What to Know About Hallux Rigidus (Stiff Big Toe)

Hallux rigidus is a type of arthritis affecting the big toe's metatarsophalangeal (MTP) joint where the big toe meets the foot. It is one of the most common arthritic conditions affecting people ages 30 to 60. Hallux rigidus causes stiffness in the big toe. It can be painful and affect standing and walking. 

The MTP joint experiences stress from bearing weight when standing or walking. That wear and tear can lead to cartilage damage and hallux rigidus. Cartilage is a connective tissue that acts as a protective cushion and shock absorber for the joints and bones. Other inflammatory disorders can also lead to arthritis in the toes, especially the big toe.

Hallux rigidus can be managed with nonsurgical measures, including anti-inflammatory pain relievers and wearing comfortable shoes. Surgery might be considered for people who experience severe pain that affects their mobility and ability to participate in daily activities.

This article will explain hallux rigidus, its causes and symptoms, treatment, and more. 

What Is Hallux Rigidus Exactly?

Your big toe has two joints, and the MTP joint is the bigger of the two. The function of the MTP joint is to bend and grip the floor to offer foot flexibility with walking.

Hallux rigidus is sometimes considered a type of osteoarthritis (wear-and-tear arthritis). Research shows up to 10% of adults have symptomatic hallux rigidus. However, evidence of it can be seen on imaging in 20% to 48% of adults over age 40. When there are symptoms, the condition can be quite painful and affect overall health and well-being.

This condition causes pain and stiffness of the MTP joint. Over time, it gets harder to bend the toe. It is a progressive condition in which the big toe's motion will decrease over time. As hallux rigidus advances, the big toe will become completely stiff, and movement will be impossible.

Hallux limitus is sometimes confused with hallux rigidus. Both conditions affect the big toe, cause stiffness and swelling, and make walking uncomfortable. Hallux limitus can advance into hallux rigidus, when the joint cannot move at all, and walking is painful or near impossible due to pain and the inability to bear weight on the joint.

Stiff Big Toe Stages

Hallux rigidus is sometimes classified in stages from 0 to 4. Each grade is based on how much the condition affects your ability to move the big toe.

Hallux rigidus stages are:

• Stage 0: In this early stage, there might be up to 20% loss of normal movement but no radiologic findings (evidence seen in an X-ray). There might be some stiffness, but no pain.
• Stage 1: In stage 1, there could be a 20% to 60% loss of normal movement. Bone spurs (bony growths at the ends of bones) are present. Some joint space narrowing and narrowing of the area surrounding a joint may occur, along with flattening of the nearby metatarsal bone. You might experience mild pain and stiffness with movement. 
• Stage 2: In this stage, there is a 50% to 75% loss of normal motion, further bone spurs, and joint space narrowing. Imaging often shows joint space narrowing and narrowing of the areas surrounding joints. You might experience moderate to severe pain and stiffness. 
• Stage 3: At stage 3, there is a 75% to 100% loss of normal motion. There is more joint space narrowing, cystic changes (fluid-filled areas in the bone), significant narrowing visible on imaging, and sesamoiditis (inflammation of the sesamoid bones—the tiny bones embedded in tendons near joints). Pain becomes constant, and there's considerable stiffness. Loss of motion is extreme in this stage but not completely gone.
• Stage 4: In this most advanced stage, loss of movement is up to 100%. Joint space narrowing, cystic changes, and sesamoiditis are all common. Pain and stiffness are constant and severe, and there is significant resistance to movement of the toe.

What Are the Symptoms of Hallux Rigidus?

Symptoms of hallux rigidus can vary from person to person and will worsen over time.

Symptoms might include:

• Pain in the big toe: Pain will increase with walking and activity. In the early stages of hallux rigidus, pain occurs at the top of the foot but will be felt deep inside the joint over time.
• Swelling around the joint: Swelling will affect your gait (how you walk) and the type of footwear you choose.
• Stiffness of the big toe: Stiffness will affect the joint's ability to move.
• Loss of range of motion: Over time, the range of motion of the big toe (how far you can bend the toe) will decrease. Without treatment, or in severe cases, the range of motion could be lost entirely.
  

Because hallux rigidus is a progressive condition (one that worsens over time), you may experience additional symptoms due to cystic bone changes and joint damage.

Symptoms of cystic bone changes and bone or joint damage related to hallux rigidus include:

• Constant, persistent pain that is felt even during rest
• An inability to move the big toe
• A hard bump at the top of the foot 
• Limping due to pain and changing the way you walk to reduce pain
• Pain in the knees, hips, or low back from limping and changes in gait
  

What Causes Hallux Rigidus?

What causes hallux rigidus is not well understood. Researchers believe trauma is the leading cause of hallux rigidus affecting only one toe. Bilateral involvement (affecting both big toes) might be linked to family history and female sex.

Degenerative changes over time or repetitive stress might also cause someone to develop hallux rigidus. Toe and foot structure and certain medical conditions are also believed to be linked to the condition, including:

• Injury: Any big toe injury like a sprain or simply stubbing the toe could cause hallux rigidus to develop over time. 
• Sex: Hallux rigidus is more common in people assigned female at birth. This group is twice as likely to develop the condition as people assigned male at birth, although the reasoning as to why isn't well explained in the literature. It is suspected that this might be related to footwear choices, foot structure, and higher incidences of stress on the foot joints from body mechanics and joint wear and tear.
• Family history: Having a family member with hallux rigidus means you have a higher risk for the condition. This might be because you have the same foot structure or gait.
• Degenerative changes: The term "degenerative changes" refers to the loss or breakdown of body areas (usually the joints) due to aging, wear and tear, injury, and disease. These changes are commonly seen on X-rays and often point to osteoarthritis but don't always cause pain or other symptoms. Hallux rigidus can occur because of wear and tear degenerative changes in the foot as people age.
• Overuse: Repetitive stress on the forefoot and big toe from stooping and squatting can cause overuse of the MTP joint in the big toe. This might be the case for people participating in sports or working in certain jobs. 
• Foot structure: Variations in the metatarsal bones could increase your risk for hallux rigidus and other forefoot problems.
• Certain medical conditions: Rheumatoid arthritis, gout, post-traumatic arthritis, and other types of inflammatory arthritis have been linked to hallux rigidus.
  

How Is Hallux Rigidus Diagnosed?

If you have problems bending your toe or walking because you are experiencing big toe pain, it is crucial to see a healthcare provider as soon as possible.

Hallux rigidus is easier to treat in its early stages. If you wait until you see a bony bump at the top of the toe, bone spurs will have already formed, and treatment may need to be more aggressive.

The first step in diagnosing hallux rigidus is the physical exam. A healthcare provider will examine your foot to look for bone spurs. They will also move your toe around to determine what movements cause pain and how deep that pain is. This can help determine the severity and the best treatment for your hallux rigidus. 

Your healthcare provider may also request X-rays of your foot and toe. X-rays can help identify bone spurs, the severity of arthritis, joint space narrowing, and cartilage loss.

Your healthcare provider might refer you to a podiatrist for further treatment. A podiatrist is a doctor who specializes in diagnosing and treating foot conditions. Seeing a podiatrist can allow for better assessment and treatment of foot problems like hallux rigidus.

Can Hallux Rigidus Be Treated at Home?

The treatment your healthcare provider recommends for hallux rigidus will depend on the cause and severity of the symptoms. While there is no one best treatment for hallux rigidus, a combination of therapies can help manage pain and other symptoms. 

A healthcare provider might recommend one or more of the following treatments to manage symptoms and keep the condition from worsening.

Footwear Changes

Wearing shoes with plenty of room for your toes can reduce pressure on the MTP joint. You will want to avoid high heels and consider shoes with stiff soles.

Additional footwear options for managing hallux rigidus symptoms are inserts and orthotics. Inserts are available in most stores and provide arch support or extra cushioning. They are placed in the shoes to make shoes more comfortable, but they cannot correct hallux rigidus and other foot problems.

Orthotics are prescription medical devices placed inside your shoes to correct foot problems, including those that affect walking and standing. 

Limiting Toe Movement and High Impact Activity

You will want to avoid activities that stress your big toe joint. This might include playing sports or repetitive on-the-job tasks. Your healthcare provider can also recommend gel pad toe supports like those used for bunion care, as well as splints to support the big toe and limit movement.

OTC Pain Relievers

Your healthcare provider might suggest over-the-counter (OTC) pain relievers to manage symptoms of hallux rigidus. Your options include various oral and topical non-steroidal anti-inflammatory drugs (NSAIDs) such as Advil (ibuprofen) or Aleve (naproxen) to ease pain and reduce swelling.

Cold Therapy 

Applying ice or a cold pack to the affected big toe can relieve pain and reduce swelling. Wrap the ice or cold pack in a thin towel to avoid placing the ice directly on your skin.

Foot Soaks

A contrast bath (foot soak) might help to reduce inflammation in your big toe. It alternates hot and cold, which means you will need two buckets of water—one warm to comfortably hot and the other cold.

The American Academy of Orthopaedic Surgeons recommends you soak in cold water for 30 seconds, then switch to warm water for 30 seconds. Continue to switch for at least five minutes, ending at the cold one. You can do this foot soak up to three times a day.

You will want to avoid extreme hot and cold temperatures, especially if your feet are sensitive to one temperature or both.

Prescription Injections

Injections in the MTP joint of the toe can temporarily relieve pain and swelling. Both corticosteroid and hyaluronic acid injections might offer relief.

However, the Food and Drug Administration (FDA) has not approved hyaluronic acid injections for injection in the first MTP joint. Such use is considered off-label (unapproved use of an approved drug). This use has typically been confirmed with rigorous clinical study, but there is no FDA approval. Approval might be pending or upcoming at a later time, and the FDA is aware of its benefits and risks.

Corticosteroid injections have been found to help people with mild arthritis, but their effectiveness for severe arthritis is limited. Some research on hyaluronic acid injections shows them as being far superior to steroid injections in managing arthritis symptoms, reducing pain, and improving function. 

Physical Therapy 

Physical therapy might help manage hallux rigidus. It can help reduce pain, improve the toe joint's motion, and strengthen the muscles in the foot.

A physical therapist can recommend interventions to help you manage hallux rigidus. 

Therapies might include:

• Mobility exercises, including stretching and strengthening exercises for the foot
• Education on joint mobilization techniques 
• Gait training to reduce the need for an assistive device like a cane to help normalize the way you walk
• Joint manipulation (manual therapy)
• Ultrasound therapy for pain management 
  

Surgeries for Hallux Rigidus

If nonsurgical treatments cannot manage symptoms and pain or if you lose function in the MTP joint, your healthcare provider might recommend surgery. They will share your options with you and help you decide based on how severe the hallux rigidus is. Surgery is the only way to get rid of hallux rigidus. 

Cheilectomy

Cheilectomy surgery can treat mild to moderate damage. A cheilectomy is sometimes done in combination with an osteotomy. The cheilectomy is done to shave bone spurs, while the osteotomy cuts bone to change the big toe's position and relieve pressure off the top of the joint. 

Studies on cheilectomy show it results in good outcomes, especially in the condition's early stages of hallux rigidus. Cheilectomy might be less successful in later stages.

Interposition Arthroplasty

Interposition arthroplasty can treat moderate to severe hallux rigidus. It can eliminate the need for a joint replacement or fusion surgery. Interposition arthroplasty involves removing damaged bone and putting a spacer between the bones to reduce bone contact.

This surgical option has been found effective for moderate to severe hallux rigidus. It can be helpful for people who want to maintain their range of motion of the big toe. 

Arthrodesis 

Arthrodesis surgery is recommended if damage to the big toe is severe. It involves removing damaged cartilage and using pins and screws to place the joint into a permanent position.

The fused bone will grow together slowly, eliminating the toe joint, which means you cannot bend the toe. Even so, it is the most helpful way to reduce pain in severe hallux rigidus for some people. 

Arthrodesis is considered in cases in which a cheilectomy has failed. Overall satisfaction will arthrodesis is more than 90%.

Arthroplasty

Arthroplasty is joint replacement surgery. It involves replacing damaged joint parts with artificial parts made of plastic or metal. This surgery might help relieve hallux rigidus symptoms while maintaining your range of motion. Arthroplasty is not often used to manage hallux rigidus because implant failure is high.

What's the Outlook for Stiff Big Toe?

Hallux rigidus is a progressive condition that will get worse over time. Nonsurgical treatments can manage symptoms, reduce pain, and slow down progression. 

Surgery may be needed if nonsurgical therapies no longer offer relief. Some surgical procedures might minimize the ability to bend the toe, but they help you to walk and be active without pain and discomfort.

For example, cheilectomy has a high success rates for people in the early stages of hallux rigidus, and arthrodesis is considered the gold standard surgical procedure for end-stage hallux rigidus.

Summary 

Hallux rigidus is a type of arthritis affecting the MTP joint at the base of the big toe. It causes pain and stiffness. Because it is a progressive condition, it will eventually affect the ability to bend the big toe. The condition is sometimes measured in stages based on the symptoms and effects on the joint, including the growth of bone spurs and joint space narrowing.

Causes of hallux rigidus include trauma and osteoarthritis. If hallux rigidus runs in your family or you have a structural problem in your foot, you are more likely to develop the condition. People in certain occupations requiring repetitive movements of the MTP joints are also at a higher risk. 

The symptoms of hallux rigidus can be managed with nonsurgical treatments. Some of these therapies might slow down progression. Ways to manage hallux rigidus nonsurgically include physical therapy, injections, OTC pain relievers, wearing appropriate footwear, and avoiding activities that can worsen the condition. 

If hallux rigidus worsens and you experience damage to the MTP joint, your healthcare provider might recommend surgery to fix the damaged bone. The type of surgery recommended is dependent on the severity of the condition. Surgery might also help you become active again, although you may lose the ability to bend the toe in some cases.