"Is It a Bunion?" - Part 1 - Hallux Rigidus

"My bunion is playing up".

 The big toe joint causes a lot of trouble for some people, but it isn't always a bunion, even if the joint is swollen, red and painful.                                

Quite often it is a condition called Hallux Rigidus. The 'Hallux' refers to the big toe and 'Rigidus' means that the toe is rigid, or does not move easily. It requires very different treatment to a bunion.

 It is actually  a form of degenerative arthritis which is a progressive condition  and with time, stiffness develops in the toe.  In the early stages when movement is only slightly limited it is referred to as 'Hallux Limitus', but eventually the motion deceases and when the joint is very stiff, it becomes Hallux Rigidus.

We use the big toe joint for many activities, walking, climbing, kneeling, stooping or even standing and so, any inflammatory condition affecting the joint is very painful.

This type of arthritis is often referred to as 'wear and tear' and may be  attributed to the internal 

architecture of the foot, the way in which the joint moves in relation to the other joints in the foot.  There are many biomechanical discrepancies that can lead to this problem including excessive 'pronation' of the foot. Some people have occupations  that require putting excessive strain on the joint, for example climbing ladders or squatting for long periods of time. This may be the sole cause or it may be adding to the inherited problems. There is often a family history of Hallux Rigidus which may be due to the inherited predisposition and the bony alignment or even that career paths may also 'run in families'.

Hallus Rigidus may be caused by injury or trauma, such as stubbing the toe(common in athletes); or through suffering other inflammatory conditions such as gout or rheumatoid arthritis.

As Hallux Rigidus develops, the symptoms progress. Pain and stiffness are the first signs which are aggravated by cold, damp weather and made worse during certain activities (squatting, running). There may be inflammation around the joint combined with swelling. All of these may cause a limp and, as a result of the altered gait, knee, hip and back pain are often evident.

Your podiatrist can usually diagnose this condition by manipulating the toe, but an x ray would determine it.

Treatment involves reducing the inflammation and pain.

 Keeping the joint straight is very helpful and so thick stiff soled shoes are advised. For once, flexible trainers are not advised by the professionals! Well placed pads inside the shoe can reduce the movement in the joint and high heels are definitely not recommended. Avoid all activities which include repeated trauma on the joint, such as jogging. Once the inflammation has reduced, the pain will subside.  Ultimately the toe may become completely inflexible. This may not necessarily cause any problems, as  instinct is to hinge off the second toe joint if the first one is not functioning.

Gout

Gout has a very long history. Hippocrates (c. 460 – c. 370 BC) identified gout (Greek: podogra) as different from other forms of arthritis. It is a member of the family of arthritides, it is inflammation of joints, but it differs because it is caused by the build up of monosodium urate crystals. These are often referred to as uric acid.

Two very brave gentlemen, Faires and MacCarty, investigated the role of these crystals in gout during the 1960's by injecting their left knee joints with them. Within four hours they were experiencing violent attacks of gout and the pain was excruciating.

Surveys have found that gout is an agonising and incapacitating form of  arthritis which "negatively affects daily activities, lifestyle and work "  (N. Lawrence Edwards, MD, Professor of Medicine, Rheumatology and Clinical Immunology, University of Florida College of Medicine) Flare ups are sudden, intense and last an average of 8 days.

Gout sufferers usually produce too much uric acid or are unable to get rid of the excess produced by their bodies. The uric acid forms needle-like crystals which are deposited in the joints. It typically affects one joint, often the big toe (62% of cases) and it can also cause feverish symptoms.

The presence of the crystals trigger an immune response, leading to  inflammation;  joint swelling, pain, heat, redness and stiffness. In some patients the condition can become chronic causing repeated flare ups, joint damage, kidney stones and kidney disease.

Gout tends to run in families, affects about 1% of the population and, it is more common in men than women.

For a long time, alcohol has been considered a trigger for gout attacks.  Little research has been carried out in this area, although one recent study on 197 subjects found that alcohol can  trigger recurrent gout attacks, usually occurring within 24 hours of consumption.

Dehydration is another factor often associated with gout. During periods of increased perspiration, less uric acid is excreted and so at times of high humidity and high temperatures, those prone to gout should drink lots of water. 

A very interesting paper in 2007 (Arthritis Rheum. 2007;56:2048-2054,) connects a reduced incidence of recurrent gout attacks in men over the age of 40 with coffee drinking,

"A study of a nationally representative sample of US adults showed that coffee consumption was associated with a lower serum level of uric acid and a lower frequency of hyperuricemia."

Many gout patients are managed with Allopurinol, the urate lowering drug, with varied success. Allopurinol will not work during an attack as it is not a painkiller and, it may take up to 3 months to be effective against another episode.

If you are unfortunate enough to suffer with gout, one of the most painful conditions known, please reduce your alcohol intake and  increase your fluid levels, especially in hot and humid weather.  Your GP can prescribe painkillers for use during an attack; it's worth paying a visit.

For more information on Podiatry, click here: The Footcare Clinic