Big Toe Got You Down? It May Be Hallux Rigidus.

Big toe got you down? It may be hallux rigidus. A stiff and painful big toe can knock you off your feet. Here's what you can do about it.

The big toe may be small, but its role in our lives is enormous. Just imagine how hard it would be to walk, run, squat, bend over, rise up on the balls of the feet, or simply keep your balance without the aid of your big toes.

A crucial element of big-toe function is the metatarsophalangeal (MTP) joint, which joins the first long bone (metatarsal) in the forefoot to the first bone of the big toe (phalanx). Every time you take a step, the MTP joint bends, allowing the foot to roll forward and push off. During this phase of the walking cycle, the joint supports 50% of the body's weight. If the joint doesn't function properly, not only walking, but also exercising and many other activities of daily life can be difficult, sometimes impossible. One of the most common ailments of the big toe joint is hallux rigidus - literally, "stiff big toe."

Anatomy of Hallux Rigidus

In hallux rigidus, osteoarthritis breaks down the cartilage covering the ends of the bones that make up the big toe joint. Joint space narrows and bone spurs (osteophytes) may form.

Hallux rigidus is the loss of flexibility in the big toe due to arthritis in the MTP joint. In an earlier stage of the condition, called hallux limitus, movement is only somewhat affected and conservative measures can often relieve pain and improve function. If pain and stiffness worsen, surgery is an option.

How Does Hallux Rigidus develop?

In the MTP joint, like other joints in the body, the ends of the bones are covered with articular cartilage, a slick substance that aids in smooth joint movement. Gradual wear and tear or acute injury can cause articular cartilage to break down - a process known as osteoarthritis or degenerative arthritis. The resulting bone-on-bone contact produces pain and inflammation. As part of the degenerative process, bone spurs (osteophytes) may develop on top of the bones, and the joint space may narrow, reducing the joint's upward bending motion. This can impinge on the way you walk and contribute to pain in the ball of the foot and even the back.

It's not entirely clear why hallux rigidus develops in some people and not in others. Hereditary or congenital defects in the foot or faulty foot mechanics can place chronic stress on the big toe joint, triggering arthritis. Certain athletic injuries have also been implicated. For example, turf toe, so-named because it often happens to people who play games on artificial surfaces, is an injury to the MTP joint caused by the sudden bending back of the big toe. When turf toe is not treated properly over time it can advance into hallux rigidus. A toe stub or break can also contribute to degeneration of the joint, as can an inflammatory condition such as rheumatoid arthritis and the metabolic disorder, gout. Toe injuries that can progress into hallux rigidus can also occur in certain dance disciplines (notably ballet) that require repetitive use of positions such as demi-pointe, which forces the MTP joint to flex at a 90 degree angle. Some research suggests that women are more likely to develop hallux rigidus, but studies are inconsistent.

What To Do?

Early signs of hallux rigidus include pain and stiffness in the big toe joint during use, such as walking or exercising, especially as the foot rolls forward to push off. The joint may also become swollen and red. It's important to see a clinician in the disorder's early stages. If you wait until bone spurs develop or the toe is completely stiff or hurts all the time, restoring function can be more difficult. Also, you can develop other foot and joint problems if you start walking on the outer edge of the foot to avoid putting pressure on the toe.

Your clinician will examine the toe and may order x-rays to check for bone spurs, cartilage degeneration, loss of space between the bones of the joint, and other possible toe problems. Treatment usually starts with conservative measures aimed at the following goals:

Symptom Relief
  • Rest, ice, and anti-inflammatory medications such as ibuprofen can help relieve pain and swelling.
  • For severe pain, your podiatrist may recommend treating the joint with a corticosteroid injection, sometimes in combination with an anesthetic.
  • To reduce inflammation, the American Academy of Orthopaedic Surgeons suggests a contrast bath three times a day: Immerse the affected foot in water as cold as you can stand for 30 seconds, then in water as warm as you can stand for the same amount of time, alternating cold and warm baths for a total of five minutes (ending with cold water).
Improved Foot Mechanics
  • For longer-lasting relief, it's important to correct some of the things that may be aggravating the big toe.
  • High heels are out, and shoes with a spacious toe box are in. Your clinician may recommend a thick-soled shoe or one with a rocker bottom (like an orthopedic clog), which allows the foot to roll forward as you walk, so that your big toe doesn't bend sharply.
  • Shoe orthotics may help correct abnormalities of the foot or problems with the way you walk that could be contributing to the problem.
  • A shoe stretcher can be used to loosen the toe box and other areas of the shoe that come in contact with the big toe or big toe joint.
Injury Prevention
  • Try to avoid physical activity that places high-impact stress on the foot, such as running, jumping, and sports that involve bursts of activity and quick stops, like tennis. Swimming and bicycling are good alternatives.
  • If the big toe isn't completely stiff, you may be able to improve its upward flexibility with some simple range-of-motion exercises. For example, grasp your big toe and gently pull it back until the point of resistance. Hold the position for 20 seconds. Repeat several times a day.
  • A regular schedule of walking can also help. You may want to consult a physical therapist for additional suggestions.
/ Harvard Women's Health Watch / 2006 / November, 2006