Stiff big toe treatment

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What causes a painful stiff big toe?

The rigid big toe is manifested by pain in the metatarsophalangeal joint of the big toe while walking, when the heel rises above the ground and the foot prepares to take off. The cause of the pain is the dorsal conflict when the upper edge of the proximal phalanx hits the surface of the metatarsal head. The bone conflict results from the presence of degenerative changes that limit the passive dorsiflexion of the big toe. X-ray images show a narrowing of the joint space and the presence of bone spurs (osteophytes). Pain often makes it impossible to fully climb on toes or wear high-heeled shoes.

Stiff big toe is a progressive disease, which means that it is only possible to slow down its progress and treat the pain symptomatically. Toe joint disease is associated with negative movement compensation - to avoid pain, the patient rolls the foot more over its outer edge. The abnormal gait pattern becomes permanent, which leads to overloading the muscles and joints of the lower limb and the spine.

Reasons for the formation of a stiff big toe

Accelerated degenerative changes in the metatarsophalangeal joint may result from the following factors:

Acute big toe injuries

A common injury is a "turf toe" injury, which involves damage to the capsulo-ligamentous-navicular complex of the metatarsophalangeal joint of the big toe. The injury occurs in the mechanism of excessive dorsiflexion of the big toe during sports activities or as a result of adopting the position of kneeling on the heels with the toes folded. Failure to take appropriate treatment results in joint instability, which generates faster wear of the articular cartilage and the development of degeneration. The rigid big toe may also develop against the background of past joint fractures and contusions within the big toe, e.g. as a result of kicking a hard obstacle or falling of a heavy object on the front of the foot.

Raising the first metatarsal (flat feet, hallux valgus)

Elevation of the first metatarsal means excessive dorsiflexion of the first metatarsal associated with hypermobility of the first radius and overpronation of the foot. While walking, when the heel is lifted above the ground, there is an abnormal imbalance between the internal forces affecting the metatarsophalangeal joint (muscle tension and plantar fascia) and the force acting on the toe from the ground. As a result, pathological tissue stresses and uneven pressure distribution within the joint cartilage occur. These conditions also create a state of limited dorsiflexion of the joint without any clear structural changes in the joint - it is the so-called limited toe (hallux limitus). It is believed that hallux limitus may precede development of the rigid big toe.
Poor fit of the surfaces forming the metatarsophalangeal joint
Poor fit of the articular surfaces may be a congenital lesion. Moreover, incorrectly operated hallux valgus with subluxation of the metatarsophalangeal joint may lead to arthrosis and stiffening of the joint.

Inflammatory diseases involving the metatarsophalangeal joint of the big toe
The most common disease affecting the small joints of the locomotor system is rheumatoid arthritis (RA). The essence of the disease is inflammation of the synovium, which spreads to the remaining structures of the joint, leading to fibrosis of the capsulo-ligamentous apparatus, secondary destruction of the articular cartilage and progressive limitation of joint mobility. RA is the cause of multiple toe deformities and acquired flat feet. In order to reduce the progression of deformation, during the exacerbation of RA, do not overload the feet and use individual orthopedic insoles made of soft materials.
The second condition leading to the development of the toe is gout (gout), which selectively attacks the first metatarsophalangeal joint. Inflammation develops due to the deposition of uric acid crystals in the big toe joint. The symptoms of gout are periodic redness, swelling and pain in the metatarsophalangeal joint of the big toe, which increases after eating meat products. Management consists of dietary modification and treatment of metabolic disorders leading to increased blood uric acid levels.

Aseptic necrosis of the metatarsal head
Aseptic necrosis is the death of bones without inflammation. As a result of bone softening, the contour of the metatarsal head is distorted and the mechanics of the metatarsophalangeal joint of the big toe are disturbed. Aseptic necrosis rarely occurs in the toe joint, the risk of its occurrence is greater in people with an excessively long first metatarsal bone and hollow foot. Chronic overload can lead to disturbed blood supply to the metatarsal head and the development of necrosis.
Wearing the wrong shoes
Wearing shoes with narrow toes or high heels may also contribute to the formation of a stiff big toe. Footwear of this type forces the unnatural position of the toe joint and increases the degree of overload of the metatarsal head.

Treatment

Conservative treatment
Identification of risk factors for rigid big toe allows the implementation of a procedure aimed at slowing down the progression of the disease. If you find a tendency to flat feet, it is worth doing exercises to strengthen the deep muscles of the foot and exercises to improve the stability of the ankle joint. Manual therapy of the metatarsophalangeal and other joints of the foot is also recommended to maintain the mobility of the foot allowing for walking without compensation.

Pain relief can be achieved by wearing special orthopedic insoles that relieve the first radius of the foot. It is also advisable to use shoes with a stiff roller sole with a rounded tip. While walking, the shoe is rolled over and the toe joint is relieved and the correct gait pattern is maintained without negative compensation at the ankle, knee or hip level.

Surgery
Surgical treatment is undertaken in people with severe pain and limited mobility of the joint, as well as when conservative treatment remains ineffective. Qualification for the appropriate type of surgery takes into account the degree of advancement of the rigid big toe determined on the basis of X-ray images, the patient's level of activity and his expectations as to the effect after the procedure. The use of surgical treatment allows for effective pain relief, free walking, and even taking up sports activities such as jogging.

Cheilectomy involves the removal of bone growths that have arisen as a result of degenerative changes. The surgeon removes a quarter of the dorsal part of the metatarsal head along with the osteophyte. It also releases adhesions and fibrosis within the big toe joint. The procedure should allow the range of dorsiflexion to be increased to a minimum of 60 degrees - the mobility of the toe is checked intraoperatively. Cheilectomy is performed in young people who have a small defect in the metatarsal head cartilage on radiographs. There is also a cheilectomy combined with the Moberg wedge osteotomy, which involves cutting the phalanx of the proximal toe and correcting its axis in order to obtain an even greater range of flexion movement of the big toe. The choice of the final technique depends on the individual anatomical conditions of the patient's foot and the surgeon's proficiency in the operating procedures used.

Surgery

Surgical treatment is undertaken in people with severe pain and limited mobility of the joint, as well as when conservative treatment remains ineffective. Qualification for the appropriate type of surgery takes into account the degree of advancement of the rigid big toe determined on the basis of X-ray images, the patient's level of activity and his expectations as to the effect after the procedure. The use of surgical treatment allows for effective pain relief, free walking, and even taking up sports activities such as jogging.

Arthrodesis (stiffening) of the metatarsophalangeal joint is the "gold standard" in the treatment of advanced rigid toes, especially if the disease is inflammatory. The procedure consists in cutting out the articular surfaces and then permanently stiffening the joint with special screws. The big toe is set to a position of about 25 degrees dorsiflexion, which allows the patient to freely undertake most activities. Pain in the big toe joint is relieved and the quality of life is significantly improved. A well-performed arthrodesis procedure brings permanent results, and complications are very rare. After the procedure, the forefoot needs to be relieved until the bone joins - for about 6 weeks the patient should wear special "Geisha" footwear that allows walking and at the same time relieves the operated area.

Keller resection arthroplasty is performed in elderly people over 60 years of age and leading a sedentary lifestyle. The procedure involves the excision of a third of the proximal phalanx. Loading the limb in normal footwear is possible in a shorter period of time compared to arthrodesis. This enables the elderly to stand up early and to move around without having to wear a relief shoe for a long time. However, this procedure carries a greater risk of complications, and therefore should not be performed in young, active people.

Arthroplasty of the metatarsophalangeal joint of the big toe

Implantation of an artificial prosthesis of the metatarsophalangeal joint enables the restoration of the mobility of the big toe in the advanced stage of degenerative disease. The durability of the artificial joint and the risk of dislocation or loosening of the prosthesis are currently under discussion. Thanks to the progress of biomedical engineering, more and more modern and more durable models of endoprostheses are produced, which gives hope for the use of endoprostheses in a wider group of patients.

Important information

Frequently asked questions about rigid toe condition and methods of its treatment: