Big Toe Joint Arthritis
Let’s Meet the Big Toe Joint:
The big toe joint plays a very important role in gait and propelling the body forward when it flexes upward and pushes off the ground. A significant amount of force and pressure are imparted upon this joint with each step. The anatomy of the big toe joint includes: the big toe (hallux), the big toe joint cartilage (1st metatarsophalangeal joint), the 1st long bone (1st metatarsal), and the sesamoids. The normal big toe joint should be able to have an upward motion (dorsiflexion) of 50 to 90 degrees for normal function. When there is limited motion of the big toe it cannot propel the body forward efficiently leading to other joints of the body to compensate, adding undo strain through the rest of the foot and lower extremity. Pain and fatigue from this inefficient gait pattern will develop.
What is Arthritis?
Arthritis is simply damage to the cartilage of a joint. Each part of the body that moves has a joint between the bones that move. Cartilage is the material that lays over the surface of each bone of the joint. If there were no cartilage between a joint, the two bones would want to join together. Cartilage takes on a great deal of pressure and force and can absorb these forces very efficiently. However, cartilage is not strong when there is a sheering force applied to it or when it is fractured. Arthritis is a progressive disease that will compound on itself. Even a small amount of damaged cartilage, leads to an uneven amount of pressure within the joint and the bones will move upon the damaged surface and erode more and more of the cartilage until there is more bone contact. Any amount of damage to the cartilage of a joint is referred to as arthritis.
There are many types of arthritis. Some diseases like, Rheumatoid Arthritis, are an autoimmune problem where the body attacks its own cartilage. This kind of arthritis will affect the whole body equally. Osteoarthritis or Degenerative Joint Disease (DJD) is a problem that affects one joint at a time. There must be an external force, such as a fracture of the bone and joint, or a biomechanical deformity that leads to the deterioration of the joint.
What is Hallux Limitus / Rigidus?
Hallux Limitus or Rigidus is defined as limited motion to the big toe joint. The big toe joint plays a very important role in gait and propelling the body forward when it flexes upward and pushes off the ground. The normal big toe joint should be able to have an upward motion (dorsiflexion) of 50 to 90 degrees for normal function. When there is limited motion of the big toe it cannot propel the body forward efficiently leading to other joints of the body to compensate, adding undo strain through the rest of the foot and lower extremity. Pain and fatigue from this inefficient gait pattern will develop.
Arthritis of the big toe joint (hallux limitus /rigidus) is a deformity involving the big toe, the long bone behind it (1st metatarsal), and the joint between them. It usually presents as a form of osteoarthritis. It will usually affect one foot, but it can be symmetrical as well. As the cartilage begins to wear, and the toe bends with each step that is taken the bones rub against the worn defect. This constant pressure continually enlarges the amount of damaged cartilage. The space between the hallux and the 1st metatarsal becomes less and less, limiting the amount the toe can bend when walking. The limited bending causes the bones to jam into each other causing even more cartilage damage. The constant jamming of the joint stimulates extra bone growth, which is seen as a spur or growth of bone bump on the top of the joint. This spur additionally limits the motion of the joint, accelerating the joint damage. This becomes a vicious cycle of progressive damage. When there is arthritis, movement of the joint is painful. Arthritis is always progressive and will always get worse.
What are the Symptoms of Hallux Limitus / Rigidus?
Patients will complain of pain within the joint. The pain will be mild to severe depending on the amount of cartilage damage. The joint will move less and have a smaller range of motion than it used to. Patients will complain of a feeling of stiffness in the joint. Movement of the joint becomes painful and debilitating. Extra bone formation (bone spur) will appear on the top of the joint and sometimes the side of the joint. This spur is often painful to touch and will not allow use of tighter shoes. High heel shoes become harder to wear because the toe will not bend enough. Inflammation and swelling around the joint can be seen from day to day. Numbness and shooting pain into the toe is caused by nerve damage from the pressure of the extra bone and shoes over the nerves. Some patients will hear cracking and popping from the joint when it is moving.
What Causes Hallux Limitus / Rigidus?
An external force or an internal biomechanical deformity can cause big toe arthritis. Athletes, soldiers, ballet dancers, construction workers, and others that place great demand on the big toe joint can eventually develop arthritis. Constant micro damage to the joint from these activities will eventually lead to a significant loss of cartilage. A biomechanical disadvantage to the structure of the foot bones can cause damage to the joint. This can been seen when the 1st long bone (1st metatarsal) is too long, or too short, or too raised up, when compared to the other long bones. These structural abnormalities lead to poor movement of the big toe (hallux) on the joint leading to chronic micro trauma and arthritis. Fractures of the hallux or 1st metatarsal that involve the joint will lead to arthritis. Bone heals well after a fracture, while cartilage has difficulty healing. This means that there will be damage to the joint surface after a fracture leading to chronic micro trauma and progressive arthritis of the joint. Chronic Gout can lead to arthritis. Misalignment of the joint such as in a bunion (hallux abducto valgus) deformity can lead to arthritis.
How is Hallux Limitus / Rigidus Diagnosed?
Diagnosis is simply achieved by the clinical examination and x-rays of the patient. Dr. Soomekh will listen to the patient’s complaints, symptoms, and goals. The examination involves a hands-on analysis of the patient’s foot and evaluating their gait. Digital radiographs (x-rays) of the feet will be obtained and reviewed with the patient. The positions of the bones and joints evaluated on the x-rays help to determine the severity of the deformity and any associated deformities. In some cases CT scan, performed in the office, is used to determine the quality of the bone and the cartilage.
How is Hallux Limitus / Rigidus treated?
Dr. Soomekh educates that early diagnosis and treatment of hallux limitus are the keys to successful treatment, faster recovery and painless lifestyle.
Conservative Treatment For Hallux Rigidus:
Joints do not have a significant blood supply. For this reason it is difficult for joints to repair damage on their own.
Conservative treatments rely on their ability to accommodate big toe arthritis. This can be achieved by wearing appropriate shoes with a wide toe box and stiff sole. A stiff soled shoe reduces the amount of movement in the joint leading to less pain with each step. Rocker-bottom shoes will roll the foot forward leading to less movement of the joint. Reducing the activities that cause pain and damage to the joint can help to reduce the painful inflammation and the progressive wear on the joint. Padding over the bone spur bump can take the pressure off the area. Ice and anti-inflammatories can reduce the irritation when there is a flare. Custom molded orthotics can be made as an important tool to slow the progression of the damage to the joint in cases of a biomechanical deformity.
Injected steroids are catabolic. This means that they break down tissue. They are used in an effort to reduce inflammation and scar tissue that are a secondary cause of pain within the arthritic joint. They cannot reverse or heal any damaged cartilage. They are used to bring temporary relief. There is a limit to the number of these injections that are recommended. Dr. Soomekh offers this injection with little discomfort in the office setting under ultrasound guidance for precision. There is no restriction of activity after this type of injection. Most patient’s pain will return over time.
Joint Fluid Replacement (Hyaluronic Acid Injection, Supartz):
Dr. Soomekh offers an injectable material that can lubricate the joint. This fluid has been shown to help the joint move with less irritation and damage to the cartilage. This can translate to less pain within the joint. Some studies even show mild regeneration of cartilage after these injections. Most patients will need multiple injections over time to achieve relief. There is no limit to the number of injections. Dr. Soomekh offers this injection with little discomfort in the office setting under ultrasound guidance for precision.
PRP – Platelet Rich Plasma Therapy:
Platelets are the cells that produce the healing factors in the body. When there is an injury, platelets rush to the area to begin the healing process. In a chronic injury there are very little platelets in the area to aid in repair. The introduction of platelets by injection can lead to a higher concentration that may be able to better aid in the healing process. In the office setting, a small amount of blood is taken from the patient. The blood is spun in a centrifuge to filter the platelets from the other blood products and obtain the PRP. The PRP is then injected into the big toe joint. Dr. Soomekh performs this injection with little discomfort under ultrasound guidance for precision. Read more about PRP.
Surgical treatment for Hallux Rigidus:
Dr. Soomekh will always recommend and attempt conservative treatment when appropriate. However, when hallux limitus becomes painful, daily activities become a struggle, and conservative treatments have failed, surgical repair may be indicated.
Considering surgery can be intimidating. Foot surgery including surgery to correct hallux limitus is not supposed to be painful during recovery. When the skin and the soft tissues are handled with care and focus, most patients experience little to no pain immediately after surgery and throughout the recovery period. Dr. Soomekh takes great care and focus to minimize the chance of postoperative pain. The goal of surgery to correct hallux limitus is to remove any extra bone, clean out the joint, promote new cartilage growth when possible, alleviate pain, allow a return to normal shoes, and allow a return to activities. Most procedures allow for immediate walking and a return to work while wearing a special walking boot. Dr. Soomekh performs the procedures in an outpatient setting at state of the art facilities.
There are many different procedures and techniques to treat hallux limitus. It is the responsibility of the surgeon to investigate each specific aspect of the deformity for each individual patient in order to formulate the proper procedure for repair. Dr. Soomekh will use the information gained from the patient’s symptoms, age, activity level, lifestyle goals, the severity of the deformity, the clinical examination, the patient’s gait, and the x-rays, to make a recommendation on the proper procedure.
Mild to Moderate Arthritis:
Cheilectomy (Cleaning out the Joint):
The purpose of this procedure is to buy the joint some more time before it becomes even more arthritic. The earlier in the disease process that this procedure is performed, the more rewarding it will be for the patient. A small incision is made on the side of the big toe joint. Any extra bone around the joint is removed. Any floating pieces of cartilage or bone are removed. A precision cut is made at the head of the 1st metatarsal to remove even more bone to allow for the big toe move over the joint more easily. Any areas of missing cartilage are stimulated to promote new growth of cartilage. Dr. Soomekh will then close the skin using plastic surgery techniques. The patient is able to bear wight in an assistive boot immediately for 2 to 3 weeks, then move into an athletic shoe. The patient will begin immediate range of motion exercises.
In some cases, Dr. Soomekh may offer the patient the placement of a regenerative human umbilical cord graft material (Amniox) in order to lessen scar tissue within the joint. This will allow for increased range of motion in the long run. The addition of Bone Marrow Aspirate (BMA) may be offered to promote new cartilage formation.
Moderate to Severe Arthritis:
CarTIVA® Synthetic cartilage implant:
This was a revolution in the treatment of Big Toe Joint Arthritis over the last couple years. The research had shown the implant to be reliable and long lasting and stable. Our experience using this implant for our patients has not been as rewarding. We are seeing more complications, as well as our colleagues as well. The implant can begin to sink into the bone farther than where it was placed, leading to a failure of the implant. We have also seen that the area of coverage for the implant may not be sufficient. At this time, we are reserving the use of the implant to a very select patient population. The Cartiva® Synthetic Cartilage Implant is used to replace the areas of lost cartilage on the joint (1st metatarsal head) with a synthetic material made from those used to make contact lenses. The implant is a dense “silicone like” material that mimics cartilage. The purpose of the procedure is to replace poor cartilage with an implant, while preserving the contour of the joint, maintaining the bone structure, increasing the range of motion of the joint, and eliminating pain. A cheilectomy (cleaning out of the joint) is performed. A drill hole is made into the bone at the level of the joint. The implant is then placed into the hole. Dr. Soomekh will then close the skin using plastic surgery techniques. The patient is able to bear weight in an assistive boot immediately for 2 to 3 weeks, then move into an athletic shoe. The patient will begin immediate range of motion exercises.
The purpose of this procedure is to clean out the joint while also shortening the 1st metatarsal to allow more room in the joint for the big toe to move on the long bone. An incision is made on the side of the big toe joint. Any extra bone around the joint is removed. Any floating pieces of cartilage or bone are removed. A precision cut is made at the head of the 1st metatarsal (osteotomy) removing a section of bone. This head is now allowed to shorten closing the gap created in the bone cut, giving more room to the joint. This bone is then stabilized with 1 or 2 small screws. The screws hold the bone in its new corrected position while the bone heals. Once the bone heals, the screws are not needed and are generally not removed. Any areas of missing cartilage are stimulated to promote new growth of cartilage. Dr. Soomekh will then close the skin using plastic surgery techniques.
Cartilage Grafting with Stem Cell Therapy:
The purpose of this procedure is an attempt to replace large areas of missing cartilage with new cartilage growth. It is usually performed in addition to the earlier mentioned procedures. Stem cells are special cells that have not decided (differentiated) what type of tissue they will become. When these stem cells are placed near cartilage, they become cartilage. Stem cells can be found within the bone marrow. The area of missing cartilage is prepared and stimulated. Bone Marrow Aspirate (BMA) is obtained from the patient’s own heel bone. The stem cells are obtained from the BMA. Donated human cartilage graft, Denovo®, is then mixed with the BMA. The cartilage graft is then placed upon the defect of the joint. Over time, the patient will incorporate the new cartilage graft and use it as a scaffold to build new cartilage.
Big Toe Joint Replacement with Arthrosurface impant:
In severe cases of arthritis, where one part of the joint may still be viable, some may be a candidate for a joint replacement. This is a wonderful procedure. The purpose of this procedure is to replace the missing cartilage and bone with a new metal joint. This will allow for pain free motion of the joint. Dr. Soomekh uses the most advanced implants available. An incision is made on the side of the big toe joint. Any extra bone around the joint is removed. The surface of one side of the joint (the more damaged side) is prepared by removing all the remaining cartilage and some bone. A special sized hemi-implant is placed and anchored into the bone. Dr. Soomekh will then close the skin using plastic surgery techniques. The patient is able to bear wight in an assistive boot immediately for 2 to 3 weeks, then move into an athletic shoe. The patient will begin immediate range of motion exercises.
Big Toe Joint Fusion (Arthrodesis):
The purpose of a fusion of the big toe joint is to remove the joint and take away all movement. No movement = No pain. This procedure joins the big toe bone (phalanx) and the 1st metatarsal into one bone. The fusion of this joint still allows for normal walking and some activity. An incision is made on the side of the big toe joint. Any extra bone around the joint is removed. The surfaces of each bone are prepared by removing all the remaining cartilage. The 2 bones are brought together and 2 small screws are placed across the joint. The screws hold the bone in its new corrected position while the bone heals into one. Once the bone heals, the screws are not needed and are generally not removed. In some cases a plate may also be used to hold the bones together. Dr. Soomekh will then close the skin using plastic surgery techniques.
In some cases, Dr. Soomekh may offer the patient the addition of Bone Marrow Aspirate (BMA) with Platelet Rich Plasma (PRP) to facilitate the fusion. Stem cells are special cells that have not decided (differentiated) what type of tissue they will become. When these stem cells are placed near bone, they become bone. Stem cells can be found within the bone marrow. Bone Marrow Aspirate (BMA) is obtained from the patient’s own heel bone. The stem cells are obtained from the BMA and mixed with PRP (the healing factors). The material is then placed into the space between the bones.
Dr. Soomekh has perfected and reinvented these surgical procedures and techniques and is recognized by his peers as one of the top arthritis specialists and surgeons in the Los Angeles area.