Hallux rigidus: from biomechanical assessment to minimally invasive surgery
Pain at the base of the big toe when climbing stairs, pushing off while running or rising onto tiptoes. It is one of the most frequent reasons for consultation, and one of the best managed when treatment is staged: custom orthoses, ultrasound-guided injection and, when indicated, minimal incision surgery.
Hallux limitus and hallux rigidus: the same disease at different grades
Hallux rigidus is osteoarthritis of the first metatarsophalangeal joint (first MTP joint), the joint connecting the first metatarsal to the proximal phalanx of the big toe. When stiffness appears without relevant osteophytes we speak of hallux limitus; once there are dorsal osteophytes, mechanical pain at push-off and a clear limitation of dorsiflexion, we speak of hallux rigidus. The classification we use in clinic is the Coughlin/Shurnas grading (grades 0–IV), and it guides treatment from the very first visit.
Clinical classification: the language of staged treatment
Coughlin/Shurnas: a classification that directs treatment
Clinical review covering the Coughlin/Shurnas radiographic classification (grades 0–IV) and the treatment ladder: in mild to moderate grades, conservative care (activity modification, footwear, orthoses, injection) may be sufficient; in advanced grades, joint procedures (cheilectomy) are considered or, in end-stage disease, arthroplasty or arthrodesis.
The key clinical message: the radiographic grade does not decide on its own, but together with the clinical picture it points to which step to apply first. In grades I–II the usual surgical option is cheilectomy (resection of the dorsal osteophyte); in grades III–IV the joint procedure is discussed according to the patient's age and functional expectations.
Hamid KS, Parekh SG. Clinical Presentation and Management of Hallux Rigidus. Foot Ankle Clin. 2015;20(3):391-9. doi:10.1016/j.fcl.2015.04.002
Biomechanical assessment and a well-designed custom orthosis
The design that does make biomechanical sense
Clinical review detailing what a useful orthosis for hallux rigidus should look like: around 3 mm thick with the right stiffness, medial arch support extended proximal to the first metatarsal head to elevate the first ray and decompress the dorsal aspect of the first MTP joint, and correction of the pronation moment that overloads the medial column.
The important point: an orthosis designed with that logic is not a generic off-the-shelf insole. It is a safe, reversible, low-risk device that buys time, can avoid surgery in mild to moderate grades and, in many patients, maintains pain-free activity for years. Before prescribing one, we carry out the full biomechanical gait assessment in clinic and, where indicated, musculoskeletal ultrasound to rule out accompanying lesions.
Colò G, Fusini F, Samaila EM, Rava A, Felli L, Alessio-Mazzola M, et al. The efficacy of shoe modifications and foot orthoses in treating patients with hallux rigidus: a comprehensive review of literature. Acta Biomed. 2020;91(14-S):e2020016. doi:10.23750/abm.v91i14-S.10969
When conservative care is not enough: ultrasound-guided corticosteroid injection
A single injection with a significant effect at 6 weeks
RCT with 50 patients (35 women, mean age 49.8 ± 10.3 years) who received a single intra-articular injection into the first MTP joint of 40 mg of methylprednisolone + 1 mL of lidocaine: significant pain reduction and AOFAS improvement at 6 weeks (p<0.001), with no complications.
The study compared landmark guidance with ultrasound guidance and found both to be effective, but real-time control of the needle under ultrasound adds precision and safety: the needle enters exactly into the joint space of the first MTP joint, not into the soft tissues. That is why in clinic we always perform the injection under ultrasound guidance.
Emami Razavi SZ, Azadvari M, Fateh HR, Ghahvechi Akbari M, Kazemi S, Rezaee E. Short-term Efficacy of Ultrasonographic Guidance for Intra-articular Corticosteroid Injection in Hallux Rigidus: A Single-Blind Randomized Controlled Trial. Foot Ankle Int. 2021;42(11):1410-1418. doi:10.1177/10711007211015988
Intra-articular hyaluronic acid: an alternative with a good safety profile
Clinical improvement with a low complication rate
Recent systematic review with 5 studies and 218 patients (mean follow-up 4.4 ± 1.4 months) after intra-articular hyaluronic acid injection for hallux rigidus: improvement in pain at rest and during activity (VAS), in function (AOFAS) and in quality of life (FHSQ). Complication rate of 10 %, mostly transient post-injection pain that resolved within a few days. Only 3.2 % required a secondary procedure.
Ultrasound-guided hyaluronic acid is a reasonable alternative when the preference is to delay surgery or when the patient is not an ideal surgical candidate. The technique is outpatient-based, safe and allows an immediate return to daily activity.
Butler JJ, Hartman H, Mener A, Mercer NP, Randall GW, Petropoulos S, et al. Limited Evidence to Support the Use of Intra-Articular Injection of Hyaluronic Acid for the Management of Hallux Rigidus: A Systematic Review. Foot Ankle Orthop. 2024;9(3):24730114241265109. doi:10.1177/24730114241265109
When surgery is indicated: minimal incision cheilectomy (MIS)
MIS cheilectomy: a series with a postoperative AOFAS of 88.7
Surgical case series with 38 patients (21 women, 17 men) operated on for grade II–III hallux rigidus through a minimal incision: mean postoperative AOFAS of 88.7 points at a minimum follow-up of 12 months, using a dorsomedial incision of approximately 1 cm, burr resection of the dorsal third of the metatarsal head and early joint mobilisation.
Only 2 patients required revision surgery. The technique allows controlled resection of the osteophyte while keeping the joint, with soft-tissue preservation and a return to normal footwear in 1–2 weeks depending on pain. It is the surgical option with the best recovery profile once the patient has exhausted full conservative care and the indication is correct.
Walther M, Chomej P, Kriegelstein S, Altenberger S, Röser A. Minimally invasive cheilectomy. Oper Orthop Traumatol. 2018;30(3):161-170. doi:10.1007/s00064-018-0543-y
MIS matches open surgery in outcome, with less morbidity
Results equivalent to open cheilectomy, with a faster recovery
Updated review of MIS cheilectomy for hallux rigidus: the literature confirms results equivalent to open cheilectomy, with clear advantages: better cosmesis, fewer wound complications, less soft-tissue disruption and a faster recovery.
General indications for MIS cheilectomy: grade I–II hallux rigidus with symptomatic dorsal osteophytes causing dorsal impingement or conflict with footwear, in patients in whom a full course of conservative management has failed. In grade IV with end-stage osteoarthritis, the final steps are arthrodesis or arthroplasty, which are considered in due course if that point is reached.
Fletcher AN, Patel V, Cerrato R. Minimally Invasive Cheilectomy for Hallux Rigidus. Foot Ankle Clin. 2024;29(3):471-484. doi:10.1016/j.fcl.2024.01.003
Take-home
- Hallux limitus and hallux rigidus are the same disease at different grades. The Coughlin/Shurnas classification sets the treatment step.
- A custom orthosis designed specifically to offload the dorsal aspect of the first MTP joint is the first step in grades I–II, together with footwear advice and manual therapy.
- Ultrasound-guided injection with corticosteroid or hyaluronic acid is the next option when conservative care is not enough, with a good safety profile.
- If surgery is indicated, minimal incision cheilectomy (MIS) offers results equivalent to open surgery with less morbidity and a faster recovery.
At Avanza Salud we can help
We manage hallux rigidus with a complete stepwise protocol: a biomechanical gait assessment with gait analysis and a pressure platform, Podonexus custom orthoses designed specifically to offload the first ray and reduce dorsal conflict at the first MTP joint, manual therapy and exercise for the big toe, musculoskeletal ultrasound and ultrasound-guided injection (corticosteroid, hyaluronic acid or PRP as indicated), and minimal incision surgery (MIS) once the conservative ladder has been exhausted and surgery is clinically indicated. If you have been living with big toe pain when climbing stairs, running or rising onto tiptoes, we can offer the assessment and the full plan in a single visit.