What is hallux rigidus and how is it treated in older adults?

What is Hallux Rigidus?

Hallux rigidus is arthritis of the first metatarsophalangeal (MTP) joint characterized by diseased cartilage, large periarticular osteophytes, and progressive stiffness that causes a painful, rigid big toe. 1

Clinical Presentation

The condition manifests with specific features that distinguish it from other foot pathologies:

• Pain and stiffness at the base of the big toe, particularly with dorsiflexion (upward bending) 1, 2
• Palpable bony prominences (osteophytes) around the joint that can be felt on examination 1, 2
• Progressive loss of motion, especially dorsiflexion, which worsens over time 1, 3
• Occasional joint swelling (synovitis) during inflammatory episodes 2
• Positive axial grind test when the joint is compressed and rotated 2

The diagnosis should be made when at least 4 of these features are present: pain, stiffness, palpable exostosis, positive radiographic findings, positive axial grind test, occasional synovitis, and decreased motion on examination. 2

Epidemiology

Hallux rigidus is particularly common in adults aged 31-69 years and represents one of the most frequent sources of disabling foot pain in the adult population. 1, 2

Treatment Approach in Older Adults

Conservative Management (First-Line)

Begin with non-operative measures, which should be attempted before any surgical consideration: 1

• Activity modification to avoid aggravating movements 1
• Appropriate footwear with rigid soles and adequate toe box space; "punching out" shoes over the dorsal prominence can provide relief 1, 2
• Orthotic devices to limit motion and reduce stress on the joint 1
• Topical NSAIDs (diclofenac gel) applied 3-4 times daily as first-line pharmacologic treatment in elderly patients to minimize systemic exposure 4
• Oral acetaminophen up to 3-4 grams daily as the safest systemic analgesic option 4
• Intra-articular corticosteroid injections (triamcinolone hexacetonide) for acute pain episodes, especially with inflammation or effusion 4, 1

A critical pitfall: avoid oral NSAIDs in elderly patients with cardiac, renal, or fluid retention concerns due to significant risks of exacerbating these conditions. 4, 5

Surgical Options (When Conservative Treatment Fails)

Surgery should only be considered after 6+ months of comprehensive non-surgical treatment has failed and symptoms substantially affect quality of life. 4

The surgical approach depends on disease severity:

For Mild to Moderate Disease (Stage I-II):

• Cheilectomy (removal of dorsal osteophytes and diseased cartilage) is the procedure of choice for dorsal impingement pain 1, 3
• Corrective osteotomy of the phalanx or first metatarsal can be added if needed 3

For Advanced Disease (Stage III-IV):

• Arthrodesis (joint fusion) remains the gold standard treatment due to predictable, reliable outcomes 1, 3, 6
• Total joint replacement can achieve similar results to arthrodesis in strictly selected patients treated by experienced foot surgeons, with 85.7% patient satisfaction reported at 8.8-year follow-up 6
• Resection arthroplasty (Keller-Brandes procedure) is an option for less active elderly patients 3

Surgical Complications to Monitor

Common complications vary by procedure type:

• Joint-preserving techniques: progression of arthritis, continued pain, transfer metatarsalgia 7
• Arthrodesis: nonunion, malunion, incorrect toe positioning, interphalangeal joint arthritis 3, 7
• Arthroplasty: component loosening (11% in one series), bone loss with implant failure requiring revision 7, 6

Alternative Therapies

Foot mobilization and manipulation may provide marked pain reduction in some patients, though evidence is limited to case reports. 2 This can be considered as an adjunct to standard conservative care but should not replace proven treatments.