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Hallux Rigidus M20.20 735.2

hallux rigidus xray 
ICD-9 Classification / Treatment
Etiology / Natural History Associated Injuries / DDx
Anatomy Complications
Clinical Evaluation Follow-up Care
Xray / Diagnositc Tests Review References

synonyms:hallux rigidus, turf toe, hallux osteoarthritis, great toe arthritis, big toe arthritis

Hallux Rigidus ICD-10

Hallux Rigidus ICD-9

  •  735.2 Hallux Rigidus

Hallux Rigidus Etiology / Epidemiology / Natural History

  • term used to describe the symptoms commonly associated with degenerative arthritis of the 1st MTP joint.
  • Lont-term sequele of turf toe (football injury)

Hallux Rigidus Anatomy

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Hallux Rigidus Clinical Evaluation 

  • loss of dorsiflexion of 1st MTP joint, loss of ROM and pain
  • average age of onset 43yrs old.  Female>male
  • average age at time of surgery = 53yrs

Hallux Rigidus Xray / Diagnositc Tests

  • typical show dorsal spur/exostosis  

Hallux Rigidus Classification / Treatment

  • Coughlin Classification (Coughlin MJ, J Bone Joint Surg Am. 2003 Nov;85-A(11):2072).
  • Grade 0: xray normal.  Exam=10%-20% decreased dorsiflexion. No pain.   Treatment =  plantar release.
  • Grade I: xray=dorsal osteophyte, minimal joint space narrowing. Exam=20%-50% loss of dorsiflexion. Mild pain. Treatment = Cheilectomy
  • Grade II: xray=dorsal,lateral, medial osteophytes; <1/4 dorsal joint space involved. Moderate joint space narrowing, subchondral sclerosis. Exam=75% loss of dorsiflexion. Moderate-severe pain. Treatment=Cheilectomy
  • Grade III: xray=Same as 2 with substantial joint narrowing, cystic changes, >1/4 joint involved, sesamoid changes.  Exam = 75%-100% loss of dorsiflexion.  Constant pain.  Treatment=Arthrodesis, Consider metallic hemiarthroplasty, Consider cheilectomy with proximal phalangeal osteotomy (O'Malley MJ, JBJS 2013;95(7):606)
  • Grade IV:xray=Same as 2 with substantial joint narrowing, cystic changes, >1/4 joint involved, sesamoid changes. Exam = 75%-100% loss of dorsiflexion. Definite pain at mid-range of passive motion. Treatment=Arthrodesis, Consider metallic hemiarthroplasty
  • Non-operative: shoe modifications, full-length rigid orthotic, NSAIDS, activity modification (Smith, Foot ankle Int 2000;21:906)
  • Intra-articular sodium hyaluronate or steriod injection. @50% will still require surgery. (Pons M, Foot Ankle Int 2007;28:38).
  • Cheilectomy(excision of an irregular osseous rim that interferes with motion of a joint) is indicated for pts who fail non-operative treatement(Mann, JBJS 1988) Cheilectomy is a better than arthrodesis, resection arthroplasty, or arthroplasty with the use of a flexible implant. In older adults who present late, with more severe X-Ray changes, Keller procedure is indicated. Cheilectomy technique see Pfeffer GB, Master Techniques: Foot Ankle 2nd ed, 2002
  • Hallux MTP Arthrodesis (Goucher NR, Foot Ankle Int 2006;27:869).
  • Consider cheilectomy with proximal phalangeal osteotomy (O'Malley MJ, JBJS 2013;95(7):606)

Hallux Rigidus Associated Injuries / Differential Diagnosis

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Hallux Rigidus Complications

  • Nonuion
  • Infection
  • Painful hardware
  • CRPS
  • Arthrodesis: 7% cellulits, 6% plate removal due to pain, 6% painless fibrous union.
  • Cheilectomy: 6% cellulits, 9% fail requiring arthrodesis

Hallux Rigidus Follow-up Care

  • AOFAS hallus MTP score. Kitaoka Foot Ankle Int. 1994;15:349-53
  • Cheilectomy=PROM within 10 days.  Aggressive stretching.  WBAT in stiff-soled shoe. 3 months for maximal improvement. 72% Excellent, 24% Good, 4% fair, 0% poor subjective patient result
  • Arthrodesis=WBAT in stiff-soled shoe on lateral aspect and heel until radiographic fusion. 3 months for maximal improvement.  87% Excellent, 13% Good, O%fair/poor subjective patient result.

Hallux Rigidus Review References

  • Coughlin MJ, Shurnas PS. Hallux rigidus. J Bone Joint Surg Am. 2004 Sep;86-A Suppl 1(Pt 2):119-30
  • Coughlin MJ, Shurnas PS. Hallux rigidus. Grading and long-term results of operative treatment. J Bone Joint Surg Am. 2003 Nov;85-A(11):2072-88.
  • Pfeffer GB, Master Techniques: Foot Ankle 2nd ed, 2002
  • Raikin SM, Ahmad J, Pour AE, Abidi N. Comparison of arthrodesis and metallic hemiarthroplasty of the hallux metatarsophalangeal joint. J Bone Joint Surg Am. 2007 Sep;89(9):1979-85
  • Giannini S, Ceccarelli F, Faldini C, Bevoni R, Grandi G, Vannini F. What's new in surgical options for hallux rigidus? J Bone Joint Surg Am. 2004;86-A Suppl 2:72-83.
  • Mann RA, Clanton TO. Hallux rigidus: treatment by cheilectomy. J Bone Joint Surg Am. 1988 Mar;70(3):400-6