Hallux Rigidus (Arthritic Big Toe)

Hallux rigidus is arthritis and stiffening of the joint at the base of the big toe. As the cartilage wears, the joint becomes painful and loses movement, especially when the toe bends upwards, and a bony lump often forms on top. Treatment starts with stiff-soled shoes, insoles and injections, with surgery if these fail.

The big toe joint (the first metatarsophalangeal joint) bends with every step as the foot pushes off and takes a large share of body weight. In hallux rigidus, the smooth cartilage covering the joint wears down. Bone spurs (osteophytes) grow on the top of the joint and block the toe from bending upwards. Hallux rigidus can be worsened by previous injury.

What are the symptoms?

• Pain and stiffness in the big toe, especially when walking or pushing off
• Limited movement, particularly bending the toe upwards (dorsiflexion)
• Swelling and inflammation around the joint
• A bony bump (osteophyte) on top of the toe joint
• Difficulty walking and an altered gait

Pain is typically eased by stiff-soled shoes and made worse by flexible footwear. Shifting weight away from the big toe can cause pain under the other metatarsals.

Who gets it, and why?

Hallux rigidus is mainly of unknown cause, with a tendency to run in families and often affecting both feet (Coughlin and Shurnas). Injury is a common cause, especially when only one foot is affected. Gout and rheumatoid arthritis are among the other risk factors.

In a series of 110 patients treated surgically by one surgeon (Coughlin and Shurnas, Foot & Ankle International), the average age when symptoms started was 43. Both feet were often affected when there was a family history, and one foot when there had been an injury. At the first examination, 81% of patients had it in one foot, but by final follow-up (an average of nearly nine years later) 79% had it in both. Older age, gout and knee arthritis are among the factors linked to it in population studies (Yagi and colleagues).

How is it diagnosed?

Mr Hester will examine your foot, assess range of motion, and review weight-bearing X-rays to grade the severity of arthritis. MRI or CT scans may be requested in complex cases but are not usually necessary.

What are the non-surgical options?

• Rigid-soled footwear or orthotic insoles to limit painful joint movement
• Anti-inflammatory medication (NSAIDs)
• Hyaluronic acid or steroid injections into the joint
• Activity modification

Non-surgical treatment should always be offered first. Shoes with a high, wide toe box make room for the bony bump, and rocker-bottom soles can help. Steroid injections usually give only temporary relief, with less effect as the arthritis becomes more advanced. Some evidence supports hyaluronic acid injections.

When is surgery recommended?

Surgery is considered only for people who have not responded to simple measures. The surgical options are:

• Cheilectomy: removal of the bony prominence (spur) on top of the joint. Suitable for mild to moderate arthritis. Swelling can persist for several months. Mr Hester often uses cheilectomy for suitable cases.
• Arthrodesis (fusion): the gold standard for advanced arthritis. The joint is fused using a screw or plate, aiming to relieve pain while allowing normal gait. Return to impact activity from 12 weeks.
• Implant arthroplasty: a big toe joint replacement, typically for lower-demand patients. Quick recovery with return to shoes at approximately two weeks.
• Osteotomy: realignment of the metatarsal bone. A rare procedure used where healthy cartilage is present but joint position limits motion.

Cheilectomy (spur removal) is used mainly for early arthritis; patients are counselled that further surgery may later be needed. Fusion complications include non-union (which is often painless), healing in a poor position and prominent metalwork. Results of metal and ceramic joint replacements have historically been poor, with high revision rates; a systematic review (Stevens and colleagues) reported revision after 11% of replacements versus 3.9% of fusions. Fusion is the most common procedure offered for advanced disease, and replacement may suit only a very small group of typically lower-demand patients.

What does the research show?

A systematic review (Stevens and colleagues, JBJS Reviews) compared 741 fusions with 555 joint replacements across 33 studies. In the studies that could be pooled, fusion gave greater improvements in function and pain scores. Complications were reported after 23.1% of fusions and 26.3% of replacements, and revision surgery after 3.9% and 11%. The evidence was Level IV, and the authors called for randomised trials.

Complications can occur after foot surgery; most are minor, though some people are not satisfied with the result.

What is recovery like?

• 0–2 weeks: rest; bulky dressing and surgical shoe; keep the toes above the nose
• 2 weeks: wound review; dressing reduced; begin gentle toe movement
• 2–6 weeks: return to moderate activities in the surgical shoe
• 6–8 weeks: move into trainers (after fusion); swelling may persist
• 12 weeks onwards: return to impact activity if bone healing is confirmed

After cheilectomy, recovery involves two weeks in a bulky dressing, then a gradual return to activity. Driving is usually possible after about six weeks, or sooner with an automatic car, and full recovery can take many months.

How Mr Hester can help

Mr Hester is a dual fellowship-trained foot and ankle surgeon (FRCS Tr&Orth), trained at Guy's and St Thomas' and in Toronto and Calgary, and a member of BOFAS and EFAS. He sees patients privately at The London Clinic, Cromwell Hospital, King Edward VII's Hospital and HCA The Shard. His NHS practice is at King's College Hospital.

Insured patients need a GP referral and an authorisation code from their insurer. Self-pay patients are welcome. To book, call 020 7046 8004.

Frequently Asked Questions

Sources

1. Coughlin MJ, Shurnas PS. Hallux rigidus: demographics, etiology, and radiographic assessment. Foot Ankle Int. 2003;24(10):731–743. PMID: 14587987. https://pubmed.ncbi.nlm.nih.gov/14587987/
2. Stevens J, de Bot RTAL, Hermus JPS, van Rhijn LW, Witlox AM. Clinical Outcome Following Total Joint Replacement and Arthrodesis for Hallux Rigidus: A Systematic Review. JBJS Rev. 2017;5(11):e2. PMID: 29135720. https://pubmed.ncbi.nlm.nih.gov/29135720/
3. Yagi Y, et al. Radiographic prevalence and associated factors of hallux rigidus in a large-scale population-based cohort. Osteoarthr Cartil Open. 2025. PMID: 41211534. https://pubmed.ncbi.nlm.nih.gov/41211534/
4. Osteoarthritis. NHS. https://www.nhs.uk/conditions/osteoarthritis/