce the pain and reduce the inflammatory response. By removing the stimulus that would arise from moving the joint, the progression of the disease is slowed down.
However, the splint or the plastering of the foot is only a measure for acute therapy. It can be used to heal an acute inflammation of the joint.

This type of immobilization can also be used after an operation. Depending on the surgical procedure, the lower leg can also be included. The splint protects the ball of the foot and improves the posture of the feet, similar to an insert.
In principle, the splint is also suitable for everyday movement, but wearing it in the shoe is rather difficult. Accordingly, the use of insoles or orthopedic shoes is recommended for long-term therapy. In the early stages, wearing the splint indoors and for limited periods of time may help to relieve symptoms.

A disadvantage of the splint compared to insoles, however, is that it is not made to measure to fit exactly. The splint can stabilize the big toe and relieve the ball of the foot, but a splint cannot have the other positive effects on other joints and the axis position.

Read more on this topic here: The Hallux rigidus splint.

The operation of the hallux rigidus

A large number of procedures are available for operating hallux rigidus. The respective procedure must be adapted to the patient's condition, the stage of the disease and of course to the desired result. An operation is only considered in the later stages, while the early stages are treated conservatively. In the middle stages of the disease, surgery should definitely be performed to preserve the joints.

You can find more information here: Hallux rigidus surgery

Cheilectomy for hallux rigidus

One procedure that comes into question is the so-called cheilectomy. The joint capsule is opened. After removing part of the joint membrane, the cartilage is inspected. In the area of the articular cartilage, protruding parts (Ostephytes) removed and the cartilage smoothed overall in the area of the joint. After extensive irrigation, the wound is then closed again.
With this method, the relevant joint parts and the ligaments and tendons remain intact. Due to the low invasiveness, later operations with other methods are still possible.
In terms of the procedure, this variant is comparable to the smoothing that is often used in the knee joint as part of a knee reflection. After the operation, movement exercises and loading with the help of a thick sock should be started as soon as possible.

L.Find out more about this surgical method at: Cheilectomy for hallux rigidus

Osteotomy for hallux rigidus

Another method to restore the mobility of the big toe joint is the osteotomy of the proximal phalanx. A wedge is cut out of the metatarsal bone from above. The bone layer facing the sole of the foot initially remains intact and is then slightly cracked to close the wedge-shaped incision.
With this surgical method, the result is then stabilized with clamps or screws. After the operation, rigid shoes must be worn for 6 weeks to stabilize the foot until the bone has healed firmly together.
This technique can be used on different bones of the foot, but it always has the effect that by cutting out a wedge or a disc, the position of the joint head is changed so that greater mobility is possible and incorrect loading is minimized.

Arthrodesis in hallux rigidus

Arthrodesis is another method that is used, especially for patients who want a high level of stability under stress. Arthrodesis stiffens the affected joint. The aim of the whole is to firmly connect the bones of the big toe and the metatarsus through a bony structure.
The original joint area, including cartilage and joint surface, is replaced by this ossification. During the operation, the joint is removed and the bone surfaces are connected to one another. This construction must first be stabilized with nails or screws until the resulting bone can cope with this task on its own.
There are also modifications to this technique, depending on the exact symptoms. In the so-called lapidus arthrodesis, for example, the joint between the metatarsal bone and the tarsus is stiffened. In addition to screws for stabilization, plates are also used.
After the operation, the foot should be elevated for a few days. The big toe itself should then not be loaded for about 6 weeks in order to give the bone the opportunity to achieve a certain degree of strength.
Arthrodesis changes the rolling process of the foot under load. This is especially useful to prevent pain. In contrast to prosthetic procedures, there is no risk of loosening later. 90% of patients say they are satisfied with the result after the operation.

Large toe joint prosthesis in hallux rigidus

The replacement of the metatarsophalangeal joint of the big toe with a prosthesis is also possible in hallux rigidus. Prostheses should primarily have the advantage that the natural mobility of the joint is preserved or restored as far as possible. This should reduce the restrictions after the operation.
However, even with these prostheses, no more stressful activities may be carried out. The prosthesis is fitted to the knee joint, for example, and adjusted to the anatomical features.
This procedure is now regarded as the standard in many places. In addition to mobility, the benefits also include rapid freedom from pain. In addition, should problems arise with the prosthesis, the very gentle installation process means that another procedure can be used later.
Here, too, a shoe with a stable sole should be worn for about 6 weeks and rolling should be avoided. After 6 weeks, however, the prosthesis should be well fused with the bone so that loading is possible.

Post-treatment of hallux rigidus

The follow-up treatment for a Hallux Rigidus operation differs, as mentioned above, depending on the surgical procedure. Except for the cheilectomy, a shoe with a rigid sole must always be worn first to give the bone the opportunity to establish a stable connection.
The main aim is to prevent rolling stress in the newly operated joint. This means that a load on the heel is allowed.

Despite the shoe, exercise therapy should be started as soon as possible after the operation. Of course, this is especially true if a joint replacement has been implanted. Especially in the period shortly after the operation, it is also important to take sufficient pain relievers and anti-inflammatory agents to support healing and prevent the development of chronic pain.
For this purpose, e.g. Ibuprofen or diclofenac.
These effects can be supported by elevation, cooling and lymphatic drainage, especially in the first few days after the operation. With the help of the movement exercises, running and mobility can be improved very well. However, one should not expect the range of motion of a healthy joint.