Hallux rigidus

Anatomy and function of the metatarsophalangeal joint of the big toe

The big toe joint connects the first metatarsal bone (os metatarsale I) with the basal phalanx of the big toe. It is essential for the push-off phase of the gait. There are two sesamoid bones under the joint head, which, together with tendons and capsules, stabilize rolling.

• Normal mobility: approx. 60-75° dorsiflexion (lifting the toe), 10-20° plantar flexion
• Sesamoid apparatus serves as a pulley for the flexor tendons
• In hallux rigidus: cartilage wear, capsule thickening and bony attachments (osteophytes) - especially. a. dorsal

Pain typically arises from wear and tear of cartilage in the joint and anterior impingement from bony attachments that press in the shoe or bump when rolling.

Typical symptoms

• Pain when rolling, especially on the first steps and when walking faster
• Increased pressure pain on the back of the foot above the big toe joint (dorsal “bone ridge”)
• Feeling of stiffness, reduced mobility of the big toe
• Stress-dependent swelling, occasionally irritation
• Evasive movements with increased load on the outer metatarsal (can promote metatarsalgia)
• Shoe conflict: Tight, hard toes or high heels increase the symptoms

Causes and risk factors

Hallux rigidus is usually caused by degenerative causes. Familial predisposition and repeated microtraumas are common. Less commonly, the cause is an accident (e.g. “turf toe”), an axial deviation or a previous inflammatory illness.

• Aging articular cartilage and repetitive mechanical overload
• Anatomical factors: Metatarsus primus elevatus, long metatarsal I, flat condyle
• Forefoot deformities (e.g. Hallux limitus as a preliminary stage)
• Previous injuries (capsule/ligament injuries, fractures)
• Systemic influences: gout, rheumatoid arthritis (important in the differential diagnosis)
• Work/sport with kneeling, squatting, sprinting/jumping activities
• Unsuitable footwear (hard, tight toes; extreme heel heights)

Diagnosis: clinical and imaging

The physical examination is crucial: range of motion, location of pain and palpable osteophytes. This includes an assessment of gait and footwear.

• Flexibility test: limited dorsiflexion; painful end impact (impingement)
• Palpation: tenderness dorsally; Possibly crepitation (rubbing) when moving
• X-ray under stress (ap.-p., lateral): joint space narrowing, osteophytes, subchondral sclerosis
• Sonography: soft tissue irritation; MRI only if findings or differential diagnoses are unclear

The staging supports therapy planning. A classification based on radiological joint wear and loss of movement is often used.

Stages of hallux rigidus (simplified orientation)

The classification serves as a guide. The decisive factor is the individual combination of symptoms, activity level and radiological assessment.

Conservative therapy: exhaust it first

The aim is to relieve pain, reduce irritation and make rolling easier. Depending on the stage, symptoms can often be significantly improved.

• Adjust shoes: firm, stiff sole or rocker/roll-off sole; sufficient space above the big toe joint
• Insoles and carbon plates: Rigidus spring or rigid forefoot plate to relieve the MTP I
• Load modification: reduce inclines/sprints, walking breaks, alternative endurance training (cycling, swimming)
• Medication: time-limited NSAIDs for acute irritation (after consultation; contraindication tested)
• Physiotherapy: mobilization of surrounding joints, stretching of calf muscles, strengthening of foot muscles, gait training
• Manual techniques and tape for short-term symptom control
• Cold/thermothermic measures depending on the irritation condition
• Weight management when the forefoot is overloaded

Injections can temporarily relieve pain. Local cortisone injections are used cautiously; They can temporarily dampen irritations, but are not intended for repeated, frequent use.

Intra-articular and regenerative procedures: weigh the benefits individually

There is evidence for possible pain relief in selected cases for hyaluronic acid or platelet-rich plasma (PRP) in the metatarsophalangeal joint of the big toe. However, evidence is limited and long-term effects are uncertain. An individual indication and information about opportunities and limitations are therefore essential.

• Possible use in early to middle stages of stress-dependent pain
• Goal: Reducing irritation and improving function, not “curing” osteoarthritis
• Decision based on clinical examination, activity profile and previous treatments

Surgical options: when conservative is no longer sufficient

Surgery is considered if persistent pain and significant limitations persist despite consistent conservative therapy. The procedure depends on the stage, joint quality and individual goals (e.g. sport, job requirements).

• Cheilectomy: removal of dorsal osteophytes and capsule release to improve dorsiflexion. Suitable v. a. in early to middle stages. Advantage: joint preservation; Disadvantage: Osteoarthritis persists, recurrences are possible.
• Moberg osteotomy (proximal phalanx): In addition to cheilectomy to expand functional dorsiflexion.
• Arthrodesis (joint stiffening): Gold standard for advanced hallux rigidus with a high satisfaction rate. Goal: Pain reduction through a stable, pain-free position; Disadvantage: Loss of movement in the MTP I, adjustment in the shoe required.
• Endoprosthetic procedures/interposition arthroplasty: Joint-preserving alternatives for selected patients with special requirements; Results more variable than with arthrodesis, careful explanation required.
• Minimally invasive techniques: possible in selected cases; Indications and benefits must be examined individually.

The choice of procedure is made after information about realistic goals, possible complications (e.g. impaired wound healing, nonunion during arthrodesis, persistent pain) and follow-up treatment.

Follow-up treatment and rehabilitation

• Cheilectomy/Moberg: early functional mobilization, bandage shoe/bandage for 2–4 weeks; gradual increase in load after pain.
• Arthrodesis: Special forefoot or walking shoe for approx. 4-6 weeks; Full weight bearing depending on fixation and healing process. X-ray checks up to the bony development.
• Physiotherapy: reduction of swelling, mobilization of neighboring joints, correction of gait, adjustment of insoles.
• Return to everyday life/sport: everyday stress often after a few weeks, sport depending on the procedure and healing typically after 6-12 weeks (contact and highly dynamic sports later).

The individual course varies. A gradual increase in load and a good supply of shoes/insoles are important for sustainable results.

Course and prognosis

Hallux rigidus is a wear-and-tear disease. Many affected people benefit significantly from conservative measures. In advanced stages, targeted surgery can reduce pain and make rolling possible again. There is no guarantee that there will be no symptoms; In any case, the aim is to improve functionality that is suitable for everyday life and sports.

Self-help, exercises and prevention

• Choice of shoes: Firm, well-rolling soles, enough toe room; Rocker soles if necessary.
• Inserts/carbon plates with Rigidus spring to relieve the load on the MTP I.
• Stretching calf muscles (e.g. 2-3 times daily for 30-45 seconds) to reduce compensatory stress.
• Activate foot muscles: Cloth claws, target short foot muscles – pain-adapted.
• Load dosage: Control the pace, inclines and jump load based on pain.
• Irritation control: cooling for acute swellings; Warmth rather when there is stiffness without inflammation.

Exercises should be painless. If symptoms continue to increase, please seek medical attention.

Differential diagnoses

• Sesamoiditis/sesamoid fracture
• Gout attack (Podagra) or other crystal-induced arthritis
• Rheumatoid arthritis/inflammatory arthropathies
• Metatarsalgia due to overloading of the central rays
• Morton's neuroma (neuropathic forefoot pain)
• Hallux valgus with secondary joint irritation
• Stress reactions/fractures in the forefoot

When should I seek medical advice?

• Persistent forefoot pain for weeks despite protection/shoe adjustment
• Pain at rest, pain at night or significant swelling/redness
• Acute, severe pain with overheating (suspected gout/infection)
• Increasing walking restrictions or relevant loss of everyday life/work

Sport, work and footwear

Many sports are still possible with adjustments. The selection depends on individual resilience and stage.

• Well suited: cycling, swimming, rowing ergometer, strength training with sturdy shoes
• With adjustment: hiking (rocker sole), jogging on flat surfaces with a stiff forefoot sole
• Rather unfavorable: sprints, jumps, sports with abrupt changes of direction
• Occupation: Safety shoes, if necessary with an adapted insole/roll-off aid; ergonomic advice makes sense

Your path to our practice in Hamburg

In our orthopedic practice at Dorotheenstrasse 48, 22301 Hamburg, we value a thorough anamnesis, a structured examination and clear, understandable therapy planning.

Make an appointment easily online via Doctolib or by email. We provide advice based on evidence and without promises of cure - with a focus on solutions suitable for everyday use.