What is hallux limitus/rigidus? These terms are used to describe arthritis or degenerative joint disease as it specifically relates to the great toe joint. In hallux limitus/rigidus, there is typically damage to the cartilage within the great toe joint as well as bone spurs from repetitive jamming of the joint.
What causes hallux limitus/rigidus? Arthritis in the great toe joint can arise from a genetic predisposition or a foot type that places additional stress here while walking. Hallux limitus can also occur from a traumatic injury to the joint, such as stubbing the toe or a history of a fracture of the big toe.
What is the course of treatment? The treatment for hallux limitus/rigidus varies depending on the severity of damage and bone spurring present to the joint. Another factor is the amount of pain in the joint or the impact that this pain is having on your daily life.
- In early, mild cases: If hallux limitus is addressed prior to appreciable destruction of cartilage and spurring around the joint, treatment is geared toward preventing future breakdown and damage to the joint. This typically involves a custom orthotic insert that can redirect pressures in the foot while walking and decrease the stress at the great toe joint. If certain foot deformities cannot be accommodated well with a custom orthotic, sometimes a surgical procedure to correct deformity and restore normal function to the joint is necessary. Cortisone injections into the joint may be indicated in cases of flare-ups or topical anti-inflammatories can be used as an alternative. Physical therapy can also aid in mobilizing the soft tissue surrounding the joint to increase motion.
- In moderate-severe cases: If there is moderate joint space narrowing (indicating damage to the cartilage) and moderate bone spurring present, the conservative treatment protocol is very similar to that described for early/mild cases. Custom orthotics can still provide some relief of symptoms and slow the process of degeneration in the joint. In addition to custom orthotics, cortisone injections may be recommended to decrease the inflammation within the joint. There are a few surgical options available in cases where conservative treatment fails;
- Cheilectomy: This is a procedure in which bone spurs that cause jamming of the joint or painful prominences are cleaned up from around the joint. If there is significant damage to the cartilage within the joint, this may indicate a need for future procedures as described below.
- Joint resurfacing implant: This is an option for a select population of people that involves removing damaged cartilage and spurring from the joint and then replaces the surface of the joint with a titanium implant. As is a rule with all joint replacements, this procedure may be only effective in buying 5, 10 or 15 years of relief of pain while maintaining non-painful range of motion in the joint. All implantable devices in the body have a tendency to loosen and this may result in a need for future surgery either to remove the device and either replace it or fuse the joint.
- Joint fusion: Fusion of the joint eliminates painful motion by removing motion all together. Joint fusion is most indicated in end-stage arthritis of the joint. This procedure has the best possibility of being a “once and done” experience, but it can cause stress at adjacent joints years down the line.
- In severe cases: Severe cases of hallux rigidus indicate that the joint has had enough damage to the cartilage that it has begun to fuse on its own. When this happens, the position of the joint is assessed to determine if there is a need for surgical repositioning or if the joint can be left to fuse on its own. In cases where there is concern about one’s healing abilities, it may be recommended to remove the joint altogether. Orthotics are still a conservative treatment option, but the orthotic will be designed to limit motion rather than promote it (as with the mild/moderate cases).
Hallux limitus/rigidus is a complex condition to treat and every case is different. This handout serves as a basic guide to options for treatment. At PPFAC, we are always available to answer any questions or concerns that arise which are not addressed here.