Big Toe Arthritis

Mr Billy Jowett | Consultant Orthopaedic Surgeon

Understanding Hallux Rigidus, Cheilectomy and Big Toe Fusion

What is Hallux Rigidus?

Hallux rigidus literally means stiff (rigidus) big toe (hallux). It is a condition where arthritis develops in your first MTP joint (metatarsophalangeal joint) – the joint at the base of your big toe. This is one of the most common forms of arthritis in the foot and big toe joint pain.

What are the Symptoms of Big Toe Arthritis?

Big toe arthritis causes several characteristic symptoms:

Pain: Sometimes this pain only occurs towards the end of the range of upward movement of your toe, but as the arthritis becomes more severe, the pain occurs with any movement.

The pattern of your pain is crucial for determining the most appropriate treatment. If you have an aching joint that is painful when sitting at rest or at night, this differs significantly from pain that only occurs when walking fast or running and bending your toe upwards. This distinction guides my treatment recommendations.

Stiffness: The condition leads to progressive stiffening of your big toe. The joint becomes increasingly rigid, limiting your toe’s ability to bend upwards (dorsiflex).

Bony bump: As the arthritis develops, a bony lump may form at the edges of the joint. These bone spurs may be prominent and rub on your shoes, causing additional discomfort beyond the joint pain itself.

Is Hallux Rigidus the Same as a Bunion?

No, hallux rigidus is not the same as a bunion, though both affect the big toe joint.

Bunion (Hallux Valgus): A bunion occurs when your big toe angles outward towards your other toes. The angulation of the big toe can be more likely to develop if the first joint in the middle of your foot is more mobile, alternatively, often when the big toe is angulated the joint in the middle of the foot becomes more mobile.

Hallux Rigidus: This is arthritis and stiffness of your big toe joint, where the toe becomes rigid rather than angled.

However, both conditions can lead to similar cascade effects. When your big toe is painful or doesn’t function normally, you are more likely to overload other areas of your foot – particularly the lesser metatarsals (the bones at the base of your second, third, and fourth toes).

This creates a host of problems grouped into a category called metatarsalgia, which describes pain in the metatarsal area rather than serving as a specific diagnosis.

What Causes Hallux Rigidus?

The most common cause for a stiff big toe is arthritis. Arthritis may develop for no obvious reason (in some people there may be a genetic cause i.e. some people’s make up makes them at greater risk of developing osteoarthritis), following an injury, due to a generalized arthritic condition (a polyarthropathy eg. rheumatoid arthritis) or due to a condition affecting the big toe joint alone (a monoarthropathy eg. gout).

What’s the Difference Between Hallux Limitus and Hallux Rigidus?

Hallux means great toe and limitus means limited, while rigidus means rigid i.e. doesn’t move. The two terms are sometimes used interchangeably and sometimes hallux limitus refers to an earlier stage of the condition of an arthritic joint at the base of the great toe, however, it is possible to have limited upward movement of the great toe for another reason eg. tightness of the flexor hallucis longus tendon (FHL) when the upward movement will be liited when the ankle is bent up but less so when the ankle is bent down because in that position there is less tension on the FHL tendon. Some people feel that tightness of the FHL plays a part in the4 dvelopment of arthritis in the 1st MTP joint.

How is Hallux Rigidus Diagnosed – Do I Need an X-Ray?

Normally the diagnosis can be made by assessing:

  • Pain location and timing (at rest, with movement, at end range)
  • Whether you have mid-range pain versus end-range pain
  • Range of motion in your big toe joint
  • Presence of bony prominences

For most conditions, including big toe arthritis, symptoms are the most important diagnostic factor.

During the consultation, I will assess the above and prior to any intervention eg. injection or surgery I will typically order X-rays to confirm the diagnosis and the severity of your arthritis, and to help plan appropriate treatment.

What is the Best Treatment for Hallux Rigidus Without Surgery?

Before considering surgery, I recommend exploring several non-surgical options:

If the prominent bone is your primary concern, shoes with soft uppers may help. If your pain worsens with movement, stiff-soled shoes – particularly those with a camber to the sole (a curve when viewed from the side) – can provide relief. Several commercially available shoes meet these specifications.

Stiff-soled shoes reduce the amount of bending required at your big toe joint during walking, which can significantly reduce pain.

Orthotics that provide support and limit motion at the first MTP joint may provide some symptom relief.

Pain relievers or anti-inflammatory tablets may be sufficient to keep your pain under control, particularly in the early stages of the condition.

Local anaesthetic will help the pain in the very short term i.e. hours, the addition of steroid or hyaluronic acid can provide pain relief although it is difficult to determine how long this effect will last. This later benefit sometimes follows a flare causing pain +/- swelling occurring a day or so after the injection.

Many patients initially request injections whilst declining fusion surgery, but often return within a short time reporting excellent but short-lived relief and requesting a permanent solution i.e. surgery. Injections can be useful if you wish to avoid surgery, but understand that while they are typically beneficial in earlier stages of the condition, they only provide temporary relief and can potentially make the cartilage damage (arthritis) worse.

Recent research indicates no difference in surgical site infection rates or non-union rates whether steroid injection occurs one, two, or three months before surgery. However, I recommend waiting three months.

Injections are not without risk eg. infection, worsening of the arthritis, fat thinning at the site of the injection etc.

Whilst exercises may help maintain remaining range of motion and support general foot function, they cannot reverse the arthritic changes in your joint and I feel they are more likely to exacerbate your symptoms.

When Does Big Toe Arthritis Need Surgery?

Surgery becomes appropriate when the condition affects your day-to-day life.

If you cannot perform activities important to you, whether work-related or recreational, this is the time to consider intervention be that an injection or surgery.3

Some patients tolerate their symptoms whilst taking painkillers to maintain activities. Others prefer to address the problem surgically rather than rely on ongoing medication. Both approaches are valid and depend on how the condition impacts your life.

I offer two primary surgical options:

  • 1
    Cheilectomy – appropriate when pain occurs primarily during upward toe bending or results from prominent bone rubbing on shoes.
  • 2
    Fusion (First MTP Arthrodesis) – recommended for more comprehensive pain relief.

There are other surgical options such as interposition arthroplasty and half joint replacement, but these are less reliable and therefore would only be considered in special circumstances, indeed one type of interposition arthroplasty, the Cartiva, is no longer available on the market. Full joint replacements have been tried in the past but tended to fail relatively early and requiring complex revision surgery so should not be considered.

What is a Cheilectomy?

Cheilectomy addresses impingement pain – when discomfort occurs during upward toe bending, with minimal or no mid-range pain. It is also appropriate if you wish to preserve movement, or if prominent bone rubbing against shoes is your primary concern.

Arthritis in the big toe joint causes extra bone formation on top of the metatarsal bone. This creates pain during upward toe bending. During cheilectomy, I remove this extra bone and address any cartilage damage as necessary.

Am I a Candidate for Cheilectomy?

For all surgical procedures, including big toe surgery, symptoms are the primary determining factor.

You Are Likely a Good Candidate for Cheilectomy If:

Your pain occurs primarily when walking fast or running and bending your toe upwards. This pattern indicates cheilectomy is appropriate.

You Are Likely Not a Good Candidate If:

If you have an aching joint that is painful at rest or during the night, cheilectomy is unlikely to provide adequate relief.

Cheilectomy for More Advanced Arthritis:

Some surgeons utilise cheilectomy for more significant arthritis and report reasonable results. The comparative evidence between cheilectomy and fusion requires further review.

If your pain occurs primarily, but not solely, at end-range motion and preserving movement is your priority but you understand some pain may persist, a cheilectomy may still be appropriate.

When Fusion is Preferable:

If you seek complete pain relief, particularly with aching pain at rest or at night, and examination reveals mid-range motion discomfort, fusion is a more reliable operation.

Cheilectomy and Big Toe Fusion Surgery, Recovery, Risks and What to Expect

Anaesthetic: Light general anaesthetic combined with local anaesthetic either around your ankle or just around the big toe (you will be able to discuss this with the anaesthetist prior to the operation).

Scars: A scar over the top or inside of your big toe joint. Alternatively, the procedure may be performed through small incisions (minimally invasive or keyhole surgery).

The Surgery: I remove the extra bone formation on top of the metatarsal and address any cartilage damage as necessary.

Stitches: Removable sutures are typically required (possibly unnecessary with keyhole technique). I remove these at your two-week post-operative appointment.

Dressings: A special dressing is placed on your foot and should remain in place until your clinic review. Bandages are placed over the dressing, and I will instruct you regarding their removal.

Cheilectomy is typically a day case procedure. You will go home either the same day or the following morning.

Pain Relief: The local anaesthetic around your ankle provides initial pain relief. The hospital will supply pain-relieving tablets (typically ibuprofen, co-codamol and/ or tramadol). I recommend taking these regularly initially, gradually reducing as your pain subsides (tramadol is the stronger pain reliever).

The local anaesthetic wears off several hours after surgery. It is important to take pain-relieving tablets regularly before the local anaesthetic wears off. You can gradually reduce frequency after twenty-four hours.

You will be able to walk once you have recovered sufficiently from the general anaesthetic.

Keeping your foot elevated during rest is important – as much as possible for the first two weeks after surgery (roughly 45 minutes out of every hour), ideally above heart level. Without adequate elevation, your foot will swell, throb, and be uncomfortable.

Driving is not permitted until you can walk confidently in normal shoes. However, if the surgery is on your left foot and you have an automatic car, you may be able to drive after your two-week clinic appointment.

Please check with your insurance company in all cases.

My Recommendations:

  • Office job: 2 weeks
  • Mobile job requiring driving: 2-3 weeks
  • Manual labour: 3-4 weeks

When Can I Wear Normal Shoes?

You will be able to wear normal shoes when the post-operative shoe is removed, typically at 2-4 weeks following surgery. You may experience difficulty fitting into your normal shoes initially as swelling can persist up to 3 months.

Follow-Up Appointments:

Clinic appointments are scheduled at:

  • 2 weeks after surgery for suture removal
  • roughly 3 months after surgery, with further follow-up depending on your progress

Surgical risks include infection, nerve damage, blood clots, ongoing pain, being made worse, the potential need for further surgery and the tiny risks of amputation and death.

The arthritis can progress after cheilectomy. This is why patient selection is critical – cheilectomy works best when pain results primarily from impingement at end-range motion rather than mid-range arthritis.

I stiffen the joint at the base of your big toe and secure it with a plate and screws. This permanently joins the two bones, eliminating the arthritic joint and its associated pain.

Since arthritic big toe joints are typically already quite stiff, fusion converts a stiff, painful joint into a stiff, painless joint and therefore most patients do not notice the loss of movement.

I recommend fusion when:

  • You experience aching pain at rest or at night
  • You have discomfort in the mid-range of motion (not just at extremes)
  • Previous cheilectomy has not provided adequate relief or is inappropriate

Anaesthetic: Light general anaesthetic combined with local anaesthetic around your ankle.

Scar: A scar on the inside of your big toe joint or occasionally on top.

The Surgery: I stiffen the joint at the base of your big toe and secure it with a plate and screws.

Stitches: Dissolving sutures are typically used. If removable sutures are necessary, these are removed at your two-week post-operative appointment.

Dressings: Special dressings are placed on your foot and should remain in place until your clinic review.

You will need to wear a post-operative shoe for 6 weeks after the surgery (there is no need for plaster immbolisation. This should be worn at all times (including night), unless otherwise instructed.

What Our Patients Say

Needs new testimonial here

“I suffered for a long time in a lot of pain with a bunion and a shortening of ligaments in another toe. Mr Jowett operated on both of these and I am no longer in pain and back on the golf course pain free.”

Verified patient, Spire Southampton Hospital

How Long is Recovery After Big Toe Fusion?

You will return home on the day of the operation unless your operation takes place in the evening in which case you would return home the following morning.

You will be able to walk on the foot from the day of the operation, but would need to wear a post-operative shoe for 6 weeks avoiding placing too much pressure through the great toe.

The foot will be swollen for around three months.

You will be able to start walking in normal shoes after six weeks and then gradually increase your activity from then on and should have returned to all activity by six months. Return to contact sports is likely to take four to six months.

When Can I Walk/Weight-Bear After Fusion?

Return Home: Either the same day or the following morning.

Pain Relief: The local anaesthetic wears off several hours after surgery. It is important to take pain-relieving tablets regularly before the local anaesthetic wears off. You can gradually reduce frequency after twenty-four hours.

Walking: You will be able to walk from the day of the operation keeping your weight on the flat of your foot/ heel.

Walking Technique: The best way to walk is for each step to move the operated foot forward first and then bringing the other foot beside it, but not in front of it. For example, if your right foot was operated on, advance the right foot forward, bring the left foot up beside it, then advance the right foot again. This prevents transferring weight to the front of your operated foot.

This technique requires effort but helps limit inappropriate weight-bearing.

Elevation Is Critical: For the first two weeks after surgery, you should keep your foot elevated, above the level of your hip, for roughly 45 minutes out of every hour, I do not recommend having your foot down for more than 5 minutes at a time.

Without adequate elevation, your foot will swell, throb, and be uncomfortable. Swelling increases the tension on the sutures and the chance that the wound will not heal up properly.

When Can I Drive After Big Toe Fusion?

Driving is not permitted until you can walk confidently in normal shoes. However, if the surgery is on your left foot and you have an automatic car, you may be able to drive after your two-week clinic appointment.

I recommend taking two weeks off work regardless of your occupation. Patients with office jobs and automatic cars can typically return at two weeks.

If you require your right foot to drive, or have a manual car and left foot surgery, evidence suggests waiting at least six weeks to safely perform an emergency stop.

Please check with your insurance company in all cases.

Specific Problems

Big Toe Fusion Recovery, Risks and Long Term Outcomes

I recommend two weeks off work for all patients regardless of occupation.

Specific Timelines:

Office Job with Automatic Car: Patients with office jobs and automatic cars can typically return at two weeks.

Office Job Without Driving: Office workers unable to drive can also return at two weeks after surgery, if alternative transport is available.

Jobs Requiring Walking: Jobs requiring significant walking typically require six weeks.

Manual Labour: typically you should be able to return at three months after the operation.

You will be able to wear normal shoes when the post-operative shoe is removed, typically at 6-8 weeks depending on X-ray findings. You may experience difficulty with shoe fitting initially as swelling can persist for around 3 months.

Follow-Up Appointments:

Clinic appointments are scheduled at:

  • 2 weeks after surgery for wound review
  • 6 weeks after surgery for X-ray – if satisfactory, you may discontinue the post-operative shoe
  • 3-4 months after surgery, with further follow-up depending on your progress

Yes, the joint at the base of the big toe joint itself will be completely stiff – this is the purpose of the fusion. However, this does not have a major impact on the overall foot function. Although you your walking will not be absolutely normal, your gait should be better than before the surgery.

The first MTP fusion works effectively because the IP joint (the next joint down in your toe) tends to hyperextend, compensating for the stiffened big toe joint.

Yes. I position the toe to accommodate a small heel.

Many patients – particularly those whose IP joint hyperextends – can tolerate higher heels than might be expected. However, I advise patients not to expect to wear high heels.

Return to Impact Activities:

Three months represents the absolute minimum for returning to impact activities. A realistic timeframe is three to six months, with patients typically resuming when they feel capable.

For patients undergoing bilateral fusions, I typically recommend six months before returning to football for example.

Activity Possibilities:

Evidence suggests that most people can return to recreational activities, although some people   may experience some difficulty running, but recent research on elite athletes and first MTP fusions showed 12 out of 16 returned to their original level of sport by a year after the surgery.

Modern running shoes with curved soles further support athletic activity.

The fusion lasts permanently.

This is a very reliable, reproducible operation with permanent results.

IP Joint Arthritis Concerns:

Some evidence suggests potential development of IP joint arthritis following big toe fusion. However, given that Portsmouth has five foot and ankle surgeons and Southampton has four or five more, I rarely see patients with IP joint arthritis.

Once joined, the fusion is permanent. The non-union rate has been quote is occurring in up to 10% of people, but I feel we should be quoting much less than 5%. If non-union occurs, I can perform a revision fusion without significant difficulty.

Surgical risks include infection, nerve damage (leading to pain and/ or numbness), blood clots, non-union (the bone not joining), ongoing pain, being made worse, the potential need for further surgery and the tiny risks of amputation and death.

Cheilectomy vs Fusion: Which is Better?

Decision-Making Factors

The choice between cheilectomy and fusion depends on your specific symptoms and goals:

Cheilectomy is Recommended When:

  • Pain occurs primarily during upward toe bending
  • Mid-range pain is minimal or absent
  • Movement preservation is desired
  • Prominent bone rubbing on shoes is the primary concern
  • If you have pain on the mid-range of movement, but want to maintain movement and understand that some residual pain may persist

Fusion is Recommended When:

  • Aching pain occurs at rest or at night
  • Mid-range pain is present
  • The most reliable operation is preferred
  • Movement preservation is less important than pain relief

Yes, fusion remains possible after unsuccessful cheilectomy. The cheilectomy removes some joint bone, which slightly increases fusion complexity, but does not prevent successful completion.

Why Don’t Joint Replacements Work for Big Toe Arthritis?

Joint Replacement Challenges

Joint replacements fail under shear stress, and significant shear forces exist between first MTP joint surfaces. However, the big toe joint’s complexity results in frequent replacement failure. Current literature does not support these procedures, though this may change with future developments.

Silastic Implants

Silastic implants have emerged, having failed previously. Newer generations may perform better due to slight material changes. I would suggest they may be considered for low-demand patients with mid-range pain who are keen to maintain movement. However, it is important to remember that if the operation failed the revision surgery might be complex eg. trying to obtain a fusion with the need to replace the bone lost when inserting the implant with bone graft from the pelvis.

Interposition arthroplasty may occasionally be appropriate – please discuss this if interested.

CARTIVA Implant

The CARTIVA implant is an interposition arthroplasty. A non-inferiority study compared it to big toe fusion. CARTIVA appeared non-inferior but required longer time to achieve equivalent pain relief. As usage increased, results deteriorated. The product has since been withdrawn from the market.

One-Sided Joint Replacements

Some surgeons perform one-sided joint replacements, but this is not widespread practice.

What Other Problems Can Big Toe Arthritis Cause?

Forefoot Cascade Effects

When your big toe is painful or dysfunctional, you typically overload other foot areas – particularly the lesser metatarsals.

Painful big toe arthritis (or bunions) alters biomechanics. When your big toe is angulated or painful, the first joint in your midfoot becomes hypermobile.

In both scenarios – big toe arthritis pain and poor big toe function – you place excessive pressure on your second, third, and fourth metatarsals. This creates multiple problems grouped as metatarsalgia, which describes metatarsal pain rather than providing specific diagnosis.

Specific Problems

1. Pure Overload:

Overload ranges from simple callosity (hard skin) formation underneath metatarsal heads.

2. Joint Inflammation:

Inflammation of the joint at the toe base – most commonly the second, sometimes the third.

3. Plantar Plate Failure:

Ongoing inflammation can damage the plantar plate (the ligament securing the toe base). This causes the toe to curl over due to muscular imbalance – extrinsic muscles pulling on your foot without adequate intrinsic muscle balance.

4. Hammer Toe:

After prolonged absence of the plantar plate the curled over posture of the toe becomes more marked, known as a hammer toe, which can rub against shoes.

5. Stress Fractures:

Forefoot overload can cause lesser metatarsal stress fractures. These are painful but typically heal without intervention, requiring only time.

6. Morton's Neuroma:

This can cause nerve irritation between metatarsal heads, most commonly between the third and fourth, known as Morton’s neuroma.

This often represents not just nerve thickening, but a Morton’s neuroma/bursitis complex – soft tissue inflammation around the nerve caused by excessive pressure.

Morton’s Neuroma: Anatomical Explanation

An anatomical quirk exists. The interdigital nerve between your third and fourth metatarsal heads forms (in many people) from medial and lateral plantar nerve branches at the proximal end.

Distally, it divides – one branch to your third toe, one to your fourth toe. The nerve is fixed proximally and distally.

Your second and third metatarsal joints have limited motion. Your third and fourth move considerably. This creates differential friction.

Your second and third remain relatively stationary whilst your fourth and fifth move. The fixed nerve becomes irritated between the metatarsal heads.

Evidence for stem cell treatment is limited. Most patients presenting to my clinic have cartilage damage of severity where stem cell benefit is nearly negligible.

For patients interested in stem cell or regenerative treatments, a London clinic offers these services. However, if these treatments were highly effective, multiple clinics would exist throughout the country.

What About Stem Cells and Regenerative Treatments for Big Toe Arthritis?

Evidence for stem cell treatment is limited. Most patients presenting to my clinic have cartilage damage of severity where stem cell benefit is nearly negligible.

For patients interested in stem cell or regenerative treatments, a London clinic offers these services. However, if these treatments were highly effective, multiple clinics would exist throughout the country.

Private Hallux Rigidus Surgery – Self-Pay Pathway

The private self-pay pathway offers significantly faster access:

  • Initial consultation typically within 1-2 weeks
  • Surgery typically scheduled within 2-4 weeks of decision
  • No waiting lists for self-funding patients
  • Flexible appointment times and surgical dates

Cheilectomy costs vary by hospital and surgeon. As a self-pay day-case procedure, competitive pricing is available (an all-inclusive fee including follow up appointments of somewhere in the region of £5000).

Big toe fusion pricing varies by facility and surgeon experience (an all-inclusive fee including follow up appointments of somewhere between £4000 and £10000). Self-funding patients should expect costs reflecting the expertise required for this reliable, long-lasting operation.

Speed of Access: Rapid appointments and surgical scheduling to accommodate your schedule.

Consultant-Led Care: Consistent care with the same experienced foot and ankle surgeon throughout treatment.

Personalised Treatment: Comprehensive discussion of all options with adequate consultation time.

Modern Facilities: Access to well-equipped private hospitals with excellent post-operative care.

Predictable Outcomes: Self-funding first MTP fusion offers high success rates. The procedure typically joins successfully, requires routine follow-up appointments, has low complication risk, and provides high patient satisfaction.

Finding the Right Surgeon

Hallux Rigidus Surgeon Near Me

When selecting a hallux rigidus surgeon, consider:

  • Specialist Foot & Ankle Training: Ensure your surgeon specialises specifically in foot and ankle surgery
  • Experience with Both Procedures: Your surgeon should have extensive experience in both cheilectomy and fusion to provide unbiased recommendations
  • Understanding of Biomechanics: Complex foot problems require comprehensive anatomical knowledge

Private Foot and Ankle Surgeon Southampton/ Portsmouth / Chichester/ Jersey

The Hampshire and West Sussex region, including Portsmouth/ Southampton and Chichester, has several experienced private foot and ankle surgeons. When selecting your surgeon, look for:

  • Fellowship training in foot and ankle surgery
  • Regular surgical practice
  • Membership in specialist societies (British Orthopaedic Foot and Ankle Society)
  • Experience with complex reconstructive procedures
  • Strong communication skills and thorough explanation of options

Why Big Toe Fusion is Such a Reliable Operation

This is a very reliable, reproducible operation with permanent results.

Big toe fusion success derives from several factors:

  • 1
    Compensatory Motion: The first MTP fusion works effectively because the IP joint (the next joint in your toe) tends to hyperextend, compensating for the stiffened big toe joint.
  • 2
    Eliminates Pain Source: Complete arthritic joint removal permanently eliminates the pain source.
  • 3
    Long Track Record: This operation has been performed successfully for decades with excellent long-term outcomes.
  • 4
    Elite Athlete Evidence: Recent research on elite athletes and first MTP fusions showed 17 out of 19 returned to professional sport level, which is remarkable.

Final Thoughts: Making Your Decision

Determining whether you need hallux rigidus surgery, and which type, depends on:

  • 1
    Your symptoms – Pain location and timing
  • 2
    Your goals – Complete pain relief versus motion preservation
  • 3
    Your activity level – Desired activities post-recovery
  • 4
    Your risk tolerance – Everyone’s attitude to risk is different and although the risks are small they should not be ignored.

Both procedures offer excellent results when performed for appropriate indications. Big toe fusion stands out as one of the most reliable operations in foot and ankle surgery, providing long-lasting relief and return to normal activities – including high-level sport in many cases.

Get in touch:

+44 (0) 7856 853175

office@sdfac.co.uk