Big toe joint pain – limited/painful motion

Big toe joint pain – limited / painful motion (Hallux Limitus / Rigidus)

This is a common condition within the big toe joint that restricts the normal amount of motion.

The big toe is medically called the hallux. When a joint loses its normal amount of motion but still has some motion present that is called limitus. Rigidus is the descriptive term to mean that all motion is lost within the big toe joint. The disease process of the big toe joint is pretty much an arthritic condition where the cartilage is worn away from “wear-and-tear”, that’s of course assuming there was no acute trauma. We are going to discuss the most common cause of this deformity.

What causes osteoarthritis at the big toe joint?

Osteoarthritis is the “wear-and-tear” arthritis. Most online searches will show that researchers have no idea why this kind of arthritis attacks the big toe joint. It is important to understand the underlying cause of big toe joint pain. If you don’t know what is broken, how can you fix it? This condition is usually ignored until there is so much pain that surgery is required. This is a pretty easy puzzle to solve. So, let’s dig in.

Sometimes big toe joint disease can be due to trauma, gout, or some unusual situation. The majority of cases are due to a mechanical issue of the big toe joint, over-pronation, a longer-than-should-be first metatarsal bone, an elevated first metatarsal bone.

Osteoarthritis develops in a joint that is not properly aligned and abnormally excessive forces are acting on the cartilage within the joint. The combination of an excessive force acting on a portion of the joint cartilage leads to compression of that part of the joint and then add the mechanical trauma. This leads to inflammation and pain. Walking is one of the most common conscious functions of our body. We take thousands of steps per day and millions of steps every year. That mechanical imbalance within the big toe joint never stops. Eventually, the cartilage wears away and the surrounding tissue does what it can to try to stabilize the big toe joint by limiting the motion.

Foot x-ray showing the results of decades of walking with faulty foot mechanics

The real underlying cause of big toe joint arthritis begins at the back of the foot.

The hindfoot bones control the forefoot bones. Specifically, the ankle bone is responsible for the faulty mechanics of the big toe joint. The ankle bone should only have a slight amount of motion. The joint surfaces between the ankle and heel bones should remain in constant contact. The partial dislocation of the ankle bone on the heel bone results in excessive ankle bone motion. The ankle bone abnormally shifts forward, closing the naturally occurring space between the ankle and heel bones, called the sinus tarsi. The ankle bone also turns inward and can tilt downward.

Foot x-ray showing a stabile and aligned ankle bone compared to a partially dislocated ankle bone
Foot x-ray showing an ankle bone realigned on the heel - corrected stance and a partially dislocated ankle bone - relaxed stance

It may not seem that dramatic but you have to remember the average person takes thousands of steps per day, millions of steps a decade. Eventually, even a slight amount of excessive ankle bone motion can have severely damaging effects on the cartilage of the big toe joint.

The head of the 1st metatarsal is jamming into the base of the big toe from the excessive ankle bone motion. Seven tendons attach to the big toe. When the muscles contract, it creates excessive force from the tip of the toe pushing back onto the head of the 1st metatarsal.

The head of the 1st metatarsal is jamming into the base of the big toe from the excessive ankle bone motion.

The combination of forces narrows the big toe joint. When the heel lifts off the ground during the walking cycle, this forces the big toe to bend on the head of the metatarsal bone. The cartilage at the head of the metatarsal bone becomes damaged because the joint space is narrowed. This creates inflammation and uneven joint pressure – the ingredients needed to cause osteoarthritis.

The combination of forces narrows the big toe joint

What is the best treatment?

The treatment of big toe joint disease usually begins with injections, physical therapy, arch supports, and many others. Do those treatments make any sense? The cause of big toe joint pain begins with ankle bone instability. If you only provide a “treatment” to a big toe joint, that does not address the underlying cause. Think about getting a painful injection into your big toe joint. It feels better after the shot because of the numbing medication. The big toe joint has not been fixed; it’s just been numbed. The mechanics of the joint are still broken. The only difference is that without pain, you try to walk more. What does that do? It damages the joint even more.

Putting anti-inflammatory medicine, steroids, into the big toe joint won’t help anything either because the mechanical source of the inflammation is still there. Many other “promising” substances can be injected into the big toe joint. Just remember that until the ankle bone dislocation is fixed, those other treatments will be ineffective long-term.

Non surgical options cannot prevent the progression of big toe joint disease

Eventually, the pain is so bad that surgery seems to be the only, and hopefully, last option. There are many different types of joint replacement implants for the big toe joint. Hemi implants work to resurface one side of the joint. There are total implants that replace both sides of the joint. These devices seem to work great in the operating room, but what happens when the person stands and starts to walk? Well, that great result in the operating room doesn’t really work because the joint replacement focused on removing the diseased cartilage, but it did nothing to solve the underlying cause. The excessive abnormal forces are still attaching the big toe joint. Doctors need to consider that big toe joint disease is a mechanical issue. If you don’t fix the altered mechanics, then how can one expect to have a good outcome?

When the partial or total joint implants fail, surgeons will “fix” it by completely removing the big toe joint and fusing the big toe to the metatarsal. There was a reason why the big toe joint bends at the big toe joint and not within the big toe itself. Eliminating the motion of the big toe alters the forefoot mechanics. Plus, excessive ankle bone motion is still there. The ankle bone continues to partially dislocate with every step.

Joint replacement is not the answer. Limited joint motion i still present.

The first place to initiate treatment is to remove the underlying cause of the symptom. If you have pain in your heel from a nail that you stepped on, it makes sense that you first pull the nail out of your heel. Why would you take pain medicine or put some padding around the nail? Every step is pushing the nail deeper into your flesh. If big toe joint disease is associated with a partially dislocating ankle bone, then that ankle bone needs to be stabilized. External measures are not proven to stabilize and maintain the alignment of the ankle bone. The best method to stabilize and maintain the alignment of the ankle and heel bones is to insert a titanium spacer into the sinus tarsi (HyProCure). This soft tissue procedure instantly reduces/eliminates the first metatarsal from being jammed into the base of the big toe.

HyProCure prevents the ankle bone from sliding forward. The results can be seen instantly, depending on how much damage has occurred to the big toe joint. If caught early enough, the only surgery needed is to stabilize the ankle bone. If there is significant damage at the big toe joint, then additional surgery may be required.

HyProCure internally stabilizes the ankle bone on the heel bone to reduce/eliminate the excessive 1st metatarsal jamming into the base of the big toe

HyProCure is truly the answer to big toe joint disease. It is possible to have that disease prevented from getting progressively worse or maybe even allow the body to heal from the repeated, and never-ending micro-trauma within the big toe joint.

What happens if you don’t treat big toe joint disease?

Early intervention is critical when treating big toe joint pain. Walking on a partially dislocating ankle bone will lead to continued trauma to the big toe joint. The cartilage will continue to erode and wear away until it’s completely gone. The dislocating ankle bone doesn’t care because it will continue to exert its damage to the big toe joint. Eventually, after suffering from chronic pain, the decision to undergo surgery will be necessary. If you wait too long, your conservative surgical options will no longer be available and your only option will be irreversible surgical joint removal.

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