Great Toe Interphalangeal Joint Arthritis

Summary

Great toe interphalangeal (IP) joint arthritis often leads to pain in the affected great toe. The involved joint suffers a partial or complete loss of joint cartilage leading to pain, swelling, and stiffness in this area of the big toe. A previous history of a fracture or trauma to the great toe is common. Patients with symptomatic great toe interphalangeal joint arthritis can usually be treated conservatively with comfort shoes, activity modification, appropriate medications, and possibly a local corticosteroid injection. Patients that remain considerably symptomatic in spite of optimal conservative treatment may benefit from surgical fusion of the arthritis great toe IP joint.

Symptoms Commonly Associated with Great Toe Interphalangeal Joint Arthritis

Great toe interphalangeal joint arthritis often produces chronic pain in the affected great toe. The main area of discomfort is at the knuckle of the great toe — just before the toenail begins. This pain may be associated with local swelling. Stiffness of this joint is common, although movement of this joint is naturally limited. A history of a previous significant injury to the great toe is common. Pain symptoms are often aggravated by an increase in standing and walking activities. Patients may describe an increase in symptoms with a change in the weather.

Great toe interphalangeal joint arthritis is a much less common cause of great toe pain than hallux rigidus. Hallux rigidus is great toe arthritis that affects the joint at the base of the great toe — the first metatarsophalangeal (MTP) joint. This is the great toe joint immediately before the great toe IP joint (Figure 1). Patients with great toe interphalangeal joint arthritis are often less symptomatic than patients with hallux rigidus. This may be due to the fact that the interphalangeal joint normally does not have as much motion as the first MTP joint.

Physical Exam Findings in Great Toe Interphalangeal Joint Arthritis

The involved great toe joint may be more swollen relative to the unaffected toe. There is often localized discomfort to touch at the level of the joint — just before the start of the great toenail. Downward motion of the affected great toe interphalangeal joint may be limited compared to the unaffected side. In some patients, there will be an associated claw toe deformity of the great toe IP joint. Usually, sensation to the tip of the toe is normal although in some patients local irritation to the nearby nerves can create areas of abnormal sensation or burning pain near the tip of the great toe.

Imaging Studies 

Plain x-rays of the great toe will usually demonstrate the arthritis of the affected joint. The joint will have a loss of joint space and there may also be the presence of bone spurs associated with the IP joint. Many patients with great toe arthritis will have a history of trauma, and this can often be seen on a plain x-ray where evidence of a previously healed fracture may be seen.

Non-Operative Treatment of Great Toe Interphalangeal Joint Arthritis 

Most patients with great toe interphalangeal (IP) joint arthritis can be treated successfully without surgery. Conservative treatment of great toe IP joint arthritis focuses on decreasing the localized discomfort and minimizing the loading and motion through the great toe IP joint. Common treatment strategies include:

Comfort Shoes: Stiff soled shoes with a soft orthotic insert and a wide flexible toe box will often considerably improve symptoms. The stiff sole limits motion through the arthritic joint, and the soft upper and wide toe box helps minimize local irritation from a swollen or deformed toe rubbing against the shoe.

Activity Modification: Increased repetitive loading, such as would occur during prolonged standing or running, will tend to exacerbate symptoms. Avoiding or limiting these activities or trying alternative activities (ex. bicycling instead of running for fitness) can greatly improve overall symptoms.

Anti-inflammatory Medication: Providing there are no contraindications, the use of an anti-inflammatory medication (ex. ibuprofen) can often considerably improve symptoms from great toe IP joint arthritis. Anti-inflammatory medications are often taken prior to certain activities if the patient knows that activity will likely exacerbate their symptoms.

Acetaminophen: The regular (ex. daily) use of acetaminophen can also improve pain control in patients with great toe interphalangeal joint arthritis. This medication can be taken regularly provided there is no contraindication.

Corticosteroid Injections: Injections of corticosteroids into the arthritic joint can be an effective treatment of great toe IP joint arthritis in the short and intermediate term. These injections usually need to be performed under sterile conditions with the aid of fluoroscopy or ultrasound to ensure the injection is placed into the affected joint. A considerable improvement in pain symptoms can often be achieved for 3-6 months following an injection. Repeat injections may also be beneficial, although the effect tends to lessen over time. Corticosteroid injections will not reverse the arthritis, but they can improve the pain symptoms associated with the arthritic joint.

Surgical Treatment of Great Toe Interphalangeal Joint

Some patients with great toe IP joint arthritis will continue to be significantly symptomatic in spite of optimal conservative treatment. For these patients surgery may need to be considered. The most predictable surgical treatment is a fusion of the arthritic great toe interphalangeal joint. This fusion surgery essentially takes a painful, stiff, arthritic joint and turns into a painless stiff joint. The surgery is fairly straightforward. The arthritic IP joint is prepared for fusion by removing any remaining cartilage, and then fixed in position with screws or a plate and screws. However, the recovery does require an extended period of activity limitations in order to allow the joint to fuse solidly. A solid bony fusion can take 6-10 weeks, or longer to achieve. A great toe IP joint fusion surgery does have the usual risks of all orthopedic fusion operations including: infection, wound healing issues, nerve irritation or injury, nonunion, painful hardware, local blood clotting, loss of blood supply to the tip of the toe, and persistence of pain and discomfort. However, in the right patient and performed appropriately by an experienced surgeon a great toe IP joint fusion procedure can be a very effective surgical treatment for this condition.

June 5th, 2024