Big toe arthritis (hallux rigidus): symptoms, footwear and surgery

An NHS trust leaflet explains that hallux rigidus happens when the toe joint becomes rigid because of arthritis, causing pain and swelling, and that arthritis occurs when the lining of the bones in a joint becomes damaged. A UK foot and ankle service page describes it as the joint at the base of the big toe becoming painful and stiff, sometimes with painful bony swellings on top of the joint that can rub on footwear and restrict movement further.

The NHS describes osteoarthritis generally as a condition in which the protective cartilage on the ends of the bones breaks down, causing pain, swelling and problems moving the joint, with bony growths developing. Almost any joint can be affected, and the NHS says it most often causes problems in the knees, hips and small joints of the hands, so the big toe is a less typical but well-recognised site.

According to the trust leaflet, big toe arthritis may follow infection or trauma (an injury), an episode of gout, or inflammatory arthritis or osteoarthritis. The foot and ankle service page says it is caused by wear and tear within the joint and is most common in people who have led sporty and active lifestyles, with damage from rheumatoid arthritis or gout as other causes.

The NHS lists several general risk factors for osteoarthritis: joint injury, other conditions such as rheumatoid arthritis or gout, increasing age, family history, obesity and being a woman. It says the exact cause is not known.

The main symptoms are pain and stiffness at the base of the big toe, with swelling and sometimes a bony lump on top of the joint. Shoes can rub on that lump, and a stiff joint makes pushing off when walking painful. The NHS lists osteoarthritis symptoms as joint pain and stiffness, problems moving the joint, and sometimes swelling, tenderness and a grating or crackling sound, with severity varying greatly between people and between joints.

The NHS advises seeing a GP if you have persistent symptoms of osteoarthritis so they can confirm the diagnosis and prescribe any necessary treatment. A GP may suspect osteoarthritis if you are 45 or older, the pain worsens with use of the joint, and morning stiffness is absent or lasts less than 30 minutes, whereas prolonged morning stiffness can point to rheumatoid arthritis.

The foot and ankle service page says a surgeon assesses the foot and how it affects you, usually by asking about relevant medical conditions, examining the foot and performing X-rays, and uses that information to advise whether treatment should be non-surgical or surgical. The NHS says further tests such as X-rays or blood tests are not usually necessary for osteoarthritis in general, but may be used to rule out other causes such as rheumatoid arthritis or a fracture.

The trust leaflet and the foot and ankle service page suggest the following steps before considering surgery:

• Painkillers such as paracetamol and anti-inflammatory medicines, taken as tablets or applied as a gel over the joint where suitable. Ask a pharmacist or GP whether they are right for you.

• Footwear changes: a soft shoe with a roomy toe box relieves pressure on the toe, and a stiff-sole or rocker-bottom shoe reduces joint movement and pain.

• Over-the-counter silicone pads to stop bony prominences from rubbing.

• A steroid and local anaesthetic injection into the joint in the earlier stages, usually guided by X-ray or ultrasound.

The foot and ankle service says an injection of steroid into the joint can relieve pain and inflammation when clinical assessment and X-rays do not show severe damage, or if you do not wish to have surgery. It adds that steroid injections do not stop the wear and tear process and symptoms are likely to return over time. The trust leaflet likewise limits the benefit to the earlier stages of arthritis. The NHS notes that osteoarthritis is long term and cannot be cured, but does not necessarily get worse over time and can sometimes gradually improve.

The trust leaflet says surgery should only be considered after the non-surgical options have been tried. The type of operation depends on symptoms and how much of the joint is worn.

The trust leaflet says surgery is usually a day case, though fusion may need an overnight stay, with most people having a general anaesthetic. After fusion you wear a surgical shoe when putting weight on the toe for approximately five to six weeks, wounds are checked at two weeks and an X-ray is taken at six weeks. It suggests return to work after two weeks for a sitting job with the foot elevated, or four weeks for a more active one, and says swelling can persist for up to 12 months, particularly in the evenings.

The foot and ankle service quotes a sedentary job after 2 to 4 weeks, manual work around 12 weeks, driving normally after about 6 weeks, and sport after a cheilectomy at around 6 weeks. Both stress that these are guides and that you must check driving with your insurer. Risks include infection, nerve injury with numbness or tingling, failure of the bones to join after fusion (more likely in smokers), noticeable metalwork, complex regional pain syndrome (rare) and blood clots (rare). Stopping smoking before fusion surgery reduces the risk of the bones not uniting.

Most people begin with a GP or podiatry advice and footwear changes, with referral to orthopaedic foot and ankle services if symptoms persist. Private foot and ankle surgeons can offer imaging, injections and surgery sooner. Ask which operation is proposed and why, what the realistic outcome is for pain and movement, how long you will be off work or driving, and what happens if the arthritis progresses.