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Hallux rigidus

32 citationsUpdated Sep 2026

Overview

Hallux rigidus is a common disorder characterized by restriction of motion at the first metatarsophalangeal joint, often associated with mechanical block from periarticular osteophytes [4]. The reliability and validity of current grading criteria for this condition may require further exploration [2]. Surgical management is selected based on the grade of involvement [20]. Early to mid-stage hallux rigidus is best managed with cheilectomy or cheilectomy and proximal phalanx osteotomy [20], while arthrodesis and arthroplasty are reserved for late-stage disease [20]. Arthroscopic dorsal cheilectomy, plantar capsular release, flexor hallucis brevis release, and sesamoid cheilectomy is indicated for symptomatic grade 1 or 2 hallux rigidus recalcitrant to conservative treatment [1]. Joint preserving operation in patients with grade I and II hallux rigidus shows an increase of dorsi flexion and decrease of daily pain [13].

For advanced or end-stage presentations, interposition arthroplasty relieves pain and restores motion in patients with advanced hallux rigidus [14] and may offer a reliable option to fusing the joint [14]. A double-stemmed silastic implant provides a predictable and reliable alternative with comparable outcomes to arthrodesis for the treatment of end-stage hallux rigidus [15]. The arthrectomy described by Valenti is a highly reproducible intervention that serves as a good compromise between mobility and stability [11], providing good results for all hallux rigidus grades and entailing a low complication rate [11]. A sound arthrodesis of the metatarsophalangeal joint confers freedom from pain and a high level of functional efficiency in a very high proportion of patients who suffer from hallux rigidus [10].

Arthroscopic techniques yield good outcomes without complications for osteochondral lesions, loose bodies, and synovitis [37], though they show minor findings in patients with degenerative arthrosis and osteophytes who may require other techniques [37]. The arthroscopic microhole drill technique can be applied with impressive functional scores and without any complication in persons who failed conservative therapy for hallux rigidus with focal chordal injury [18]. After arthroscopic dorsal cheilectomy for hallux rigidus, patients are allowed to weight-bear as tolerated in a hard-soled shoe with no limitations on flexion and extension of the great toe metatarsophalangeal joint [17]. Postoperative management must be meticulously carried out to ensure optimal alignment of the hallux [7].

Anatomy & Pathophysiology

Definition and Clinical Presentation

Hallux rigidus is defined as arthrosis of the first metatarsophalangeal (MTP) joint characterized by restriction of motion [43, 34]. The condition is frequently associated with a mechanical block caused by periarticular osteophytes [4]. Patients primarily complain of pain in the first MTP joint, which is especially pronounced during extension [34]. Initial symptoms typically consist of pain during gait, with discomfort in the MTP joint reaching its peak during heel rise because the great toe normally dorsiflexes at this time [43]. Physical examination reveals painful limitation in dorsiflexion of the first MTP joint, with dorsiflexion lost before plantar flexion [43]. A palpable osteophyte is often present on the dorsum of the joint [43]. Additionally, the base of the metatarsal appears more plantar than normal, and the metatarsal head is elevated [43]. To avoid rolling over the great toe, patients with hallux rigidus walk on the lateral border of the feet [43].

Etiology and Risk Factors

Hallux rigidus is seen in patients from their thirties onward, though it is far more common in older adults and can rarely occur in adolescents [34, 43]. The reason arthritis of this joint is seen in younger patients is unclear but may be associated with an unrecognized chondral injury to the metatarsal head [34]. Several theories regarding the etiology of hallux rigidus have been proposed, including repetitive trauma, a hypermobile long first ray, osteochondritis dissecans, and plantar contracture [43]. The disease is frequently bilateral, and there may be a positive family history [43]. Hallux rigidus is associated with female gender, with girls affected more often than boys [34, 43]. It is also associated with hallux valgus interphalangeus and bilateral involvement in those with a family history [34]. Hallux rigidus is not associated with elevatus, first ray hypermobility, a long first metatarsal, Achilles tightness, abnormal foot posture, symptomatic hallux valgus, adolescent onset, shoe wear, or occupation [34].

Radiographic Findings

Weight-bearing radiographs of the foot demonstrate arthritic changes, including loss of joint space, subchondral sclerosis, and the presence of osteophytes, especially on the dorsal aspect of the metatarsal neck [34]. Radiographs show narrowing of the joint in hallux rigidus [43]. Lateral plain films can demonstrate dorsal osteophytes at the base of the proximal phalanx and metatarsal head [43]. These exostoses may become quite large and obscure visualization of the joint itself [43]. Osteochondritic lesions of the metatarsal head can be seen in young patients with hallux rigidus [43].

Biomechanics and Kinematics

For normal specimens, instant centers of rotation fell within the head of the first metatarsal [19]. Surface motion in normal specimens consisted of minor distraction during early plantar flexion, followed by tangential sliding throughout the rest of motion [19]. In contrast, feet with hallux valgus displayed instant centers of rotation and surface-velocity vectors that were variable, with early distraction, some sliding, and late compression [19]. Sesamoid motion in specimens with hallux rigidus revealed displaced instant centers of rotation [19]. Compression of the joint surfaces was present throughout the arc of motion in specimens with hallux rigidus [19]. Dysfunction of the windlass mechanism is associated with hallux rigidus, as evidenced by significantly decreased navicular elevation and altered joint rotations during dorsiflexion compared with healthy feet [35].

Classification

Modified Grading System: Hallux rigidus is characterized by restriction of motion at the first metatarsophalangeal joint, often associated with mechanical block from periarticular osteophytes [4]. A grading system was modified to add a Grade 4 for advanced disease and a Grade 0 for asymptomatic patients with early loss of metatarsophalangeal joint motion [32]. This classification incorporates elements of prior grading systems and requires both subjective and objective examination and radiographic data to determine the grade [32].

Prognostic Utility: When applied retrospectively, the modified grading system correctly predicted a successful outcome in 108 of 110 patients [32]. The system accurately predicted a fair or poor outcome in patients with Grade-4 hallux rigidus treated with cheilectomy [32]. Cheilectomy uniformly failed in patients with Grade-4 hallux rigidus, as predicted by the grading system [32]. Five of the nine feet with Grade-4 hallux rigidus treated with cheilectomy subsequently underwent arthrodesis [32]. Two of the four remaining patients with Grade-4 hallux rigidus treated with cheilectomy had moderate to severe metatarsophalangeal joint pain with a mean pain score of 4.4 points [32]. Cheilectomy unexpectedly failed in two of thirty-four patients with Grade-3 hallux rigidus [32]. Both patients in whom cheilectomy failed for Grade-3 hallux rigidus had radiographic evidence of chondrolysis within one year after surgery [32]. The two patients with failed cheilectomy for Grade-3 hallux rigidus underwent arthrodesis of the metatarsophalangeal joint at seven and eight years following the initial procedure [32].

Other Considerations: In a cross-sectional study in Japan, the prevalence of hallux rigidus among individuals over 50 years old was 26.7% [60]. Knee osteoarthritis (KOA) was significantly associated with the severity of hallux rigidus [60]. The frequency of KOA was significantly associated with the severity of hallux rigidus with a p-value of less than .001 [60]. The frequencies of hallux rigidus grades 0, 1, 2, and 3 in the Japanese cohort were 23.9%, 37.4%, 50.0%, and 50.0%, respectively [60]. Hallux valgus (HV) and gout (GA) were not associated with the severity of hallux rigidus in the Japanese cohort [60].

Radiographic Definitions: * Grade 1: Defined by preservation of joint space and mild osteophyte formation [60]. * Grade 2: Defined by mild to moderate joint-space narrowing, moderate osteophyte formation, subchondral sclerosis, and cysts [60]. * Grade 3: Defined by severe joint-space narrowing, significant osteophyte formation, loose bodies, subchondral sclerosis, and cysts [60].

Clinical Presentation

Definition and Epidemiology

Hallux rigidus is frequently bilateral, and a positive family history may be present [43]. Girls are affected more often than boys [43]. In a Japanese village study, the prevalence of hallux rigidus among individuals over 50 years old was 26.7% [60]. Knee osteoarthritis (KOA) is significantly associated with the severity of hallux rigidus [60]. Conversely, hallux valgus and gout were not associated with the severity of hallux rigidus in a Japanese cross-sectional study [60].

Symptoms and Physical Examination

Pain in hallux rigidus is exacerbated by weight bearing and sports activities [34]. A dorsal eminence may prevent shoewear and is associated with swelling and redness [34]. Swelling may be present on examination [43]. Physical examination reveals painful limitation in dorsiflexion of the first MTP joint [43]. Dysfunction of the windlass mechanism is associated with hallux rigidus, evidenced by significantly decreased navicular elevation and altered joint rotations during dorsiflexion compared with healthy feet [35].

Imaging

Weight-bearing radiographs of the foot demonstrate arthritic changes, including loss of joint space, subchondral sclerosis, and the presence of osteophytes [34]. Osteophytes are especially present on the dorsal aspect of the metatarsal neck [34]. Lateral plain films can demonstrate dorsal osteophytes at the base of the proximal phalanx and metatarsal head [43]. Exostoses may become quite large and obscure visualization of the joint itself [43].

Grading and Kinematics

In normal specimens, instant centers of rotation fell within the head of the first metatarsal [19].

Investigations

Clinical Assessment: Hallux rigidus is a common disorder characterized by restriction of motion at the first metatarsophalangeal joint, often associated with mechanical block from periarticular osteophytes [4]. A dorsal eminence may prevent shoewear and is associated with swelling and redness [34]. Weight bearing and sports activities exacerbate pain in patients with hallux rigidus [34]. First MTP pain can be caused by multiple etiologies, which can be present simultaneously [54].

CT: Weight-bearing CT scans better demonstrate the true orientation of bones and joints during loading compared to standard imaging, aiding in the diagnosis and preoperative planning of complex foot and ankle pathologies [63].

Other Considerations: In feet with hallux rigidus, sesamoid motion reveals displaced instant centers of rotation [19]. Compression of the joint surfaces is present throughout the arc of motion in feet with hallux rigidus [19]. Methods using the metatarsal shaft as a reference have poor measurement accuracy, especially postoperatively [68].

Treatment

Non-Operative

Conservative management for hallux rigidus begins with shoe modifications and orthotics [50]. Recommended shoe modifications include a high toe box to relieve rubbing of the dorsum of the joint, a rigid shank within the sole to limit motion of the metatarsophalangeal (MTP) joint at heel rise, and a stiff insert that extends past the MTP joint medially to limit MTP motion [43]. Patients should wear a stiff-soled shoe with a deep toe box [34]. An orthotic device with a Morton’s extension or a carbon fiber plate is beneficial for conservative management [34]. A rocker-bottom shoe is also helpful in the conservative management of hallux rigidus [34]. Nonsteroidal anti-inflammatory drugs (NSAIDs) are part of the conservative treatment regimen [34]. In older (>60 years), sedentary patients, conservative measures are usually adequate [34]. Patients should be restricted from participating in sports during initial symptomatic relief treatment [43].

Operative

Indications: Surgery for hallux rigidus is selected based on the grade of involvement, with early to mid-stage hallux rigidus best managed with cheilectomy or cheilectomy and proximal phalanx osteotomy [20]. Cheilectomy is indicated in patients with mild to moderate arthrosis but who have a large dorsal osteophyte [34]. In advanced cases of hallux rigidus, arthrodesis of the MTP joint is recommended in young, active patients who remain limited in function after other forms of treatment have failed [43].

Surgical Approach / Technique: In cheilectomy for hallux rigidus, approximately one fourth to one third of the dorsal metatarsal head is excised with an osteotome [34]. During the procedure, medial and lateral osteophytes are debrided and a thorough synovectomy of the joint is performed [34]. If cheilectomy is unsuccessful for early hallux rigidus, a dorsal closing wedge osteotomy of the proximal phalanx may be helpful [43]. Distal oblique osteotomy is an effective surgical procedure for grade II hallux rigidus with a high patient satisfaction [76]. The Valenti arthroplasty is a highly reproducible intervention that serves as a good compromise between mobility and stability, providing good results for all hallux rigidus grades [11]. Percutaneous forefoot surgery produces results similar to conventional surgery for hallux rigidus [3].

Implant Selection: Prosthetic replacement of the arthritic first metatarsophalangeal joint can be used in older, lower demand patients with hallux rigidus but has high rates of failure in younger, more active individuals [34]. Interposition arthroplasty relieves pain and restores motion in patients with advanced hallux rigidus and may offer a reliable option to fusing the joint [14]. A Keller procedure is a resection arthroplasty that may be useful in older, less active patients with hallux rigidus but has a high rate of complications [34]. For first metatarsophalangeal joint arthrodesis fixation, the unlocked plate plus screw and crossed screw constructs were the stiffest and most resistant to joint opening under cyclic loading [51].

Postoperative Management: After arthroscopic dorsal cheilectomy for hallux rigidus, patients are allowed to weight-bear as tolerated in a hard-soled shoe with no limitations on flexion and extension of the great toe MTPJ [17]. Distal oblique osteotomy for hallux rigidus allows immediate weight bearing in a postoperative shoe for 6 weeks [76]. Active and passive dorsiflexion and plantarflexion exercises of the first metatarsophalangeal joint are started on the first postoperative day following distal oblique osteotomy for hallux rigidus [76]. The postoperative management must be meticulously carried out to ensure optimal alignment of the hallux [7].

Outcomes: Postoperatively, patients undergoing cheilectomy for hallux rigidus regain up to 50% of their dorsiflexion and have improvement of their total motion [34]. More than 90% of patients undergoing cheilectomy for hallux rigidus have improvement of pain, ability to wear shoes, and increased physical abilities [34]. The joint preserving operation in patients with grade I and II hallux rigidus shows an increase of dorsi flexion and decrease of daily pain [13]. First metatarsophalangeal joint arthrodesis is a predictable and durable procedure for hallux rigidus [34]. Patients can remain quite active with a first metatarsophalangeal joint fusion for hallux rigidus [34]. If arthrodesis is obtained and the position is good, the result will be satisfactory both to the patient and the surgeon, and it may be confidently offered as a permanent cure of the deformity [38].

Complications: Cheilectomy is less likely to have a favorable outcome on joints with advanced arthritis [34]. Cheilectomy uniformly failed in patients with Grade-4 hallux rigidus, with five of nine feet subsequently undergoing arthrodesis [32]. Two of four remaining patients with Grade-4 hallux rigidus treated with cheilectomy had moderate to severe metatarsophalangeal joint pain with a mean pain score of 4.4 points [32]. Cheilectomy unexpectedly failed in two of thirty-four patients with Grade-3 hallux rigidus, both of whom had radiographic evidence of chondrolysis within one year after surgery [32]. Patients who experienced cheilectomy failure in Grade-3 hallux rigidus subsequently underwent arthrodesis at seven and eight years following the initial procedure [32]. The Valenti arthroplasty entails a low complication rate [11]. Arthroscopic microhole drill technique for focal osteochondral lesions in hallux rigidus was applied without any complication [18]. Hallux arthroscopy shows good outcomes without complications for osteochondral lesions, loose bodies, and synovitis [37]. Arthroscopic arthrodesis of the first metatarsophalangeal joint offers fewer wound complications compared to open approaches [16].

Revision: Outcomes in revision MTP1 arthrodesis surgery cases are practically equivalent to published results of primary MTP1 arthrodesis and are considered acceptable [69]. Successful treatment of recurrent hallux valgus requires understanding the underlying reason for the failure of initial treatment and correcting bony alignment, restoring joint congruity, and balancing soft tissues [8].

Other Considerations: The drawback of first metatarsophalangeal joint arthrodesis for hallux rigidus is lost motion at the joint [34]. Acquired hallux varus is usually acquired as a complication of hallux valgus surgery in adults [26]. Overcorrection from bunion surgeries, such as the McBride procedure, is a cause of acquired hallux varus [26]. Postoperative hallux varus can result from nonunion following salvage surgery for failed Keller resection arthroplasty [73]. Hallux rigidus is characterized by restriction of motion at the first metatarsophalangeal joint [4]. In specimens with hallux rigidus, sesamoid motion reveals displaced instant centers of rotation [19]. Compression of the joint surfaces is present throughout the arc of motion in specimens with hallux rigidus [19].

Recovery

Rehabilitation protocol: Following arthroscopic dorsal cheilectomy, plantar capsular release, flexor hallucis brevis release, and sesamoid cheilectomy for early-stage hallux rigidus, patients are allowed to weight-bear as tolerated in a hard-soled shoe [17]. There are no limitations on flexion and extension of the great toe MTPJ [17].

Key Evidence

  • [L5] The procedure is indicated for symptomatic grade 1 or 2 hallux rigidus recalcitrant to conservative treatment. [1] (10.1016/j.eats.2024.103198)
  • [L3] The reliability and validity of current grading criteria for hallux rigidus may require further exploration. [2] (10.5435/jaaos-d-16-00878)
  • [L5] The procedure is particularly reliable for fifth ray abnormalities and produces results similar to conventional surgery for hallux valgus and hallux rigidus. [3] (10.1016/j.otsr.2013.06.017)
  • [L5] Hallux rigidus is a common disorder characterized by restriction of motion at the first metatarsophalangeal joint, often associated with mechanical block from periarticular osteophytes. [4] (10.2106/00004623-199806000-00015)
  • [L5] The postoperative management must be meticulously carried out to ensure optimal alignment of the hallux. [7] (10.5435/00124635-199501000-00005)
  • [L4] Successful treatment of recurrent hallux valgus requires understanding the underlying reason for the failure of initial treatment and correcting bony alignment, restoring joint congruity, and balancing soft tissues. [8] (10.1007/s00402-011-1447-6)
  • [L4] This study suggests that a sound arthrodesis of the metatarsophalangeal joint confers freedom from pain and a high level of functional efficiency in a very high proportion of patients who suffer from hallux valgus and hallux rigidus. [10] (10.2106/00004623-196345030-00003)
  • [L4] The arthrectomy described by Valenti is a highly reproducible intervention that serves as a good compromise between mobility and stability, providing good results for all hallux rigidus grades and entailing a low complication rate. [11] (10.1016/j.otsr.2009.02.004)
  • [L3] The joint preserving operation in patients with grade I and II hallux rigidus shows an increase of dorsi flexion and decrease of daily pain. [13] (10.1007/s00402-009-0857-1)
  • [L4] Results of our study indicate that interposition arthroplasty relieves pain and restores motion in patients with advanced hallux rigidus and may offer a reliable option to fusing the joint. [14] (10.1097/01.blo.0000201166.82690.23)
  • [L4] These results suggest that this double-stemmed silastic implant provides a predictable and reliable alternative with comparable outcomes to arthrodesis for the treatment of end-stage hallux rigidus. [15] (10.1302/0301-620x.102b2.bjj-2019-0518.r2)
  • [Paper] Arthroscopic arthrodesis of the first metatarsophalangeal joint combined with endoscopic lateral release is a reliable technique for severe and rigid hallux valgus deformity, offering advantages of less soft tissue trauma, better cosmesis, and fewer wound complications compared to open approaches. [16] (10.1016/j.eats.2017.06.004)
  • [L5] Patients are allowed to weight-bear as tolerated in a hard-soled shoe with no limitations on flexion and extension of the great toe MTPJ. [17] (10.1016/j.eats.2022.12.014)
  • [L3] Arthroscopic microhole drill technique can be applied with impressive functional scores and without any complication in persons who failed conservative therapy for hallux rigidus with focal chordal injury. [18] (10.1177/2325967117s00069)
  • [L5] [19] (10.2106/00004623-198668030-00012)
  • [L4] Surgery is selected based on the grade of involvement, with early to mid-stage hallux rigidus best managed with cheilectomy or cheilectomy and proximal phalanx osteotomy, while arthrodesis and arthroplasty are reserved for late-stage hallux rigidus. [20] (10.5435/jaaos-20-06-347)
  • [L3] Dysfunction of the windlass mechanism is associated with hallux rigidus, as evidenced by significantly decreased navicular elevation and altered joint rotations during dorsiflexion compared with healthy feet. [35] (10.2106/jbjs.24.00437)
  • [L4] Hallux arthroscopy has good outcomes without complications for osteochondral lesions, loose bodies, and synovitis, but shows minor findings in patients with degenerative arthrosis and osteophytes who may require other techniques. [37] (10.1177/2325967114s00257)
  • [L4] The author states that if arthrodesis is obtained and the position is good, the result will be satisfactory both to the patient and the surgeon, and it may be confidently offered as a permanent cure of the deformity. [38] (10.2106/00004623-195234010-00013)
  • [Paper] Non-surgical intervention begins with shoe modifications and orthotics. [50] (10.1302/2058-5241.2.160031)
  • [L5] The unlocked plate plus screw and crossed screw constructs were the stiffest and most resistant to joint opening under cyclic loading. [51] (10.1186/s13018-017-0525-z)
  • [L5] First MTP pain can be caused by multiple etiologies, which can be present simultaneously. [54] (10.5435/jaaos-d-22-00821)
  • [L4] [60] (10.1186/s12891-021-04666-y)
  • [L5] Weight-bearing CT scans better demonstrate the true orientation of bones and joints during loading compared to standard imaging, aiding in the diagnosis and preoperative planning of complex foot and ankle pathologies. [63] (10.5435/jaaos-d-19-00700)
  • [L4] Methods using the metatarsal shaft as a reference have poor measurement accuracy, especially postoperatively. [68] (10.2106/00004623-200303000-00015)
  • [L4] Outcomes in this series of revision MTP1 arthrodesis surgery cases are practically equivalent to published results of primary MTP1 arthrodesis and are considered acceptable. [69] (10.1016/j.otsr.2018.08.011)
  • [L3] [73] (10.2106/00004623-200406000-00003)

See Also

References

[1] Arthroscopic Dorsal Cheilectomy, Plantar Capsular Release, Flexor Hallucis Brevis Release, and Sesamoid Cheilectomy for Management of Early Stages of Hallux Rigidus. Arthroscopy Techniques. 2024. DOI: 10.1016/j.eats.2024.103198

[2] Hallux Rigidus Grade Does Not Correlate With Foot and Ankle Ability Measure Score. Journal of the American Academy of Orthopaedic Surgeons. 2017. DOI: 10.5435/jaaos-d-16-00878

[3] Percutaneous forefoot surgery. Orthopaedics & Traumatology: Surgery & Research. 2014. DOI: 10.1016/j.otsr.2013.06.017

[4] Current Concepts Review - Hallux Rigidus and Osteoarthrosis of the First Metatarsophalangeal Joint. The Journal of Bone & Joint Surgery*. 1998. DOI: 10.2106/00004623-199806000-00015

[7] Disorders of the First Metatarsophalangeal Joint. Journal of the American Academy of Orthopaedic Surgeons. 1995. DOI: 10.5435/00124635-199501000-00005

[8] Salvage of recurrence after failed surgical treatment of hallux valgus. Archives of Orthopaedic and Trauma Surgery. 2011. DOI: 10.1007/s00402-011-1447-6

[10] Arthrodesis of the First Metatarsophalangeal Joint for Hallux Valgus and Ridigus. The Journal of Bone & Joint Surgery. 1963. DOI: 10.2106/00004623-196345030-00003

[11] The Valenti technique in the treatment of hallux rigidus. Orthopaedics & Traumatology: Surgery & Research. 2009. DOI: 10.1016/j.otsr.2009.02.004

[13] Mid- and long-term results of the joint preserving therapy of hallux rigidus. Archives of Orthopaedic and Trauma Surgery. 2009. DOI: 10.1007/s00402-009-0857-1

[14] Outcomes after Interposition Arthroplasty for Treatment of Hallux Rigidus. Clinical Orthopaedics and Related Research. 2006. DOI: 10.1097/01.blo.0000201166.82690.23

[15] Silastic first metatarsophalangeal joint arthroplasty for the treatment of end-stage hallux rigidus. The Bone & Joint Journal. 2020. DOI: 10.1302/0301-620x.102b2.bjj-2019-0518.r2

[16] Arthroscopic Arthrodesis of the First Metatarsophalangeal Joint in Hallux Valgus Deformity. Arthroscopy Techniques. 2017. DOI: 10.1016/j.eats.2017.06.004

[17] Dorsal Cheilectomy Using Great Toe Metatarsophalangeal Joint Arthroscopy for the Treatment of Hallux Rigidus. Arthroscopy Techniques. 2023. DOI: 10.1016/j.eats.2022.12.014

[18] Arthroscopic Treatment of Focal Osteochondral Lesions of the First Metatarsophalangeal Joint. Orthopaedic Journal of Sports Medicine. 2017. DOI: 10.1177/2325967117s00069

[19] Kinematics of the first metatarsophalangeal joint.. The Journal of Bone & Joint Surgery. 1986. DOI: 10.2106/00004623-198668030-00012

[20] Surgical Management of Hallux Rigidus. Journal of the American Academy of Orthopaedic Surgeons. 2012. DOI: 10.5435/jaaos-20-06-347

[26] Tachdjian S Pediatric Orthopaedics From The Texas Scottish Rite Hospital For Children E Book. Plate 15.3 Kramer/Barmada Osteotomy of the Base of the Femoral Neck for Slipped Capital Femoral Epiphysis > Distal Metatarsal Osteotomy > Hallux Varus.

[32] Hallux rigidus Grading and long-term results of operative treatment. 2004.

[34] A Lange Medical Book Current Diagnosis Treatment In Orthopedics Fifth Edition. 8Foot and Ankle Surgery > 2. Hallux Rigidus.

[35] Dysfunction of the Windlass Mechanism Is Associated with Hallux Rigidus. Journal of Bone and Joint Surgery. 2025. DOI: 10.2106/jbjs.24.00437

[37] Efficacy, Indications and Limitations of Hallux Arthroscopy. Orthopaedic Journal of Sports Medicine. 2014. DOI: 10.1177/2325967114s00257

[38] ARTHRODESIS OF THE FIRST METATARSOPHALANGEAL JOINT FOR HALLUX VALGUS, HALLUX RIGIDUS, AND METATARSUS PRIMUS VARUS. The Journal of Bone & Joint Surgery. 1952. DOI: 10.2106/00004623-195234010-00013

[43] Tachdjian S Pediatric Orthopaedics From The Texas Scottish Rite Hospital For Children E Book. Plate 15.3 Kramer/Barmada Osteotomy of the Base of the Femoral Neck for Slipped Capital Femoral Epiphysis > Hallux Rigidus.

[50] Hallux rigidus. EFORT Open Reviews. 2017. DOI: 10.1302/2058-5241.2.160031

[51] Weight-bearing recommendations after first metatarsophalangeal joint arthrodesis fixation: a biomechanical comparison. Journal of Orthopaedic Surgery and Research. 2017. DOI: 10.1186/s13018-017-0525-z

[54] Assessment and Management of Atraumatic First Metatarsophalangeal Joint Pain. Journal of the American Academy of Orthopaedic Surgeons. 2023. DOI: 10.5435/jaaos-d-22-00821

[60] Prevalence of and risk factors for hallux rigidus: a cross-sectional study in Japan. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-04666-y

[63] Weight-bearing CT Scans in Foot and Ankle Surgery. Journal of the American Academy of Orthopaedic Surgeons. 2020. DOI: 10.5435/jaaos-d-19-00700

[68] REPRODUCIBILITY OF THE RADIOGRAPHIC METATARSOPHALANGEAL ANGLE IN HALLUX SURGERY. The Journal of Bone and Joint Surgery-American Volume. 2003. DOI: 10.2106/00004623-200303000-00015

[69] Incidence and outcomes of revision surgery after first metatarsophalangeal joint arthrodesis: Multicenter study of 158 cases. Orthopaedics & Traumatology: Surgery & Research. 2018. DOI: 10.1016/j.otsr.2018.08.011

[73] Salvage of a Failed Keller Resection Arthroplasty. The Journal of Bone and Joint Surgery-American Volume. 2004. DOI: 10.2106/00004623-200406000-00003

[76] Campbell S Operative Orthopaedics 4 Volume Set. MULTIPLE Z-PLASTY RELEASE OF A CONGENITAL RING > DISTAL OBLIQUE OSTEOTOMY FOR HALLUX RIGIDUS.

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Section 1 -- Definitions.

a. Adapted Material means material subject to Copyright and Similar Rights that is derived from or based upon the Licensed Material and in which the Licensed Material is translated, altered, arranged, transformed, or otherwise modified in a manner requiring permission under the Copyright and Similar Rights held by the Licensor. For purposes of this Public License, where the Licensed Material is a musical work, performance, or sound recording, Adapted Material is always produced where the Licensed Material is synched in timed relation with a moving image.

b. Adapter's License means the license You apply to Your Copyright and Similar Rights in Your contributions to Adapted Material in accordance with the terms and conditions of this Public License.

c. Copyright and Similar Rights means copyright and/or similar rights closely related to copyright including, without limitation, performance, broadcast, sound recording, and Sui Generis Database Rights, without regard to how the rights are labeled or categorized. For purposes of this Public License, the rights specified in Section 2(b)(1)-(2) are not Copyright and Similar Rights.

d. Effective Technological Measures means those measures that, in the absence of proper authority, may not be circumvented under laws fulfilling obligations under Article 11 of the WIPO Copyright Treaty adopted on December 20, 1996, and/or similar international agreements.

e. Exceptions and Limitations means fair use, fair dealing, and/or any other exception or limitation to Copyright and Similar Rights that applies to Your use of the Licensed Material.

f. Licensed Material means the artistic or literary work, database, or other material to which the Licensor applied this Public License.

g. Licensed Rights means the rights granted to You subject to the terms and conditions of this Public License, which are limited to all Copyright and Similar Rights that apply to Your use of the Licensed Material and that the Licensor has authority to license.

h. Licensor means the individual(s) or entity(ies) granting rights under this Public License.

i. NonCommercial means not primarily intended for or directed towards commercial advantage or monetary compensation. For purposes of this Public License, the exchange of the Licensed Material for other material subject to Copyright and Similar Rights by digital file-sharing or similar means is NonCommercial provided there is no payment of monetary compensation in connection with the exchange.

j. Share means to provide material to the public by any means or process that requires permission under the Licensed Rights, such as reproduction, public display, public performance, distribution, dissemination, communication, or importation, and to make material available to the public including in ways that members of the public may access the material from a place and at a time individually chosen by them.

k. Sui Generis Database Rights means rights other than copyright resulting from Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the legal protection of databases, as amended and/or succeeded, as well as other essentially equivalent rights anywhere in the world.

l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.