Big Toe Problem?
First Metatarsophalangeal Joint Arthritis / Hallux Rigidus
By David J. Pochatko, M.D., Jessica Beck, MS, RPA-C
Arthritis of the first toe metatarsophalangeal (MTP) joint is the second most common pathology of this joint following hallux valgus, or bunion deformity. First MTP joint arthritis is a progressive degenerative condition, which results in decreased motion of the joint. The exact cause of first MTP joint arthritis is unknown. Predisposing factors that precipitate this condition include acute injury, such as forced plantar flexion or dorsiflexion (turf toe), stubbing the toe, repetitive micro-trauma, fractures into the joint or a crush injury. Congenital deformities of the first MTP joint may also predispose an individual to develop arthritis; these include a short or long first metatarsal head, flattened first metatarsal head or an elevated first metatarsal. Shoe wear that is too tight in the toe box area can also cause this.
Onset of symptoms is usually insidious, but may occur after an acute injury. Stiffness of the first MTP joint, as well as pain and swelling of this joint are common presenting symptoms. Pain is often increased with activity. Positions such as squatting, which cause the joint to hyperextend, will also cause pain. For women, high-heeled shoes often cause increased discomfort due to hyperextension and increased jamming of the joint. Pain is often relieved with rest. Patients may also complain of pain on the lateral aspect of their foot as they may compensate and weight bear more laterally to decrease the stress on the first MTP joint.
After taking an accurate history from the patient, physical examination of the patient’s feet is the next step toward making a correct diagnosis. In mild cases of arthritis, a physical exam may only reveal tenderness or synovial thickening of the joint space. The joint may appear erythematous (red) due to inflammation. Bone hypertrophy and osteophyte formation is often palpable if not visible on examination. There is often limited or no motion of the joint. Patients often experience increased pain with passive range of motion of the joint. This may be due to inflammation of the synovial tissue, the capsule surrounding the joint, stretching of tendons crossing the joint or impingement of the soft tissue between osteophytes. Patients may also complain of tingling or increased sensitivity as a result of nerve compression due to the osteophytes. With the patient standing, it may be noted that the patient weight bears on the lateral aspect of their foot to decrease the stress on the first MTP joint.
An accurate history and physical examination can lead to the correct diagnosis the majority of the time. X-rays of the foot are taken to be thorough and rule out any other causes of the patient’s pain. Findings on X-ray may include narrowing of the joint space, a flattened / widened first metatarsal head, bone spur formation, cyst formation in the bone or an osteochondritis dessican lesion.
Conservative treatment of arthritis of the first MTP joint is aimed at slowing the progression of the disease and relieving pain. Anti-inflammatories, such as Motrin or Ibuprofen, are used to decrease the inflammation of the joint. A steroid injection into the joint is another option to decrease the inflammation, although this may only temporarily relieve the pain. Complications of steroid injections include further degeneration of the joint cartilage, infection and nerve damage that can result in numbness / tingling. Orthotics (custom molded inserts) and stiff-soled shoes are used to decrease the stress on the joint. With bone spurs located on the dorsal / top aspect of the joint, shoes with an increased-depth toe box will decrease the pressure placed on the top of the joint. Shoe wear with lower heels will also decrease the stress on the joint.
Surgical treatment options are dependent upon the severity of the arthritis, patient age and activity level. Surgery options include debridement/cheilectomy, joint replacement (arthroplasty) and joint fusion (arthrodesis). Debridement of the first MTP joint involves removal of the bone spurs and bony formations that are causing pain and restricting motion of the joint. Debridement preserves joint motion. Patients are able to walk on their foot the day of surgery in a rigid postoperative shoe, but are asked to limit their activities. When the patient returns to the office for their first postoperative appointment, he / she is taught how to perform range of motion exercises of the joint to prevent recurrent stiffness.
Joint replacement, or arthroplasty, may also preserve motion of the joint. In this procedure a portion of the first metatarsal and/or proximal phalanx are removed to allow implantation of the joint replacement. Although the joint is salvaged with arthroplasty, there are many inevitable complications associated. Patients lose push-off ability of their first toe while walking, as tendon attachments are lost secondary to the need to remove enough bone in order to place the implant. Patients may also develop great toe deformities, because of the loss of these tendon attachments. Patients often get pain in other parts of their foot, which could lead to stress fractures, as the weight bearing stresses are altered. It is not recommended that you run with a joint replacement.
Arthrodesis is reserved for end-stage arthritis of the joint or revision of previous failed procedures. With joint fusion, the first metatarsal and proximal phalanx of the first toe are fused together, which inhibits movement of this joint. The joint is fused together using plates and screws in a position for walking. Post-operatively, patients are in a cast for three months. Weight bearing on the operative foot is usually allowed at one month after surgery. Three months after surgery the patient usually goes to physical therapy and may progress to regular activity as tolerated. Joint fusion allows for normal push-off with the great toe, which is needed for normal walking. With first metatarsophalangeal joint fusion, running is limited and heels greater than one inch can be difficult to wear.
Some of the common complications of surgery include infection, incisions not healing, bones not healing, pain in other areas of the foot and numbness/tingling. Swelling after any procedure to the foot may last up to 6 months postoperatively.
The foot and ankle team at Northtowns Orthopedics is specially trained to help you with your foot and ankle problem. Dr. David Pochatko is a foot and ankle specialist who is a board certified orthopedic surgeon. He completed a foot and ankle fellowship at Emory University in Atlanta, Georgia. A fellow in the American Academy of Orthopaedic Surgery, he specializes in the care of the foot and ankle and has provided care to many people including many injured professional athletes. He would love to help you with your foot and ankle problem. Please call Northtowns Orthopedics at 204-2550 and ask for an appointment with the foot team to get some help. Northtowns Orthopedics; where your first surgery is your best chance to get better.