Hallux Rigidus – Osteoarthritis of the Metatarsophalangeal Joint of the Big Toe: Causes, Symptoms, and Treatment of Degenerative Changes

Hallux rigidus is a degenerative joint disease (osteoarthritis) of the metatarsophalangeal joint of the big toe. It is also commonly referred to as a stiff toe.

The condition affects the area between the first metatarsal bone and the proximal phalanx of the big toe. As hallux rigidus progresses, it causes pain on the one hand. On the other hand, it also leads to restricted movement, making it difficult or impossible to roll the big toe forward.

The reason for this is the continuous loss of cartilage mass in this joint, which is typical of osteoarthritis. In the late stages, the bone surfaces rub against each other because the articular cartilage is severely damaged or completely absent. As the condition progresses, bony spurs (osteophytes) may form, further restricting mobility.

In many cases, the exact cause of hallux rigidus is not entirely clear. However, there are factors that can contribute to this condition. For example, excessive or improper stress on the joint may play a role, as may wearing the wrong footwear—such as high heels—for extended periods. Competitive athletes, for instance, are at greater risk because their joints are generally subjected to higher levels of stress. 

Factors such as minor, possibly undiagnosed injuries can also lead to hallux rigidus. Hereditary factors must also be included in the list of possible causes.

Hallux rigidus often develops as a result of a misalignment of the big toe, which increases pressure on the joint. For example, if you roll your ankle inward while running, you place improper stress on your knee, foot, and big toe. This misalignment of the ankle joint is called overpronation.

A metabolic disorder such as gout is also a possible cause. These conditions often trigger secondary osteoarthritis, which can also affect the big toe joint.

Another cause: excessive compressive pressure on the metatarsophalangeal joint of the big toe.

Hallux rigidus causes pain in the big toe joint © © staras | AdobeStock

There are several symptoms that indicate hallux rigidus. Typical symptoms include severe pain when rolling the foot forward and an increasing restriction of movement. The limited mobility makes walking increasingly painful. Due to the stiffness of the joint, the toe can no longer roll forward as it normally would. Patients tend to protect the metatarsophalangeal joint of the big toe and, as a compensatory mechanism, roll the foot over the lateral side, which promotes improper weight-bearing and further pain.

Inflammatory reactions may also occur. These manifest as

• swelling,
• redness,
• heat, and
• further pain and functional limitations.

In addition, over time,

• a feeling of tightness in the shoe on the affected foot, as well as
• a certain sensitivity to weather changes—especially in cold temperatures—

.

A clinical examination by the treating physician, usually an orthopedic surgeon, can provide clarity in most cases. An X-ray provides important information about changes in the joint. For this purpose, X-rays are taken while the foot is bearing weight to show the actual load-bearing situation. Limited mobility and so-called bone spurs (exostoses) are signs of hallux rigidus.

The following symptoms in the area of the metatarsophalangeal joint of the big toe indicate hallux rigidus:

• Pain
• Inflammatory reactions
• Limited range of motion
• A feeling of tightness in shoes
• Sensitivity to weather changes
• Inability of the toe to roll forward

In the treatment of hallux rigidus, a distinction is generally made between conservative and surgical therapy. The type of treatment depends on

• the stage of the disease,
• the patient’s level of discomfort, and
• the patient’s activity level.

Conservative Measures

In the early stages, special orthotics or hallux rigidus shoes can provide relief. The insoles are usually made with a stiff sole. This transfers the rolling motion from the big toe to the sole. The result: less movement in the toe joint and thus less pain. Early symptoms can often be effectively alleviated through physical therapy measures such as manual therapy and special foot exercises.

A bunion pad also restricts mobility in the toe joint, thereby providing pain relief. Athletes suffering from hallux rigidus can benefit from a different technique: The sole area under the toe is milled down and lined with a soft material. This also prevents the toe from being pressed too far toward the top of the foot during the rolling motion, which would lead to severe pain.

Other conservative treatment methods include, among other things, the administration of anti-inflammatory medications or cartilage-regenerating supplements.

Orthopedic shoe inserts can already help with hallux rigidus © glashaut | AdobeStock

Surgical Treatment

Foot surgery may be considered if

• the condition is too far advanced or
• conservative treatment methods are not sufficiently effective.

Various surgical techniques are available for this purpose.

In standard surgical treatment, the metatarsophalangeal joint of the big toe is completely fused (arthrodesis). During this hallux rigidus surgery, the damaged cartilage is removed and the two joint surfaces are firmly screwed together.

Joint-preserving procedures include cheilectomy, in which bony spurs are removed to improve mobility. This joint-preserving surgery is often performed in the early stages.

Despite patients’ initial reluctance to undergo fusion, most patients are very satisfied with the results. Not only does the pain largely disappear, but the ability to engage in sports activities can also be restored. The rolling motion of the toe is primarily ensured by the toe’s distal joint.

Cartilage reconstruction is another procedure. In this procedure, damaged cartilage is restored using grafts from other parts of the body. Alternatively, a membrane can be implanted to stimulate cartilage growth. As with the knee joint, these methods have not yet been conclusively researched scientifically, and success is not guaranteed.

Another surgical option for hallux rigidus is joint replacement. However, this method should only be used when all other joint-preserving methods have failed.

A disadvantage of joint-preserving therapies is that they do not eliminate the underlying cause of hallux rigidus. As a result, the condition can continue to progress. Some specialists also offer a procedure to shorten the metatarsal bone, which widens and decompresses the joint space. Surgery is recommended when the joint space has narrowed and mobility is severely restricted.

Postoperative Care

After hallux rigidus surgery, the primary focus is initially on pain relief. In addition to lymphatic drainage, physical therapy measures support the healing process. 

Except in cases of joint fusion, mobilization should begin as soon as possible. Patients who have undergone joint-preserving surgery can begin mobilization earlier. Depending on the severity of symptoms, therapy may extend over a period ranging from a few weeks to several months. After joint fusion, the foot is immobilized for 6–12 weeks, depending on the postoperative healing process.

It is not always possible to prevent this condition, as its causes are varied.

If misalignments are present, they should be treated with orthotics or special footwear. Insoles help protect the metatarsophalangeal joint of the big toe and prevent improper weight-bearing. Deformities may not only lead to hallux rigidus but also to problems in other joints, such as the ankle or knee joints.

1. What exactly is hallux rigidus?
The term “hallux rigidus” refers to osteoarthritis of the metatarsophalangeal joint of the big toe—that is, progressive wear and tear of the joint cartilage in the big toe. Those affected experience pain when rolling the foot forward, limited range of motion, and often increasing joint stiffness.

2. What treatment options are available?
Treatment for hallux rigidus depends on the stage of the condition. In the early stages, orthotics, physical therapy exercises, or anti-inflammatory medications can help. In advanced cases, surgical options such as cheilectomy or fusion of the metatarsophalangeal joint may be considered.

3. Is surgery always necessary?
Not always. Surgery is usually performed only when conservative measures no longer provide relief. The goal is to reduce pain and stabilize the joint surfaces. After the procedure, many patients are able to walk again with almost no pain.

4. How can hallux rigidus be prevented?
It is crucial to protect the metatarsophalangeal joint of the big toe. We recommend wearing flat, comfortable shoes, avoiding the prolonged use of high heels, and using custom-fitted orthotics. Early treatment of misalignments also helps prevent bone spurs.