Hallux rigidus, a term derived from the Latin for “stiff big toe,” is a progressive and often debilitating form of degenerative arthritis that affects the first metatarsophalangeal (MTP) joint—the joint at the base of the big toe.1 This condition, which is the second most common ailment of the MTP joint after hallux valgus (bunions), is characterized by pain, stiffness, and a gradual loss of motion in the big toe.2 While it may start as a mild limitation of movement, known as hallux limitus, it can progress to a state of near-total rigidity, profoundly impacting an individual’s mobility and quality of life.3 The onset of this condition typically occurs in adults between the ages of 30 and 60, but its root causes and progression are complex and multifactorial.4
The pathophysiology of hallux rigidus centers on the gradual deterioration of the articular cartilage that cushions the ends of the bones in the MTP joint.5 This cartilage, which allows for smooth, pain-free movement, can be worn down by a variety of factors.6 In many cases, the cause is idiopathic, meaning it develops without a clear reason.7 However, a significant number of cases are linked to structural and biomechanical abnormalities of the foot.8 For example, individuals with a long or elevated first metatarsal bone, or those with flat arches or excessive pronation, may place undue stress on the MTP joint, leading to premature wear and tear.9 A genetic predisposition also plays a role, with a family history of hallux rigidus or other foot deformities increasing an individual’s risk.10
Beyond inherent anatomical factors, lifestyle and environmental elements can also contribute to the development of hallux rigidus. Repeated microtrauma or a history of significant injury, such as a sprain or a stubbed toe, can damage the joint and accelerate the arthritic process.11 Certain occupations or sports that require frequent squatting, stooping, or stress on the big toe—such as ballet or running—can also be contributing factors.12 Furthermore, inflammatory diseases like rheumatoid arthritis or gout can cause joint damage, paving the way for the development of hallux rigidus.13 As the cartilage erodes, the body attempts to stabilize the joint by forming bony overgrowths, known as osteophytes or bone spurs.14 These spurs further limit the joint’s range of motion and can cause significant pain, especially when they rub against footwear.15
The symptoms of hallux rigidus often begin subtly and worsen over time.16 Early signs may include pain and stiffness in the big toe, particularly during activities that require bending the toe, such as walking, running, or climbing stairs.17 This discomfort may be aggravated by cold or damp weather.18 As the condition progresses, the pain can become more severe and constant, even when at rest.19 The formation of bone spurs can lead to a visible and often painful bump on the top of the foot, making it difficult to wear certain types of shoes.20 In an effort to alleviate the pain, individuals may alter their gait, leading to secondary pain in other joints, such as the knee, hip, and lower back.21 This compensatory change in walking mechanics is a clear indicator of the functional limitations imposed by the condition.
Diagnosing hallux rigidus is a process that combines clinical examination with imaging studies.22 A foot and ankle specialist will assess the range of motion of the big toe, looking for signs of pain, swelling, and the presence of bone spurs.23 X-rays are a crucial diagnostic tool, as they provide a clear picture of the extent of cartilage loss, joint space narrowing, and the size and location of any osteophytes.24 The severity of the condition is often classified into grades, from early-stage hallux limitus with minimal joint changes to advanced-stage hallux rigidus with severe joint degeneration and significant loss of motion.25
Treatment for hallux rigidus is typically a phased approach, starting with conservative, non-surgical options.26 For mild to moderate cases, these treatments are often effective in managing symptoms and slowing the progression of the disease.27 Shoe modifications are a primary recommendation, including wearing footwear with a stiff sole, a wide toe box, and a rocker-bottom design. The rigid sole reduces the need for the toe to bend during walking, thereby minimizing pain. Over-the-counter pain relievers and anti-inflammatory medications can help manage discomfort and swelling.28 Corticosteroid injections into the joint may provide temporary relief, though they do not address the underlying degenerative process.29 Physical therapy, focusing on strengthening and mobility exercises, can also be beneficial in maintaining function and reducing stiffness.30
When conservative treatments fail to provide adequate relief, or in cases of advanced-stage disease, surgical intervention becomes the next logical step.31 The choice of surgical procedure depends on the severity of the arthritis, the patient’s age, and their lifestyle. For early-stage hallux rigidus, a cheilectomy is a common procedure.32 This involves the removal of the bone spurs from the joint, which can relieve pain and improve the range of motion.33 While effective in many cases, it does not prevent the underlying arthritis from progressing. In more severe cases, a joint fusion, or arthrodesis, is often considered the gold standard.34 This procedure involves removing the damaged cartilage and fusing the two bones of the MTP joint together with plates and screws. While this sacrifices all motion in the joint, it is highly effective at providing permanent pain relief. Although it may seem drastic, studies have shown that a properly fused MTP joint allows for a near-normal gait and does not significantly hinder activities like walking or running, though it does preclude wearing high heels. Other surgical options, such as joint replacement or joint resurfacing, are also available, but the long-term outcomes and durability of these procedures are still being researched.
In conclusion, hallux rigidus is a complex and progressive condition that can have a significant impact on an individual’s mobility and daily life.35 It is a form of degenerative arthritis driven by a combination of genetic, anatomical, and environmental factors. From the initial stages of hallux limitus to the final rigidity of hallux rigidus, the condition is characterized by pain and stiffness that can profoundly limit function.36 Fortunately, a wide range of treatment options, from conservative management like shoe modifications and physical therapy to a variety of surgical interventions, are available to alleviate pain and restore function.37 By understanding the causes, symptoms, and treatment pathways, individuals with hallux rigidus can work with healthcare professionals to effectively manage their condition and maintain an active, fulfilling life.38