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Hallux rigidus (HR) is a degenerative osteoarthritic condition affecting the first metatarsophalangeal joint (MTPJ), resulting in pain, stiffness, and reduced dorsiflexion. HR is the most common form of osteoarthritis of the foot , affecting an estimated one in 40 adults over the age of 50 years . While onset typically occurs around 50 years of age ^, , younger patients—especially athletes—are also affected, with an average onset age of 43 years .

HR is one of the most common disorders of the first MTPJ, second only to hallux valgus. This condition has a significant negative impact on quality of life, particularly in active adults, as it limits normal daily, recreational, and sports activities ^, .

HR is a common condition among athletes, particularly those involved in high impact sports, though it also affects patients in less traumatic sports. This condition results in pain and a reduced range of motion (ROM) and it is especially debilitating for athletes, as MTPJ flexibility is crucial for sports requiring foot push-off, such as running and jumping.

Hallux rigidus often develop from repetitive stress on the first MTPJ, leading to cartilage degradation and bony proliferation. The diagnosis is based on patient history, physical examination, and weight-bearing radiographic imaging of the foot. The clinical and radiographic features serve as the basis for the classification proposed by Coughlin and Shurnas in 2003, which remains the most used system for evaluating this condition ^, .

The goal of the treatment of HR is to correct the underlying deformity, alleviate pain, improve the overall function and flexibility of the first MTPJ, and allow athletes to return to sport (RTS) at their previous performance level.

The treatment of symptomatic hallux rigidus begins with nonsurgical intervention: nonsteroidal anti-inflammatory drugs (NSAIDs), intra-articular steroid injections, orthotics, and shoe modifications designed to limit MTPJ motion can all be used ^, .

When conservative management fails, a variety of surgical options are available . Joint-sparing procedures (e.g., cheilectomy ^, and phalanx and first metatarsal osteotomy ^,, ) are generally preferred in the early stages, while in cases of recurrence and severe arthritis, joint-sacrificing procedures (e.g., arthrodesis , arthroplasty ) are indicated . The choice is based on the degree of HR, patient’s age, motivation, activity level and expectations.

The first ray is one of the most important weight-bearing part of the foot. During the normal stance phase of the gait cycle, the hallux bears twice the load compared with the lesser toes and approximately 40–60 % of the body weight . Forces on the first ray are increased during sporting activity with approximately two to three times the body weight during running and up to eight times body weight in running and jumps .

Excessive length of the first ray increases the stress concentrated at MTPJ during toe-off. People with a long first ray are more prone to developing hallux rigidus .

For these reasons several first metatarsal osteotomies (MTO) have been described for the treatment of HR ^, . The main goals of these procedures are to decompress the joint by shortening the metatarsal, to realign the articular surface to bring the residual arc of motion into a more functional position, and to address metatarsus primus elevatus by plantarflexing the first ray. Complications reported are transfer metatarsalgia, weak push-off strength, and residual pain.

The primary objective of this study was to evaluate the effectiveness of the modified Youngswick osteotomy for treating grade II HR ^,, . A secondary aim was to assess return-to-sport rates and types of athletic activities resumed postoperatively. This information is important when counselling patients about the expected functional outcomes after hallux rigidus surgery .

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A retrospective observational study was performed to assess the clinical outcomes and effectiveness of the modified Youngswick osteotomy in the surgical management of HR grade II among active, non-elite adult athletes. The study included a consecutive cohort of 55 patients who underwent the procedure between 2015 and 2022 ²⁴.

Inclusion criteria were stage II HR, first metatarsal osteotomy according to modified Youngswick technique, age between 25 and 60 years at time of surgery, and a minimum two year follow up. Exclusion criteria included concomitant lateral metatarsal osteotomies, previous surgeries, midfoot or hindfoot fusions, and inflammatory, systemic, or other musculoskeletal diseases.

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Key technical considerations

• 1.

  The width of the shortening osteotomy should correspond to the severity of the deformity.

• 2.

  The osteotomy is usually performed with a longer plantar cut in a proximal-distal direction, slightly oblique, extending up to the upper third of the metatarsal head. This creates a shorter dorsal arm, allowing for plantarization of the head, which could be more difficult in the classic Youngswick osteotomy.

• 3.

  Accurate alignment of osteotomy surfaces is essential.

• 4.

  The screw should be inserted dorsally to plantarly, traversing the proximal to distal fragment with adequate length.

Postoperative full weight-bearing was permitted using a specialized postoperative shoe (stiff-soled postoperative shoe). Sutures were removed two weeks after surgery. Active and passive mobilization of the affected joint was initiated on the first postoperative day. Radiological follow-up was conducted six weeks postoperatively. The mean follow-up duration for this cohort was 79.32 months, with three patients lost to follow-up (Fig. 1) .

Dorsal approach to the first MTP joint. Osteophyte removal from the metatarsal head ( Fig. 1 a). Modified Youngswick osteotomy with dorsal wedge resection to allow proximal and plantar displacement ( Fig. 1 b). Fixation with a compression screw ( Fig. 1 c and d). Closure and postoperative evaluation of alignment and range of motion ( Fig. 1 d and e). This technique decompresses the joint, improves dorsiflexion, and preserves motion, especially useful in active patients with preserved cartilage.

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After a mean follow-up of 79.3 months, 52 patients were re-evaluated clinically and through questionnaires (EFAS and VAS scores). Patients were asked to report their pre- and postoperative physical activity. Results demonstrated that 49 out of 52 patients resumed athletic activities after surgery:

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  Ten patients resumed running, CrossFit, and kickboxing and is now engaged in high-intensity functional activities.

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  Another patient continues running and cycling, occasionally playing tennis and padel.

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  One patient discontinued running due to discomfort at the first toe during activity but now practices trekking, covering an average of 20 km per day.

• •

  One patient ceased physical activity due to unrelated multi-ligamentous knee instability.

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  Another discontinued running due to comorbidities unrelated to the surgical procedure.

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  Ten patients regularly practice Pilates.

• •

  One patient reported an inability to engage in physical activity due to foot-related pathology.

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  One patient reported second-ray transfer metatarsalgia during prolonged activity but continues jogging.

• •

  One patient practices cross-country running and capoeira.

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  Twelve patients engage in regular jogging.

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  Two patients remain sedentary.

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  One patient expressed dissatisfaction with the procedure, citing foot supination during gait rather than pain at the first toe.

Mean scores from the EFAS questionnaire indicate a high level of postoperative satisfaction.

EFAS total score changed from 22.7 ± 6. in pre-operative to 37.1 ± 5.4 in post-operative (p <.001).

Responses to questions 1–6 ranged from pre-operative score of 11.0 to post-operative of 22.7 (p <.001), reflecting a consistent trend toward the highest satisfaction levels. For physical activity-related questions (questions 7–10), mean scores ranged from 9.3–14.3 (p <.001). Lower scores were observed in some cases, a few patients were unable to answer and express a numerical value after abandoning physical activity entirely. ( table )

Table 1

Parameter	Value	P value
Number of Patients	52
Mean Age (years)	42.8 ± 8.6
Gender (Female: Male)	25:30
Follow-up Duration (months)	79.3 ± 10.5
Preoperative VAS Score	5.04 ± 1.2
Postoperative VAS Score	0.9 ± 0.8
Pre-operative EFAS General Score	22.71 ± 0.22
Post-operative EFAS General Score	37.05 ± 0.15	(p <.001).
Pre-operative EFAS Sport Score	9.28 ± 0.25
Post-operative EFAS Sport Score	14.33 ± 0.25	(p <.001).
Pre-operative R.O.M.	24.5°(range 5–55)
Post-operative R.O.M.	52.5°(range 30–70)	(p <.001).

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