Hallux rigidus: How do I approach it?

Table 1 Coughlin and Shurnas Clinical Radiographic System for Grading Hallux Rigidus

Grade	Dorsiflexion	Radiographic findings	Clinical findings
0	40° to 60° and/or 10% to 20% loss compared with normal side	Normal	No pain; only stiffness and loss of motion on examination
1	30° to 40° and/or 20% to 50% loss compared with normal side	Dorsal osteophyte is main finding, minimal joint-space narrowing, minimal periarticular sclerosis, minimal flattening of metatarsal head	Mild or occasional pain and stiffness, pain at extremes of dorsiflexion and/or plantar flexion on examination
2	10° to 30° and/or 50% to 75% loss compared with normal side	Dorsal, lateral, and possibly medial osteophytes giving flattened appearance to metatarsal head, no more than ¼ if dorsal joint space involved on lateral radiograph, mild-to-moderate joint-space narrowing and sclerosis, sesamoids not usually involved	Moderate-to-severe pain and stiffness that may be constant; pain occurs just before maximum dorsiflexion and maximum plantar flexion on examination
3	≤ 10° and/or 75% to 100% loss compared with normal side. There is notable loss of metatarsophalangeal plantar flexion as well (often ≤ 10° of plantar flexion)	Same as in grade 2 but with substantial narrowing, possibly periarticular cystic changes, more than ¼ of dorsal joint space involved on lateral radiograph, sesamoids enlarged and/or cystic and/or irregular	Nearly constant pain and substantial stiffness at extremes of range of motion but not at mid-range
4	Same as in grade 3	Same as in grade 3	Same criteria as grade 3 but there is definite pain at mid-range of passive motion