Hallux rigidus, a degenerative arthritic condition of the first metatarsophalangeal (MTP) joint, represents the most common form of arthritis in the foot, affecting approximately one in forty individuals over the age of fifty. Characterized by progressive pain, stiffness, and loss of dorsiflexion, this condition significantly impairs the gait cycle, as the hallux fails to dorsiflex adequately during the propulsive phase of walking. The treatment of hallux rigidus is not a monolithic pathway but a graduated, dynamic algorithm that meticulously balances patient demographics, disease severity, functional demands, and anatomical considerations. This therapeutic journey progresses from conservative, non-operative measures through a spectrum of joint-preserving procedures, culminating in definitive joint-sacrificing arthrodesis, with the overarching goal of restoring pain-free function.
The foundation of hallux rigidus management invariably rests upon a robust trial of conservative care, particularly in early-stage disease (Grades I and II according to the Coughlin and Shurnas classification). The primary objectives are to reduce inflammation, alleviate pain, and modify biomechanical forces across the compromised joint. First-line interventions include patient education and activity modification, advising avoidance of high-impact activities and footwear with a stiff sole or rocker-bottom design, which reduces the demand for hallux dorsiflexion. Pharmacological management typically involves oral non-steroidal anti-inflammatory drugs (NSAIDs) for pain and inflammation, while intra-articular corticosteroid injections can provide potent, albeit often temporary, symptomatic relief, particularly during acute exacerbations. Physical therapy, focusing on gentle range-of-motion exercises and strengthening of intrinsic foot muscles, aims to maintain whatever mobility remains. A cornerstone of non-operative treatment is orthotic management. Custom-made or prefabricated orthotics with a Morton’s extension—a stiff insert under the hallux—or a rocker bar placed proximal to the MTP joint, effectively offloads the joint during toe-off. While these measures are successful in managing symptoms for many patients, they do not halt the underlying degenerative process, and disease progression often necessitates surgical intervention.
When conservative measures for hallux rigidus are exhausted and pain becomes debilitating, surgery is indicated. The choice of procedure is dictated by the stage of arthritis, the patient’s age, activity level, and the presence of concomitant deformities. For younger, active patients with mild to moderate arthritis (Grade I-II) and preserved joint space, joint-preserving surgeries are preferred. Cheilectomy is the gold standard in this category. This procedure involves the surgical excision of dorsal osteophytes, debridement of degenerative cartilage, and often includes a dorsal closing-wedge osteotomy of the proximal phalanx (Moberg osteotomy) to improve functional dorsiflexion. Cheilectomy’s success lies in its ability to relieve impingement pain, improve motion, and delay the need for more invasive surgery, with high patient satisfaction rates reported at over ten-year follow-ups. For patients with more advanced joint disease but a salvageable articular surface, particularly in the presence of a dorsiflexed metatarsal, a distal metatarsal osteotomy (e.g., Weil or Watermann osteotomy) can be employed to plantarflex the metatarsal head, thereby repositioning healthier plantar cartilage into the weight-bearing arc of motion.
As arthritis advances to Grade III (severe joint space narrowing with widespread chondral loss) but before significant collapse or deformity occurs, interpositional arthroplasty emerges as a viable alternative, especially for patients who wish to avoid fusion. This technique involves resection of the base of the proximal phalanx and interposition of a biologic spacer—such as autologous tendon (gracilis, plantaris), capsule, or synthetic scaffolds—into the joint space. The goal is to create a pain-free, mobile pseudarthrosis. While it preserves some motion and allows for faster recovery than fusion, concerns regarding potential joint instability, transfer metatarsalgia, and the possibility of late-term failure have tempered its universal adoption. It remains a valuable option for the lower-demand patient who prioritizes joint motion.
For end-stage hallux rigidus (Grade IV), characterized by complete loss of joint space, significant pain at the extremes of motion, and often fixed deformity, arthrodesis (fusion) of the first MTP joint is considered the definitive and most reliable procedure for providing durable pain relief. By eliminating motion at the painful, arthritic joint, arthrodesis creates a stable, plantigrade hallux capable of withstanding significant loads. The modern technique involves preparing the joint surfaces to achieve optimal bony apposition, fixing them in a position of approximately 10-15 degrees of dorsiflexion relative to the plantar foot and 15-25 degrees of valgus, and securing them with low-profile dorsal locking plates and screws. This position allows for a near-normal gait and accommodates most footwear. The success rate for pain relief and patient satisfaction exceeds 90%. However, the sacrifice of MTP motion can limit activities requiring extreme dorsiflexion (e.g., deep squats) and places increased stress on the interphalangeal joint and adjacent metatarsals, with a risk of developing transfer lesions.
The most controversial option for hallux rigidus in the surgical armamentarium is total joint replacement (arthroplasty) with prosthetic implants. Designed to preserve motion while relieving pain, early generation silicone implants were plagued by high rates of synovitis, particulate wear, and implant failure. Newer, two-component metal and polyethylene designs, including hemi- and total replacements, offer improved materials and fixation. While promising in theory, outcomes have been inconsistent. Concerns persist regarding polyethylene wear, osteolysis, component loosening, and the technical challenge of revision surgery. As such, prosthetic arthroplasty is generally reserved for older, lower-demand patients with end-stage disease who are poor candidates for arthrodesis but desire preserved motion, or in salvage situations.
The treatment of hallux rigidus exemplifies the principles of personalized, staged orthopedic care. The algorithm begins with a comprehensive non-operative regimen aimed at symptom control and biomechanical optimization. As the disease progresses, surgical strategy is carefully tailored: cheilectomy for early impingement, osteotomies for realignment, interposition for motion preservation in moderate disease, and ultimately, arthrodesis for reliable, lasting relief in severe, debilitating arthritis. Implant arthroplasty remains a niche, evolving option. The surgeon’s role is to guide the patient through this complex decision-making landscape, balancing the predictable success of fusion against the potential benefits—and risks—of motion-preserving techniques. Future advancements in biologic treatments, cartilage restoration, and improved prosthetic designs may further refine this algorithm, but for now, a nuanced, patient-centered approach remains paramount in successfully navigating the stiff and painful path of hallux rigidus.