A stiff, painful big toe is usually hallux rigidus, which is arthritis in the joint at the base of the big toe. It’s common: about 1 in 40 adults over 50 have it.
Most people manage it WITHOUT surgery.
The main fixes are shoes with a stiff sole and a roomy toe box, which stop the joint having to bend, and sometimes an injection. When that isn’t enough, there are two main operations: a clean-up of the bone spurs, or a fusion that stops the joint moving for good.
Which one suits you depends mostly on how much of the cartilage in the joint is left.
What it feels like
- Pain on the top of the big toe joint, worse when you walk, run, squat or push off
- Stiffness: the toe won’t bend up as far as the other one. Rising onto your toes or climbing stairs can be hard
- A bony bump on top of the joint: bone spurs that can rub on your shoes. It’s sometimes mistaken for a bunion, which sits on the side instead
- Swelling around the joint, often worse in cold weather or after a long day
- Pain elsewhere in the foot: if you walk on the outside of the foot to protect the toe, the smaller toes can get sore. See ball of foot pain (metatarsalgia)
It usually starts between the ages of 30 and 60. Wear and tear, old injuries to the toe, foot shape and family history all play a part.
Shoes and insoles
The big toe joint has to bend every time you push off. The less it bends, the less it hurts. That’s the whole idea behind footwear changes.
- A stiff sole: if you can fold the shoe in half at the ball of the foot, it’s too flexible for a sore big toe
- A rocker sole: a sole that’s curved at the front rolls you forward so the toe doesn’t have to bend
- A roomy, deep toe box: so the bump on top of the joint isn’t pressed on
- A low heel: heels force the toe to bend upward with every step
- A stiff insert: a firm plate that sits in the shoe under the big toe limits movement at the joint
- Ice and anti-inflammatory tablets: can help flare-ups. Check with your doctor or pharmacist before taking them for more than a few days
A sore big toe calms down when you stop asking it to bend.
Injections
A cortisone shot into the joint can ease pain for several months.
It tends to work better in milder arthritis. It doesn’t slow the arthritis down, and the effect usually wears off. See cortisone shot side effects before you decide.
Surgery: cheilectomy or fusion
Surgery is for pain that still limits your walking, work or sleep after a proper trial of shoes and inserts.
- Cheilectomy: the surgeon removes the bone spurs from the top of the joint so the toe can bend up further without jamming. It keeps the joint and its movement. It works best for mild to moderate arthritis
- After cheilectomy: a stiff post-op shoe for about two weeks, then back into normal shoes as swelling allows. Swelling can take a few months to settle
- What to expect: most people are pleased with the result. Fewer than 1 in 10 go on to need a fusion within ten years, and that’s more likely when arthritis was already advanced
- Fusion: the joint surfaces are removed and the two bones are held together with screws or a plate until they grow into one. Pain relief is reliable. The trade-off is that the big toe no longer bends at that joint
- After fusion: a cast, boot or stiff shoe for about six weeks, often with crutches at first. Swelling can last three to six months
- Life after fusion: most people walk normally, and many return to hiking, golf, jogging or tennis. High heels and deep squats on your toes become difficult
- Joint replacement: an option some surgeons offer, often to less active people. Ask your surgeon how its results compare with fusion in someone like you
The American Academy of Orthopaedic Surgeons explains the options in its guide to stiff big toe (hallux rigidus).
Recovery from big toe surgery has a lot in common with bunion surgery, especially managing swelling. See swelling after bunion surgery.
Questions to ask your surgeon
- How much cartilage is left? This decides whether a cheilectomy is likely to last
- What will I lose? Ask which shoes and activities will be harder after each option
- How long off work? Desk work, standing work and driving all come back at different times
- What if the first operation doesn’t last? Ask whether a later fusion is still possible
Call your surgeon today if
- The wound is red, hot, spreading or leaking, or you have a fever after surgery
- Pain after surgery is getting WORSE rather than slowly better
- Your calf is painful, swollen or warm. It could be a clot
- The toe turns pale, blue or cold
- You’re short of breath or have chest pain: call emergency services
Get it checked if
- The joint is suddenly red, hot and very painful without an injury. Gout can hit the same joint
- Pain is stopping you walking despite stiff-soled shoes
- The smaller toes or the outside of the foot are getting sore from the way you walk
- Pain wakes you at night or is there even when you rest
A stiff big toe doesn’t need to bend to stop hurting. It needs the right shoe first, and the right operation only if that fails.