LET’S MEET THE BIG TOE JOINT:
The big toe joint plays a very important role in gait and propelling the body forward when it flexes upward and pushes off the ground. A significant amount of force and pressure are imparted upon this joint with each step. The anatomy of the big toe joint includes: the big toe (hallux), the big toe joint cartilage (1st metatarsophalangeal joint), the 1st long bone (1st metatarsal) and the sesamoid. The normal big toe joint should be able to have an upward motion (dorsiflexion) of 50 to 90 degrees for normal function. When there is limited motion of the big toe it cannot propel the body forward efficiently leading to other joints of the body to compensate, adding undo strain through the rest of the foot and lower extremity. Pain and fatigue from this inefficient gait pattern will develop.
WHAT IS ARTHRITIS?
Arthritis is simple damage to the cartilage of a joint. Each part of the body that moves has a joint between the bones that move. Cartilage is the material that lays over the surface of each bone of the joint. If there were no cartilage between, the two bones would want to join together. Cartilage takes a great deal of pressure and force and can absorb these forces very efficiently. However, cartilage is not strong enough when there is a sheering force applied to it or when it is fractured. Arthritis is a progressive disease that will compound on itself. Even a small amount of damaged cartilage, leads to an uneven amount of pressure within the joint and the bones will move upon the damaged surface and erode more and more on the cartilage until there is more bone contact. Any amount of damage to the cartilage of a joint is referred to as arthritis.
There are many types of arthritis. Some diseases like, Rheumatoid Arthritis, are an autoimmune problem where the body attacks its own cartilage. This kind of arthritis will affect the whole body equally. Osteoarthritis or Degenerative Joint Disease (DJD) is a problem that can affect one or multiple joints. There is often an external force, such as a jam or a bump to the bone and joint, or a biomechanical deformity that leads to the deterioration of the joint.
WHAT IS HALLUX LIMITU/RIGIDUS?
Hallux limitus or Rigidus is defined as limited motion to the big toe joint. The big toe joint plays a very important role in gait and propelling the body forward when it flexes upward and pushes off the ground. The normal big toe should be able to have an upward motion (dorsiflexion) of 50 to 90 degrees for normal motion.
Arthritis of the big toe joint (hallux limitus/rigidus) is a deformity involving the big toe, the long bone, behind it (1st metatarsal), and the joint between them. It usually presents as a form of osteoarthritis. It can affect one or both feet. As the cartilage begins to wear, and the toe bends with each step that is taken the bones rub against the worn defect. This constant pressure continually enlarges the amount of damage cartilage. The space between the hallux and the 1st metatarsal becomes less and less, limiting the amount the toe can bend when walking. The limited bending causes the bones to jam into each other causing even more cartilage damage. The constant jamming of the joint stimulates extra bone growth, which is seen as a spur or growth of bone bump on the top of the joint. This spur additionally limits the motion of the joint, accelerating the joint damaged. This becomes a vicious cycle of progressive damage. When there is arthritis, movement of the joint is painful. Arthritis is always progressive and will get worse.
WHAT ARE THE SYMPTOMS OF HALLUX LIMITUS/RIGIDUS?
Patients will complain of pain within the joint. The pain will be mild to severe depending on the amount of cartilage damage. The joint will move less and have a smaller range of motion than it use to. Patients will complaint of a feeling of stiffness in the joint. Movement of the joint becomes painful and debilitating. Extra bone formation (bone spur) will appear on the top of the joint and sometimes the side of the joint. this spur is often painful to touch and will not allow the use of tighter shoes. High heel shoes become harder to wear because the toe will not bend enough. Inflammation and swelling around the joint can be seen from day to day. Numbness and shooting pain into the toe is caused by nerve damage from the pressure of the extra bone and shoes over the nerves. Some patients will hear cracking and popping from the joint when it is moving.
HOW IS HALLUX LIMITUS/RIGIDUS DIAGNOSED?
Diagnosis is simply achieved by the clinical examination and x -rays of the patient. Dr. Heath will listen to your complaints, symptoms, and goals. The examination involves a hand-on analysis of the patient’s foot and evaluation of their gait. Radiographs (x-rays) of the feet will be obtained and reviewed with the patient. The positions of the bones and joints evaluated on the x-rays help to determine the severity of the deformity and any associated deformities. In some cases, a CT scan is performed and is used to determine the quality of the bone and the cartilage.
HOW IS HALLUX LIMITUS/RIGIDUS TREATED?
Dr. Heath educates that early diagnosis and treatment of hallux limitus are the keys to successful treatment, faster recovery and improved lifestyle.
CONSERVATIVE TREATMENT FOR HALLXU RIGIDUS?
Joints do not have a significant blood supply. For this reason, it is difficult for joints to repair damage on their own. Conservative treatments rely on their ability to accommodate big toe arthritis. This can be achieved by
wearing appropriate shoes with a wider toe box, and stiff sole. A stiff soled shoe reduces the amount of movement in the joint leading to less pain with each step. Rocker-bottom shoes will roll the foot forward leading to less movement of the joint. Reducing the activities that cause pain and damage to the joint can help reduce the painful inflammation and the progressive wear on the joint. Padding over the bone spur bump can take the pressure off the area. Ice and anti-inflammatory can reduce the irritation when there is a flare. custom molded orthotics can be made as an important tool to slow the progression of the damage to the joint in cases of a biomechanical deformity.
INJECTION THERAPY CORTICOSTEROIDS:
Injected steroids are catabolic. This mean that they break down tissue. They are used in an effort to reduce inflammation and scar tissue that are a secondary cause of pain within the arthritic joint. They cannot reverse or heal any damage cartilage. They are used to bring temporary relief. There is a limit to the number of these injections that are recommended. Dr. Heath offers this injection with little discomfort in the office. There is no restrictions of activity after this type of injection. Most patients pain will return over time.
SURGICAL TREATMENT FOR HALLUX RIGIDUS:
Dr. Heath will always recommend and attempt conservative treatment when appropriate. However, when hallux rigidus becomes painful, daily activities become a struggle, and conservative treatments have failed, surgical repair may be indicated. Considering that surgery can be intimidating. Dr. Heath takes great care and focus to minimize the chance of post-operative pain. The goal of surgery is to correct hallux rigidus to remove any extra bone, clean out the joint, promote new cartilage growth when possible, alleviate pain, allow a return to normal shoes, and allow a return to activities. Most procedures allow for immediate walking and a return to work within a few days. While wearing a special walking shoe. Dr. Heath performs the procedure in an outpatient setting at a state of the art facility.
There are many different types of procedures and techniques to treat hallux rigidus. It is the responsibility Of the surgeon to investigate each specific aspect of the deformity for each individual patient in order to formulate the proper procedure for repair. Dr. Heath will use the information gained from the patient’s symptoms, age, activity level, lifestyle goals, the severity of the deformity, the clinical examination, the patients gait, and the x-rays to make a recommendation on the proper procedure.
MILD TO MODERATE ARTHRITIS:
CHEILECTOMY (CLEAING OUT THE JOINT)
The purpose of this procedure is to buy the joint some more time before it becomes even more arthritic. The earlier in the disease process that this procedure is performed, the more rewarding it will be for the patient. A small incision is made on the side of the big toe joint. Any extra bone around the joint is removed. Any floating pieces of cartilage or bone are removed. A precision cut is made at the head of the 1st metatarsal to remove even more bone to allow for the big toe to move over the joint more easily. Any areas of missing cartilage are stimulated to promote new growth of cartilage. The patient is able to bear weight in an assistive shoe immediately for 2 weeks, then move into an athletic shoe. The patient will begin immediately range of motion exercises.
BIG TOE JOINT REPLACEMENT:
In moderate to severe cases of hallux rigidus where one part of the joint may still be viable, some may be a candidate for a joint resurfacing procedure called an Arthrosurface Hemi-cap. The purpose of this procedure is to replace the missing cartilage and bone with a new metal cap. This will allow for increased motion of the joint. Dr. Heath uses the most advanced implants available. An incision is made on the side of the big toe joint. Any extra bone around the joint is removed. The surface of one side of the joint (the more damaged side) is prepared by removing all the remaining cartilage and some bone. A special, sized hemi-implant is placed and anchored into the bone. Dr. Heath will then close the skin using plastic surgery technique. The patient is able to bear weight in an assistive shoe immediately for 2 weeks, then move into an athletic shoe. The patient will begin immediately range of motion exercises.
BIG TOE JOINT FUSION (ARTHRODESIS)
The purpose of a fusion of the big toe joint is to remove the joint and take away all movement. No movement-no pain. This procedure joins the big toe bone (phalanx) and the I s metatarsal into one bone. The fusion of this joint still allows for normal walking and most activity. An incision is made on the side of the big toe joint. Any extra bone around the joint is removed. The surfaces of each bone are prepared by removing all the remaining cartilage. The two bones are brought together, and a plate and screws are placed across the joint. The screws hold the bone in its new corrected position while the bone heals into one.