Osteoarthritis of the Big Toe Joint

This common condition is the cause of significant pain and disability. A painful big toe joint with reduced range of motion will affect the way you walk and is often the source of pain on the outside of your foot and possibly ankle and knee pain.

Causes of Ostearthritis of the big toe joint

Arthritis of the big toe joint is commonly due to a combination of biomechanics and trauma. This can be repetitive, or occasionally, people recall a single incident that they believe precipitated the painful joint. As with osteoarthrosis of other joints, there is often no obvious cause. X Ray may reveal a relatively long first metatarsal. Clinical examination may demonstrate a hypermobile foot. Other causes of pain in the big toe joint include inflammation of the joint capsule and occasionally gout.

Conservative management

The non-surgical management of an arthritic big toe joint often involves a combination of shoe modification, orthoses, physiotherapy and steroid injections.

The benefit from conservative measures depends on the level of mobility and pain. If the range of motion is reasonable shoe modification such as wearing a stiff soled shoe may be of benefit.

When there is inflammation of the soft tissue around the joint and the arthritis in the big toe joint is minimal manipulation under anesthetic and steroid infiltration into the joint may relieve symptoms and delay surgery. Repeat steroid injection is contraindicated in a relatively preserved joint as this will lead to more speedy degeneration of the articulating cartilage.

A series of physiotherapy treatments employing manipulation and pain relieving techniques(ultrasound,laser) may be of benefit.

Orthoses can play a major role in force redistribution and can be attempted in early onset of pain and reduced joint mobility.

When these modalities do not resolve the pain or restore function to the foot then a surgical solution may be required.

Surgery

The main criterion for surgical management is pain. Osteoarthritis within the big toe joint often presents as a painful bony prominence that rubs on the shoe along with painful restricted motion of the joint. Frequently however, people present with stiffness of the joint but no discomfort and the indications for surgery depend on the extent of the arthritis and symptoms.

The history and level of pain are vital in choosing the correct surgical approach. Removal of the bony prominence (Cheilectomy) may resolve the discomfort from footwear but might generate pain within the joint by increasing the range of motion. The surgical objective must therefore be to preserve the joint where possible but to recognize the need for joint destructive procedures when necessary.

The commonest surgical procedures for significant osteoarthritis of the first MTP joint are Cheilectomy, Keller arthroplasty, decompressive osteotomy, Big toe joint arthrodesis/fusion and joint implant surgery.

Big Toe Joint Cheilectomy

Occasionally people present with a thickened big toe joint with restricted motion and a bony prominence on top of the joint. In these patients the bony prominence rubs on the upper part of the shoe and causes pain whilst the joint itself is asymptomatic.

In this situation simple removal of the dorsal "bump" may cure the problem.

The aim of a simple cheilectomy is to remove the bony prominence without affecting the joint. This relatively straightforward procedure can bring early pain relief and patient satisfaction. If there are obvious biomechanical issues causing pain then these must be addressed

Keller Arthroplasty

This was described by Keller in 1904. This procedure involves removal of the arthritic joint leaving a gap between the big to and the metatarsal bone. This is a good procedure when used for people who fulfill specific criteria. The indications for the Keller arthroplasty are for people who have a painful deformed big toe joint with evidence of significant degenerative changes. The amount of bone removed from the big toe is critical. Excessive bone removal leads to shortening of the hallux (big toe) and reduction in hallux purchase of the ground. As the hallux has a major role in propulsion and takes approximately 80% of digital load, this can have a significant affect on foot function. If inadequate bone is removed, the hallux may abut the metatarsal head and the joint will continue to be restricted and painful

In the appropriate candidate the Keller arthroplasty continues to be an excellent procedure giving pain relief and rapid post operative recovery.

Decompressive Osteotomy

The principle behind the decompressive osteotomy is to open the joint space between the head of the first metatarsal and base of the big toe. This decompression will allow for an increased range of motion at the big toe joint and resolve pain. The most obvious indication for this procedure is when there is clear radiographic evidence of a long first metatarsal with minor to moderate arthritic changes at the big toe joint.

In this procedure a wedge of bone is removed from the 1st metatarsal thus shortening the length of the first metatarsal and increasing first MTP joint range of motion.

Fusion of the Big Toe Joint

Fusion/Arthrodesis of the big toe joint is a common procedure indicated where the arthritis in the joint is advanced and the pain significant. The procedure involes removing the arthritic joint and fusing the bones together using an internal plate or screws. This will bring about pain relief but the joint will be fused and not move. For some people, especially women who like to wear high heels there may be some difficulty with accommodating this type of foot wear but in normal shoes the foot copes well and the outcome of this surgery is normally good.

Swanson Joint Replacement

An alternative to fusing the joint is to have a silastic joint spacer. This is a small gel like spacer placed in between the big toe and 1st Metatarsal. The benefit of this procedure is a mobile joint and a relatively quick recovery. There are many different joints available but the one I use has been available for many years and is the NICE recommended joint.

The video below demonstrates a joint replacement procedure. Please only view this video if you wish to see a surgical procedure.

Conclusion

There are a variety of procedures available to address a painful osteoarthritic big toe joint. These range from conservative to surgical procedures and from non joint destructive procedures such as cheilectomy and joint decompression to removal of one or both articulating surfaces via the Keller, fusion and silastic implant procedures. The level of deformity, state of the articulating cartilage, your health and mobility will help to determine the procedure of choice.