Question
A 48 year old man has pain and stiffness at the base of his big toe, worse pushing off when walking. There is a dorsal bony lump.
- What is the diagnosis and how is it graded?
- What are the non-operative options?
- What are the surgical options?
Answer
Diagnosis and grading
- Hallux rigidus, osteoarthritis of the first MTP joint
- Dorsal osteophyte limiting dorsiflexion, with pain on forced dorsiflexion
- Coughlin and Shurnas grades 0 to 4, with grade 4 having pain in mid range of passive motion
Non-operative options
- Stiff soled shoes or a rocker bottom sole
- Carbon fibre insert or Morton extension
- Shoe with a high toe box to reduce pressure on the osteophyte
- Analgesia and intra-articular steroid injection
Surgical options
- Cheilectomy, removing the dorsal third of the metatarsal head, for grades 1 and 2
- Add a Moberg dorsiflexion osteotomy of the proximal phalanx
- First MTP arthrodesis for grades 3 and 4, the most reliable option, positioned in slight valgus and dorsiflexion
- Hemiarthroplasty or synthetic cartilage implants have variable results
- Keller resection arthroplasty for low demand older patients
Related pages
Author Contributions
Orthofracs team
Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.