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.

Aetiology

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
• Osteophytes
• 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. The dorsal articular surface is particularly affected with cartilage becoming dehydrated and vulnerable to injury.¹

Epidemiology

• Hallux rigidus is the most common affliction of the great toe metatarsophalangeal (MTP) joint after Hallux Valgus (separate article).
• Most studies report a higher incidence in men.
• Most cases (80%) are bilateral and, of these, nearly all have a family history.²

Presentation

• History:
  • Typically:
    • Male, middle-aged
    • Active (runners)
    • Bilateral and familial
  • Pain:
    • Worse with certain activities and particular footwear
    • 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
  • Stiffness:
    • Less common complaint
    • Occurs most often in adolescent group (complaining of rigid first toe)
• Examination:
  • Inspection:
    • Osteophytic swelling to the dorsum of the first metatarsophalangeal (MTP) joint
  • Palpation:
    • Limited first MTP dorsiflexion and plantarflexion (with pain as well)
    • Pain and crepitus in late presentation
  • Gait:
    • May be affected
    • Markedly limited dorsiflexion at toe-off
    • May be antalgic

Differential diagnosis

• Hallux valgus
• Other forms of arthritis
• Surgical or traumatic arthropathy

Investigations

Plain X-ray reveals the radiographic features of the degenerative changes (see Staging below):

• Osteophytes
• Joint space narrowing
• Sclerosis
• Joint irregularities
• Bone cysts

Associated diseases

One study of 110 patients² 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
• Footwear
• Occupation
• Obesity
• Metatarsus adductus

Staging

Often classified as:

• Mild - maintained joint space, minimal changes
• Moderate - some narrowing, cysts and sclerosis
• Severe - severe changes with loose bodies

A classification was proposed in 1999 which incorporated radiographic features.²

Management

• Nonsurgical or conservative approaches:
  • Can be used for various stages of disease
  • Analgesics including non-steroidal anti-inflammatory drugs may be helpful
  • Orthotics limiting extreme dorsiflexion are helpful
  • Modification of activities (avoid kneeling/squatting for example)
  • Manipulation and injection (for grades 1 and 2 only)³
• Surgical therapy:
  • Choice depends on:
    • Stage of involvement
    • How limited the range of movement is
    • Activity levels of the patient
    • Preference of the surgeon and the patient
  • Joint sparing procedures such as dorsal cheilectomy:^4,5,6,7
    • Mild-to-moderate disease with less than 50% of the joint affected
    • With or without proximal phalangeal osteotomy
  • Excision arthroplasty or Keller procedure:
    • High complication rate and generally not recommended⁶
    • Favoured by some for advanced cases⁷
  • Metatarsophalangeal (MTP) arthrodesis:
    • Favoured procedure⁶
    • Suitable for most cases and severity but usually grades 3 and 4
    • Suitable as salvage when other procedures have failed (for example, Keller procedure)⁸
  • Arthroplasty:
    • Not yet recommended
    • High complication rate

Complications

These depend on the particular treatment used.

Prognosis

This again depends on the severity, patient activity and expectation as well as the particular treatment used. Generally speaking, operative treatments are offered to patients refractory to nonoperative treatments.

Document references

1. Ahn TK, Kitaoka HB, Luo ZP, et al; Kinematics and contact characteristics of the first metatarsophalangeal joint. Foot Ankle Int. 1997 Mar;18(3):170-4. [abstract]
2. Coughlin MJ, Shurnas PS; Hallux rigidus: demographics, etiology, and radiographic assessment. Foot Ankle Int. 2003 Oct;24(10):731-43. [abstract]
3. Solan MC, Calder JD, Bendall SP; Manipulation and injection for hallux rigidus. Is it worthwhile? J Bone Joint Surg Br. 2001 Jul;83(5):706-8. [abstract]
4. Mackay DC, Blyth M, Rymaszewski LA; The role of cheilectomy in the treatment of hallux rigidus. J Foot Ankle Surg. 1997 Sep-Oct;36(5):337-40. [abstract]
5. Mulier T, Steenwerckx A, Thienpont E, et al; Results after cheilectomy in athletes with hallux rigidus. Foot Ankle Int. 1999 Apr;20(4):232-7. [abstract]
6. Coughlin MJ, Shurnas PS; Hallux rigidus. J Bone Joint Surg Am. 2004 Sep;86-A Suppl 1(Pt 2):119-30. [abstract]
7. Beertema W, Draijer WF, van Os JJ, et al; A retrospective analysis of surgical treatment in patients with symptomatic hallux rigidus: long-term follow-up. J Foot Ankle Surg. 2006 Jul-Aug;45(4):244-51. [abstract]
8. Machacek F Jr, Easley ME, Gruber F, et al; Salvage of a failed Keller resection arthroplasty. J Bone Joint Surg Am. 2004 Jun;86-A(6):1131-8. [abstract]

Acknowledgements