Limited motion of the big toe joint (1st metatarsal-phalangeal joint), also known as hallux limitus, is a progressive
disorder that starts with flattening of the 1st metatarsal head, minimal cartilage damage, and small bone spurring and
ends with a stiff, painful joint (aka hallux rigidus).
CAUSES OF BIG TOE JOINT ARTHRITIS
Arthritis of the big toe is most often associated with advanced age because the more we walk and the more mileage we
put on our feet, the more wear and tear there is on the joints. Arthritis of the big toe joint can result from several other
factors, as well, though, including foot structure (e.g. long or elevated 1stmetatarsal bone), acute or blunt trauma to the
joint, athletic injuries, and gout.
Pain occurs around the big toe joint and is most often present when the toe is bent upwards. Therefore, pain is usually worse with extended ambulation or running, while squatting, and when wearing high-heeled shoes.
Swelling and redness may also occur around the big toe joint, as well as a dorsal bony prominence (or bump), which is the bone spur that often develops with arthritis.
Because hallux limitus can exhibit redness, swelling, and pain, it is important to rule out other potential causes of those symptoms, especially infectious ones. Take a look at the list below of different things that can potentially cause a similar presentation to hallux limitus.
A bunion develops when the first metatarsal bone moves away from the smaller metatarsal bones and the big toe
moves towards the second toe, thus creating a bump around the big toe joint. Unlike hallux limitus, where the bony
bump is along the top of the big toe joint, with a bunion, the bony bump is along the inside of the foot. Therefore, in
tighter shoes the bunion can become irritated, causing pain and redness.
Although a bunion and hallux limitus differ, in advanced stages of a bunion deformity, one may can develop arthritis in
the big toe joint because of the asymmetry of the joint. Therefore, you could have both a bunion and hallux limitus of
the big toe joint.
To learn more about bunions, click here.
Gout is a specific type of arthritis that is the result of uric acid build-up in joints with the big toe joint being the most
commonly affected one. Acute gouty attacks can cause increased redness, swelling, and severe pain in the joint. The
pain can be so bad that even a sheet touching the area can cause discomfort.
If gout is suspected, further workup is done by a healthcare professional, including lab tests and crystal analysis of a
joint aspiration. Treatment for gout may include a low purine diet and specific medications for treating, and preventing,
acute gouty attacks.
Infection of the joint is rare, but can occur, especially if there is an open wound or sore around the area.
Like the other differential diagnoses of a painful big toe joint, the area may be red, warm, swollen, and painful; however, in the presence of an infection, there may also be abnormal drainage (e.g. yellow) if an open wound exists. If the infection gets into your bloodstream, it can also make you feel ill (i.e. nauseated, vomiting, fevers, chills). Therefore, it is crucial to seek help immediately if you feel you may have a joint infection.
Check out my blog “Such a Pain in the Big Toe” to learn more about the different pain syndromes that occur around the big toe joint.
Rest/Modification of Activities
During acute exacerbations of pain, you should avoid higher impact activities (e.g. walking, running, jumping) and switch to lower impact activities (e.g. swimming, biking) until symptoms improve.
Trying to predict how long to rest is difficult and depends on several variables, including the severity of the arthritis, how long you have been having symptoms and/or how much inflammation is around the joint, and what your daily activities are. It usually requires weeks of rest, or modification of activities, though, not just a couple days.
Heat & Cold Therapies
Choosing whether to use heat or ice for your arthritic symptoms is dependent on the goal you
are trying to achieve. For joint stiffness, heat therapy (e.g. heating pad, warm water soaks) will be
more helpful because it will cause vasodilation (which increases blood flow to the area),
relaxation and improved flexibility of the surrounding soft tissue structures and improve joint
motion. After exercising, cold therapy (e.g. ice pack, ice bath), may be more beneficial to cool
down the area and decrease any swelling that may have occurred.
Heat & cold treatments should be avoided if you have neuropathy (loss of sensation) or poor
circulation, unless otherwise directed by your physician.
Anti-inflammatory medications can also help with inflammation and swelling, which, in turn, help with pain; however, pain medications should not be used long-term.
Steroid– Steroid injections can help decrease inflammation and pain around the big toe joint.
The pain relief is usually only temporary (lasting weeks to months), and the use of steroids do
have their potential side effects, so the injections should only be performed 3-4 times per year.
Prolotherapy– Prolotherapy (aka proliferation therapy) is a nonsurgical, serial injection of a
dextrose solution that is injected into the affected area to stimulate an acute low-grade
traumatic process, allowing the body to use its own inflammatory markers to aid in the body’s
healing process naturally, thus regenerating and repairing damaged tissues, restoring joint
stability, and improving pain.
It is important to wear good, supportive shoe gear with a roomy toe box for both at-home and outdoors. Stiff-soled shoes and rocker-bottom shoes often work best for hallux limitus/rigidus. The aim with many shoe gear choices is to find something that restricts movement of the big toe. If the shoe doesn't bend, the toe doesn't bend inside of it.
Avoid barefoot walking, flip-flops, and shoes with a significant heel. In flop-flops, your toes have to curl and work harder to keep the sandal on, and high heels put the big toe in an extended and stressed position.
These are devices that go into your shoes to help cushion, support, and control abnormal motions of
your feet. They can also help with the alignment of the lower extremity more proximally, including your
knees, hips, and back.
Oftentimes, a custom orthotic is better for hallux limitus/rigidus because specific modifications can
be made to a custom orthotic to either help increase the range of motion at the joint or prevent motion
at the joint, depending on the severity or stage of the arthritis.
For earlier stages of hallux limitus, a Reverse Morton’s Extension can be incorporated into an orthotic, which allows for more motion at the 1st metatarsal-phalangeal joint. For advanced stages of hallux limitus, including rigidus, when the joint is stiff, a Morton’s Extension is incorporated. A Morton’s extension involves adding a rigid piece of material under the 1st metatarsal-phalangeal joint, extending underneath the hallux. The purpose is to restrict any sort of movement at the big toe joint.
A physical therapist may provide additional adjunctive services such as modalities or stretching and strengthening exercises.
If conservative care does not help with your symptoms and the pain is affecting your daily activities, surgical treatment options can be considered. The surgical options for the big toe can be divided into two main categories: joint-sparing and joint-destroying. Joint-sparing procedures are less invasive and keep the joint intact, while the joint-destructive procedures alter the joint in some way.
All of the procedures can be performed as out-patient, meaning that you can go home the same day, and most can be performed without general anesthesia. Instead, MAC with the use of local anesthetic is used, which is safer and allows for a quicker recovery after surgery. The best choice of anesthesia for you will be determined by the surgeon and anesthesiologist.
The cheilectomy procedure involves removing the bone spurs around the joint, which allow for more motion. The procedure is usually done for earlier stages of arthritis when there is not too much damage within the joint.
After surgery, usually just a postoperative shoe is needed until the sutures are taken out (10-14 days). Then, you can return to regular shoes and increase your activity level as you are able.
If the 1stmetatarsal is significantly longer than the 2ndmetatarsal, or it is elevated, the 1stmetatarsal bone can be cut and then shifted to shorten the bone and/or improve the big toe joint alignment.
Recovery from osteotomy procedures is usually longer because the cut in the bone needs to heal; therefore, a walking boot or cast is worn, and protection is needed for about 6 weeks. Return to higher impact activities is about 3 months from the time of surgery.
Like the 1st metatarsal, cuts within the proximal phalanx (toe bone) can also be made to help improve range of motion of the big toe joint. After surgery, the foot is protected in a post-op shoe for about 4-6 weeks.
The Keller arthroplasty procedure involves resection and decompression of the joint to allow for more motion at the big toe joint. It can be combined with tendon transfers, interposition allografts, and other procedures to help stabilize the joint after surgery. Because the procedure destroys the joint, it is saved for more advanced stages of arthritis.
Depending on all the procedures performed, the protected device used after surgery and the recovery period can significantly vary.
There are several different implants available on the market that help resurface either the head of the 1stmetatarsal and/or the base of the proximal phalanx. The goal with an implant is to restoration motion at the 1stmetatarsal-phalangeal joint and for the device to be durable and long-lasting. Some potential problems with implants include loosening and movement, wear, bony overgrowth, and rejection of the implant.
You can usually walk in a postop shoe or walking boot immediately after surgery. Length of protection depends on the implant used, where it is placed, and surgeon’s personal protocol. Starting early range-of-motion exercises is important, though, to prevent stiffness.
As with other joint-destroying procedures, fusion of the big toe joint is saved for severe arthritic cases. Oftentimes, people get nervous about fusing the joint, but it is a predictable procedure that eliminates the arthritis at that joint. It is also fused in a position that allows the foot to still be functional.
Altered gait is a potential complication of a big toe joint fusion and the procedure should not be done on persons with poor bone stock or who need to bend the joint for work or other daily activities, such as doing squatting motion or wearing high-heeled shoes.
Because healing requires having no motion at the site of fusion, immobilization is usually required for 6-8 weeks to allow the joint to fuse properly. Return to higher impact activities may be 3-6 months after surgery.
Other Surgical Comments:
Despite the procedure chosen, pain and swelling are to be expected. Keeping the extremity elevated, icing, and taking anti-inflammatory medications as directed by your doctor can help. The pain should significantly improve after 2-3 days from the time of surgery.
If you notice any signs of infection (e.g. increasing redness, swelling, pain, abnormal drainage from surgical site) or symptoms of infection (e.g. nausea, vomiting, fevers, chills), you should notify your surgeon and/or go to the nearest emergency care center immediately.
Disclaimer: The above information is meant for educational purposes only and should not be construed as medical advice. Should you feel that you are suffering from arthritis of the big toe joint or another foot-related issue, please schedule an appointment to see the doctor.