If you’re experiencing pain, swelling and limited movement in the main joint of your big toe – often characterised by a bony lump on the top of the toe – you probably have wear and tear arthritis (even if you are young).
A bony lump on the main joint of the big toe – the first metatarsophalangeal joint – is likely to have been caused by gradual damage. This sort of arthritis is common and in the toe sometimes known as ‘hallux rigidus’. It is called this because the main feature of the condition is stiffness (‘rigidus’) of the big toe (‘hallux’).
There is no way of telling how the joint has become arthritic, but the likely reason is that it is the result of being put under stress in walking, with each step sending a force equal to twice your body weight through the joint.
What treatments are there?
Shoes make a big difference. A stiff sole (like a hiking boot) prevents the joint moving, so it hurts less. Slip-on shoes are to be avoided, since they only stay on by being “too tight” over the toes. Pressure on the painful joint makes the pain worse.
Insoles (orthotics) can redistribute weight and stiffen the part of the shoe beneath the painful joint.
Switching to “foot friendly” activities – cycling or rowing machine, rather than running – is part of the compromise.
Painkillers and anti-inflammatories help a bit, but long term use should be avoided.
Injections can be useful but are usually temporary.
Surgery is a last resort, but can be very effective.
What operations are there?
Manipulation and injection. A joint injection can be combined with a manipulation (under anaesthetic) to mobilise the joint.
Cheilectomy. Bony lumps that grow on the bones or around the joints are called spurs and it is these which a surgeon will remove from the toe during a cheilectomy – along with any free-floating debris that may be causing stiffness and a lack of movement around the joint.
Cartiva implant. This is a newer procedure where a spacer pushes the bones apart to prevent painful rubbing. Only selected patients are suitable. Cheilectomy is currently used more commonly.
If the joint is very arthritic (too severe for cheilectomy or Cartiva) then “welding it shut” with a joint fusion (arthrodesis) is very effective at abolishing pain. The joint is permanently stiff afterwards, but there are so many other joints in the foot that this has surprisingly little effect.
Is a cheilectomy right for me?
A cheilectomy is often offered to people who are experiencing early arthritis of the big toe, when the joint is not yet too badly affected. Some patients may be suitable for a Cartiva instead.
However, if your arthritis is more severe, these operations may not be appropriate, as they may not be successful in relieving the pain. A foot and ankle specialist will be able to help you decide the best course of action, based on your individual symptoms and circumstances.
What is involved in the operation?
Surgery should only be undertaken if your symptoms are significant and appropriate treatment without surgery is not satisfactory to you. Once you have sought expert advice and decided upon the right option, you will want to understand the recovery process. This is virtually identical for cheilectomy and Cartiva
Cheilectomy involves making an incision on the big toe, to allow the surgeon to remove the spurs on top of the bones and to clean the joint of any residual tissue or debris. In selected cases it can be done with “keyhole” technology.
Cartiva implants are embedded in the knuckle bone to push the toe bone away and prevent painful rubbing.
These operations are usually done under general anaesthetic, but there may be the option of local anaesthetic with sedation. This involves injections around the ankle to numb the foot.
How long does the recovery process take?
Immediately after the surgery, your foot will be put in a soft dressing and you will be advised to keep the limb elevated for a few days to minimise swelling. As the swelling goes down, you will be able to transition back into a regular shoe, but you should avoid walking far for the first 14 days. When you walk try to avoid putting all your weight on the heel, since this makes the toes curl up. Instead walk (or plod) on the whole foot, without rising onto your toes.
After 1 week – even before the stitches are out – physiotherapy begins. The goal is as much movement as possible. Resting for too long can produce stiffness.
Greater mobility will be possible once your stitches have been removed (2 weeks). At this point, you will be encouraged to continue the range of motion exercises on the toe, building up to gentle stretching and running once you feel comfortable to do so.
It’s difficult to be precise about how long it will take until you’re back playing contact, twisting and impact sports, but most people return to their previous activities within six months of a cheilectomy / Cartiva.
Are there any potential complications I should be aware of?
Like any form of surgery there are risks associated with anaesthesia, infection, damage to nerves and blood vessels or blood clots (thrombosis).
Also, given that arthritis is a progressive problem, there is a chance you may have continued arthritis pain despite surgery, which may result in you having to need a further operation. Your cheilectomy or Cartiva does not compromise a future fusion operation.
Cheilectomy is an extremely successful operation, with an 85% patients significantly improved afterwards. Cartiva, being a newer procedure, has only 5 year results but is considered to be very promising – in carefully selected cases.
Why come to Wimbledon Clinics?
At Wimbledon Clinics we offer a comprehensive and professional service for a wide range of sports and orthopaedic problems and injuries, ensuring that our patients have access to every option for treatment, not just surgery.
We bring together experienced consultants, surgeons, physiotherapists and other sports medicine specialists under one roof so that no matter what sports-related issue you might be experiencing, at Wimbledon Clinics you can expect to find the best advice and treatment to help you recover.
Call us on: 0208 944 0665 or email us at: [email protected]