Hallux Rigidus: Osteoarthritis of the First MTP Joint
Hallux rigidus, also known as osteoarthritis of the first metatarsophalangeal (MTP) joint, is a common cause of stiffness and pain in the big toe. This joint, located at the base of the great toe, plays a vital role in walking and balance. When arthritis damages the joint, it limits the toe’s ability to bend upward, making everyday activities like walking or climbing stairs painful. Over time, bone spurs may develop, and the joint may become increasingly stiff.
How Common It Is and Who Gets It? (Epidemiology)
Hallux rigidus most often affects middle-aged and older adults, although it can occur earlier, particularly after injury. It may affect one or both feet, but is often unilateral. Studies suggest that about 2–3 % of people over 50 experience first MTP joint arthritis, with a slightly higher frequency in women.
Why It Happens – Causes (Etiology and Pathophysiology)
In most patients, hallux rigidus results from degenerative wear and tear of the joint surfaces. The cartilage covering the bones gradually breaks down, leading to pain, stiffness, and formation of bony growths (osteophytes).
It can also occur after repetitive minor injuries or trauma that damages the cartilage. As the dorsal (top) part of the joint deteriorates, bone spurs form that mechanically block toe motion, particularly when bending upward (dorsiflexion). Some cases are related to abnormal foot mechanics, genetics, or inflammatory conditions such as gout or rheumatoid arthritis.
How the Body Part Normally Works? (Relevant Anatomy)
The first MTP joint connects the head of the first metatarsal bone to the base of the proximal phalanx of the big toe. Smooth cartilage allows painless gliding during motion, and the extensor hallucis longus tendon lifts the toe during walking. The dorsal joint capsule and surrounding ligaments stabilize the joint while permitting movement. Proper motion here is essential for push-off during each step.
What You Might Feel – Symptoms (Clinical Presentation)
Patients typically experience pain and stiffness in the big-toe joint, especially during walking, running, or standing on tiptoe. A bony bump may be felt on the top of the toe, and painful push-off is common. As the condition progresses, motion becomes limited, and swelling or inflammation can occur around the joint.
How Doctors Find the Problem? (Diagnosis and Imaging)
Diagnosis begins with a physical examination. The doctor will check toe movement, look for tenderness or bony enlargement, and assess gait.
X-rays confirm the diagnosis by showing joint-space narrowing, flattening of the metatarsal head, and dorsal bone spurs. The severity is graded based on the amount of joint-space loss and motion restriction.
Classification
Hallux rigidus is classified from mild to severe depending on:
- Amount of cartilage loss
- Degree of motion limitation
- Size of osteophytes (bone spurs)
Mild cases have preserved motion with early spur formation, while severe cases show almost complete joint destruction and fusion tendency.
Other Problems That Can Feel Similar (Differential Diagnosis)
Several other conditions can mimic hallux rigidus:
- Turf-toe injuries (sprains of the MTP joint)
- Gout, which causes sudden, intense joint pain
- Sesamoid disorders under the first metatarsal head
- Hallux valgus (bunions) with medial joint pain.
Treatment Options
Non-Surgical Care
Early or moderate disease can often be managed without surgery:
- Shoe modifications such as stiff or rocker-bottom soles to limit painful motion
- Orthotic inserts that reduce pressure on the joint
- Activity modification to avoid excessive bending
- Anti-inflammatory medications (NSAIDs) for pain control
- Corticosteroid or hyaluronic-acid injections for temporary relief
Surgical Care
When pain persists despite conservative treatment, surgery may be recommended. Surgical choices depend on how damaged the joint is:
- Cheilectomy – removal of bone spurs and part of the metatarsal head to improve motion; ideal for early disease.
- Moberg or decompression osteotomy – adjusts bone position to shift motion to a healthier part of the joint.
- Arthrodesis (fusion) – eliminates motion at the joint for end-stage arthritis, reliably relieving pain.
- Joint replacement (arthroplasty) – in selected cases, preserves movement using synthetic or partial implants.
Recovery and What to Expect After Treatment
Recovery depends on the chosen treatment.
- After cheilectomy, patients often walk in a stiff-soled shoe within days, with gradual return to full activity over several weeks.
- Fusion requires a longer recovery, with limited weight-bearing for about six weeks until the bones heal.
Physical therapy helps restore strength and flexibility following surgery.
Possible Risks or Side Effects (Complications)
Most patients heal well, but possible complications include:
- Persistent stiffness or pain
- Incomplete pain relief after cheilectomy
- Nonunion (bones not fusing) after arthrodesis—though this is rare with modern techniques.
Long-Term Outlook (Prognosis)
For early disease, cheilectomy successfully relieves pain and improves motion in most patients. In advanced arthritis, fusion offers the most predictable pain relief and allows comfortable walking, though toe movement is lost. Overall, patients achieve excellent function with the right procedure.
Out-of-Pocket Cost
Medicare
CPT Code 28289 (Cheilectomy): $157.62
CPT Code 28750 (Arthrodesis): $178.82
CPT Code 28291 (Joint Replacement): $154.56
Medicare usually covers 80% of the approved cost, leaving patients responsible for 20%. Most supplemental insurance plans—such as Medigap, AARP, or Blue Cross Blue Shield—cover this 20% coinsurance. Secondary insurance (such as TRICARE or employer health plans) may also pay any remaining deductible or coinsurance.
Workers’ Compensation
If the arthritis or surgery is related to a workplace injury, Workers’ Compensation typically covers all medical, surgical, and rehabilitation costs with no out-of-pocket expenses for the patient.
No-Fault Insurance
If the condition results from a motor vehicle accident, No-Fault insurance generally pays for all medical expenses related to the injury, subject to policy limits.
Example
James underwent a cheilectomy (CPT 28289). His total Medicare-approved amount was $157.62. His Medigap plan covered the 20% balance, leaving him with no personal expense.
Frequently Asked Questions (FAQ)
Q. What is hallux rigidus?
A. Hallux rigidus is a type of degenerative arthritis affecting the joint at the base of the big toe, leading to pain and stiffness.
Q. What are the symptoms of hallux rigidus?
A. Symptoms include pain and stiffness in the big toe during walking, standing, or bending, swelling and inflammation around the joint, and difficulty wearing certain shoes.
Q. What causes hallux rigidus?
A. Hallux rigidus is primarily caused by wear and tear of the joint cartilage, often from abnormal foot mechanics, injury, or inflammatory diseases like gout.
Q. Who is at risk for developing hallux rigidus?
A. Individuals with abnormal foot anatomy, previous toe injuries, or inflammatory joint diseases are at higher risk for developing hallux rigidus.
Q. How is hallux rigidus diagnosed?
A. Diagnosis is made through a physical examination assessing the range of motion and tenderness of the big toe, and confirmed by X-rays showing joint space narrowing or bone spurs.
Q. What non-surgical treatments are available for hallux rigidus?
A. Non-surgical treatments include wearing stiff-soled shoes, using orthotic devices, applying ice, taking anti-inflammatory medications, and undergoing physical therapy.
Q. When is surgery recommended for hallux rigidus?
A. Surgery is recommended when conservative treatments fail to relieve symptoms and the condition significantly impacts daily activities.
Q. What types of surgery are available for hallux rigidus?
A. Surgical options include cheilectomy, fusion (arthrodesis) of the joint, and joint replacement (arthroplasty).
Q. What is a cheilectomy?
A. A cheilectomy involves removing bone spurs and a portion of the foot bone to improve joint movement and reduce pain.
Q. What is arthrodesis for hallux rigidus?
A. Arthrodesis is the fusion of the bones in the big toe joint, eliminating movement to relieve pain.
Q. What is arthroplasty for hallux rigidus?
A. Arthroplasty involves replacing the damaged joint with an artificial implant to restore some range of motion.
Q. How long is recovery after surgery for hallux rigidus?
A. Recovery varies depending on the procedure, with some patients resuming activities within weeks and others requiring several months for full healing.
Q. Can hallux rigidus recur after surgery?
A. Recurrence is less common after fusion but can occur with other procedures, especially if the underlying cause is not addressed.
Q. How can hallux rigidus be prevented?
A. Prevention strategies include wearing appropriate footwear, avoiding repetitive stress on the toe, and treating underlying foot abnormalities early.
Q. Is hallux rigidus the same as a bunion?
A. No. A bunion (hallux valgus) causes the big toe to drift sideways, while hallux rigidus causes stiffness and limited motion due to arthritis.
Q. Will the arthritis come back after surgery?
A. Cheilectomy may not stop long-term degeneration, but it can delay progression. Fusion permanently relieves pain by stopping motion at the affected joint.
Q. Can exercise make it worse?
A. High-impact or repetitive bending can worsen symptoms. Low-impact activities like cycling or swimming are usually safe.
Summary and Takeaway
Hallux rigidus is a degenerative arthritis of the big-toe joint that leads to stiffness, pain, and difficulty with movement. Early cases respond well to shoe changes and orthotics, while advanced arthritis often needs surgical correction. With proper treatment, most patients regain comfort and return to normal daily activities.
Clinical Insight & Recent Findings
A 2025 review by Nakajima (J Clin Med 2025; 14:1595) challenges traditional thinking about hallux rigidus. The author argues that most joint-preserving surgeries overlook the true cause of the condition—shortened, tight plantar soft tissues that create dorsal impingement and cartilage damage at the first MTP joint.
The paper reviews evidence showing that metatarsal decompression osteotomy, which lowers and repositions the metatarsal head to relieve plantar tension, produces better long-term outcomes than cheilectomy, the current gold-standard procedure.
It also introduces the minimally invasive arthroscopic Cochrane procedure, which directly releases the tight plantar structures to restore motion while preserving the joint. The article concludes that future treatment of hallux rigidus should target the underlying mechanical tightness—not just remove bone spurs—to improve function and reduce recurrence. (“Review on joint-preserving surgery for hallux rigidus—see PubMed.”)
Who Performs This Treatment? (Specialists and Team Involved)
Treatment is performed by orthopedic foot-and-ankle surgeons or podiatric surgeons with expertise in joint preservation and reconstruction. The care team may also include anesthesiologists, nurses, and physical therapists to assist with surgery, recovery, and rehabilitation.
When to See a Specialist?
You should see a specialist if you have persistent pain, stiffness, or swelling in the big-toe joint, or if shoe changes and rest no longer help. Early evaluation can prevent worsening arthritis and preserve joint motion.
When to Go to the Emergency Room?
Emergency evaluation is rarely needed but should be sought for sudden severe pain, inability to bear weight, visible deformity, or signs of infection such as redness, fever, or drainage after surgery.
What Recovery Really Looks Like?
Expect some swelling and mild pain for several weeks after surgery. Walking aids may be used at first. Most patients return to regular footwear in four to eight weeks, depending on the procedure. Ongoing stretching and physical therapy promote long-term comfort and flexibility.
What Happens If You Ignore It?
Without treatment, hallux rigidus tends to progress over time, leading to worsening stiffness, larger bone spurs, and difficulty walking. Delayed care can limit surgical options and make recovery more difficult.
How to Prevent It?
Wearing comfortable, supportive shoes with wide toe boxes and avoiding high heels can reduce stress on the big-toe joint. Maintaining healthy body weight, stretching the calf and toe muscles, and avoiding repetitive toe stress can also help prevent progression.
Nutrition and Bone or Joint Health
A balanced diet rich in calcium, vitamin D, and protein supports joint and bone health. Staying hydrated and maintaining a healthy weight reduce stress on joints and improve healing after surgery.
Activity and Lifestyle Modifications
After recovery, patients can return to most daily and recreational activities. Avoid repetitive stress on the toe and choose low-impact exercises like cycling, swimming, or elliptical training. Supportive shoes and custom orthotics can help maintain comfort long-term.
Dr. Mo Athar
