Diagnosis and Treatment of FirstMetatarsophalangeal Joint Disorders.Section 2: Hallux Rigidus

Clinical Practice Guideline First Metatarsophalangeal Joint Disorders Panel:John V. Vanore, DPM,1 Jeffrey C. Christensen, DPM,2 Steven R. Kravitz, DPM,3

John M. Schuberth, DPM,4 James L. Thomas, DPM,5 Lowell Scott Weil, DPM,6

Howard J. Zlotoff, DPM,7 and Susan D. Couture8

This clinical practice guideline (CPG) is based uponconsensus of current clinical practice and review of theclinical literature. The guideline was developed by the Clin-ical Practice Guideline First Metatarsophalangeal (MTP)Joint Disorders Panel of the American College of Foot andAnkle Surgeons. The guideline and references annotateeach node of the corresponding pathways.

Hallux Rigidus (Pathway 3)

Hallux rigidus is a progressive disorder of the first MTPjoint, characterized by a diminished range of motion (ROM)and degenerative alterations of the joint (1–9). Becausesome degree of movement is generally available, the termhallux limitus (7) has been used to describe the condition,although the pathologic process is one of progressive de-generative joint disease secondary to biomechanical distur-bance or local pathology (Fig. 1). Generally, a cyclic dete-rioration of the articulation and the reduction of motionoccur, and ultimately, ankylosis with virtual absence of jointmovement results (3, 10).

Significant History (Node 1)

Patients who present with the condition of hallux rigidususually do so with complaints of pain localized to the firstMTP joint or joint stiffness. Onset of symptoms may beinsidious or subsequent to injury; a history of an arthriticcondition may be given (4,8,11).

Patient symptoms are often associated with increasedactivities or occupational demands that require patients toextend the first MTP joint; for example, stooping or squat-ting by a laborer. Symptoms also may be caused by shoesthat irritate the soft tissues overlying the subcutaneous bonyprominence or by high-heeled shoes that increase jointjamming. Patients may present with lateral metatarsalgiaand/or suprastructural complaints secondary to gait alter-ation (12).

Significant Findings (Node 2)

The hallmark of hallux rigidus is the typical dorsal bun-ion caused by both the proliferative disease and the flexionat the first MTP joint (13). This position of hallux equinusresults in retrograde elevation of the metatarsal and theuncovering of the dorsal portion of the articulation (14).Dorsiflexion is generally limited because of abutment of thearticular surfaces of the phalanx and metatarsal head, andmotion is painful with/without crepitus (Fig. 2) (6). Gaitrequirements for extension at this joint results in compen-satory hyperextension at the hallucal interphalangeal joint.

Associated Findings (Node 3)

Compensatory gait patterns can lead to central metatar-salgia and plantar hyperkeratotic lesions at the hallucalinterphalangeal joint or lesser metatarsal heads.

Radiographic Findings/Classification (Node 4)

Because hallux rigidus is a disorder of osteoarthrosis,the radiographic findings are characteristic of this ar-thritic process. Hallux rigidus is often categorized ordivided into stages predominantly based on the progres-sion of the osteoarthrosis. Regnauld (15) proposed a3-stage classification from developing arthrosis, estab-

1 Chair, Gadsden, AL; 2 Everett, WA; 3 Richboro, PA; 4 San Francisco,CA; 5 Board Liaison, Birmingham, AL; 6 Des Plaines, IL; 7 Camp Hill,PA; and 8 Park Ridge, IL. Address correspondence to: John V. Vanore,DPM, Gadsden Foot Clinic, 306 South 4th St, Gadsden, AL 35901; e-mail:jvanore@prodigy.net

Copyright © 2003 by the American College of Foot and Ankle Surgeons1067-2516/03/4203-0003$30.00/0doi:10.1053/jfas.2003.50037

124 THE JOURNAL OF FOOT & ANKLE SURGERY

Pathway 3

VOLUME 42, NUMBER 3, MAY/JUNE 2003 125

lished arthrosis, to ankylosis describing the end-stagejoint disease. Later, a fourth stage was included toaddress the biomechanical imbalance without radio-graphic joint changes (7). This modified 4-stage classifi-

cation has been adopted (6,10,16). Therefore, a patientmay present with little to no radiographic joint findings(stage I) or severe end-stage arthrosis, (stage IV) (Figs.3– 6).

FIGURE 1 Etiology of hallux rigidus. MPJ, metatarsophalangeal joint.

FIGURE 2 Normal first MTP joint motion (A) requires initial stability of the first metatarsal and subsequent plantarflexion. In the presenceof (B) first ray instability, ROM is restricted with jamming of the base of the proximal phalanx into the first metatarsal head and thus initiatingthe degenerative process.

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Initial Treatment Options (Node 5)

Initial treatment options are symptom driven (17). Jointpain, capsulitis, or other acute episodic pain may be allevi-ated with the use of nonsteroidal anti-inflammatory drugs(18). Judicious use of corticosteroid injections may providerapid relief, even in recalcitrant joint pain. Modalities thatrelieve inflammation and pain are often indicated.

Biomechanical treatment is often an integral componentof initial treatment. Orthotic management in the treatmentof hallux rigidus should attempt to improve the abnormalpathomechanics or to limit joint motion (12,19,20). Shoemodifications with stiff or rocker-bottom soles or extra-depth shoes may be helpful.

Early surgical intervention with performance of jointpreservation procedures may be appropriate in patients withlesser degrees of arthrosis. Although it has not been proven,this may restore function and should be part of the patienteducation process.

Clinical Response (Node 6)

When nonsurgical care is rendered, the clinical responseis assessed. If the patient is doing well, initial treatment maybe continued (Node 8). If there has been little or no im-provement or if initial improvement deteriorates, surgicaltreatment is appropriate. If a primary care physician per-formed the initial evaluation and treatment, referral to apodiatric foot and ankle surgeon is indicated (Node 7).

Surgery is considered in patients who continue withsymptoms (Node 7), or simply prefer surgical intervention(Node 7). The surgical treatment of hallux rigidus will bepredicated on recognition of the condition of the joint as onethat is still salvageable through primary joint reconstructionor one that would be more appropriately treated with ajoint-destructive procedure (Fig. 7).

Surgical Treatment: Joint-Salvage Procedures

Joint-preservation procedures usually use cheilectomy byitself or in combination with additional procedures. Theseprocedures include cheilectomy, metatarsal osteotomy, andphalangeal osteotomy. Chondroplasty has also been per-formed as an adjunctive procedure in this group.

Cheilectomy. Cheilectomy is the resection of hypertro-phic bony or osteochondral proliferation along the peripheryof the articulation, which may be restricting joint motion(9,21–37). There is some debate about the appropriateamount of bone that should be resected. All osteophytosisshould be resected from the metatarsal, phalanx, and sesa-moids; some authors advocate aggressive partial joint re-sections (38,39).

Metatarsal osteotomy. Metatarsal osteotomy is per-formed to plantarflex the first metatarsal, to transpose adistal segment in a plantar direction, to realign the metatar-sal articular surface, or to shorten the metatarsal to achievedecompression (6,7,10,22,40–47). Both distal and proximalosteotomies have been performed for correction of thesedeformities; Figure 13 shows the comparison of the surgicalprocedures.

The extent of elevatus will determine the anatomic loca-tion of the osteotomy. Distal first metatarsal procedures canprovide for plantar displacement of the capital fragment, butto a lesser degree than a proximal osteotomy. Often mod-erate degrees of elevatus can be reduced simply through ajoint decompression procedure (Fig. 8).

In cases of significant metatarsus primus elevatus, a prox-imal osteotomy should be considered. These proceduresshould be reserved for rigid or structural deformity, asopposed to positional elevatus. A variety of osteotomieshave also been described to plantarflex the first metatarsal,such as the sagittal Z or crescentic osteotomy (30). Alter-natively, the Lapidus first metatarsal-cuneiform arthrodesiswith or without a bone graft may be considered (Fig. 9).

Phalangeal osteotomy. Limitation of first MTP joint dor-siflexion in patients with hallux rigidus and the presence ofan adequate range of plantarflexion may be addressedthrough phalangeal osteotomy. A dorsal-based wedge os-teotomy within proximal phalanx realigns the toe and re-duces the hallux equinus (7,48–53).

A separate category of phalangeal osteotomies ap-proaches the problem from the concept of joint decompres-sion (6,10,30,47,54). By achieving relaxation of the firstMTP joint, any secondary elevation of the first metatarsal asa result of hallux equinus should reduce (Fig. 10). Thisshould occur whether the relaxation is accomplished on thephalangeal side or on the metatarsal side of the joint.

Chondroplasty. At surgery, the first metatarsal articularsurface must be evaluated. Degeneration of the cartilagi-nous surface is usually present predominantly centrally anddorsally. Chondroplasty by abrasion, with or without sub-chondral drilling, has been advocated to initiate cartilagerepair of both chondromalacia and areas of full-thicknesscartilage excoriation (30,55).

Joint-Destructive Procedures

As the arthrosis of hallux rigidus progresses, the firstMTP joint may be altered to such an extent that salvageprocedures are not appropriate. Joint-destructive proceduresinclude resection arthroplasty, implant arthroplasty, and ar-throdesis.

Resection arthroplasty. Resection arthroplasty of the firstMTP joint may include excision of either or both sides of

VOLUME 42, NUMBER 3, MAY/JUNE 2003 127

FIGURE 3Stage I: Stage of Functional Limitus

• Hallux equinus/flexus• Plantar subluxation proximal phalanx• Metatarsus primus elevatus• Joint dorsiflexion may be normal with nonweightbearing, but

ground reactive forces elevate the first metatarsal and yield limita-tion

• No degenerative joint changes noted radiographically• Hyperextension of the hallucal interphalangeal joint• Pronatory architecture

Classification of Hallux Rigidus: Staging of Joint Pathology Based on Degree of Arthrosis

FIGURE 4Stage II: Stage of Joint Adaptation

• Flattening of the first metatarsal head• Osteochondral defect/lesion• Cartilage fibrillation and erosion• Pain on end ROM• Passive ROM may be limited• Small dorsal exostosis• Subchondral eburnation• Periarticular lipping of the proximal phalanx, the first metatarsal

head, and the individual sesamoids

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FIGURE 5Stage III: Stage of Established Arthrosis

• Severe flattening of the first metatarsal head• Osteophytosis, particularly dorsally• Asymmetric narrowing of the joint space• Degeneration of articular cartilage• Erosions, excoriations• Crepitus• Subchondral cysts• Pain on full ROM• Associated inflammatory joint flares

FIGURE 6Stage IV: Stage of Ankylosis

• Obliteration of joint space• Exuberant osteophytosis with loose bodies within the joint space or

capsule• �10° ROM• Deformity and/or malalignment• Total ankylosis may occur• Inflammatory joint flares possible• Local pain is most likely secondary to skin irritation or bursitis

caused by the underlying osteophytosis

VOLUME 42, NUMBER 3, MAY/JUNE 2003 129

the joint. In the case of hallux rigidus with its severeproliferative activity and progressive loss of joint space,resection arthroplasty reestablishes joint space and allowsmovement.

The most commonly practiced resection arthroplasty isthe removal of the base of the proximal phalanx (54).Resection arthroplasty varies from excision of only theproximal phalangeal base with cheilectomy of the firstmetatarsal head to resection on both sides of the joint(38,39,47,56–60).

The choice of procedure must be tailored to the age and thebiomechanical demands of the particular patient. Resectionarthroplasties are probably most appropriate for end-stage ar-

throsis in older patients with limited functional demands be-cause of frequency of postoperative metatarsalgia.

Interpositional implant arthroplasty. Interpositional im-plant arthroplasty may be performed with hemi or double-stem implants. Hemi silicone implants were used in the past,but because of complications, they are no longer consideredappropriate for patients with hallux rigidus (61–67). Thesecond generation of hemi implants is metallic and requiresless bone resection and less disruption of the intrinsic mus-culature; these may be considered in younger patients (Fig.11) (68,69).

Interpositional arthroplasty with double-stem siliconehinged implants is still a useful procedure for the end-stage

FIGURE 7 Surgical treatment of hallux rigidus. IPJ, interphalangeal joint; MC, metacarpal.

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FIGURE 8 Distal first metatarsal osteotomy may be performed to allow joint decompression (shortening), plantar transposition of the capitalfragment, or realignment of the metatarsal articular surface; (A) preoperative anteroposterior (AP) and (B) lateral radiograph, and (C)postoperative AP and (D) lateral views.

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FIGURE 9 Proximal osteotomy may be performed as a metatarsal osteotomy or, as shown, a Lapidus firstmetatarsal cuneiform fusion. Preoperative (A) AP and (B) lateral radiographs show degenerative changes inthe presence of metatarsus primus elevatus treated with cheilectomy and metatarsal cuneiform fusion.Postoperative (C) AP and (D) lateral radiographs.

FIGURE 10 Phalangeal os-teotomy is useful particularlyas a Regnauld decompressionprocedure. (A) PreoperativeAP radiograph of hallux valgusrigidus with (B) postoperativeRegnauld phalangeal–type pro-cedure with Herbert bonescrew fixation.

FIGURE 11 Implant arthro-plasty is still a useful proce-dure for (A) stage 3 and 4 hal-lux rigidus with a (B) metallichemi implant.

VOLUME 42, NUMBER 3, MAY/JUNE 2003 133

arthrosis of hallux (36,70,71). Titanium grommets are rec-ommended as an adjunct to minimize ectopic bone forma-tion, although their main benefit may be in protection of theimplant from the adjacent bone (71). Patients should beinformed of the alternatives to implant arthroplasty and theirpotential complications.

Total joint replacement. Total joint systems have beendesigned for the first MTP joint generally as 2-componentnonconstrained articulations in an effort to allow motion inmore than 1 plane. Materials used for opposing articularsurfaces are chosen for their low coefficient of friction andfor their minimum wear characteristics. Numerous implantsystems have been developed during the years, and severalare still used clinically, although long-term clinical useful-ness has yet to be established (72,73). Judicious use andstrict criteria are recommended to avoid complications andproblematic revisions.

Arthrodesis. Arthrodesis has been a mainstay of surgicaltreatment both as an initial treatment of end-stage diseaseand as a revision of prior surgical intervention (5,74–86).Although arthrodesis eliminates movement at the first MTPjoint, it provides stability of the medial column and efficientweight transfer through the medial portion of the foot (87–90).

The technique of obtaining the arthrodesis is less a con-sideration than the actual position of the fusion (Fig. 12).The sagittal plane position is based on the normal declina-tion of the first metatarsal and the shoe types and functionaldemands of the patient. The transverse plane position isusually reflected to that of the lesser toes.

Summary

Hallux rigidus is a progressive osteoarthrosis of the firstMTP joint, and although numerous etiologic factors exist,the most common are attributable to biomechanical defects.Surgical procedures have been discussed in light of appro-priateness to the degree of joint arthrosis, based on classi-fication.

The goal is to reduce pain and to improve the function ofthe foot. This means that a rational approach to joint pres-ervation is necessary to salvage joints, whenever possible,particularly in the younger patient.

Acknowledgment

On behalf of the Americam College of Foot and AnkleSurgeons, the authors acknowledge and thank Maria Bidny,DPM, who kindly supplied the line art that appears in thisCPG.

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FIGURE 12 First MTP jointfusion is advocated in patientswith significant arthrosis andprovides a durable recon-struction. (A) Preoperative and(B) postoperative AP views.

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