Hallux%20rigidus%20Grading%20and%20non-surgical%20treatment

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Hallux rigidus Grading and non-surgical treatment

• Jim Barrie
• East Lancs Foot and Ankle Service

www.foothyperbook.com www.hyperblog.eastlancsfeet.
org.uk
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Why grade hallux rigidus?

• Identify populations by
• Natural history
• Response to treatment
• Risk of adverse effects
• Standard tool for research/audit

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How?

• Clinical features
• Imaging
• Markers

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Options

• Coughlin
• Roukis
• Regnauld

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Coughlin grade 0

• Range of dorsiflexion
• 40-60deg 10-20deg less than normal side
• Clinical
• No pain
• Stiffness and loss of motion
• Radiography
• normal

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Coughlin grade 1

• Range of dorsiflexion
• 30-40deg 20-50 less than normal side
• Clinical
• Mild/occasional pain/stiffness
• Pain at extremes of movement
• Radiography
• Dorsal osteophyte
• Minimal loss of space, sclerosis, flattening

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Coughlin grade 2

• Range of dorsiflexion
• 10-30deg 50-75 less than normal side
• Clinical
• Moderate/severe pain/stiffness
• Pain just before extremes of motion
• Radiography
• Osteophytes
• Mild/moderate sclerosis/narrowing
• Limited to dorsal 25

Roukis Cysts loose bodies
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Coughlin grade 3

• Range of dorsiflexion
• lt10deg 75-100 less than normal side, loss of
  plantarflexion
• Clinical
• Constant pain
• Pain at extremes of range
• Radiography
• Substantial narrowing
• gt25 of joint
• Sesamoid involvement

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Coughlin grade 4

• Range of dorsiflexion
• lt10deg 75-100 less than normal side, loss of
  plantarflexion
• Clinical
• Constant pain
• Pain at midrange
• Radiography
• Substantial narrowing
• gt25 of joint
• Sesamoid involvement

Roukis/Regnauld ankylosis Roukis IPJ/TMTJ OA
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Summary - grading

• Several similar grading systems
• Minimal validation
• Which features predict outcome?
• Is MPE relevant?

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Non-surgical treatment

• Natural history
• Simple analgesia
• Activity alteration
• Orthoses/shoe adaptations
• Injections

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Orthoses/shoe adaptations

• Reduce pressure on osteophytes

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Reduce pressure
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Reduce pressure
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Orthoses/shoe adaptations

• Reduce pressure on osteophytes
• Reduce MTPJ movement

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Reduce MTPJ movement
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Reduce MTPJ movement
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Reduce MTPJ movement
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Reduce MTPJ movement
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Reduce MTPJ movement
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Orthoses/shoe adaptations

• Reduce pressure on osteophytes
• Reduce MTPJ movement
• Increase MTPJ movement

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Increase MTPJ movement
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Increase MTPJ movement
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Increase MTPJ movement
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Increase MTPJ movement
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How effective is non-surgical care?

• Grady (2002)
• 772 patients with symptomatic HR
• FU 1-7y
• 428(55) treated non-surgically

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How effective is non-surgical care?

• Smith (2000)
• 24 patients treated non-surgically
• FU 12-19y
• 75 still wished non-surgical treatment
• Radiographic progression 67

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Injection

• Pons et al 2007
• RCT hyaluronate vs triamcinolone
• Improvement in both groups
• No difference in pain at rest
• Hyaluronate group better to 84d
• Pain walking 20m
• AOFAS pain score
• 50 surgery at 1y

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MUA injection

• Solan (2001)
• 31 pts MUA depomedrone/bupovacaine injection
• Blinded Xray grading
• Minimum 1y FU

Grade Surgery Survival
1 4/12 6m
2 12/18 3m
3 5/5 2m
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Non-surgical treatment

• Benign condition
• Simple management
• Shoe adaptations
• Functional orthoses probably selective
• Injections of marginal benefit

www.foothyperbook.com www.hyperblog.eastlancsfeet.
org.uk
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