Walking asks the big toe for about fifty-five degrees.
Everything else is arithmetic against that number. How much arc is there off the ground, how much survives under load, how much of the shortfall a dorsal clearance buys back, and whether there is pain through the middle of the arc rather than only at its end. This instrument does that arithmetic and then tells you, without being asked, that the test it rests on has been challenged in print.
This is the weakest instrument in the programme, and here is exactly why.
The hip's second film is a seated radiograph. The ankle's is a wooden block under the forefoot. Both measure what they claim to. This page's second position is passive hallux dorsiflexion in standing, and there is published work reporting that it is not related to hallux dorsiflexion during walking. The measurement that is supposed to stand in for what the toe does at push-off may not stand in for it at all.
Two nested two-position tests.
The first asks whether the toe loses its arc when you stand on it. The second asks whether the calf is the reason the forefoot is overloaded at all. The toe is downstream of the calf, which is why an isolated gastrocnemius contracture changes the plan even though it is a long way from the joint.
The toe
The calf above it
The arithmetic sets the tier. Mid-range pain overrules it.
The arc is already there.
Whatever is hurting, it is not a shortfall against what walking asks. Look at footwear, at load, and upstream at the calf.
Hallux rigidus overview →Clear the dorsal block.
The shortfall sits inside what removing the dorsal osteophyte restores. Confirm the arc under load afterwards rather than on the couch.
Stages of hallux limitus →Rotate what is left.
More than the dorsal block accounts for. Rotating the available arc dorsally, or resurfacing, covers the rest.
Hallux rigidus: how do I approach it? →Mid-range pain ends the argument.
Grade 4 is grade 3 plus definite pain at the mid-range of passive motion. That means the surface is gone, and preserving motion preserves a painful arc. Fusion is reliable and it is not a failure.
The Coughlin and Shurnas grading →One demand figure, one gate, and one challenged test.
Measure the envelope, absorb what you can, escalate only on the residual.
| Joint | The envelope | The second look | Escalation | Mandate |
|---|---|---|---|---|
| The thesis · Elbow · Wrist · Girdle · Cervical · Knee | Opening under load, across flexion | Stress at each angle | Conformity, lip, step | TEAM |
| Hip | Pelvic tilt, across posture | The seated film | Dual mobility | TEAM |
| Shoulder | Distance from the premorbid glenoid | The vault reconstruction | Augment, graft, reverse | none |
| Ankle | What the hindfoot gives back | The Coleman block | Osteotomy, or fusion | TEAM |
| Foot | Arc available against arc demanded | Jack’s test (contested) | Clear it, rotate it, or fuse | none |
| Hand | What the adjacent joint is compensating | MCP hyperextension | Reach past the base | none |
| Spine | Sagittal alignment against an age-adjusted target | The patient’s age | Longer construct, osteotomy | TEAM |
Put the first row in.
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