In the past three weeks I have had three patients who complained of pain at their big toe joint. They all had limited range of motion and pain when walking. These three patients unfortunately did not have any long term relief with conservative therapy and therefore decided to have their problem fixed with surgery. I performed three different procedures since the severity of the symptoms varied for each individual. Today’s blog will cover the ins and out of arthritis of the great toe joint (hallux rigidus) and what our treatment plans entail.
Diagnosing hallux rigidus or arthritis of the great toe joint is quite simple. Typically the patient presents with pain when moving the toe up and down while undergoing passive and/or active range of motion. The big toe joint has a decreased range of motion as well not only because of pain but because of the arthritic bone that blocks the motion of the joint. A radiographic evaluation of the foot is necessary in order to determine the possible causes of the arthritis. When examining the X-ray your doctor will assess the joint space of the great toe as well as identifying any extra bone surrounding the big toe joint. The top of the great toe will likely have a bone spur that acts as a stopper at the joint level. This spur is the cause of the limited range of extension at the great toe joint. The doctor will also assess the structure of the foot to identify any abnormalities in length of the metatarsal bones, bunion deformities, or any previous trauma. The cause of arthritis to the great toe joint is usually a result of three things. Trauma, elongated first metatarsal, or generalized arthritis of the foot. Each cause has a different treatment surgically so therefore the doctor’s assessment is crucial to gaining relief of symptoms.
Conservative therapy should always be exhausted before any surgical procedures are considered. Orthotics, padding, icing, NSAIDs, injections, and bracing can all be utilized to minimize motion of the great toe joint and decrease inflammation. Oftentimes these simple treatments can get rid of the pain but if the symptoms persist then surgical options should be explored. Surgically their are many levels of treatment and in this article we will cover three of the methods.
Minimally invasive techniques can be a treatment option for hallux rigidus if the arthritis is limited in nature. The joint should still have movement and only be painful at the end range of motion. The dorsal spur is typically removed through a small opening in the skin. A burr is inserted into the opening and the bone is shaved down so that it does not limit motion or cause pain. Fluoroscopy (real time x-ray) machine is used in order to assess the joint and the spur while the doctor is burring. Upon removal of the spur the doctor tests the range of motion of the joint to ensure proper motion. This procedure can take place in the office under local anesthesia and the patient walks out of the office in a small surgical shoe. No stitches are required so the patient is able to resume their daily activities in a shorter period of time.
The next procedure which is more invasive is called a cheilectomy or Valenti procedure. This procedure is used for patients who have a joint space and range of motion that is limited with pain and spurring. The joint space is more narrow and therefore a simple burring would not be sufficient to gain pain free range of motion of the toe joint. This procedure is performed typically at a surgery center since it is more invasive and monitored anesthesia care (MAC) is utilized in conjunction with local anesthetics. The opening in the skin is about 4-6 centimeters in length so that the surgeon is able to gain access to the great toe joint. The arthritic bone is removed from the metatarsal and also the base of the great toe so that proper range of motion can be achieved. This procedure does not destroy the joint but merely augments it so that it can accommodate motion more freely.
Finally, the third method is called a joint decompression osteotomy. This is where the surgeon makes precise cuts of the metatarsal bone in order to shorten it. This shortening of the first metatarsal allows for an increase in the joint space therefore allowing more motion at the joint. This procedure is more invasive than the aforementioned techniques since it requires a screw to hold the bone in place. This procedure is perfect for those patients who suffer from a bunion and also arthritis at the great toe joint. The surgeon can correct for both problems with a single procedure thus increasing efficacy of the procedure. The surgeon will also clean up any bone spurs that are at the joint so that pain free motion can be achieved.
At Advanced Podiatry Drs. Katz and Cruz always assess each patient individually and tailor a treatment plan that will best suit their needs. Our skilled doctors utilize the latest techniques and therefore can offer our patients many different options in treating your unique foot pain. Remember that your comfort is very important to us and therefore your opinion is valued. We present all the options to our patients and in the end we can create a treatment plan utilizing a team approach. Please make an appointment today to have your foot pain relieved.
Dr. Jairo Cruz Jr