Aetiology
- Ankle osteoarthritis mostly post-traumatic after malleolar or pilon fractures or recurrent instability
- Affects younger patients than hip or knee osteoarthritis
- Also inflammatory, haemochromatosis, haemophilia, osteochondral lesions and neuropathy
- Subtalar arthritis follows calcaneal fracture, tarsal coalition, inflammatory arthritis or adult acquired flatfoot
- Midfoot arthritis is primary or follows Lisfranc injury
Clinical Features
- Ankle pain anteriorly, stiffness, swelling and reduced walking tolerance
- Assess hindfoot alignment, ankle and subtalar motion, stability and adjacent joints
- Midfoot arthritis causes dorsal pain and osteophytes rubbing in shoes
- Hallux rigidus causes dorsal pain, a dorsal osteophyte and lost dorsiflexion
Investigations
- Weight bearing AP, mortise, lateral and hindfoot alignment views
- CT or weight bearing CT for bone loss, deformity and adjacent joints
- SPECT CT localises the symptomatic joint
Classification
Coughlin and Shurnas classification grades hallux rigidus.
| Grade | Dorsiflexion | Radiographs | Clinical |
|---|---|---|---|
| 0 | 40 to 60° (10 to 20% loss) | Normal | Stiffness only |
| 1 | 30 to 40° (20 to 50% loss) | Dorsal osteophyte, minimal joint narrowing | Mild or occasional pain and stiffness at extremes of motion |
| 2 | 10 to 30° (50 to 75% loss) | Mild to moderate narrowing, osteophytes, under a quarter of the dorsal head involved | Moderate to severe, more constant pain and stiffness |
| 3 | Under 10° (75 to 100% loss) | Severe narrowing, cysts, over a quarter of the dorsal head involved | Near constant pain, no pain in mid range |
| 4 | As grade 3 | As grade 3 | Pain in mid range of passive motion |
Original publication Coughlin MJ, Shurnas PS. Hallux rigidus. Grading and long-term results of operative treatment. J Bone Joint Surg Am. 2003;85(11):2072-88.
Management
Ankle
- Activity modification, weight loss, rocker shoe, AFO or brace and injection
- Arthroscopic debridement for anterior osteophytes with preserved joint space
- Distraction arthroplasty with external fixator for young patients avoiding fusion
- Supramalleolar osteotomy for asymmetric varus or valgus arthritis
- Arthrodesis is standard for end stage disease in young, high demand patients
- Fuse in neutral dorsiflexion, slight valgus, matched external rotation, talus slightly posterior
- Arthroscopic fusion gives faster union and fewer wound problems
- Fusion leads to adjacent subtalar and midfoot arthritis long term
- Ankle replacement for older, lower demand patients with good bone and a stable hindfoot
- Ankle replacement preserves motion, favoured with adjacent joint arthritis
- Replacement contraindicated by infection, neuropathy, uncorrectable deformity, talar AVN or poor soft tissues
Subtalar
- Orthoses and guided injection, then in situ arthrodesis
- Bone block distraction arthrodesis for lost calcaneal height and anterior impingement
Midfoot
- Stiff rocker shoe, orthoses and injection, then first to third TMT arthrodesis
- Mobile fourth and fifth TMT joints preserved, interposition arthroplasty if symptomatic
Hallux rigidus
- Stiff soled shoe or Morton extension
- Cheilectomy for mild to moderate disease, with or without Moberg osteotomy
- First MTP arthrodesis for advanced disease
Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.