Big Toe Arthritis - Footcare Friday

Symptoms

Most patients feel pain in the big toe joint while active, especially when pushing off to walk. Often, there is swelling around the big toe joint or difficulty moving and bending the toe. A bump, like a bunion or bone spur, can develop on top of the big toe joint and be aggravated by rubbing against the inside of a shoe.

Causes

The cause of hallux rigidus is not known; however, there are several risks factors, including a long or elevated first foot bone or other differences in foot anatomy, prior injury to the big toe, and family history. These can lead to excessive wear of the joint, which in turn leads to arthritis.

Diagnosis

In many cases, the diagnosis of hallux rigidus can be made with a physical examination. Dr. Reichard will examine the MTP joint to see how much you are able to move and where the pain occurs. Dr. Reichard also will check your foot for evidence of bone spurs. X-rays may be taken to identify the extent of joint degeneration and to show the location and size of bone spurs. These X-rays are best done with you standing and putting weight on your foot. MRI and CT scans usually aren’t needed.

Treatments

Non-surgical Treatment

Non-surgical management is always the first option for treatment of hallux rigidus. A physician may suggest pain relievers and anti-inflammatory medicines and ice or heat packs to reduce pain.  Platelet rich plasma injections and similar injections into the joint are promising but vary in effectiveness.

Changes in footwear also may help. Avoiding thin-soled or higher-heeled shoes can minimize the pressure at the top of the joint. Shoes with a stiff sole, curved sole (rocker bottom), or both also may minimize joint pain. Shoe inserts as well as arch supports that limit motion at the MTP joint also can help.

Although these treatments may decrease the symptoms, they do not stop the condition from worsening.

Surgical Treatment 

If pain persists after the non-surgical treatments, surgical treatments will be considered. The type of surgery would be determined by the extent of arthritis and deformity of the toe. 

Bone Spur Removal (Cheilectomy)
For mild to moderate damage, removing some bone and the bone spur on top of the foot and big toe can be sufficient. This procedure is called a  cheilectomy. Removing the bone spur allows more room for the toe to bend up and relieves pain caused when pushing off the toe. This procedure also can be combined with other bone cuts that change the position of the big toe and further relieve pressure at the top of the joint. 

The advantages of this procedure are that it maintains stability and motion, and preserves the joint itself. Patients can participate in physically strenuous activity such as running without pain.

Joint Fusion (Arthrodesis)
Advanced stages of hallux rigidus with severe joint damage are often treated by "welding" the big toe joint. This procedure is called arthrodesis or joint fusion. In this procedure, the damaged cartilage is removed and the two bones are fixed together with screws and/or plates so they can grow together. 

The main advantage of this procedure is that it is a permanent correction to reduce pain. The major disadvantage is that it restricts movement of the big toe, although most patients can still be active.

Joint Resurfacing (Interpositional Arthroplasty)
For the patient with moderate to severe hallux rigidus who wants to avoid loss of motion, an interpositional arthroplasaty may be an option. This procedure removes some of the damaged bone (similar to a cheilectomy) and places a spacer between the two bones to minimize contact on either side of the joint.

Interpositional arthroplasty is primarily performed in two ways. In one technique, a piece of soft tissue is used as the spacer in an attempt to resurface the joint. This soft tissue can come from your foot, another part of your body, or even prepared cadaver tissue. The operation does preserve some motion but is not as predictable for pain relief and may not restore the normal mechanics of the joint.

Alternatively, another technique uses a synthetic cartilage implant plug made out of polyvinyl alcohol as the spacer. The advantages of this procedure are that it requires less bone to be removed and it is theoretically easier than a failed joint replacement to convert to fusion if it fails. In limited studies, it also has shown to be as effective as fusion in relieving pain, while preserving motion of the joint. This is a newer procedure and additional studies are needed to examine the results over time.

Joint Replacement (Arthroplasty)
Arthroplasty or replacing one or both sides of the joint with metal or plastic parts, is intriguing due to the success orthopaedic surgeons have demonstrated with these procedures in the knee, hip, ankle, and other joints. While there are studies that support this technique with particular implants, orthopaedic surgeons are cautious to recommend it at this time due to reports of higher complication rates, unpredictable short- and long-term results, as well as difficulty with salvage procedures should the joint replacement fail. Orthopaedic surgeons continue to study this technique as well as the types of implants available. Consult with Dr. Reichard for more information. 

Recovery

The length of recovery depends upon the type of surgery performed. For cheilectomy and interpositional arthroplasty, most surgeons recommend wearing a hard-soled sandal and allowing weightbearing as tolerated for about two weeks before a gradual return to normal footwear. For a fusion or procedure that cuts the bone, the foot may be in a cast or boot for 4-8 weeks, and limited weightbearing may be allowed for 2-3 months. You can expect some foot swelling, stiffness, and aching for several months after the procedure, depending on your level of activity.

After recovery, most patients are able to exercise, run, and wear most shoes comfortably. Running and jumping may be more difficult for patients undergoing fusion surgery and is not recommended after joint replacement. Patients may still find stiff-soled, rocker bottom shoes more comfortable for exercise.

Risks and Complications

Any surgery has risks, including scarring, infection, and failure to relieve symptoms. However, these risks are very infrequent with the above procedures unless there are other factors such as cigarette use or a poor immune system. Consult with Dr. Reichard for specifics in your situation.