Image by Danie Franco

Big Toe Arthritis

(Hallux Rigidus)

Foot Massage

Hallux Rigidus

Arthritis of the big toe, also known by the Latin name hallux rigidus, is where the joint at the base of the big toe becomes painful and stiff. It may also be accompanied by painful bony swellings on the top of the joint which can rub on footwear and cause further restriction in movement.

It is caused by wear and tear occurring inside the joint and is most common in people who have led sporty and active lifestyles. Other causes include damage to the joint caused by rheumatoid arthritis or gout.

Self Help

In the early stages of the joint becoming worn, or if symptoms are minor or infrequent, wearing shoes with a stiff sole can help. Over-the-counter pads, made of silicone or similar materials can help prevent rubbing from bony prominences.

Some people benefit from use of anti-inflammatory medications which can be taken as tablets or by applying a gel directly over the affected joint. Your GP will be able to advise if this is suitable for you.

Arthritis of the big toe (hallux rigidus) – what is it?

Wet Feet
Running Shoes

Assessment

Your surgeon will assess your foot and how the bunion or lesser toe deformity affects you. This normally involves asking about relevant medical conditions, examining your foot and performing x-rays. This information will be used to advise on the best treatment for you - this may be non-surgical or surgical.

Non-Surgical Treatment

If clinical assessment and x-rays do not show severe joint damage, or you do not wish to have surgery, then injecting steroid into the joint can help to relieve pain and inflammation. They are normally performed using either x-rays or an ultrasound scan to  make sure the injection gets into the joint.

It is worth noting that steroid injections do not stop  the wear and tear process and it is likely that symptoms will return over time.

Orthopedic Insoles
Baby's Feet
Calcaneus X-ray

Surgery

The type of operation you are offered will depend on  your degree of symptoms and the extent of wear in the joint. Your surgeon will discuss the options with you.

Cheilectomy

This is the surgical name for removal of the bony lump which can develop at the top of the worn joint.  It is most beneficial in patients who have mild to moderate wear in the joint but a large bony lump which restricts movement.

Good, long lasting results are possible from this procedure if you have mild arthritis. However, over time it is possible that the arthritis in the joint may worsen, with pain and stiffness returning. If this happens then further surgery may be required.

 

Fusion

This is the main operation performed when there is severe arthritis in the big toe joint. It aims to convert a stiff, painful joint into a rigid but pain-free joint.

In order to do this, the worn out joint and any bony lumps are removed. This tricks the body into thinking that there has been a broken bone and the result is that it tries to heal the two bones together - forming new bone in between them. Metal screws and / or plates are used to hold the two bones in place until they have healed together.  Bone healing normally takes between 6 and 12 weeks.

After the surgery there will be no movement in the fused joint, but there will still be movement in the joint at the end of the toe. There will be an inability to wear high-heeled shoes and a return to any vigorous sporting activity such as football is highly unlikely.

Joint Replacement

The worn out joint is removed and replaced with an artificial joint made from metal and plastic. This is reserved for relatively low demand patients who wish to preserve some movement in the joint.

 

As with all joint replacements, these can wear out or become loose over time and further surgery may be required.

 

Not all foot and ankle surgeons offer this procedure.

Foot Massage
Gym Shoes
Image by Omid Armin

General Information on big toe arthritis surgery

 

Most surgery is performed as  day case either under a general anaesthetic (asleep), or under spinal or regional anaesthesia (awake). The anaesthetic doctors will discuss the best option for you.

 

Weight bearing through the heel of your operated foot using a special shoe is permitted for the first six weeks. If you have had a cheilectomy, then the special shoe only needs to be worn for two weeks. You may or may not need crutches to help you walk .  It is important to elevate the foot for the first two weeks to reduce pain and swelling and to encourage the wounds to heal.

After two weeks you will be seen in clinic to remove the bandage and dressings and to check wound healing. Sometimes stitches used to close the wounds may need to be removed also.

After six weeks you will have a further clinic appointment. Depending on the surgery performed, you may need x-rays to check bone healing.

So when can I...

Leaving Hospital
Most patients leave hospital the same day. Some patients may need to stay overnight.

Medication
The hospital will ensure you have the correct medication & pain relief when you go home. This can be different for each patient

Sedentary job
2-4 weeks as tolerated, providing you don't need to be on your feet for long periods. This time may be less if you have undergone a Cheilectomy.

Manual job
Around 12 weeks; may need to modify activities for 3-4 months

Driving

Normally 6 weeks.

When you no longer need to wear your protective post-operative shoe.

The law states that the patient should be in complete control of the car, it is your responsibility to ensure this and to inform your insurance company about your surgery.

If you drive an automatic car and have had left foot surgery you may be able to resume driving sooner. Again, it is advised you contact your insurer to ensure your insurance is valid.

Sport

You may be able to return to sports after a cheilectomy after around 6 weeks.

A return to vigorous sporting activity after a fusion operation is unlikely.

Screenshot 2022-05-13 at 11.12_edited.png

This is only a guide. It It will be different for each patient. Speak to your healthcare team if you have any questions.

What are the risks?

If you do encounter a complication after surgery, it is important to let your surgeon or your GP know so that appropriate measures or treatment may be initiated. If you are concerned you may have developed a blood clot (DVT/PE) you should seek urgent medical attention (see section on blood clots).

  • Wound infection - It is important to keep your wounds clean and dry until they have fully healed. Unfortunately infections can happen and most of the time a short course of antibiotics is the only treatment required. Infrequently severe infection may require further surgery.

  • Stiffness – The foot and ankle can become stiff after surgery. This normally resolves with time and you may be referred to Physiotherapy. 

 

  • Further Arthritis (cheilectomy patients only - Thankfully this only occurs after a cheilectomy and can take years to develop. Fusion surgery may be required.

 

  • Toe Position (Fusion  patients only) Very infrequently the joint heals in an unintended position. This may be due to the correct position not being achieved at the time of surgery, or if the bones have shifted after surgery. Sometimes repeat surgery is needed.

  • Non-Union (fusion patients only) - This is term used to describe joint fusions which do not heal. This is more common in smokers and diabetic patients. Smoking cessation is strongly advised prior to surgery.

  • Metalware Prominence -The screws used to stabilise bone cuts are normally buried in the bone and do not cause problems. However sometimes they can become prominent over time. They can be removed with further surgery if required.

  • On-going pain – X% of patients will have some on-going discomfort / pain after surgery.

  • Blood clot - It is important you inform your surgeon if you have a blood clotting disorder or have ever suffered from a blood clot  in the leg (deep vein thrombosis / DVT) or lung (pulmonary embolism or PE), or if there is a strong family history of blood clots. Medication to thin the blood after surgery may be required if this applies to you. Thankfully blood clots are uncommon after forefoot surgery and we do not routinely need to give blood thinners after surgery.If you develop painful leg swelling , chest pain, shortness of breath of difficulty in breathing after your surgery you should seek urgent medical attention – contact NHS 111 or attend the Emergency Department for assessment.