Patient Guide · Foot & Ankle Surgeon · London
Written by Mr Matthew Welck, Consultant Orthopaedic Foot & Ankle Surgeon · Last reviewed 31 July 2026
On this page
- In short
- Is it a bunion or is it arthritis?
- What is happening inside the joint
- How doctors grade it
- What to try before surgery
- Cheilectomy: shaving off the extra bone
- Adding a bone cut to take pressure off the joint
- Synthetic cartilage implants (Cartiva)
- Silicone (silastic) joint replacement
- Fusion: the long-lasting option
- How the choice is usually made
- Frequently asked questions
- Speak to a specialist
- References
In short
Hallux rigidus is arthritis in the big toe joint. It is the most common type of arthritis in the foot, and it is often mistaken for a bunion. They are two different problems, and they need different treatment.
The clue is stiffness, not the lump. With a bunion, the toe leans sideways but still bends. With arthritis, the toe goes stiff, and it hurts most when you push off, walk uphill, or wear soft bendy shoes.
A shoe with a stiff sole, or a curved “rocker” sole, often helps more than anything else. It stops the toe having to bend so far. Many people cope well for years just by changing their shoes.
Shaving off the extra bone — an operation called a cheilectomy — is a reliable first step. In a study that followed 169 feet for about six and a half years, roughly 7 in 10 people were still pain-free, three-quarters would have it done again, and only about 1 in 20 needed a second operation.
Shortening or lowering the long bone behind the toe — a “decompressive osteotomy” — may help some people. A review of 30 studies covering 1,293 feet, published this month by the foot and ankle team at the Royal National Orthopaedic Hospital, found real improvements in pain, movement and everyday function. The catch is that most of those patients also had the extra bone shaved at the same time, so it is hard to know which part did the work.
The Cartiva implant was withdrawn in October 2024 and can no longer be used. If you already have one, the recall applied to unused implants still on the shelf — it was not an instruction to take out implants that are working. The advice is to keep an eye on it, not to remove it.
A silicone (silastic) joint replacement is now the main choice if keeping movement matters most to you. In one group of 108 implants, 97 out of 100 were still in place after about five years, and 9 in 10 patients were happy with the result.
For a badly worn-out joint, fusing it — joining the two bones so the joint no longer moves — is the longest-lasting answer. It fits in with normal life far better than most people fear.
Is it a bunion or is it arthritis?
It is worth sorting this out first. People often arrive certain they have a bunion when the real problem is arthritis — and the two are treated very differently.
| Bunion (hallux valgus) | Hallux rigidus | |
|---|---|---|
| The visible change | Lump on the inner edge; toe leans towards the second toe | Lump on top of the joint; toe stays straight |
| Movement | Joint usually still flexible | Toe gets stiff, especially bending upwards |
| Where it hurts | Rubbing against the shoe | Deep inside the joint, worse when you push off |
| Worst shoes | Narrow and pointed | Flat and flexible, and high heels |
| Typical complaint | “My shoes don’t fit” | “I can’t push off, and it’s getting stiff” |
You can have both at once, and the lump on top of an arthritic joint feels a lot like a bunion, so it is easy to mix them up. An X-ray taken while you are standing gives the answer quickly.
What is happening inside the joint
Cartilage is the smooth, slippery coating on the ends of the bones. In hallux rigidus that coating wears away, and the body reacts by building extra bone — usually a ridge across the top of the joint. That ridge is what stops the toe bending upwards, and what rubs painfully against your shoe.
Your big toe has to bend up a long way every time you push off, so even a little stiffness gets noticed. That is why people describe the problem in terms of walking, stairs and hills, rather than pain when they are sitting still.
It is more likely if you have injured the toe in the past, if the long bone behind the big toe (the first metatarsal) is longer or sits higher than usual, or if it runs in your family. Often there is no single clear cause.
How doctors grade it
Surgeons grade hallux rigidus from mild through to end-stage, meaning the joint is worn out. It depends on how much movement is left, how much of the joint surface looks damaged on X-ray, and whether the toe hurts all the way through the movement or only at the very end of it.
The grade matters because it decides which operation makes sense. Operations that keep your own joint work well when the wear is mild or moderate. Once the whole surface has worn away, keeping the joint means keeping the thing that is causing the pain.
Start here: what to try before surgery
For many people this is all that is needed, and it is worth giving these a proper go before thinking about an operation.
- A shoe with a stiff sole, or a curved “rocker” sole. This is the most useful thing you can do without surgery — the toe simply does not have to bend as far.
- A firm carbon-fibre insole, or a stiff insole that runs under the big toe (called a Morton’s extension). This does much the same job inside shoes you already own.
- Avoiding flat, bendy shoes — they make the toe bend all the way with every step.
- Swapping activities — cycling and swimming rather than running and racquet sports, at least while it is flared up.
- A steroid injection. This can calm a painful spell and buy you time, often 9 months to a year, but the effect does wear off and having them repeatedly is not advisable.
None of this reverses the arthritis. What it does is make the stiff joint matter less in everyday life — and for a great many people, that is enough.
Cheilectomy: shaving off the extra bone
This is the usual first operation. The surgeon removes the ridge of extra bone across the top of the joint. That frees up the upward bend and takes away the part that rubs in your shoe. Your own joint stays where it is.
The long-term results are reassuring. A study followed 165 patients for an average of six and a half years and found:
- About 7 in 10 were still pain-free at the end of the study
- Where pain did come back, three-quarters of the time it happened in the first two years
- Only about 1 in 20 needed another operation
- Around 7 in 10 were satisfied or very satisfied, and three-quarters would have it done again
In that study it did not seem to matter much how worn the joint was to begin with, although most surgeons still expect better results when the arthritis is caught earlier.
Adding a bone cut to take pressure off the joint
In some people the long bone behind the big toe is a little too long, or sits too high, which crowds the joint. A small cut in that bone lets the surgeon shorten or lower it, which takes pressure off the joint and can help it move more freely. This is called a decompressive osteotomy.
This month the foot and ankle team at the Royal National Orthopaedic Hospital published a review of all the research on this operation, in the journal Foot and Ankle Surgery. Mr Welck is the senior author. It brought together 30 studies covering 1,293 feet, followed for an average of just under four years, and found:
- Everyday function scores improved by an average of 41 points
- Pain scores fell by an average of 5 points
- The toe gained an average of 26 degrees of extra movement
Those are big improvements, but the review was careful about what they do and do not prove. About three-quarters of these patients also had the extra bone shaved at the same time, so there is no way to tell how much of the benefit came from the bone cut and how much from the shaving. The results are much the same as those reported for shaving on its own. Most of the studies involved were also not of especially high quality.
So the review did not conclude that this operation should replace what is already done. Its conclusion was that the benefit probably applies to a particular group of people — moderate arthritis, with a long or high first metatarsal — and that better trials are needed to be certain. That is a more cautious view than this operation is sometimes given, and it is the honest reading of the evidence.
Synthetic cartilage implants (Cartiva): no longer available
For several years the synthetic cartilage implant — nearly always called by its brand name, Cartiva — was the main alternative to fusion for people who wanted to keep their toe moving. It was a small soft plug, rather like firm jelly, pressed into the worn end of the bone to resurface it while leaving the joint able to bend.
It was recalled in October 2024 and is no longer on the market.
On 31 October 2024 the manufacturer issued an urgent safety notice recalling every size and every batch supplied between July 2016 and October 2024. The reason given was that published research and reports from surgeons showed more problems than expected: implants needing further surgery or removal, sinking into the bone, slipping out of position, pain, and nerve problems or the implant breaking up. That was worse than the results the company had submitted when the implant was approved in 2016. Surgeons were told to set aside and return any unused implants.
Independent research had already been pointing the same way. In one small group of 11 feet, about a third failed, and the implant could be seen sinking into the bone in 9 out of 10. In a larger group of 219 operations by a single surgeon, about 8 in 100 needed further surgery. In a longer-term group of 173 implants, around 84 in 100 were still trouble-free at 12 years. Those numbers never sat comfortably alongside each other, and the recall reflects that.
If you already have one of these implants
This is the part that matters most, and it is more reassuring than the headlines suggest.
If your toe is comfortable and working well, you do not need to do anything other than stay under review. If it is sore, or getting sorer, it is worth being seen and having an X-ray.
If the implant does need to come out, changing it to a fusion is a well-established operation. It is worth knowing that it does not do quite as well as a fusion done from the start: the bones are less likely to knit together (in one group, more than a quarter did not) and function scores afterwards are lower. A bone graft is often needed to make up the length that has been lost.
Silicone (silastic) joint replacement
With the synthetic cartilage implant gone, attention has turned back to the silastic (silicone) implant for people who want to keep the joint moving. This is an older idea that fell out of favour when the early designs failed. It has since been redesigned and looked at again.
The most useful modern results come from Wrightington Hospital, where Clough and Ring reported on 108 of these implants in 76 patients, followed for an average of just over five years:
- 97 out of 100 implants were still in place
- Scores on a standard foot and ankle questionnaire improved sharply, from 78 to 11 (lower is better)
- Pain fell from 7 out of 10 to just over 1 out of 10
- 9 in 10 patients were satisfied with the result
- Three implants needed further surgery — one because of infection, and two where part of the implant broke, at 10 and 13 years
- About one in five had small hollows (cysts) in the bone on X-ray, but these did not get worse and caused no symptoms
Importantly, they did not see the ongoing bone loss that gave silicone implants their bad name in earlier decades. An earlier group of patients from the same hospital, followed for around eight and a half years, showed much the same thing.
These results come from one hospital looking back at its own patients, rather than a trial comparing the implant directly against fusion, and that hospital has particular expertise with it. That is a genuine caveat. Even so, they are among the better published results for any option that keeps this joint moving. For the right person — usually someone older, less hard on their feet, with a badly worn joint but good strong bone — a silastic replacement is worth discussing.
Fusion: the long-lasting option
When the joint is badly worn, fusing the big toe joint is still the most reliable operation. The surgeon removes the worn surfaces and holds the two bones together with a plate or screws until they knit into one solid piece of bone.
The worry people always raise is the loss of movement. In practice, people get on with a fused big toe far better than they expect. Walking, hiking, cycling, swimming and most gym work are unaffected. The real limits are heel height — usually about two to four centimetres afterwards — and deep squatting or kneeling with your toes bent under you. Plenty of people still run, although pushing off feels different.
The trade-off is simple: you give up movement in a joint that had already gone stiff and painful, and in return you get pain relief that lasts.
How the choice is usually made
| Situation | Usually considered |
|---|---|
| Mild symptoms, toe still moves well | Different shoes, an insole, or an injection |
| Moderate arthritis, extra bone blocking the upward bend | Cheilectomy (shaving off the extra bone) |
| Moderate arthritis, with a long or high first metatarsal | Cheilectomy plus a bone cut to take pressure off the joint |
| Badly worn joint, painful all through the movement | Fusion (joining the bones together) |
| Badly worn joint, but keeping movement matters most to you | Silicone (silastic) joint replacement, for some people (the synthetic cartilage implant is no longer available) |
This is a guide, not a rule. Two people with identical X-rays can quite reasonably make different choices, depending on what they need their feet to do.
Frequently asked questions
Is hallux rigidus the same as a bunion?
No. With a bunion, the big toe leans sideways and you get a lump on the inner edge of the foot. Hallux rigidus is arthritis in the joint, which makes it stiff and gives you a lump on top. You can have both, and they are easy to confuse just by feeling the foot.
Will my big toe get stiffer over time?
Usually yes, slowly. How fast varies a lot from person to person, and stiffness does not always mean pain — some people end up quite stiff but comfortable.
Do I have to have surgery?
No. Many people do well for years with a stiff-soled shoe and a few changes to their activities. Surgery is for pain that stops you doing what you want to do — not for how the X-ray looks.
Will a cheilectomy fix it permanently?
It is not a cure for arthritis, but the long-term results are good: about 7 in 10 people were still pain-free after an average of six and a half years, and only about 1 in 20 needed further surgery. Where pain does come back, it is usually in the first two years.
Can I still run after big toe fusion?
Many people do, although pushing off feels different. Cycling, swimming, walking and gym work are basically unaffected.
What heel height can I wear after a fusion?
Usually about two to four centimetres. The toe is set in one fixed position, so a higher heel will not feel comfortable.
I already have a Cartiva implant — should I be worried?
Not automatically. The October 2024 recall applied to unused implants on the shelf, and the manufacturer told surgeons to keep patients under review rather than remove implants that are working. If your toe is comfortable, simply stay under follow-up. If it is painful, getting stiffer, swelling or feeling weak, arrange an assessment with X-rays.
Can I still have a Cartiva implant?
No. It was recalled in October 2024 — every size and every batch supplied since July 2016 — because more problems were happening than expected: implants needing further surgery or removal, sinking into the bone, slipping out of position, pain and nerve problems. It is no longer available.
Is a silastic joint replacement a good alternative to fusion?
For the right person, yes. In one group of 108 silicone implants, 97 out of 100 were still in place after just over five years and 9 in 10 patients were satisfied, with no sign of the ongoing bone loss seen with older silicone designs. The evidence comes from one hospital looking back at its own patients, rather than a trial comparing it directly with fusion.
Do injections work for big toe arthritis?
A steroid injection can calm a painful flare-up and is useful for buying time, often several months. The effect wears off, though, and repeated injections are not recommended.
Speak to a specialist
With big toe arthritis, the right operation really does depend on the details — how much movement you have left, the shape and height of the bone behind your big toe, and what you need your feet to do. Getting that assessment right matters more than picking between named operations.
Mr Matthew Welck is a Consultant Orthopaedic Foot & Ankle Surgeon at the Royal National Orthopaedic Hospital, Stanmore, and Honorary Associate Clinical Professor at UCL. He is senior author of the systematic review on decompressive first metatarsal osteotomy referenced above, and runs clinics across North and Central London.
Call 07547 395 270 or email secretary@matthewwelck.com. Urgent same-day appointments are offered where possible.
References
- Lewis TL, Dellis S, Matheron G, Akinfala M, Nouri A, Lam P, Patel S, Cullen N, Malhotra K, Welck M. Decompressive first metatarsal osteotomy for the treatment of hallux rigidus: A systematic review. Foot Ankle Surg. 2026. doi:10.1016/j.fas.2026.07.014
- Sidon E, Rogero R, Bell T, et al. Long-term Follow-up of Cheilectomy for Treatment of Hallux Rigidus. Foot Ankle Int. 2019;40(10):1114–1121. doi:10.1177/1071100719859236
- Clough TM, Ring J. Silastic first metatarsophalangeal joint arthroplasty for the treatment of end-stage hallux rigidus. Bone Joint J. 2020;102-B(2):220–226. doi:10.1302/0301-620X.102B2.BJJ-2019-0518.R2
- Morgan S, Ng A, Clough T. The long-term outcome of silastic implant arthroplasty of the first metatarsophalangeal joint: a retrospective analysis of one hundred and eight feet. Int Orthop. 2012;36(9):1865–1869. doi:10.1007/s00264-012-1576-8
- Stryker. Urgent Medical Device Recall — Cartiva Synthetic Cartilage Implant. Advisory notice PFAA 3775099/PFAE 3794726, 31 October 2024. Manufacturer field safety notice.
- Glazebrook H, Bambarawana S, Morash J, et al. Failures of Polyvinyl Alcohol Hydrogel Implant for Hallux Rigidus and Outcomes of Revision to Arthrodesis: Mid-Term to Long-Term Results. Foot Ankle Spec. 2025. doi:10.1177/19386400251385718
- Chopra A, Fletcher AN, Madi NS, Parekh SG. Revision Surgery After Failed Index Synthetic Cartilage Implant Resurfacing for Hallux Rigidus: Single-Surgeon 5-Year Experience. Foot Ankle Spec. 2023;17(4):365–374. doi:10.1177/19386400221147773
- Shimozono Y, Hurley ET, Kennedy JG. Early Failures of Polyvinyl Alcohol Hydrogel Implant for the Treatment of Hallux Rigidus. Foot Ankle Int. 2021;42(3):340–346. doi:10.1177/1071100720962482
Trial and systematic review data above retrieved via PubMed. Recall details are taken from the manufacturer’s own field safety notice. This article is general information. It is not a substitute for advice about your own foot.
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