‘Stiff Big Toe Joint’
Deformity Number Three (including sesamoiditis)
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 2018. You 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, the bump on the top or side of the toe joint and of course the pain. 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 on but first let us consider the causes, often known as aetiology (etiology). The toe may be perfectly straight or it might be bent (hallux valgus and have a bunion). Where the toe is stiff and doesn’t move because of pain, this is either called hallux (big toe) rigidus or limitus. The difference between these two conditions is that the first is permanent and the second may be redeemed. It will make sense to talk about these conditions as two entities because the end result may be different. 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 one.
What causes stiffness?
An external force will leave an effect on the joint so pushing the toe upwards or backward sets up inflammation and possible cartilage damage that appears later. Kicking, stamping, twisting, dropping objects, crushing will all cause the toe to suffer. Footwear can cause a direct effect on the joint and that is why good shoe fit is important. Good news. The condition may settle but could end up causing pain many years later. Internal causes due to deformity or a process that starts within the body itself are entirely different although the effect on the cartilage may still be apparent. This will be described as a medical cause.
Some Medical Causes
Joint damage may arise from osteoarthrosis and typically affects more than one joint. This is a condition that may be inherited and is essentially an early loss of cartilage that does not have to relate to injury. The age this arises is often older but then defining old and age is difficult so 40 years upwards with most showing signs by the sixth decade of life. Rheumatoid arthritis is less common but causes inflammation around the joint due to the body attacking itself. The immune system seems more active and had to be suppressed. Cartilage degeneration arises again and this condition makes patients unwell and has a co-association with other medical problems e.g thyroid, this tends to be more complex. The thyroid regulates the body controlling many organs. If the thyroid is underactive and therefore slow, we feel sluggish and put weight on. The opposite is true is the thyroid is overactive. Blood pressure amongst other signs is affected.
Gout is well documented amongst the nobility but it can affect all people irrespective of parentage. The toe becomes enlarged, hot, red and shoes cannot be worn. Foods can bring it on but it is an upset in the balance of a chemical and so a build-up of crystals arises. The joint enlarges, cartilage dries out and the inside fills with what looks like a white thick paste-like crushed almonds. Gout can be treated effectively as can rheumatoid arthritis often without surgery. Psoriasis, a skin complaint can affect joints in around 7-10% of those inflicted with the skin condition. The big toe joint is not the only joint affected. All these conditions are rarer than the injury type.
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 joint has some inbuilt protection. The muscles around the joint tighten and go into spasm. Fluid limits movement and of course pain tell the body to rest. All movement is lost at this point as the toe has limited movement – limitus. The toe may reverse, get better or stay like this or worsen. An injection of steroid or anaesthetic can expose this as the correct diagnosis. 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).
Figure 1. The bone fits the undersurface of the larger first metatarsal. Also see Figures below for other anatomical relationships. The red shaded area 2(a) suggests local wear of the cartilage surface.
Figure 2 a-c. The illustrations show the sesamoid bone (a) view on with its muscle (orange) inflamed between the metatarsal and the bone (red). Middle diagram (b) is an x-ray view and (c) shows five relative positions where position 2 is ideal for the inside bone and 4 for the outside bone.
Figure 3 a-b spurs are prominent and cause skin rub. The skeletal figure provides a schematic idea of the problem suggesting gout.
When a joint is affected with long-standing inflammation, new bone forms. This will cause a bone spike called a spur to arise. This happens on the top of the joint and sides, just in a bunion. These horn-like projections (osteophytes) jam the joint further and fluid lubrication stops. Painful toe joints may be fractured, although rare, can arise at any age. Damaged joints (arthrosis) may form loose bodies which are scar tissue generated and change into bone fragments. Again, such events joint movement.
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
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Thanks for reading ‘Stiff Big Toe Joint‘ written by David Tollafield for ConsultingFootPain promoting foot health awareness from the podiatrist.
Published under BusypencilCase Communications Ltd
Original script 10/18 updated April 2019
David no longer practises but can provide information about common foot health conditions. Please read his other articles or information, sign-up or write to me personally at firstname.lastname@example.org telling me your experience, patient journey. Nothing is published without agreement and names are anonymised. I am regulated by the Health Care Professions Council (HCPC).