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Diagnosis and Treatment of First
Metatarsophalangeal 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
T his clinical practice guideline (CPG) is based upon
consensus of current clinical practice and review of the
clinical literature. The guideline was developed by the Clinical Practice Guideline First Metatarsophalangeal (MTP)
Joint Disorders Panel of the American College of Foot and
Ankle Surgeons. The guideline and references annotate
each node of the corresponding pathways.
Patient symptoms are often associated with increased
activities or occupational demands that require patients to
extend the first MTP joint; for example, stooping or squatting by a laborer. Symptoms also may be caused by shoes
that irritate the soft tissues overlying the subcutaneous bony
prominence or by high-heeled shoes that increase joint
jamming. Patients may present with lateral metatarsalgia
and/or suprastructural complaints secondary to gait alteration (12).
Hallux Rigidus (Pathway 3)
Hallux rigidus is a progressive disorder of the first MTP
joint, characterized by a diminished range of motion (ROM)
and degenerative alterations of the joint (1–9). Because
some degree of movement is generally available, the term
hallux limitus (7) has been used to describe the condition,
although the pathologic process is one of progressive degenerative joint disease secondary to biomechanical disturbance or local pathology (Fig. 1). Generally, a cyclic deterioration of the articulation and the reduction of motion
occur, and ultimately, ankylosis with virtual absence of joint
movement results (3, 10).
Significant History (Node 1)
Patients who present with the condition of hallux rigidus
usually do so with complaints of pain localized to the first
MTP joint or joint stiffness. Onset of symptoms may be
insidious or subsequent to injury; a history of an arthritic
condition may be given (4,8,11).
Significant Findings (Node 2)
The hallmark of hallux rigidus is the typical dorsal bunion caused by both the proliferative disease and the flexion
at the first MTP joint (13). This position of hallux equinus
results in retrograde elevation of the metatarsal and the
uncovering of the dorsal portion of the articulation (14).
Dorsiflexion is generally limited because of abutment of the
articular surfaces of the phalanx and metatarsal head, and
motion is painful with/without crepitus (Fig. 2) (6). Gait
requirements for extension at this joint results in compensatory hyperextension at the hallucal interphalangeal joint.
Associated Findings (Node 3)
Compensatory gait patterns can lead to central metatarsalgia and plantar hyperkeratotic lesions at the hallucal
interphalangeal joint or lesser metatarsal heads.
Radiographic Findings/Classification (Node 4)
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:
[email protected]
Copyright © 2003 by the American College of Foot and Ankle Surgeons
1067-2516/03/4203-0003$30.00/0
doi:10.1053/jfas.2003.50037
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Because hallux rigidus is a disorder of osteoarthrosis,
the radiographic findings are characteristic of this arthritic process. Hallux rigidus is often categorized or
divided into stages predominantly based on the progression of the osteoarthrosis. Regnauld (15) proposed a
3-stage classification from developing arthrosis, estab-
Pathway 3
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125
FIGURE 1 Etiology of hallux rigidus. MPJ, metatarsophalangeal joint.
lished arthrosis, to ankylosis describing the end-stage
joint disease. Later, a fourth stage was included to
address the biomechanical imbalance without radiographic joint changes (7). This modified 4-stage classifi-
cation has been adopted (6,10,16). Therefore, a patient
may present with little to no radiographic joint findings
(stage I) or severe end-stage arthrosis, (stage IV) (Figs.
3– 6).
FIGURE 2 Normal first MTP joint motion (A) requires initial stability of the first metatarsal and subsequent plantarflexion. In the presence
of (B) first ray instability, ROM is restricted with jamming of the base of the proximal phalanx into the first metatarsal head and thus initiating
the degenerative process.
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Initial Treatment Options (Node 5)
Initial treatment options are symptom driven (17). Joint
pain, capsulitis, or other acute episodic pain may be alleviated with the use of nonsteroidal anti-inflammatory drugs
(18). Judicious use of corticosteroid injections may provide
rapid relief, even in recalcitrant joint pain. Modalities that
relieve inflammation and pain are often indicated.
Biomechanical treatment is often an integral component
of initial treatment. Orthotic management in the treatment
of hallux rigidus should attempt to improve the abnormal
pathomechanics or to limit joint motion (12,19,20). Shoe
modifications with stiff or rocker-bottom soles or extradepth shoes may be helpful.
Early surgical intervention with performance of joint
preservation procedures may be appropriate in patients with
lesser degrees of arthrosis. Although it has not been proven,
this may restore function and should be part of the patient
education process.
Clinical Response (Node 6)
When nonsurgical care is rendered, the clinical response
is assessed. If the patient is doing well, initial treatment may
be continued (Node 8). If there has been little or no improvement or if initial improvement deteriorates, surgical
treatment is appropriate. If a primary care physician performed the initial evaluation and treatment, referral to a
podiatric foot and ankle surgeon is indicated (Node 7).
Surgery is considered in patients who continue with
symptoms (Node 7), or simply prefer surgical intervention
(Node 7). The surgical treatment of hallux rigidus will be
predicated on recognition of the condition of the joint as one
that is still salvageable through primary joint reconstruction
or one that would be more appropriately treated with a
joint-destructive procedure (Fig. 7).
Surgical Treatment: Joint-Salvage Procedures
Joint-preservation procedures usually use cheilectomy by
itself or in combination with additional procedures. These
procedures include cheilectomy, metatarsal osteotomy, and
phalangeal osteotomy. Chondroplasty has also been performed as an adjunctive procedure in this group.
Cheilectomy. Cheilectomy is the resection of hypertrophic bony or osteochondral proliferation along the periphery
of the articulation, which may be restricting joint motion
(9,21–37). There is some debate about the appropriate
amount of bone that should be resected. All osteophytosis
should be resected from the metatarsal, phalanx, and sesamoids; some authors advocate aggressive partial joint resections (38,39).
Metatarsal osteotomy. Metatarsal osteotomy is performed to plantarflex the first metatarsal, to transpose a
distal segment in a plantar direction, to realign the metatarsal articular surface, or to shorten the metatarsal to achieve
decompression (6,7,10,22,40 – 47). Both distal and proximal
osteotomies have been performed for correction of these
deformities; Figure 13 shows the comparison of the surgical
procedures.
The extent of elevatus will determine the anatomic location of the osteotomy. Distal first metatarsal procedures can
provide for plantar displacement of the capital fragment, but
to a lesser degree than a proximal osteotomy. Often moderate degrees of elevatus can be reduced simply through a
joint decompression procedure (Fig. 8).
In cases of significant metatarsus primus elevatus, a proximal osteotomy should be considered. These procedures
should be reserved for rigid or structural deformity, as
opposed to positional elevatus. A variety of osteotomies
have also been described to plantarflex the first metatarsal,
such as the sagittal Z or crescentic osteotomy (30). Alternatively, the Lapidus first metatarsal-cuneiform arthrodesis
with or without a bone graft may be considered (Fig. 9).
Phalangeal osteotomy. Limitation of first MTP joint dorsiflexion in patients with hallux rigidus and the presence of
an adequate range of plantarflexion may be addressed
through phalangeal osteotomy. A dorsal-based wedge osteotomy within proximal phalanx realigns the toe and reduces the hallux equinus (7,48 –53).
A separate category of phalangeal osteotomies approaches the problem from the concept of joint decompression (6,10,30,47,54). By achieving relaxation of the first
MTP joint, any secondary elevation of the first metatarsal as
a result of hallux equinus should reduce (Fig. 10). This
should occur whether the relaxation is accomplished on the
phalangeal side or on the metatarsal side of the joint.
Chondroplasty. At surgery, the first metatarsal articular
surface must be evaluated. Degeneration of the cartilaginous surface is usually present predominantly centrally and
dorsally. Chondroplasty by abrasion, with or without subchondral drilling, has been advocated to initiate cartilage
repair of both chondromalacia and areas of full-thickness
cartilage excoriation (30,55).
Joint-Destructive Procedures
As the arthrosis of hallux rigidus progresses, the first
MTP joint may be altered to such an extent that salvage
procedures are not appropriate. Joint-destructive procedures
include resection arthroplasty, implant arthroplasty, and arthrodesis.
Resection arthroplasty. Resection arthroplasty of the first
MTP joint may include excision of either or both sides of
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Classification of Hallux Rigidus: Staging of Joint Pathology Based on Degree of Arthrosis
FIGURE 3
Stage 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 limitation
• No degenerative joint changes noted radiographically
• Hyperextension of the hallucal interphalangeal joint
• Pronatory architecture
FIGURE 4
Stage 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 5
Stage 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 6
Stage 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
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129
FIGURE 7 Surgical treatment of hallux rigidus. IPJ, interphalangeal joint; MC, metacarpal.
the joint. In the case of hallux rigidus with its severe
proliferative activity and progressive loss of joint space,
resection arthroplasty reestablishes joint space and allows
movement.
The most commonly practiced resection arthroplasty is
the removal of the base of the proximal phalanx (54).
Resection arthroplasty varies from excision of only the
proximal phalangeal base with cheilectomy of the first
metatarsal 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 the
biomechanical demands of the particular patient. Resection
arthroplasties are probably most appropriate for end-stage ar-
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throsis in older patients with limited functional demands because of frequency of postoperative metatarsalgia.
Interpositional implant arthroplasty. Interpositional implant arthroplasty may be performed with hemi or doublestem implants. Hemi silicone implants were used in the past,
but because of complications, they are no longer considered
appropriate for patients with hallux rigidus (61– 67). The
second generation of hemi implants is metallic and requires
less bone resection and less disruption of the intrinsic musculature; these may be considered in younger patients (Fig.
11) (68,69).
Interpositional arthroplasty with double-stem silicone
hinged implants is still a useful procedure for the end-stage
FIGURE 8 Distal first metatarsal osteotomy may be performed to allow joint decompression (shortening), plantar transposition of the capital
fragment, 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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131
FIGURE 9 Proximal osteotomy may be performed as a metatarsal osteotomy or, as shown, a Lapidus first
metatarsal cuneiform fusion. Preoperative (A) AP and (B) lateral radiographs show degenerative changes in
the presence of metatarsus primus elevatus treated with cheilectomy and metatarsal cuneiform fusion.
Postoperative (C) AP and (D) lateral radiographs.
FIGURE 10 Phalangeal osteotomy is useful particularly
as a Regnauld decompression
procedure. (A) Preoperative
AP radiograph of hallux valgus
rigidus with (B) postoperative
Regnauld phalangeal–type procedure with Herbert bone
screw fixation.
FIGURE 11 Implant arthroplasty is still a useful procedure for (A) stage 3 and 4 hallux rigidus with a (B) metallic
hemi implant.
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133
FIGURE 12 First MTP joint
fusion is advocated in patients
with significant arthrosis and
provides a durable reconstruction. (A) Preoperative and
(B) postoperative AP views.
arthrosis of hallux (36,70,71). Titanium grommets are recommended as an adjunct to minimize ectopic bone formation, although their main benefit may be in protection of the
implant from the adjacent bone (71). Patients should be
informed of the alternatives to implant arthroplasty and their
potential complications.
Total joint replacement. Total joint systems have been
designed for the first MTP joint generally as 2-component
nonconstrained articulations in an effort to allow motion in
more than 1 plane. Materials used for opposing articular
surfaces are chosen for their low coefficient of friction and
for their minimum wear characteristics. Numerous implant
systems have been developed during the years, and several
are still used clinically, although long-term clinical usefulness has yet to be established (72,73). Judicious use and
strict criteria are recommended to avoid complications and
problematic revisions.
Arthrodesis. Arthrodesis has been a mainstay of surgical
treatment both as an initial treatment of end-stage disease
and as a revision of prior surgical intervention (5,74 – 86).
Although arthrodesis eliminates movement at the first MTP
joint, it provides stability of the medial column and efficient
weight transfer through the medial portion of the foot (87–
90).
The technique of obtaining the arthrodesis is less a consideration than the actual position of the fusion (Fig. 12).
The sagittal plane position is based on the normal declination of the first metatarsal and the shoe types and functional
demands of the patient. The transverse plane position is
usually reflected to that of the lesser toes.
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Summary
Hallux rigidus is a progressive osteoarthrosis of the first
MTP joint, and although numerous etiologic factors exist,
the most common are attributable to biomechanical defects.
Surgical procedures have been discussed in light of appropriateness to the degree of joint arthrosis, based on classification.
The goal is to reduce pain and to improve the function of
the foot. This means that a rational approach to joint preservation is necessary to salvage joints, whenever possible,
particularly in the younger patient.
Acknowledgment
On behalf of the Americam College of Foot and Ankle
Surgeons, the authors acknowledge and thank Maria Bidny,
DPM, who kindly supplied the line art that appears in this
CPG.
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