Foot Bone or Joint Injury
Bunion Pain: Differential Diagnosis
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Anatomy of Hallux Rigidus
Hallux Rigidus is a condition that affects the big toe joint. It is often referred to as big toe arthritis as it results from a structural change to the metatarsophalangeal (MTP) joint. The bone before the big toe is referred to as the 1st Metatarsal, while the big toe is a Phalanx. In normal foot mechanics, the 1st Metatarsal should drop to allow the phalanx to slide up and over it for the big toe to extend. However, with Hallux rigidus, this is impossible due to osteophytes or arthritis, resulting in reduced joint space and a stiff big toe.
Symptoms of Hallux Rigidus
The symptoms of Hallux Rigidus include pain and stiffness when extending the big toe, primarily felt when walking, running or going up onto your tip toes. The joint can be visually red, hot and swollen. Like most degenerative arthritis conditions, patients find the symptoms exacerbated in colder weather.
As symptoms of Hallux Rigidus deteriorate, there may be a pain at rest, numbness and a complete inability to bend your big toe joint. Exercises such as lunges and running can be too painful while wearing tight-fitting shoes or high heels can be excruciating.
In cases where patients have hereditary Hallux Rigidus, they may not have any pain; it may be years before they notice the condition.
Causes of Hallux Rigidus
Patients can develop Hallux Rigidus insidiously time with speculation that it results from a subtle biomechanical overload over a long period. Those with jobs thing involve a lot of squatting or bending down can be more susceptible to developing Hallux Rigidus.
Structural abnormalities of the foot, such as having a flat foot, can overload the big toe joint leading to arthritic change within the MTP joint. In contrast, poorly fitted shoes or high heels can similarly affect the joint.
Direct impact or a fracture to the big toe joint can accelerate the rate of arthritic change within the joint. At the same time, other factors, such as rheumatoid arthritis or gout, can make you more susceptible to developing Hallux Rigidus.
Hallux Rigidus is more prominent in females and having a family history of Hallux Rigidus appears to increase your risk of developing the condition.
Diagnosis of Hallux Rigidus
A Physical Therapist is in an excellent position to clinically diagnose Hallux Rigidus as it is easily identifiable through a Physical Examination. If the clinician would like further information on the condition’s severity, they may refer you for imaging. An x-ray is the normal first port of call as it is cheap and can accurately identify any loss of joint space and osteophytes (bone spurs). A clinician may request an MRI for a more detailed image of the foot, including soft tissue structures and information on swelling that an x-ray does not.
Classifications of Hallux Rigidus
- Grade 0 – x-rays are regular with the stiffness of the big toe (40-60º dorsiflexion) but no pain
- Grade 1 – minimal or no dorsal osteophytes with minimal flattening of the metatarsal head. 30-40º of dorsiflexion with mild pain and stiffness
- Grade 2 – Global osteophytes with mild to moderate joint space narrowing. 10-30º dorsiflexion with moderate to severe pain and stiffness
- Grade 3 – Cystic formation with severe joint space narrowing. Less than 10º dorsiflexion with constant pain with no mid-range pain
- Grade 4 – as above but with mid-range pain
Hallux Rigidus Treatment
Home remedies are usual for the initial management of Hallux Rigidus, including regular icing and taking anti-inflammatories. Physical Therapy is an excellent approach to managing this condition and seeking a therapist who regularly sees foot conditions is essential. A physical examination should reveal imbalances in foot mechanics that can be addressed with strengthening and stretching exercises.
In some cases, custom insoles or orthotics may be recommended, with the purpose being to limit the range of motion in the big toe, usually with Morton’s extension, as this can provide pain relief. Discussing your clinician about footwear is essential as a shoe with a large toe box can provide pain relief, while a trainer with a rocker sole is also beneficial.
A brace, taping, massage and joint mobalisations are all effective short-term pain relief, but ultimately, footwear, orthotics and exercises are the best forms of treatment for Hallux Rigidus.
If a patient tries these methods but continues to struggle with pain levels, a corticosteroid injection may be provided as this provides steroidal anti-inflammatories directly into the joint, providing 6-12 weeks of pain relief to recommence Physical Therapy.
Hallux Rigidus Surgery
Unfortunately, for severe cases of Hallux Rigidus, surgery is the only viable option due to the considerable changes within the joint space. The most common surgeries for Hallux Rigidus are as follows:
Cheilectomy: A cheilectomy is an arthroscopic procedure where bone spurs are shaved off to provide pain relief and preserve the joint
Osteotomy: An Osteotomy involves shaving or cutting the bone to realign it
Arthrodesis: Arthrodesis is a fixation of the bones using plates, screws or wires to stop the joint from moving and is used primarily for severe cases.
Arthroplasty: An Arthroplasty is the artificial replacement of one or both ends of the joint with a plastic or metal replacement
Physiotherapy with James McCormack
This is not medical advice. We recommend a consultation with a medical professional such as James McCormack. He offers Online Physiotherapy Appointments for £45.
Related Article: How to prevent a Bunion