Disorders of the big toe joint

Bunion (hallux valgus)

If the joint that connects your big toe to your foot has a swollen, sore bump, you may have a bunion. More than half the women in America have bunions, a common deformity associated with wearing tight, narrow shoes, and high heels. Bunions may also have a familial origin as well. Nine out of ten bunions happen to women. With a bunion, the base of your big toe (metatarsophalangeal joint) gets larger and sticks out. The skin over it may be red and tender. Wearing any type of shoe may be painful. This joint flexes with every step you take. The bigger your bunion gets, the more it hurts to walk. Bursitis may set in. Your big toe may angle toward your second toe, or even move all the way under it. The skin on the bottom of your foot may become thicker and painful. Pressure from your big toe may force your second toe out of alignment, sometimes overlapping your third toe. An advanced bunion may make your foot look grotesque. If your bunion gets too severe, it may be difficult to walk. Your pain may become chronic and you may develop arthritis.

Many bunions are treatable without surgery and prevention is always best. To minimize your chances of developing a bunion, never force your foot into a shoe that doesn’t fit. Choose shoes that conform to the shape of your feet. Go for shoes with wide insteps, broad toes and soft soles. Avoid shoes that are short, tight or sharply pointed, and those with heels higher than 2 1/4 inches. If you already have a bunion, wear shoes that are roomy enough to not put pressure on it. This should relieve most of your pain.

If your bunion has progressed to the point where you have difficulty walking or you experience pain despite accommodative shoes, you may need surgery. Additionally, if the bunion is causing pain and deformity (such as a claw toe) to the 2nd toe, if the bunion is not allowing the appropriate weight distribution across the forefoot and causing overload to other parts of the foot, or because continued progression of the deformity, further treatment may be necessary. The surgery itself is complex and requires significant surgical skill to appropriately realign the bone, capsule lining, ligaments, tendons, nerves, and other soft tissues of the foot artfully. This can be performed in by multiple different methods and different degrees of bone work may be necessary. This should be performed by a surgeon skilled in correcting the bunions in multiple different ways so that the most appropriate method required for each patient’s specific type of bunion is utilized. Surgery is performed in a same-day basis (no hospital stay) using an ankle-block anesthesia. The first few days after surgery can be extremely painful and rest and elevation is essential. In the first few weeks after surgery, pain may persist whenever the foot is placed in a dependent position and thus elevation should be utilized whenever possible. Patients require follow-up every 2 weeks after surgery for the first 6 weeks to have the foot rebandaged in order to maintain the soft tissue correction performed during the surgery. Once the swelling has decreased, a return to shoes can be expected. The overall recovery is related to the type of bunion procedure necessary but full return to activity, running, and sports may not occur for up to 3 to 4 months. Swelling may persist for 6 to 12 months depending upon the amount of correction that was performed.

If you have a painful swollen lump on the outside of your foot near the base of your little toe, it may be a bunionette (tailor’s bunion). You may also have a hard corn and painful bursitis in the same spot. A bunionette is very much like a bunion. Wearing shoes that are too tight may cause it. Get shoes that fit comfortably with a soft upper and a roomy toe box. In cases of persistent pain or severe deformity, surgical correction is possible. The surgical correction is similar to that as described for a regular bunion but in general, the recovery may be quicker and necessary correction may be less extensive.

Dr. Vora has written extensively about corrective bunion surgery, revision surgery from previously failed bunion surgery, and different options utilized to cut the bone (osteotomies) utilized to correct bunion during surgery and is familiar and effective utilizing multiple different techniques, utilizing the most appropriate procedure for each patient that will allow for the quickest recovery and maximize outcomes and expectations. Dr. Vora performs this procedure on an outpatient basis, utilizing immediate weight bearing, and prescribes medications and utilizes other techniques to minimize pain during recovery to make the experience as pleasing as possible.

Modified from the AAOS


Arthritis of the Big Toe Joint (hallux rigidus)

The most common site of arthritis in the foot is at the base of the big toe. This joint is called the metatarsophalangeal, or MTP joint. It’s important because it has to bend every time you take a step. If the joint starts to stiffen, walking can become painful and difficult.

In the MTP joint, as in any joint, the ends of the bones are covered by a smooth articular cartilage. If wear-and-tear or injury damage the articular cartilage, the raw bone ends can rub together. A bone spur, or overgrowth, may develop on the top of the bone. This overgrowth can prevent the toe from bending as much as it needs to when you walk. The result is a stiff big toe, or hallux rigidus.

Hallux rigidus usually develops in adults between the ages of 30 and 60 years but may develop at a younger age in somebody who has had trauma to the toe joint or is particularly athletic. No one knows why it appears in some people and not others. It may result from an injury to the toe that damages the articular cartilage or from differences in foot anatomy that increase stress on the joint.

Some of the signs and symptoms patients experience include pain in the joint when you are active, especially as you push-off on the toes when you walk, swelling around the joint, a bump, like a bunion or callus, that develops on the top of the foot (dorsal bunion), and / or stiffness in the great toe and an inability to bend it up or down. If you find it difficult to bend your toe up and down or find that you are walking on the outside of your foot because of pain in the toe, medical attention should be considered. Hallux rigidus is easier to treat when the condition is caught early. If you wait until you see a bony bump on the top of your foot, the bone spurs will have already developed and the condition may be more difficult to treat. X-rays will show the location and size of any bone spurs, as well as the degree of degeneration in the joint space and cartilage.

Non-operative treatment s such as anti-inflammatory medications and icing may ease the pain but they aren’t enough to stop the condition from progressing. Wearing a shoe with a large toe box will reduce the pressure on the toe, and you will probably have to give up wearing high heels. A stiff-soled shoe , sometimes with a rocker or roller bottom design may also provide relief as this type of shoe reduces the amount of bend in the big toe and as such may decrease the associated pain with motion.

Surgical options for hallux rigidus depend upon the degree of arthritis within the joint. Cheilectomy (kI-lek’-toe-me) is usually recommended when damage is mild or moderate. It involves removing the bone spurs as well as a portion of the foot bone, so the toe has more room to bend. The incision is made on the top of the foot. The toe and the operative site may remain swollen for several months after the operation, and you will have to wear a wooden-soled sandal for at least two weeks after the surgery. Most patients do experience long-term relief but the underlying arthritis in the joint is not removed so some pain may persist, and additional surgery may be necessary in the future. Arthrodesis (are-throw-dee’-sis) is a procedure where the bones of the big toe joint are welded, or fused together. This is often recommended when the damage to the cartilage is severe. The damaged cartilage is removed and pins, screws, or a plate are used to fix the joint in a permanent position. This type of surgery means that you will not be able to bend the toe at all at this specific joint but it is the most reliable way to reduce pain in these severe cases. During the recovery, you will be able walk immediately but will be required to use wooden-soled rigid shoe for the first 6 weeks after surgery. The third option for this condition is arthroplasty (are-throw-plas’-tee) which is a joint replacement, specifically in this scenario of the big toe joint. This procedure is appropriate for select individuals. The historical results of joint replacement have been poor but certain designs have shown some improvement. The joint surfaces are removed and an artificial joint is implanted. This procedure may relieve pain and preserve joint motion but has some significant drawbacks as well that must be considered. Dr. Vora commonly treats this condition and has written and lectured about the primary treatments for this condition as well as the options for salvage after previously failed procedures for arthritis of the big toe joint.

Modified from the AAOS



Most bones in the human body are connected to each other at joints but there are a few bones that are not connected to any other bone. Instead, they are connected only to tendons or are embedded in muscle. These are the sesamoids. The kneecap (patella) is the largest sesamoid. Two other very small sesamoids (about the size of a kernel of corn) are found in the underside of the forefoot near the great toe, one on the outer side of the foot and the other closer to the middle of the foot. These bones act like pulleys and provide a smooth surface over which the tendons slide, thus increasing the ability of the tendons to transmit muscle forces. The sesamoids in the forefoot also assist with weight bearing and help elevate the bones of the great toe. Like other bones, sesamoids can break (fracture). Additionally, the tendons surrounding the sesamoids can become irritated or inflamed. This is called sesamoiditis and is a form of tendonitis. It is common among ballet dancers, runners and baseball catchers. Some of the associated signs and symptoms include pain which is focused under the great toe on the ball of the foot, swelling in this region, and possibly difficulty and pain in bending and straightening the great toe. X-rays and other testing such as a bone scan or MRI may be necessary to confirm the diagnosis.

Treatment is generally nonoperative, however, if conservative measures fail, surgery may be recommended to remove the seasomoid bone. Conservative treatments involve activity modification (stopping the activity causing the pain), anti-inflammatory treatments, icing the affected area, and shoe wear modifications such as soft-soled, and low-healed shoes with or without the use of custom or over-the-counter orthotics with a cut-out for the sesamoid bones may be beneficial. Stiff-soled shoes like clogs may also be comfortable. If the condition is actively inflamed, immobilization in a boot or cast may provide significant relief. On occasion, steroid injections to reduce the inflammation may also be of some benefit.

Modified from the AAOS

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