Hallux rigidus is a form of arthritis that affects the first metatarsophalangeal (MTP) joint, the joint where the big toe connects to the foot. Over time, this joint becomes stiff and painful, making it difficult to walk, especially during the push-off phase of gait. The condition progresses gradually, beginning with mild discomfort and reduced motion, and may eventually result in near-complete loss of movement and the formation of painful bone spurs (osteophytes).
How Common It Is and Who Gets It? (Epidemiology)
Hallux rigidus is the most common arthritic condition of the big toe, typically affecting adults between the ages of 30 and 60. It affects both men and women but tends to be more symptomatic in women due to footwear and activity-related factors. Risk factors include previous trauma or stubbing injuries to the toe, repetitive stress from sports or work, family history of osteoarthritis, and abnormal foot mechanics such as a long first metatarsal or flatfoot deformity.
Why It Happens – Causes (Etiology and Pathophysiology)
The condition develops when the cartilage lining the MTP joint wears down due to degenerative or traumatic arthritis. The joint becomes inflamed, resulting in stiffness, swelling, and formation of bone spurs along the top of the joint. Common causes include osteoarthritis (wear-and-tear arthritis), post-traumatic arthritis after a fracture or joint injury, repetitive microtrauma from overuse, and anatomic factors such as a long or elevated first metatarsal. As the cartilage deteriorates, the joint space narrows, and bone spurs restrict motion further, creating a cycle of pain and stiffness.
How the Body Part Normally Works? (Relevant Anatomy)
The first MTP joint is critical for walking—it provides propulsion during push-off and supports balance. Normal motion includes about 60–70 degrees of extension (upward bend) and 15–20 degrees of flexion (downward bend). In hallux rigidus, this motion decreases dramatically, often to less than 10–20 degrees of extension, which alters gait mechanics and increases stress on other parts of the foot.
What You Might Feel – Symptoms (Clinical Presentation)
Pain and stiffness at the base of the big toe are the most common symptoms, especially during walking or running. Patients may notice swelling and inflammation around the joint, a visible bump over the top of the toe, and difficulty wearing shoes that press on the joint. As the condition worsens, walking becomes painful, and some may limp or shift weight to the outer foot to avoid pressure on the toe.
How Doctors Find the Problem? (Diagnosis and Imaging)
Diagnosis begins with a clinical exam and X-rays. The doctor tests toe motion, identifies tenderness, and evaluates bony enlargement. X-rays reveal joint space narrowing, bone spurs, and degenerative changes. The severity is often classified as mild, moderate, or severe based on cartilage loss and the extent of motion restriction.
Other Problems That Can Feel Similar (Differential Diagnosis)
Other causes of pain in the big toe joint include gout, sesamoiditis, turf toe, Freiberg’s disease, or metatarsalgia. Imaging and examination help distinguish hallux rigidus from these conditions.
Treatment Options
Non-Surgical Care
Conservative management is the first step for mild to moderate cases. Treatments include rest and ice, footwear modification (stiff-soled or rocker-bottom shoes), orthotic inserts to offload pressure, anti-inflammatory medications, and corticosteroid injections for temporary relief. These measures help reduce pain and improve comfort but do not reverse joint damage.
Surgical Care – Cheilectomy (CPT 28289)
A cheilectomy is the preferred surgical option for mild to moderate hallux rigidus (Grades 1–2). It aims to relieve pain and improve motion without sacrificing the joint. The procedure involves making a small incision over the top of the MTP joint, removing bone spurs, and trimming the metatarsal head to restore clearance for movement. Any inflamed tissue or loose cartilage is also removed before the incision is closed. Minimally invasive techniques can achieve the same results through tiny incisions, reducing recovery time and scarring.
Recovery and What to Expect After Treatment
Patients can usually bear weight in a post-surgical shoe soon after surgery. Swelling improves within a few weeks, and gentle motion exercises begin early to prevent stiffness. Physical therapy is important for restoring flexibility and strength. Most patients resume normal walking within four to six weeks and return to sports or high-impact activities within three months.
Possible Risks or Side Effects (Complications)
Complications are uncommon but may include infection, nerve irritation, recurrence of bone spurs, persistent stiffness, or progression of arthritis. If arthritis advances, further procedures like joint fusion (arthrodesis) or joint replacement may be required later.
Long-Term Outlook (Prognosis)
Cheilectomy provides excellent pain relief and improved joint mobility for most patients. Studies report success rates of 85–90%, with lasting benefits for many years. The procedure slows but does not stop arthritis progression. Patients with more advanced damage may eventually need additional surgery, but many maintain normal function for a long time after cheilectomy.
Out-of-Pocket Cost
Medicare
CPT Code 28289 – Cheilectomy (Excision of Bone Spurs or Debridement of the First MTP Joint): $157.62
Medicare Part B typically covers 80% of the approved cost for this procedure once your annual deductible has been met, leaving you responsible for the remaining 20%. Supplemental Insurance plans such as Medigap, AARP, or Blue Cross Blue Shield generally cover that remaining 20%, minimizing or eliminating out-of-pocket expenses for Medicare-approved surgeries. These plans coordinate with Medicare to fill the coverage gap and reduce the patient’s overall financial responsibility.
If you have Secondary Insurance, such as TRICARE, an Employer-Based Plan, or Veterans Health Administration coverage, it acts as a secondary payer. These plans usually cover any remaining coinsurance or small deductibles, which typically range between $100 and $300, depending on your plan and provider network.
Workers’ Compensation
If your cheilectomy is needed because of a work-related injury or repetitive stress condition, Workers’ Compensation will cover all medical expenses, including surgery, postoperative care, and rehabilitation. You will not have any out-of-pocket costs, as the employer’s insurance carrier pays directly for all approved treatments.
No-Fault Insurance
If your joint damage or bone spur formation requiring cheilectomy is related to an automobile accident, No-Fault Insurance will typically cover the total cost of treatment, including surgery and postoperative care. The only potential out-of-pocket cost may be a small deductible or co-payment, depending on your insurance policy.
Example
Jennifer Collins underwent a cheilectomy (CPT 28289) to remove bone spurs and improve motion in her big toe joint. Her estimated Medicare out-of-pocket cost was $157.62. Because Jennifer had supplemental coverage through Blue Cross Blue Shield, her remaining balance was fully covered, leaving her with no out-of-pocket expenses for the procedure.
Frequently Asked Questions (FAQ)
Q. What is Hallux Rigidus?
A. Hallux rigidus is a condition that causes stiffness and pain in the first metatarsophalangeal (MTP) joint of the big toe due to arthritis or wear and tear, leading to difficulty in bending the toe, especially during walking or running.
Q. What is a Cheilectomy?
A. A cheilectomy is a surgical procedure performed to treat hallux rigidus, where bone spurs and damaged tissue are removed from the joint to improve range of motion and reduce pain.
Q. When is Cheilectomy recommended?
A. Cheilectomy is recommended for patients with moderate hallux rigidus where non-surgical treatments have failed, and surgery is necessary to alleviate pain and improve mobility in the big toe.
Q. How is a Cheilectomy performed?
A. The procedure involves making an incision over the joint, removing the bone spurs, and cleaning the joint. This helps reduce pain and increases the toe’s ability to move.
Q. What are the benefits of Cheilectomy?
A. The main benefits include pain relief, improved joint mobility, and a restored ability to perform normal activities, especially walking, without pain in the big toe.
Q. What is the recovery process after a Cheilectomy?
A. Recovery typically involves rest and wearing a special shoe for several weeks. Physical therapy may be recommended to restore mobility, with most patients resuming normal activities within a few weeks.
Q. What are the risks associated with Cheilectomy surgery?
A. Risks include infection, nerve damage, recurrence of symptoms, and limited motion if the surgery does not fully address the underlying arthritis. However, these complications are rare.
Q. Can I return to sports after a Cheilectomy?
A. Most patients can return to low-impact activities within a few weeks, while high-impact sports may be resumed after 3 to 6 months, depending on the healing progress and individual recovery.
Q. How long does the Cheilectomy procedure take?
A. The procedure typically takes about 30 to 60 minutes, depending on the severity of the hallux rigidus and whether additional procedures are required during the surgery.
Q. Will I need to wear a cast after Cheilectomy surgery?
A. A cast is not typically required after a Cheilectomy. However, you will likely need to wear a special post-surgical shoe or boot for a few weeks to protect the toe and ensure proper healing.
Q. Can Cheilectomy be performed on both feet at the same time?
A. While it is possible to perform the surgery on both feet, it is generally recommended to treat one foot at a time to allow for optimal healing and reduce the risk of complications.
Q. Will I experience any stiffness after Cheilectomy surgery?
A. Some stiffness may occur initially after surgery, but physical therapy and rehabilitation are typically effective in restoring mobility and flexibility to the toe.
Q. Is Cheilectomy a permanent solution for Hallux Rigidus?
A. Yes, Cheilectomy can be a long-term solution for managing hallux rigidus, especially in mild to moderate cases. However, for severe cases, further surgery such as joint fusion or replacement may be required.
Q. Can Cheilectomy treat all cases of Hallux Rigidus?
A. Cheilectomy is most effective for mild to moderate cases of hallux rigidus. In advanced cases where joint damage is more extensive, alternative procedures like joint fusion or total joint replacement may be necessary.
Q. How soon can I drive after Cheilectomy surgery?
A. Most patients can drive within 1 to 2 weeks after surgery, as long as they are no longer using narcotic pain medications and have regained sufficient mobility to safely operate a vehicle.
Q. Will the Cheilectomy procedure change the appearance of my foot?
A. The surgery is designed to alleviate pain and improve function rather than alter the appearance of the foot. While there may be slight changes in the joint’s shape, the primary goal is restoring function and reducing pain.
Summary and Takeaway
Hallux rigidus causes stiffness and pain in the big toe joint, limiting walking and daily function. Cheilectomy is a safe, effective surgical treatment that removes bone spurs and restores mobility for patients with mild to moderate arthritis. It provides long-lasting relief, improves quality of life, and delays the need for more extensive surgery such as joint fusion.
Clinical Insight & Recent Findings
A recent study compared outcomes between minimally invasive (MIS) and open cheilectomy for treating hallux rigidus, a painful stiffness of the big toe joint. Reviewing 24 studies involving over 1,100 patients, researchers found that both techniques produced similar improvements in pain relief, mobility, and patient satisfaction.
However, open cheilectomy showed more complications (14.7%) such as persistent pain and nerve symptoms, while MIS cheilectomy had fewer complications (8.2%) but a higher rate of revision surgeries (9.3% vs. 5.0%)—often requiring further bone spur removal or joint fusion.
Overall, MIS cheilectomy offers a less invasive alternative with comparable results, though it may carry a slightly higher chance of needing additional surgery later. (“Study comparing minimally invasive vs. open cheilectomy for hallux rigidus – see PubMed.“)
Who Performs This Treatment? (Specialists and Team Involved)
Cheilectomy is performed by an orthopedic foot and ankle surgeon or a podiatric surgeon trained in forefoot reconstruction. The care team may include anesthesiologists, nurses, and physical therapists for postoperative care.
When to See a Specialist?
See a foot and ankle specialist if you experience ongoing big toe pain, stiffness, or swelling that does not improve with rest or shoe modifications.
When to Go to the Emergency Room?
Go to the emergency room if you develop severe swelling, redness, warmth, fever, or an inability to bear weight after surgery, as these may indicate infection or complications.
What Recovery Really Looks Like?
The first few weeks focus on rest, elevation, and light walking in a post-surgical shoe. Physical therapy begins early to maintain joint motion, and most patients walk normally within six to eight weeks with improved comfort and mobility.
What Happens If You Ignore It?
Untreated hallux rigidus leads to worsening arthritis, chronic pain, and limited motion. Walking mechanics can become abnormal, putting stress on the knees, hips, and lower back.
How to Prevent It?
Wear supportive shoes with wide toe boxes, avoid repetitive high-impact activities, maintain a healthy weight, and address minor foot injuries promptly.
Nutrition and Bone or Joint Health
A diet rich in omega-3 fatty acids, calcium, vitamin D, and antioxidants supports joint health and reduces inflammation. Maintaining a healthy weight reduces pressure on the big toe joint.
Activity and Lifestyle Modifications
After recovery, most patients return to normal activities comfortably. Using supportive footwear, stretching the toe regularly, and avoiding tight shoes can help maintain results and prevent recurrence.
Dr. Mo Athar
