The great toe joint is a small joint, but its normal function and ability to dorsiflex (bend upwards as in the photo on the right) is essential to normal foot function.

Unfortunately, it is possible for an abnormal limitation of great toe joint function to develop.  Indeed, this is a common condition seen in podiatric practice.  This is the topic of this web page.


Stiff big toe joints may be known by different names.  When motion is limited, the condition is called Hallux Limitus.  When the motion is completely gone, the condition is called Hallux Rigidus.  

When a patient has a bony bump on the top of the big toe joint, the condition is sometimes called a Dorsal Bunion.  (See picture to the left.)  Dorsal bunions, a type of arthritis, can be one of the more common causes of hallux limitus or hallux rigidus. 

What creates this condition?

All joints consist of two bones coming together, to form the joint.  The joint surfaces on each bone are covered with a slick, glistening, pearly-white surface called cartilage.   The type of cartilage on a joint surface is known as articular cartilage.  

When limitation of normal function occurs, however, arthritis begins to develop.  So Hallux Limitus and Hallux Rigidus can be thought of as arthritic conditions, or at least pre-arthritic.

Degenerative arthritis is a condition where the joint surface, the articular cartilage, begins to wear out.  The causes for this are many, some of the most common of which include:

  • An elevated first metatarsal  This is the case in the picture above.  As you can see, the affected bone sits higher up than the adjacent bone, and this makes the motion of   dorsiflexion more difficult.  This is best viewed with a "Weight Bearing Lateral" X-ray, a side view of the foot when the patient is standing.

  • A hypermobile first metatarsal  is the case where the first metatarsal bone may look like it's in a normal position, but it is unstable, lifting excessively relative to the other metatarsals in stance.  This judgement is usually made clinically, although there are some specialty X-ray views that may be helpful.   

  • The first metatarsal may be too long.  Normally, the 1st met should be slightly shorter than the 2nd, so as the body weight is transferred forward, the bone may plantarflex (or drop) relative to the 2nd metatarsal.  But if the 1st metatarsal is longer than the 2nd metatarsal, the bone tends to elevate relative to the 2nd metatarsal in the "toe off" portion of gait, causing jamming of the joint, and MTP joint degeneration (hallux limitus).  As an example of this, put your four fingers (minus your thumb) on a table.  Notice that your middle finger is the longest finger.  Now lift the heel of your hand, maintaining your fingertips on the table.  If you look at your fingers from the medial side, you should see that the shaft of the second finger tends to drop below the shaft of the third.  This is how the metatarsals should move.  Now, do the same thing with just your 3rd, 4th and 5th fingers, (not the thumb or 2nd finger).  Pretend that the 3rd finger is a longer-than-normal 1st metatarsal, and the 4th finger is the relatively shorter 2nd metatarsal.  Now as you lift the heel of your hand you should see that the 3rd finger elevates relative to the 4th finger.  In the foot this will tend to cause hallux limitus.  A simple weight-bearing AP (also known as a DP) x-ray will reveal whether this is the case.  (Non-weight-bearing films are less accurate.) 

  • The first bone in the big toe (the proximal phalanx) may be too long.   This can apply a retrograde force through the joint, which may cause hallux limitus.  Again, an AP (DP) film should help you discern this.

  • Excessive pronation may destabilize the great toe joint.  If the foot pronates (or flattens) excessively, there is an increase in pressure under the first metatarsal as the foot rolls in.  This force may be considered as an upward pressure from the floor on the inside of the weight-bearing portion of the foot.  This pressure beneath the first metatarsal can cause it to elevate, resulting in hypermobility, hallux limitus or hallux rigidus. 

  • Irregular bone contours can also cause a limitation of joint motion.  This is where abnormal bony bumps begin to exert friction on each other

  • Irregular joint alignment may lead to abnormal strain on the joint and wear on the bony surfaces, possibly leading to diminished motion.

  • The presence of loose fragments of bone in or near the joint may also limit motion.  Loose fragments are known as "osteophytes", or more colloquially, as "joint mice".

  • Improper sesamoid function can also adversely affect joint function.  (Sesamoids are the two small bones beneath the 1st metatarsophalangeal joint and are integral to normal function of this joint.)

  • Improper muscle or tendon function may also lead to a poorly-functioning joint, either directly causing a limitation of motion, or doing so secondarily by leading to the formation of joint wear and arthritis.

  • Scar tissue may also bind down the joint, thereby limiting motion.

  • Infection of a joint may destroy bony and soft tissues, create arthritis and scar tissue and lead to hallux limitus or rigidus.

  • Primary Arthritis is the type of arthritis that causes joint wear, as opposed to the type of arthritis that develops from abnormal motion.  Some forms of arthritis may directly damage the metatarsophalangeal joint and create hallux limitus.  

  • Excessive pressure from a shoe with a tight toe box may create hallux limitus by creating abnormal, excessive, and chronic damage.

  • High-heeled shoes tend to create hyperextension of the great toe joint, thereby altering function and leading to hallux limitus. 

  • Acute trauma to the joint, such as dropping something on the joint or kicking something may cause a sudden, acute trauma to the joint, leading to arthritis and loss of joint function.  

  • Abnormal biomechanics (abnormal function of the joint) may lead to abnormal joint wear, arthritis, and hallux limitus. 

  • Genetic causes are also thought to be involved in the development of this condition.  This is because metatarsal length, structure, position and function are factors that tend to be inherited.

How does arthritis develop?

First, as a result of some cause, the cartilage begins to wear, and the joint surface loses its lustre.  It glistens less and loses its slick feel.  This is the beginning of arthritis. 

The next step is where the joint begins to change from a pearly-white color to a dull-grey.  Sometimes holes or depressions develop in that surface, as the cartilage wears through.  Joint motion diminishes, and pain tends to develop. 

As the condition progresses, the cartilage is worn away, and all that remains is the two raw bone surfaces rubbing together.  Because bones can't function well without the cartilage between them, joint motion worsens, and the bones become more and more misshapen.  The joint surface tends to flatten on each side of the joint, and projections of bone know as "spurs" develop.  At this stage, motion of the joint is usually quite limited, and most patients experience a significant amount of pain, and the way the patient walks, the "gait", begins to become altered. 

Eventually, the motion gets so bad that the two bones can fuse together, completely obliterating what was once a joint. 

What symptoms does arthritis cause? 

The degenerative process causes two major problems:  pain, and loss of motion of the big toe joint.  This can also cause alteration in the way a patient walks, so other parts of the foot, knee, hip and back are frequently affected. 

How can a patient be certain this is the condition? 

In most cases, the diagnosis is apparent on physical examination alone.  But X-rays help us understand the extent of the joint degeneration and bone malformation. 

How can this be treated? 

First, you can try symptomatic relief, that is, just making it feel better.  Rest, ice, anti-inflammatory medications, steroid injections, physiotherapy, and massage may all help.  At least temporarily. 

Second,  and more importantly long term, you can try to identify the cause of the problem, and attempt to correct this cause.  Orthoses (orthotics), for example, can be used to increase what motion still exists in the joint, or if the degeneration is bad enough, both  orthoses and special shoe modifications can limit pressure on the spurs, and limit the painful motion that remains in the joint.  

The third option is to attempt to fix the condition surgically.  

What would be done to fix the joint surgically? 

Several options exist.  

  • If spurs are present, but the joint doesn't look too worn out, you could simply remove any spur formation that limits motion.  This is called a "Cheilectomy" or an "Exostectomy".  

These procedures have the advantage of being easy to perform and allowing for quick recovery.  Cheilectomies, however, do not do anything to address why the hallux limitus developed.  So using this procedure where it is not indicated will tend to create a return of symptoms and may make the patient undergo more surgery in the future.  It can also create scar tissue on the top of the joint, which would also tend to inhibit motion.  

For these reasons, other procedures that attempt to correct the cause may be better choices in the long run, however.  For example, if the cause of the condition is an excessively long first metatarsal, a procedure designed to shorten the metatarsal would be considered.  Alternatively, the metatarsal may be lowered if it is too high, stabilized if it is too mobile, realigned if it is crooked, recontoured if it is irregular, and so forth.  There are many more procedures that may be considered than the average patient would imagine.  

Range of motion exercises are encouraged afterwards for these procedures, and recuperation is usually quite rapid. 

  • Bonney-Kessel Procedure This procedure involves a pie-shaped piece of bone being removed from the big toe to allow the toe to "dorsiflex" or bend up.  In the right applications it may allow the patient to roll forward off the bent toe, without causing excessive painful bending the big toe joint.  

  • Waterman Procedure Similar to the Bonney-Kessel, the Waterman involves a pie-shaped wedge of bone cut to be made in the first metatarsal instead of the big toe.   It is classically done in the "head" of the first metatarsal bone, behind the big toe joint.  

  • Lambrinudi Procedure  The Lambrinudi procedure basically consists of a long, pie-shaped wedge of bone to be made in the shaft of the bone.   When the triangular-shaped piece is removed, the bone is able to "plantarflex," or drop.  

  • Giannistras Procedure  The Giannistras consists of a Z-shaped bone cut when viewed from the top of the bone.  This cut allows the metatarsal to be lowered and shortened as necessary to help the joint function.  It is typically held in place with two screws.  It is less stable than other procedures, but allows for substantial correction in severe cases.  

  • Plantarflexory Kalish Procedure or Plantarflexory Offset V Procedure  This procedure is similar to the Lambrinudi except that it involves an interlocking "V" shaped into the bone cut (when viewed from the side).  This interlocking "V" cut allows for more stability in the bone cut and allows for quicker ambulation post-operatively.  

  • Youngswick Procedure  Devised by a California podiatrist named Dr. Fred Youngswick, this common modification to the Austin Procedure allows the surgeon to shorten and drop the metatarsal head, in cases where arthritis and limitation of motion is developing at the great toes joint.  

  • To allow the head of the bone to be raised or lowered, there is the Reverdin-Green-Laird-Todd procedure.  In this procedure a triangular-shaped wedge is removed both from the top and from the side.  This procedure allows one to correct a bunion in three dimensions.  An example is demonstrated with the x-ray on the right.

When the joint is terribly worn and more conservative procedures are not sufficient, you sometimes need to give up the idea of salvaging the joint, and perform a joint-destructive procedure.  Several possible such procedures exist. 

  • A false joint, or implant could be put in.  Years ago, these false joints were metal.  Then surgeons moved towards using plastic.  Today, metal is being used more and more once again. 

    When performed correctly, this procedure can restore good motion.  The disadvantage is that the implant can irritate the bones, and the implants tend not to last forever.  Other surgery down the road to remove or replace the implant is common. 


  • Part of the joint could be removed in a procedure known as a Keller.

The Keller procedure involves removing the base of the big toe joint.  As you can see in the illustration to the left, there is a great deal of arthritic changes in the great toe joint.  

The Keller procedure involves removing the base of the first toe bone, to remove the arthritic bone surrounding the joint and limiting motion.  (See illustration below.)


Usually surrounding soft tissues are positioned between the remaining bone surfaces to prevent further bone-on-bone wear.  

The Keller procedure is quick-healing, and it increases range of motion tremendously.  This helps the patient return to a more normal gait, but the patient loses some push-off power in the toe joint.  Future surgery is rarely needed.


  • The joint could be fused.  In other words, instead of removing bone, you attempt to eliminate the joint and allow the two bones to grow together in a fused position.  Known as an arthrodesis, the advantage to this is that without motion of the joint, pain is usually resolved.  The disadvantages are that this procedure is slow-healing, sometimes requiring months to become solid, and the result is a motionless great toe joint, which can change the way the patient walks.  Alterations if shoe gear may be necessary, and other joints frequently begin to become troublesome, as they must make up for the loss of great toe joint motion.  It is also somewhat more to reverse if the procedure proves to be problematic. 

For more information on procedures that may be chosen for hallux rigidus and limitus, you may wish to visit our web page on bunion surgeries, as some of the procedures described there may be chosen for this type of abnormality.  

Which procedure is best?

It depends on each individual case, and on the preferences of both the surgeon and the patient. 

What kind of anaesthesia would be used for these procedures?  

Any type of anaesthesia may be used--general, spinal, or local.  In most cases, local anaesthesia is preferred, as it is safer, easier on the patient, and less painful afterward. 




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The Achilles Foot Health Centre
S. A. Schumacher, D.P.M., F.A.C.F.A.S., F.A.C.F.A.O.M.  
Dr. S. A. Schumacher, Podiatric Corporation  

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