Stiff Big Toe Joint

Deformity Number Three 

A Guide to Help

This is a guide to help answer some questions about foot pain associated with a stiff big toe joint but is not about surgery. You can read and download more about surgery in my Rigid toe joint fact sheet No.3 2018You may have had the problem for a while or only recently. If you have a painful big toe it can be due to several causes. In bunion hallux valgus no.1 Bunion joint fact sheet No.1 2018 I have discussed the toe deviating. This will include the bump on the top or side of the toe joint and of course the pain that you might experience. Sesamoiditis is less well known and must be considered as part of the stiff joint saga.

We need to look inside the toe joint to consider what is going. First let us consider the causes. The toe may be perfectly straight or it might be bent (hallux valgus).  Where the toe is stiff and painful to move pain, this is called hallux (big toe) rigidus. The permanent stiff toe might require surgery and the temporary stiffness may not. This type of problem ranks number three in the common referrals to podiatric surgeons. The bunion is NUMBER 1.


What causes stiffness?

Injury

If you force the toe upwards or backward this type of injury can set up inflammation and cartilage damage. Later on this can cause a big stiff toe joint. This means that any physical activity such as kicking, stamping, twisting, dropping objects onto the , toe could lead you to suffer in time. Footwear can have a direct effect on the joint and this is why good shoe fit is important. 

Good news. The condition may settle down and that’s the end. However, if unchecked a stiff toe joint can start to cause pain until it becomes totally locked up and doesn’t move. pain many years later.


These medical conditions associated with the study of rheumatology medicine. Further information can be found in my article on medical causes of a painful big toe.

What happens when you lose movement?

Lack of movement is the end process so as the toe does not bend you may walk awkwardly turning your foot out like a waddling duck (duck footed). This lack of movement changes the process of walking and can affect other joints higher up including the lower back and hip joints. We need 20-30 degrees of total movement for normal function. That means the toe can move up and down freely without pain. Walking may become painful and limiting. Painkillers and anti-inflammatories like ibuprofen fail to help. Footwear becomes a problem especially when the joint enlarges over time. This will be measured in years rather than weeks or months.

Early signs can be helped

In the early stages where mild damage arises the muscles around the big toe joint tighten. All movement is lost at this point as the toe has limited movement – limitus. Part of the joint also has a small seed like bone called sesamoid bones which must be included in any discussion and are frequently involved but overlooked. These bones can jam on movement and can cause spasm (sesamoiditis). Check out the article on sesamoid bones here.


Joint oil (synovial fluid)

The surface of the bone requires lubrication and nutrition from a special greasy like oil. This is the synovial fluid. In gout, this fills with crystals of uric acid, but normally it is a clear to slightly yellow. In books, the fluid is depicted as blue. The joint lining (synovium) produces the fluid. It is slightly stiffer when not used and better on movement and activity. Movement is therefore important to keep your joint healthy.  If the big toe becomes stiff through pain, or, if the fluid dries out, the surfaces scrape together, causing impingement and of course pain. Once poor lubrication arises by inflammation or spurs blocking movement, the cartilage may split or experience damage to its hydro elastic property. Cartilage must be able to deform helpfully during joint movement. Once this process disappears the cartilage stiffens and bone rubs on bone. The joint becomes more inflamed and fluid replacement fills with repair cells (white cells and platelets). Small clots form and act to fill in gaps but tie down movement further. This is where steroid injections come in.


Four stiff big toe joint conditions

  • Spasm due to inflammation (repeated strain)
  • Loose body (not necessarily fracture)
  • Split or worn cartilage
  • Excessive outgrowth of bone (spurs or osteophytes)

The condition is time delayed. An event when young (10-25) may not show up until 45-65. After exercise, the problem comes to light in older age.  An x-ray may report ‘arthritis’ but this has been found to be unreliable. Until a clinical specialist confirms this, the report to the GP may be wrong. Click Factsheet-109-The-painful-big-toe-joint-. Joint diagram. 2018 showing the different state of the joint and to clarify your understanding of the key changes.

The painful stiff big toe joint and sesamoids

The function of the sesamoids bones will be affected when moving against the larger bone (metatarsal Figure 2).. One of the causes of a stiff big toe pain relates to sesamoiditis. However, this is a  broad- term and means little until explained. Fractures of these small bones are rare. An ordinary x-ray may not hold the clue alone. Usually, sesamoiditis is acute or chronic but if the pain comes on suddenly and reaches a heightened level it is acute. If it creeps up gradually and remains at a level like a wave which goes up and down, it is chronic. The symptoms are constant aching pain and can even appear as toothache-like. Grossly red, very tense burning pain is likely to be something else, including fracture. Gout is rare and over diagnosed but a clinician will need to rule out degenerative changes within the joint.

Causes of sesamoiditis

The most common reasons for sesamoiditis are local inflammation associated with playing tennis, squash or other hard impact sports using sharp multi-directional twists or even high heeled footwear. The soft tissue, joint lining and ligaments can be damaged and where the sesamoid bone is less stable, local fluid will aggravate the condition. Occasionally the bone appears bruised. The bone may have a poor blood supply so its substance actually collapses leading to degeneration and pain. Soft tissue irritation is by far the more common likelihood and can affect all age groups.

What do we do for sesamoid pain?

Rest, stiff soled shoes, reduction in physical activities and local protection are all first-line treatments. Local splinting is useful to stop toe movement and special insoles to protect the sesamoid. Injections form the second line of treatment and these have to be carefully placed. Foot specialists use x-ray or ultrasound guidance as our standard approach. As you should only have limited injections blind injections are not so ideal especially as the gap between metatarsal and sesamoid is minute.

The last group of problems with the sesamoid is likened to changes of joint surfaces. The surface loses its smoothness and cracks or dries out. This means without lubrication movement reduces. Injections are required more often here to help with improvement but may be short-lived. Removal of sesamoids are occasionally used but not as frequently as one might expect. Other types of surgery will depend on detailed examination testing and can include other types of bone scan. Sesamoid pain can be helped by padded dressing using felt. Click for an information sheet to deal with sesamoids.


Pain and some ideas of self-help for the stiff big toe joint

Symptoms arise from spasm, muscle tightness or the internal swelling of the joint. Infection is rare but can arise, more so if there is an open wound. x-rays are important as the first-line diagnosis must rule out the type of cause. Blood tests will be used to screen for some arthritic conditions as above. Pain medication should be used for short periods 3-5 days and then reviewed. Pain should subside.

Stopping the joint moving can be achieved by not using the foot, using crutches, wearing a stiff soled shoe or special boot. Podiatrists and physiotherapists can strap the toe to stop it moving and help limit the pain. Ice is best for acute pain and swelling. Heat for chronic and to calm spasms down. Rub under the surface of the foot and check if the muscle is tighter and tender compared to the normal side. A cast such as an AircastTM can help allow movement and yet rest the foot. If all of the above do not help then seek a specialist in foot surgery (podiatric surgeon FCPodS). Now you have an introduction to hallux rigidus (limitus) you:

  • now know that the condition is
  • have some idea of what can be done
  • also know if it does not get better you should see a specialist

Download my film

 

Download my film and see how you can help limit pain with strapping


Thanks for reading ‘Stiff Big Toe Joint‘ written by David Tollafield for ConsultingFootPain  promoting foot health awareness from the podiatrist.

Published under BusypencilCase Reflective Communications 
Original script Oct. 2018  Updated July 2020

 

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