Hallux rigidus, literally meaning “stiff great toe,” is the most common arthritic condition affecting the foot. Characterised by progressive degeneration of the metatarsophalangeal (MTP) joint of the first toe, the condition leads to pain, stiffness, and the gradual loss of dorsiflexion that is essential for normal gait. It affects an estimated 1 in 40 people over the age of 50, though it can occur at any age, and is slightly more prevalent in women than men. The impact on daily life can be considerable — from difficulty walking and wearing shoes to an inability to participate in sport or exercise. Fortunately, a wide spectrum of treatment options exists, ranging from conservative management to complex surgical reconstruction, and the choice of intervention is guided by the severity of the disease, the patient’s age, activity level, and functional goals.
Understanding the Condition
Before exploring treatment, it is useful to appreciate the staging of hallux rigidus, as this directly informs clinical decision-making. The condition is commonly graded using the Coughlin and Shurnas classification, which ranges from Grade 0 (normal radiographs but mild pain and stiffness) through to Grade 4 (severe articular loss with pain throughout the range of motion). In the early stages, cartilage damage is limited and osteophyte formation is mild. As the disease progresses, dorsal osteophytes enlarge, joint space narrows, and subchondral sclerosis becomes evident on imaging. Understanding this progression is essential, because interventions that are appropriate in early disease may be ineffective or contraindicated in advanced stages.
Conservative Management
The first line of treatment for hallux rigidus is invariably non-operative. Many patients, particularly those with Grade 1 or 2 disease, can achieve meaningful symptom relief through conservative measures alone, and it is generally recommended that non-surgical options be exhausted before operative intervention is considered.
Footwear modification is one of the simplest and most effective early interventions. Shoes with a wide, deep toe box reduce compression on the joint and minimise irritation from dorsal osteophytes. A stiff-soled shoe or a shoe fitted with a Morton’s extension — a rigid carbon fibre insert that extends beneath the great toe — reduces the need for dorsiflexion during push-off, thereby decreasing pain with walking. Avoiding high heels, which force the MTP joint into dorsiflexion, is also important for female patients.
Orthotic therapy complements footwear modification. Custom or prefabricated orthotics can offload the first MTP joint and improve biomechanical function across the foot. Turf toe plates are particularly useful for active individuals who require some degree of forefoot stiffness during sport.
Pharmacological management plays a supporting role. Non-steroidal anti-inflammatory drugs (NSAIDs) can reduce inflammation and pain during acute flares, though they do not alter the course of disease. Intra-articular corticosteroid injections offer short-to-medium-term relief and are a useful adjunct in patients with inflammatory exacerbations. The evidence for repeated injections is less compelling, and there is theoretical concern that frequent steroid administration may accelerate cartilage degradation. More recently, intra-articular hyaluronic acid (viscosupplementation) has been used with some success, offering an alternative to steroids in patients who have not responded to other conservative measures, though the evidence base remains limited.
Physical therapy has a role in maintaining and improving the available range of motion, particularly in early-stage disease. Stretching exercises, joint mobilisation techniques, and strengthening of the intrinsic foot muscles can help preserve function and delay progression. Physiotherapists may also use modalities such as ultrasound therapy or ice to manage symptoms, though the evidence for these approaches is largely anecdotal.
Surgical Treatment
When conservative measures fail to provide adequate relief, or when the disease has progressed to a point at which non-operative treatment is unlikely to be effective, surgery is indicated. The surgical options for hallux rigidus are broadly divided into joint-preserving procedures and joint-sacrificing procedures, and the choice between them depends heavily on disease severity.
Cheilectomy is the most commonly performed joint-preserving procedure and is most appropriate for patients with Grade 1 or 2 disease. It involves the surgical removal of dorsal osteophytes and the resection of approximately 20–30% of the dorsal aspect of the metatarsal head. By removing the bony impingement, dorsiflexion is restored and pain is relieved. Outcomes are generally excellent in appropriately selected patients, with high rates of patient satisfaction and good functional improvement. The procedure preserves the joint and does not preclude further surgery if the disease progresses.
Osteotomies of the proximal phalanx or first metatarsal are employed in certain cases to decompress the joint or alter the biomechanical alignment. The Moberg osteotomy, a closing wedge osteotomy of the proximal phalanx, is useful in patients who have adequate plantar flexion but limited dorsiflexion, as it effectively shifts the arc of motion into a more functional range. These procedures are typically combined with cheilectomy in moderate-severity disease.
Arthrodesis, or fusion of the first MTP joint, is considered the gold standard surgical treatment for advanced hallux rigidus (Grade 3 and 4). While it eliminates motion at the joint, it reliably abolishes pain and restores the ability to walk comfortably. The joint is fused in a position of approximately 10–15 degrees of dorsiflexion and 15–20 degrees of valgus relative to the first metatarsal, which allows normal footwear use and gait. Patient satisfaction rates following arthrodesis are high, and long-term studies have demonstrated durable outcomes. The trade-off is the permanent loss of joint motion, which may limit certain activities and accelerate adjacent joint degeneration over time.
Arthroplasty, or joint replacement, remains controversial in the first MTP joint. Total joint replacements using synthetic implants have been developed in an attempt to preserve motion while eliminating pain. However, long-term outcomes have been inconsistent, with concerns about implant loosening, subsidence, and the technical difficulty of revision surgery. Most foot and ankle surgeons reserve arthroplasty for older, low-demand patients and continue to prefer arthrodesis for reliable long-term results.
The treatment of hallux rigidus requires a tailored, stage-dependent approach. Conservative measures, including footwear modification, orthotics, anti-inflammatory medication, and physiotherapy, form the cornerstone of early management and can provide significant symptom relief for many patients. When surgery becomes necessary, the choice between joint-preserving and joint-sacrificing procedures must be made with careful consideration of disease severity, patient expectations, and lifestyle demands. Cheilectomy offers excellent results in mild-to-moderate disease, while arthrodesis remains the most reliable option for advanced cases. As research continues and implant technology improves, the role of joint replacement may expand, but for now, the principles of evidence-based, individualised care remain the foundation of effective hallux rigidus management.