Understanding Painful Great Toe
Pain in the great toe, otherwise known as the first metatarsophalangeal joint, can be caused by osteoarthritis, rheumatoid arthritis, bone spurs, bunions and posttraumatic injuries.
Hallux limitus and hallux rigidus are terms used to describe the loss of motion in the first metatarsophalangeal joint with hallux rigidus being considered the end stage of hallux limitus. This is a challenging problem that can affect patients of all ages and activity levels. The majority of cases appear to be mechanically induced and are often associated with a long first metatarsal and fallen arch foot types. However, trauma such as a stubbing injury may also result in hallux limitus. Long-standing gout can be a contributing factor as well.
Osteoarthritis (OA), also known as degenerative arthritis, is the most common type of arthritis and usually develops slowly over several years. It occurs when there is a systematic loss of cushioning cartilage in the joints and the bones in the joint rub against one another; this can be very painful and reduce movement drastically in the joint. If the condition is not treated, the bones could overgrow and fuse together on their own causing a complete loss of function.
Rheumatoid Arthritis (RA) is an autoimmune disease that causes chronic inflammation of the joints. A typical joint in the body is made up of bones that move against each other and are held together by ligaments and a sheath (called a capsule) that surrounds the entire joint. The inner lining of the capsule is called the synovium. In rheumatoid arthritis, the synovium of the joint becomes inflamed and enlarged, eroding the neighboring bones, ligaments, and cartilage. The end result is damaged and painful joint surfaces.
Osteophytes, or bone spurs, are bony projections that form along joints. They are due to arthritis or damage of the joint, and they may limit joint movement and cause pain.
A bunion is an enlargement of bone or tissue around the joint at the base of the big toe. It is a condition caused by abnormal mechanics of the foot or congenital factors, such as flatfeet, abnormal bone structure, and neurological conditions. The end of the large toe, or the phalange, points toward the second toe causing the metatarsal to bump, or bow outward.
Common symptoms of osteoarthritis, rheumatoid arthritis, bone spurs, and/or a bunion are:
- Pain experienced when walking
- Joint tenderness
- Inflammation that may produce a mild warm feeling or occasional redness
- Significant stiffness of the toe
- Loss of function
Before considering surgery there are always non-operative treatments such as:
- Shoe modifications
- Cast immobilization with a reduction in activity
- Anti-inflammatory drugs
- Physical therapy
- Local injections
When non-operative solutions are no longer able to control the pain and disability, surgery becomes a reasonable option. Surgical options include:
Keller Arthroplasty – The base of the phalanx and the attached tendons are severed and approximately 1/3 to 1/2 of the phalange is removed. This decompresses the joint and allows soft tissue to in-grow. Complications may include flail toe, which is where the toe sticks up in the air, and a return of pain as there is still the potential for bone on bone contact.
Cheilectomy – Bone spurs on the top of the metatarsal head that interfere with movement are removed, thus allowing joint motion. Along with the Keller arthroplasty, a cheilectomy is simply the removal of bone without resurfacing the joint. The possibility of having bone on bone or diseased/damaged cartilage post surgery is still a concern.
Arthrodesis (Fusion) – The cartilage surfaces of the joint are removed and a device such as a screw or plate is utilized to prevent motion. The bones eventually grow together which prevents pain; however, a loss of function occurs as the joint will no longer bend. With this loss of motion, your gait, or way of walking, may change, which could affect other joints such as knees, hips, spine, etc. Additionally, shoe wear selection may be limited due to the inability to bend your toe.
Hemi-Joint Arthroplasty – The surface of the metatarsal head is reshaped and the phalange is resurfaced with a new, smooth-surfaced component. This eliminates the possibility of bone on bone contact, thereby reducing pain, while restoring motion and maintaining function of the toe. Great toe joint replacement is usually performed to treat severe arthritis conditions. Most patients with a great toe joint prosthesis are middle-aged and older, but the operation may be performed on younger patients at the discretion of the surgeon. Though motion and function should be restored, achieving the normal movement of a completely healthy joint may not be possible.