Stiffness in your big toe?
By the faculty of Harvard Medical School for The Harvard Medical School Adviser

Q: One of my big toes has become stiff and painful. I stubbed it several months ago, but shouldn’t it have healed by now?

A: The big toe may be small, but its role in our lives is enormous. Imagine how hard it would be to walk, bend over, rise up on the balls of your feet or simply keep your balance without the aid of your big toes. If toe pain and stiffness prevents these everyday movements, you may have hallux rigidus -- literally, “stiff big toe.”

Hallux rigidus is caused by arthritis in the joint of the big toe. The early phase of the condition is called hallux limitus. At this stage, people can still move around fairly normally, but unless the problem is treated, it can worsen.

The main joint of the big toe is the metatarsophalangeal (MTP) joint. It joins the first long bone in the forefoot (the metatarsal) to the first bone of the big toe (the phalynx; see illustration). Every time you take a step, the MTP joint bends, allowing your foot to roll forward and push off. If the joint doesn’t function properly, walking and many other activities of daily life can be difficult, even impossible.

Like all joints in the body, the ends of the MTP bones are covered with cartilage, a slippery substance that allows the joint to move freely. Gradual wear and tear or an acute injury can cause cartilage to break down. This process is known as osteoarthritis or degenerative arthritis. The resulting bone-on-bone contact produces pain and inflammation. Bone spurs may develop on the bones’ surface, and the joint space may narrow. As a result, the joint can’t bend upward normally, which affects walking. It may also lead to pain in the ball of your foot and even in your back.

Why do some people develop hallux rigidus while other don’t? Some people are simply born with minor foot defects that place chronic stress on the big-toe joint, triggering arthritis. Certain sports injuries may also be to blame. For example, “turf toe,” so-named because it often happens to people who play sports on artificial surfaces, is an injury to the MTP joint caused by the sudden bending back of the big toe. Ballet dancers frequently move through positions that force the MTP joint to flex at a 90- degree angle, which may injure the joint. And a fracture or even a simple stub can damage the MTP joint.

If you think you may have hallux limitus or rigidus, see a clinician as soon as possible. If you wait until bone spurs develop or your toe is completely stiff and hurts all the time, restoring function can be more difficult. Also, you can develop other foot and joint problems if you start walking on the outer edge of the foot to avoid putting pressure on the toe.

Your clinician will examine your toe and may order X-rays, which may reveal bone spurs, cartilage break down and loss of space between the bones of the joint. As for treatment, rest, ice, and anti-inflammatory medications such as ibuprofen can help relieve pain and swelling. For severe pain, your clinician may recommend a cortisone injection, sometimes in combination with a local anesthetic. To reduce swelling, the American Academy of Orthopedic Surgeons suggests a contrast bath three times a day. Immerse your painful foot in water as cold as you can stand for 30 seconds, then in water as warm as you can stand for the same amount of time. Alternate cold and warm baths for a total of five minutes (ending with cold water).

For longer-lasting relief, it’s important to correct things that may be aggravating your toe. High heels are out, and shoes with a roomy toe box are in. A thick-soled shoe or one with a rocker bottom (like a clog) will allow your foot to roll forward as you walk. That way, your big toe isn’t forced to bend sharply. Shoe inserts (orthotics) may help correct foot or gait abnormalities. You can use a shoe stretcher to loosen the toe box and other areas of the shoe that come in contact with your big toe or its MTP joint.

You should also avoid activities such as running and tennis, which put highimpact stress on your foot. If your big toe isn’t completely stiff, you may be able to improve its upward flexibility with some simple range-of-motion exercises. Grasp your big toe and gently pull it back until the point of resistance. Hold the position for 20 seconds. Repeat several times a day. A regular walking program can also help. Don’t let your stiff big toe keep you down. Instead, use these tips in consultation with your clinician -- to put your best foot forward.

Copyright 2006 the President and Fellows of Harvard C o l l e g e . Developed by Harvard Health Publications (www.health.harvard.edu) . Distributed by UFS. Submit questions to harvard_ adviser@hms.harvar d.edu.