Hallux Rigidus

Hallux Rigidus

Jessica J.M. Telleria, MD

John Y. Kwon, MD

Dr. Kwon or an immediate family member has received royalties from Paragon 28 and Trimed; serves as a paid consultant to or is an employee of Medline, Medshape, and Paragon 28; and has stock or stock options held in Medshape. Neither Dr. Telleria nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this chapter.


The term hallux rigidus is used to describe a painful degenerative condition of the hallux metatarsophalangeal (MTP) joint. Hallux rigidus is characterized by progressive loss of joint motion, joint space narrowing, and osteophyte formation, which lead to pain and declining physical function. The condition was first reported in 1887 as a plantarflexed hallux at the first MTP joint with degenerative arthritis.1,2

Clinical Evaluation

Radiographic Examination and Classification

The radiographic examination requires AP, oblique, and lateral weight-bearing views of the affected foot. Plain radiographs reveal joint asymmetry, joint space narrowing, sclerosis, subchondral cyst formation, osteophyte formation, and toe deviation at the MTP joint. The level of severity depends on the stage of the disease. Joint space narrowing and toe alignment are best seen in the AP view, and dorsal spur formation is best seen in the lateral view. The oblique may be helpful in assessing patients with primarily dorsal cartilage loss but retained plantar joint space. MRI or CT is rarely required for diagnosis but may be useful if the differential diagnosis is unclear. Similarly, laboratory studies or joint aspiration can be useful to rule out crystalline disorders but typically are not required unless the diagnosis of hallux rigidus is unclear.

The Coughlin grading system is commonly used to guide treatment in conjunction with clinical findings.5 In grade 0, the patient has mild pain only during recreational activity or while wearing high-heeled shoes. Examination reveals slight tenderness to palpation but no clinical deformity. Loss of range of motion is minimal. Dorsiflexion is approximately 40° to 60°, or 10% to 20% less than in the normal contralateral joint. Radiographic findings are essentially normal. In grade 1, the symptoms are similar, but examination reveals tenderness, a palpable tender dorsal spur, and dorsiflexion of 30° to 40° (20% to 50% less than in the normal contralateral joint). The grind test does not elicit pain. Radiographs reveal a small dorsal spur (mild to moderate osteophyte formation) but minimal joint narrowing, sclerosis, or change to the articular morphology. A patient with grade 2 hallux rigidus reports more consistent pain, pain with activities of daily living, and greater difficulty with shoe wear than in grade 1. Range of motion is more restricted and dorsiflexion is 10° to 30°, or 50% to 75% less than at the normal contralateral joint. The osteophytes are palpable and tender. Radiographs reveal mild to moderate (less than 50%) joint space narrowing, mild to moderate sclerosis, and osteophyte formation extending medially and laterally with increased dorsal prominence. Typical periarticular arthritic changes of the sesamoids are not profound, although irregularities may appear. In grade 3, the patient has near-constant pain during activities of daily living and increased difficulty with shoe wear. Range of motion is restricted to dorsiflexion of no more than 10°, or 75% to 100% less than at the normal contralateral joint side, with loss of as much as 10° of plantar flexion. Osteophytes are clinically palpable and tender. Patients report pain at the terminal range of motion but may not have increased pain with the grind test. Radiographic findings are similar to those in grade 2, but with more than 50% narrowing of the joint space, greater cystic changes and sclerosis, and greater sesamoid involvement (Figure 1). The radiographic and clinical findings in grade 4 are consistent with those of grade 3, but the grind test is positive.

Feb 27, 2020 | Posted by in ORTHOPEDIC | Comments Off on Hallux Rigidus

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