Hallux rigidus: An interpretation of American College of Foot and Ankle Surgeon (ACFAS) clinical consensus statements_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

 LU Yun

Department of Hand and Foot and Reconstruction Surgery, Tianjin Union Medical Center, the First Affiliated Hospital of Nankai University, Tianjin, 300121, P. R. China;

Corresponding author：

LU Yun, Email: tedaluyun@163.com

Keywords：

Hallux rigidus; American College of Foot and Ankle Surgeon; clinical consensus statements; osteophytotomy; joint debridement; arthrodesis; arthroplasty

DOI：

10.7507/1002-1892.202509053

Video：

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Abstract Full text Figures/Tables Video References Cited by

Hallux rigidus is the most common type of foot degenerative arthritis. With the aging of the population and the increasing demand for exercise, its incidence rate continues to rise. In October 2024, the American College of Foot and Ankle Surgeon (ACFAS) published 24 clinical consensus statements in the Journal of Foot & Ankle Surgery. The latest expert opinions are formed around hallux rigidus assessment, classification, conservative treatment, surgical indications, surgical method selection. Combined with the characteristics of Chinese patients and the current clinical situation, this article interprets and analyzes the key points of the consensus, and proposes individualized surgical plans for joint preservation, with the aim of providing evidence-based basis and decision-making reference for colleagues in domestic foot and ankle surgery.

Citation： LU Yun. Hallux rigidus: An interpretation of American College of Foot and Ankle Surgeon (ACFAS) clinical consensus statements. Chinese Journal of Reparative and Reconstructive Surgery, 2025, 39(10): 1219-1224. doi: 10.7507/1002-1892.202509053 Copy

1.	Dellenbaugh SG, Bustillo J. Arthritides of the foot. Med Clin North Am, 2014, 98(2): 253-265.
2.	Gould N, Schneider W, Ashikaga T. Epidemiological survey of foot problems in the continental United States: 1978-1979. Foot Ankle, 1980, 1(1): 8-10.
3.	Vanore JV, Christensen JC, Kravitz SR, et al. Diagnosis and treatment of first metatarsophalangeal joint disorders. Section 2: Hallux rigidus. J Foot Ankle Surg, 2003, 42(3): 124-136.
4.	Coughlin MJ, Shurnas PS. Hallux rigidus: demographics, etiology, and radiographic assessment. Foot Ankle Int, 2003, 24(10): 731-743.
5.	Roukis TS, Piraino JA, Hollawell S, et al. ACFAS clinical consensus statements: hallux rigidus. J Foot Ankle Surg, 2024, 63(6): 624-630.
6.	Cotterill JM. Stiffness of the great toe in adolescents. Br Med J, 1887, 1(1378): 1158. doi: 10.1136/bmj.1.1378.1158.
7.	Kelikian H. Hallux valgus allied deformities of the forefoot and metatarsalgia. Philadelphia, PA: W. B. Saunders, 1997: 262-281.
8.	Coughlin MJ. Conditions of the forefoot//DeLee J, Drez D, eds. Orthopaedic sports medicine: Principles and practice, philadelphia, PA: WB Saudners, 1994: 221-244.
9.	Coughlin MJ, Saltzman CL, Anderson RB. Mann’s Surgery of the Foot and Ankle. 9th eds. Philadelphia, PA: W. B. Saudners, 2014: 942-945.
10.	Karasick D, Wapner KL. Hallux rigidus deformity: radiologic assessment. AJR Am J Roentgenol, 1991, 157(5): 1029-1033.
11.	Beeson P, Phillips C, Corr S, et al. Classification systems for hallux rigidus: a review of the literature. Foot Ankle Int, 2008, 29(4): 407-414.
12.	Camasta CA. Hallux limitus and hallux rigidus. Clinical examination, radiographic ﬁndings, and natural history. Clin Podiatr Med Surg, 1996, 13(3): 423-448.
13.	Coetzee JC. Management of hallux rigidus in athletes. Operat Techn Sport Med, 2017, 25(2): 108-112.
14.	Cheung ZB, Myerson MS, Tracey J, et al. Weightbearing CT scan assessment of foot alignment in patients with hallux rigidus. Foot Ankle Int, 2018, 39(1): 67-74.
15.	Cohn I, Kanat IO. Functional limitation of motion of the ﬁrst metatarso-phalangeal joint. J Foot Surg, 1984, 23: 477-484.
16.	Hattrup SJ, Johnson KA. Subjective results of hallux rigidus following treatment with cheilectomy. Clin Orthop Relat Res, 1988, (226): 182-191.
17.	Regnauld B, Elson R. Disorders of the great toe editor. The foot: Pathology, aetiology, seminology, clinicalinvestigation and treatment. New York: Springer-Verlag , 1986: 269-281.
18.	Roukis TS, Jacobs PM, Dawson DM, et al. A prospective comparison of clinical, radiographic, and intraoperative features of hallux rigidus. J Foot Ankle Surg, 2002, 41(2): 76-95.
19.	Roukis TS, Jacobs PM, Dawson DM, et al. A prospective comparison of clinical, radiographic, and intraoperative features of hallux rigidus: short-term follow-up and analysis. J Foot Ankle Surg, 2002, 41(3): 158-165.
20.	Elliott AD, Borgert AJ, Roukis TS. A prospective comparison of clinical, radiographic, and intraoperative features of hallux rigidus: Long-term follow-up and analysis. J Foot Ankle Surg, 2016, 55(3): 547-561.
21.	Coughlin MJ, Shurnas PS. Hallux rigidus. Grading and long-term results of operative treatment. J Bone Joint Surg (Am), 2003, 85(11): 2072-2088.
22.	Coughlin MJ, Shurnas PS. Hallux rigidus. J Bone Joint Surg (Am), 2004, 86-A Suppl 1(Pt 2): 119-130.
23.	Massimi S, Caravelli S, Fuiano M, et al. Management of high-grade hallux rigidus: a narrative review of the literature. Musculoskelet Surg, 2020, 104(3): 237-243.
24.	Grady JF, Axe TM, Zager EJ, et al. A retrospective analysis of 772 patients with hallux limitus. J Am Podiatr Med Assoc, 2002, 92(2): 102-108.
25.	Jennings MB. Comparison of piroxicam and naproxen in osteoarthritis of the foot. J Am Podiatr Med Assoc, 1994, 84(7): 348-354.
26.	Shurnas PS. Hallux rigidus: etiology, biomechanics, and nonoperative treatment. Foot Ankle Clin, 2009, 14(1): 1-8.
27.	Kunnasegaran R, Thevendran G. Hallux rigidus: Nonoperative treatment and orthotics. Foot Ankle Clin, 2015, 20(3): 401-412.
28.	Kalichman L, Hernández-Molina G. Midfoot and forefoot osteoarthritis. Foot (Edinb), 2014, 24(3): 128-134.
29.	Grice J, Marsland D, Smith G, et al. Efficacy of foot and ankle corticosteroid injections. Foot Ankle Int, 2017, 38(1): 8-13.
30.	Solan MC, Calder JD, Bendall SP. Manipulation and injection for hallux rigidus. Is it worthwhile? J Bone Joint Surg (Br), 2001, 83(5): 706-708.
31.	Shamus J, Shamus E, Gugel RN, et al. The effect of sesamoid mobilization, flexor hallucis strengthening, and gait training on reducing pain and restoring function in individuals with hallux limitus: a clinical trial. J Orthop Sports Phys Ther, 2004, 34(7): 368-376.
32.	Galois L, Hemmer J, Ray V, et al. Surgical options for hallux rigidus: state of the art and review of the literature. Eur J Orthop Surg Traumatol, 2020, 30(1): 57-65.
33.	Hollawell S, Moen R, Coleman M, et al. Osteochondral fresh allograft transfer to address osteochondral defect of the first metatarsal head in early hallux limitus. J Foot Ankle Surg, 2021, 60(1): 157-162.
34.	Stevens J, de Bot RTAL, Witlox AM, et al. Long-term effects of cheilectomy, Keller’s arthroplasty, and arthrodesis for symptomatic hallux rigidus on patient-reported and radiologic outcome. Foot Ankle Int, 2020, 41(7): 775-783.
35.	Brewster M. Does total joint replacement or arthrodesis of the first metatarsophalangeal joint yield better functional results? A systematic review of the literature. J Foot Ankle Surg, 2010, 49(6): 546-552.
36.	Freed JB. The increasing recognition of medullary lysis, cortical osteophytic proliferation, and fragmentation of implanted silicone polymer implants. J Foot Ankle Surg, 1993, 32(2): 171-179.
37.	Clough TM, Ring J. Silastic first metatarsophalangeal joint arthroplasty for the treatment of end-stage hallux rigidus. Bone Joint J, 2020, 102-B(2): 220-226.
38.	Maes DJA, De Vil J, Kalmar AF, et al. Clinical and radiological outcomes of hallux rigidus treated with cheilectomy and a moberg-akin osteotomy. Foot Ankle Int, 2020, 41(3): 294-302.
39.	Ho B, Baumhauer J. Hallux rigidus. EFORT Open Rev, 2017, 2(1): 13-20.
40.	Cetinkaya E, Yalcinkaya M, Sokucu S, et al. Cheilectomy as a first-line surgical treatment option yields good functional results in grade Ⅲ hallux rigidus. J Am Podiatr Med Assoc, 2016, 106(1): 22-26.
41.	Lam A, Chan JJ, Surace MF, et al. Hallux rigidus: How do I approach it? World J Orthop, 2017, 8(5): 364-371.
42.	Bennett GL, Sabetta J. First metatarsalphalangeal joint arthrodesis: evaluation of plate and screw fixation. Foot Ankle Int, 2009, 30(8): 752-757.
43.	Santos Silva M, Rodrigues-Pinto R, Barros LH, et al. Arthrodesis versus arthroplasty of the first metatarsophalangeal joint in the treatment of hallux rigidus-A comparative study of appropriately selected patients. Rev Bras Ortop (Sao Paulo), 2020, 55(1): 40-47.
44.	Mermerkaya MU, Alkan E, Ayvaz M. Evaluation of metatarsal head resurfacing hemiarthroplasty in the surgical treatment of hallux rigidus: A retrospective study and mid- to long-term follow-up. Foot Ankle Spec, 2018, 11(1): 22-31.
45.	Metikala S, Mahmoud K, O’Connor KM, et al. Adverse events related to cartiva hemiarthroplasty of first metatarsal: An analysis of reports to the united states food and drug administration. Foot Ankle Spec, 2022, 15(2): 113-118.
46.	McNeil DS, Baumhauer JF, Glazebrook MA. Evidence-based analysis of the efficacy for operative treatment of hallux rigidus. Foot Ankle Int, 2013, 34(1): 15-32.
47.	Anderson MR, Ho BS, Baumhauer JF. Republication of “Current Concepts Review: Hallux Rigidus”. Foot Ankle Orthop, 2023, 8(3): 24730114231188123. doi: 10.1177/24730114231188123.
48.	Wehling P, Evans C, Wehling J, et al. Effectiveness of intra-articular therapies in osteoarthritis: a literature review. Ther Adv Musculoskelet Dis, 2017, 9(8): 183-196.
49.	Melick G, Hayman N, Landsman AS. Mesenchymal stem cell applications for joints in the foot and ankle. Clin Podiatr Med Surg, 2018, 35(3): 323-330.
50.	Munteanu SE, Zammit GV, Menz HB, et al. Effectiveness of intra-articular hyaluronan (Synvisc, hylan G-F 20) for the treatment of first metatarsophalangeal joint osteoarthritis: a randomised placebo-controlled trial. Ann Rheum Dis, 2011, 70(10): 1838-1841.
51.	Paterson KL, Gates L. Clinical assessment and management of foot and ankle osteoarthritis: A review of current evidence and focus on pharmacological treatment. Drugs Aging, 2019, 36(3): 203-211.
52.	Shimozono Y, Seow D, Kennedy JG. Concentrated bone marrow aspirate injection for hallux sesamoid disorders. J Foot Ankle Surg, 2022, 61(3): 633-636.
53.	Le HM, Stracciolini A, Stein CJ, et al. Platelet rich plasma for hallux sesamoid injuries: a case series. Phys Sportsmed, 2022, 50(2): 181-184.
54.	Pons M, Alvarez F, Solana J, et al. Sodium hyaluronate in the treatment of hallux rigidus. A single-blind, randomized study. Foot Ankle Int, 2007, 28(1): 38-42.
55.	杨文华, 李娟红. 干细胞治疗骨关节炎的研究进展. 中国疼痛医学杂志, 2023, 29(8): 565-571.
56.	陈思, 林新晓, 温建民, 等. 关节镜治疗第1跖趾关节炎近期疗效研究. 中国矫形外科杂志, 2015, 23(11): 1038-1040.
57.	中国医师协会骨科医师分会足踝基础与矫形外科学组, 中国医师协会运动医学医师分会足踝专业学组, 中国中西医结合学会骨伤科分会足踝专家委员会, 等. 第3代微创拇外翻技术规范专家共识. 中国骨伤, 2022, 35(9): 812-817.

1. Dellenbaugh SG, Bustillo J. Arthritides of the foot. Med Clin North Am, 2014, 98(2): 253-265.
2. Gould N, Schneider W, Ashikaga T. Epidemiological survey of foot problems in the continental United States: 1978-1979. Foot Ankle, 1980, 1(1): 8-10.
3. Vanore JV, Christensen JC, Kravitz SR, et al. Diagnosis and treatment of first metatarsophalangeal joint disorders. Section 2: Hallux rigidus. J Foot Ankle Surg, 2003, 42(3): 124-136.
4. Coughlin MJ, Shurnas PS. Hallux rigidus: demographics, etiology, and radiographic assessment. Foot Ankle Int, 2003, 24(10): 731-743.
5. Roukis TS, Piraino JA, Hollawell S, et al. ACFAS clinical consensus statements: hallux rigidus. J Foot Ankle Surg, 2024, 63(6): 624-630.
6. Cotterill JM. Stiffness of the great toe in adolescents. Br Med J, 1887, 1(1378): 1158. doi: 10.1136/bmj.1.1378.1158.
7. Kelikian H. Hallux valgus allied deformities of the forefoot and metatarsalgia. Philadelphia, PA: W. B. Saunders, 1997: 262-281.
8. Coughlin MJ. Conditions of the forefoot//DeLee J, Drez D, eds. Orthopaedic sports medicine: Principles and practice, philadelphia, PA: WB Saudners, 1994: 221-244.
9. Coughlin MJ, Saltzman CL, Anderson RB. Mann’s Surgery of the Foot and Ankle. 9th eds. Philadelphia, PA: W. B. Saudners, 2014: 942-945.
10. Karasick D, Wapner KL. Hallux rigidus deformity: radiologic assessment. AJR Am J Roentgenol, 1991, 157(5): 1029-1033.
11. Beeson P, Phillips C, Corr S, et al. Classification systems for hallux rigidus: a review of the literature. Foot Ankle Int, 2008, 29(4): 407-414.
12. Camasta CA. Hallux limitus and hallux rigidus. Clinical examination, radiographic ﬁndings, and natural history. Clin Podiatr Med Surg, 1996, 13(3): 423-448.
13. Coetzee JC. Management of hallux rigidus in athletes. Operat Techn Sport Med, 2017, 25(2): 108-112.
14. Cheung ZB, Myerson MS, Tracey J, et al. Weightbearing CT scan assessment of foot alignment in patients with hallux rigidus. Foot Ankle Int, 2018, 39(1): 67-74.
15. Cohn I, Kanat IO. Functional limitation of motion of the ﬁrst metatarso-phalangeal joint. J Foot Surg, 1984, 23: 477-484.
16. Hattrup SJ, Johnson KA. Subjective results of hallux rigidus following treatment with cheilectomy. Clin Orthop Relat Res, 1988, (226): 182-191.
17. Regnauld B, Elson R. Disorders of the great toe editor. The foot: Pathology, aetiology, seminology, clinicalinvestigation and treatment. New York: Springer-Verlag , 1986: 269-281.
18. Roukis TS, Jacobs PM, Dawson DM, et al. A prospective comparison of clinical, radiographic, and intraoperative features of hallux rigidus. J Foot Ankle Surg, 2002, 41(2): 76-95.
19. Roukis TS, Jacobs PM, Dawson DM, et al. A prospective comparison of clinical, radiographic, and intraoperative features of hallux rigidus: short-term follow-up and analysis. J Foot Ankle Surg, 2002, 41(3): 158-165.
20. Elliott AD, Borgert AJ, Roukis TS. A prospective comparison of clinical, radiographic, and intraoperative features of hallux rigidus: Long-term follow-up and analysis. J Foot Ankle Surg, 2016, 55(3): 547-561.
21. Coughlin MJ, Shurnas PS. Hallux rigidus. Grading and long-term results of operative treatment. J Bone Joint Surg (Am), 2003, 85(11): 2072-2088.
22. Coughlin MJ, Shurnas PS. Hallux rigidus. J Bone Joint Surg (Am), 2004, 86-A Suppl 1(Pt 2): 119-130.
23. Massimi S, Caravelli S, Fuiano M, et al. Management of high-grade hallux rigidus: a narrative review of the literature. Musculoskelet Surg, 2020, 104(3): 237-243.
24. Grady JF, Axe TM, Zager EJ, et al. A retrospective analysis of 772 patients with hallux limitus. J Am Podiatr Med Assoc, 2002, 92(2): 102-108.
25. Jennings MB. Comparison of piroxicam and naproxen in osteoarthritis of the foot. J Am Podiatr Med Assoc, 1994, 84(7): 348-354.
26. Shurnas PS. Hallux rigidus: etiology, biomechanics, and nonoperative treatment. Foot Ankle Clin, 2009, 14(1): 1-8.
27. Kunnasegaran R, Thevendran G. Hallux rigidus: Nonoperative treatment and orthotics. Foot Ankle Clin, 2015, 20(3): 401-412.
28. Kalichman L, Hernández-Molina G. Midfoot and forefoot osteoarthritis. Foot (Edinb), 2014, 24(3): 128-134.
29. Grice J, Marsland D, Smith G, et al. Efficacy of foot and ankle corticosteroid injections. Foot Ankle Int, 2017, 38(1): 8-13.
30. Solan MC, Calder JD, Bendall SP. Manipulation and injection for hallux rigidus. Is it worthwhile? J Bone Joint Surg (Br), 2001, 83(5): 706-708.
31. Shamus J, Shamus E, Gugel RN, et al. The effect of sesamoid mobilization, flexor hallucis strengthening, and gait training on reducing pain and restoring function in individuals with hallux limitus: a clinical trial. J Orthop Sports Phys Ther, 2004, 34(7): 368-376.
32. Galois L, Hemmer J, Ray V, et al. Surgical options for hallux rigidus: state of the art and review of the literature. Eur J Orthop Surg Traumatol, 2020, 30(1): 57-65.
33. Hollawell S, Moen R, Coleman M, et al. Osteochondral fresh allograft transfer to address osteochondral defect of the first metatarsal head in early hallux limitus. J Foot Ankle Surg, 2021, 60(1): 157-162.
34. Stevens J, de Bot RTAL, Witlox AM, et al. Long-term effects of cheilectomy, Keller’s arthroplasty, and arthrodesis for symptomatic hallux rigidus on patient-reported and radiologic outcome. Foot Ankle Int, 2020, 41(7): 775-783.
35. Brewster M. Does total joint replacement or arthrodesis of the first metatarsophalangeal joint yield better functional results? A systematic review of the literature. J Foot Ankle Surg, 2010, 49(6): 546-552.
36. Freed JB. The increasing recognition of medullary lysis, cortical osteophytic proliferation, and fragmentation of implanted silicone polymer implants. J Foot Ankle Surg, 1993, 32(2): 171-179.
37. Clough TM, Ring J. Silastic first metatarsophalangeal joint arthroplasty for the treatment of end-stage hallux rigidus. Bone Joint J, 2020, 102-B(2): 220-226.
38. Maes DJA, De Vil J, Kalmar AF, et al. Clinical and radiological outcomes of hallux rigidus treated with cheilectomy and a moberg-akin osteotomy. Foot Ankle Int, 2020, 41(3): 294-302.
39. Ho B, Baumhauer J. Hallux rigidus. EFORT Open Rev, 2017, 2(1): 13-20.
40. Cetinkaya E, Yalcinkaya M, Sokucu S, et al. Cheilectomy as a first-line surgical treatment option yields good functional results in grade Ⅲ hallux rigidus. J Am Podiatr Med Assoc, 2016, 106(1): 22-26.
41. Lam A, Chan JJ, Surace MF, et al. Hallux rigidus: How do I approach it? World J Orthop, 2017, 8(5): 364-371.
42. Bennett GL, Sabetta J. First metatarsalphalangeal joint arthrodesis: evaluation of plate and screw fixation. Foot Ankle Int, 2009, 30(8): 752-757.
43. Santos Silva M, Rodrigues-Pinto R, Barros LH, et al. Arthrodesis versus arthroplasty of the first metatarsophalangeal joint in the treatment of hallux rigidus-A comparative study of appropriately selected patients. Rev Bras Ortop (Sao Paulo), 2020, 55(1): 40-47.
44. Mermerkaya MU, Alkan E, Ayvaz M. Evaluation of metatarsal head resurfacing hemiarthroplasty in the surgical treatment of hallux rigidus: A retrospective study and mid- to long-term follow-up. Foot Ankle Spec, 2018, 11(1): 22-31.
45. Metikala S, Mahmoud K, O’Connor KM, et al. Adverse events related to cartiva hemiarthroplasty of first metatarsal: An analysis of reports to the united states food and drug administration. Foot Ankle Spec, 2022, 15(2): 113-118.
46. McNeil DS, Baumhauer JF, Glazebrook MA. Evidence-based analysis of the efficacy for operative treatment of hallux rigidus. Foot Ankle Int, 2013, 34(1): 15-32.
47. Anderson MR, Ho BS, Baumhauer JF. Republication of “Current Concepts Review: Hallux Rigidus”. Foot Ankle Orthop, 2023, 8(3): 24730114231188123. doi: 10.1177/24730114231188123.
48. Wehling P, Evans C, Wehling J, et al. Effectiveness of intra-articular therapies in osteoarthritis: a literature review. Ther Adv Musculoskelet Dis, 2017, 9(8): 183-196.
49. Melick G, Hayman N, Landsman AS. Mesenchymal stem cell applications for joints in the foot and ankle. Clin Podiatr Med Surg, 2018, 35(3): 323-330.
50. Munteanu SE, Zammit GV, Menz HB, et al. Effectiveness of intra-articular hyaluronan (Synvisc, hylan G-F 20) for the treatment of first metatarsophalangeal joint osteoarthritis: a randomised placebo-controlled trial. Ann Rheum Dis, 2011, 70(10): 1838-1841.
51. Paterson KL, Gates L. Clinical assessment and management of foot and ankle osteoarthritis: A review of current evidence and focus on pharmacological treatment. Drugs Aging, 2019, 36(3): 203-211.
52. Shimozono Y, Seow D, Kennedy JG. Concentrated bone marrow aspirate injection for hallux sesamoid disorders. J Foot Ankle Surg, 2022, 61(3): 633-636.
53. Le HM, Stracciolini A, Stein CJ, et al. Platelet rich plasma for hallux sesamoid injuries: a case series. Phys Sportsmed, 2022, 50(2): 181-184.
54. Pons M, Alvarez F, Solana J, et al. Sodium hyaluronate in the treatment of hallux rigidus. A single-blind, randomized study. Foot Ankle Int, 2007, 28(1): 38-42.
55. 杨文华, 李娟红. 干细胞治疗骨关节炎的研究进展. 中国疼痛医学杂志, 2023, 29(8): 565-571.
56. 陈思, 林新晓, 温建民, 等. 关节镜治疗第1跖趾关节炎近期疗效研究. 中国矫形外科杂志, 2015, 23(11): 1038-1040.
57. 中国医师协会骨科医师分会足踝基础与矫形外科学组, 中国医师协会运动医学医师分会足踝专业学组, 中国中西医结合学会骨伤科分会足踝专家委员会, 等. 第3代微创拇外翻技术规范专家共识. 中国骨伤, 2022, 35(9): 812-817.

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Advances in surgical management of severe hallux valgus

Chinese Journal of Reparative and Reconstructive Surgery

Hallux rigidus: An interpretation of American College of Foot and Ankle Surgeon (ACFAS) clinical consensus statements

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