The metatarsophalangeal (MTP) joint, commonly known as the joint at the center of the big toe, is the primary location of arthritis in the foot. This pivotal joint plays a critical role in walking, as it undergoes flexion during each step. However, when this joint becomes rigid, ambulation becomes notably challenging and painful. Analogous to other joints, the MTP joint consists of articulating bones enveloped by smooth cartilage. If there is deterioration or damage to the joint cartilage, resulting from wear and tear or other factors, the bony ends may rub against each other, causing discomfort. Additionally, there can be an overgrowth or prominence of bone at the apex, impeding the necessary flexion of the toe during walking. Consequently, this gives rise to a stiff and inflexible big toe, clinically referred to as hallux rigidus.
Hallux rigidus commonly manifests in adults ranging from 30 to 60 years of age. The exact causative factors behind its occurrence in certain individuals while sparing others remain elusive. The condition may arise from trauma to the toe or degenerative changes in the joint cartilage, or it may stem from anatomical variations in the foot that impose increased stress on the affected joint.
Symptoms and Signs:
- Pain in the metatarsophalangeal (MTP) joint, particularly during weight-bearing activities such as walking, characterized by pressing the toes.
- Swelling around the affected joint.
- Development of a protrusion resembling a bunion or callus at the dorsal aspect of the foot.
- Stiffness experienced when attempting to dorsiflex or plantarflex the hallux.
Diagnostic Approach:
If you encounter challenges in the range of motion during flexion and extension of the toe, or if walking induces pain that leads to an altered gait pattern favoring the lateral aspect of the foot, seeking medical attention is recommended. It is crucial not to delay intervention until a visible swelling manifests on the dorsal surface of the foot, indicating the presence of an osseous prominence, as this could impede treatment efficacy.
Upon examination, the healthcare provider will assess the foot, searching for indications of a bony spur or prominence. They will evaluate pain-free rotational movements of the toe. Radiographic imaging, including X-ray studies, will enable visualization of the dimensions and location of any osseous prominence, as well as the extent of degenerative changes within the joint space and cartilaginous structures.
Non-surgical (nonoperative) treatment options:
Non-surgical approaches for management include the use of analgesics and anti-inflammatory medications like ibuprofen, which can aid in reducing swelling and alleviating pain. Additionally, applying cold packs and engaging in contrast baths, involving alternating cold and hot water immersion, can help mitigate inflammation and provide temporary symptom relief. Nevertheless, it is important to note that these interventions alone may not be sufficient to impede the progression of the condition. Implementing footwear with a broader toe box can help diminish pressure on the toes, potentially necessitating the abandonment of high-heeled shoes. Moreover, healthcare professionals may recommend specially designed shoes featuring rocker or roller soles, as well as consider suggesting midsole support incorporating steel or metal components.
Contrast baths, a therapeutic modality involving alternating exposure to cold and hot water, serve to minimize inflammation. This technique requires two containers—one containing cold water within tolerable limits and the other filled with comfortably warm water. The procedure entails immersing the feet in the cold water for thirty seconds, then promptly transitioning to the warm water for an additional thirty seconds, and repeating this sequence for a duration of five minutes, concluding with cold water immersion. Contrast baths can be performed more than three times per day. However, caution must be exercised to avoid excessive temperature extremes during immersion, particularly when the feet may exhibit reduced sensitivity to thermal stimuli.
Surgical Options:
- Chevron Osteotomy:
This surgical intervention is typically recommended for individuals with mild to moderate damage. The procedure involves the excision of the bony spur that has fused with the toe bone, thereby allowing for improved flexibility in toe movement. An incision is made on the dorsal aspect of the foot. Postoperatively, swelling may persist in the toe and operative site for several months. Following the procedure, a rigid-soled postoperative sandal should be worn, typically starting around two weeks after surgery. However, the duration of postoperative sandal use may vary among patients.
- Arthrodesis:
In cases of severe cartilage degeneration, arthrodesis, or joint fusion, is often recommended. This surgical approach entails the removal of damaged cartilage tissue and the stabilization of the joint in a fixed position using screws, pins, or plates. Over time, the adjacent bones gradually fuse together. It is important to note that arthrodesis results in the loss of toe flexibility. Nonetheless, it is considered the most reliable method for alleviating pain in cases of significant degeneration.
- Arthroplasty:
For elderly patients who experience functional limitations due to the condition, joint replacement surgery, known as arthroplasty, may be a suitable option. This procedure involves the removal of the affected joint surface and the insertion of an artificial joint. Arthroplasty can effectively reduce pain and preserve joint mobility in the affected area.
