The Journal of Foot & Ankle Surgery xxx (2014) 18

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The Journal of Foot & Ankle Surgery

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Case Reports and Series

Lateral Stress Dorsiexion View: A Case Series Demonstrating Clinical

Utility in Midterm Hallux Limitus
Troy J. Boffeli, DPM, FACFAS 1, Rachel C. Collier, DPM, AACFAS 2
1
2

Director, Foot and Ankle Surgical Residency Program, Regions Hospital, HealthPartners Institute for Education and Research, St. Paul, MN
Staff Surgeon, Foot and Ankle Surgical Residency Program, Regions Hospital, HealthPartners Institute for Education and Research, St. Paul, MN

a r t i c l e i n f o

a b s t r a c t

Level of Clinical Evidence: 4

The lateral hallux stress dorsiexion view is part of our standard workup for midterm hallux limitus (HL)/
hallux rigidus (HR). It provides a functional radiographic examination of the rst metatarsal phalangeal joint.
Midterm HL primarily involves degenerative changes in the upper one third of the metatarsal phalangeal joint
involving formation of bone spurs, dorsal bone impingement, joint space narrowing with cartilage degeneration, and fragmentation of the bone spurs. The lateral hallux stress dorsiexion view provides diagnostic
information not visible on a standard weightbearing lateral view in patients with midterm HL/HR, including
joint space narrowing on the dorsal third of the joint despite intact cartilage through the center one third of
the joint, the extent of maximum rst metatarsal phalangeal joint dorsiexion, and direct visualization of
dorsal bone spur impingement. This functional radiographic examination also appears to provide improved
patient understanding regarding why their joint is stiff and painful. Improved patient understanding of their
condition positively inuences the shared decision making regarding the treatment objectives and options.
The cases of 5 patients with stage II or III HL/HR are presented to depict the utility of this radiographic view,
including objective measurement of maximum rst metatarsal phalangeal joint dorsiexion, conrmation of a
bony block at the end range of dorsiexion, the presence or absence of joint space narrowing at the dorsal
third of the joint, evaluation of the excursion of the sesamoid apparatus, a tool to help the patient understand,
an intraoperative assessment of procedure effectiveness, and a comparison of maximum dorsiexion before
and after surgery.
! 2014 by the American College of Foot and Ankle Surgeons. All rights reserved.

Keywords:
arthritis
cartilage
degenerative joint disease
hallux rigidus
patient satisfaction

Hallux limitus/hallux rigidus (HL/HR) is a common condition

affecting the rst metatarsophalangeal joint (MPJ), with an incidence
of 2.5% in those older than 50 years of age (1). The published data have
described numerous factors that contribute to the development of HL/
HR, including structural, biomechanical, traumatic, and genetic etiologies (28). Various classication systems have been described to
stage HL/HR with the use of radiographic examination or combined
radiographic and clinical examination (2,911). The classication
scheme described by Drago et al (9) has been widely used among foot
and ankle surgeons and is the classication system that is referred to
for the purpose of this article.
It has been casually noted that the ndings from clinical examination and standard weightbearing radiographs are relatively accurate at predicting the condition of the joint cartilage in end-stage

Financial Disclosure: None reported.

Conict of Interest: None reported.
Address correspondence to: Rachel C. Collier, DPM, Foot and Ankle Surgical Residency Program, Regions Hospital, HealthPartners Institute for Education and Research,
640 Jackson Street, St. Paul, MN 55101.
E-mail address: rachel.c.collier@healthpartners.com (R.C. Collier).

(stage IV) HL/HR, allowing relatively consistent intersurgeon staging

for a given patient. Accurate preoperative staging for midterm (stage II
and stage III) HL/HR is more challenging because the ndings from
clinical examination and standard weightbearing radiographs are less
predictive of the intraoperative ndings. The osseous changes associated with HL/HR can be easily viewed on radiographs; however,
inferences must be made regarding the cartilage condition, which is
determined from the apparent joint space (12). Radiographic evidence of joint space narrowing infers thinning of the cartilage and
bone on bone indicates complete loss of cartilage (13). Frequently,
cartilage degeneration in patients with midterm HL/HR has been
worse on direct intraoperative visualization than expected from the
standard radiographs, leading to an intraoperative diagnosis of a
higher disease stage.
Midterm HL/HR primarily involves degenerative arthritis in the
upper third of the rst MPJ (1417). However, the standard weightbearing views do not directly evaluate the upper third of the joint.
Standing in the neutral position allows evaluation of the middle third
of the joint where cartilage typically remains in midterm HL/HR.
Adequate joint space on standard radiographs does not rule out
localized cartilage defects or complete loss of cartilage on the upper

1067-2516/$ - see front matter ! 2014 by the American College of Foot and Ankle Surgeons. All rights reserved.
http://dx.doi.org/10.1053/j.jfas.2014.07.012

T.J. Boffeli, R.C. Collier / The Journal of Foot & Ankle Surgery xxx (2014) 18

Fig. 1. The lateral hallux stress dorsiexion view (LAT SD) is performed with the patient in maximum dorsiexion position at the level of the rst metatarsophalangeal joint (MPJ). (A) The
patient is instructed to keep the MPJ on the oor and raise the heel to the point of maximum dorsiexion or pain. (B) The setup for the radiograph is similar to that of a standard
weightbearing lateral radiograph, except that the central beam is focused at the middle of the rst MPJ. The LAT SD view can be used for measurement of maximum forced rst MPJ
dorsiexion. (C) The angle is determined by the bisection of the dorsal and plantar cortices of the proximal and distal thirds of the rst metatarsal versus bisection of the proximal phalanx
of the hallux. (From Taranto MJ, Taranto J, Bryant A, Singer KP. Radiographic investigation of angular and linear measurements including rst metatarsophalangeal joint dorsiexion and
rearfoot to forefoot axis angle. J Foot Ankle Surg 44:190199, 2005.)

third of the metatarsal head. A patient with a loss of dorsal cartilage

but intact central cartilage might therefore appear to have adequate
joint space on standard weightbearing radiographs, leading to a falsenegative nding on the radiographic examination. This can result in
some degree of preoperative ambiguity when surgeons consult with
patients regarding what they will nd at surgery. Ambiguity on the
part of the surgeon has the potential to erode the trust and condence
of the patient and can negatively inuence the patients decision
making regarding the treatment recommendations. Inaccurate preoperative staging in midterm HL/HR also may result in a patient being
prepped for cheilectomy to treat transitional stage II/III HL/HR only to
have joint fusion become the obvious procedure of choice for a new
diagnosis of late stage III HL/HR based on intraoperative inspection of
the joint surface. This scenario is less than ideal with regard to preoperative consent, shared decision making, operating room

preparation, including the procedure duration and available equipment, and postoperative recovery plans.
The lateral hallux stress dorsiexion (LAT SD) view is part of our
standard workup for HL/HR. It provides a functional examination of
the rst MPJ and clinically relevant information not visible on
standard weightbearing foot radiographs in patients with midterm
HL/HR. The LAT SD view is a functional weightbearing radiograph
that provides a view of the joint space narrowing on the dorsal third
of the joint, the extent of the maximum rst MPJ dorsiexion, and
bone on bone impingement that is typically not visible on standard
weightbearing foot radiographs in mid-stage HL/HR (18) (Fig. 1).
This view can also demonstrate the position of the joint in maximum
dorsiexion; thus, it can be used to assess the excursion or lack
of excursion of the sesamoid apparatus. Previous research has
shown the LAT SD angle can be measured reliably, and the method

Fig. 2. Patient 1, with limited rst metatarsophalangeal joint dorsiexion with the upper third joint space maintained. Anteroposterior, lateral, and lateral hallux stress dorsiexion
radiographs of 62-year-old-female with stage II hallux limitus/rigidus. On (A) anteroposterior and (B) lateral radiographs, she had reasonable joint space at the rst metatarsophalangeal
joint, with an elevated and elongated rst metatarsal. (C) Lateral hallux stress dorsiexion view documenting severely restricted dorsiexion with joint space maintained at the upper
third of the joint.

T.J. Boffeli, R.C. Collier / The Journal of Foot & Ankle Surgery xxx (2014) 18

Fig. 3. Lateral and lateral hallux stress dorsiexion radiographic views. Notice how the standard lateral view does not provide this same information regarding maximum rst metatarsal
phalangeal joint dorsiexion preoperatively (A), at 6 weeks postoperatively (B), or at 4 years postoperatively (C), when compared with the lateral hallux stress dorsiexion view preoperatively (D), at 6 weeks postoperatively (E), and at 4 years postoperatively (F). The patient can see how joint mobility is restricted preoperatively and how joint mobility is improved
after distal metatarsal osteotomy and cheilectomy. The surgeon can measure the amount of dorsiexion preoperatively and postoperativley for objective documentation purposes.

for obtaining the LAT SD radiograph has also been shown to be

reliable (18).
The extent to which patients understand why their joint hurts
inuences the shared decision making regarding surgical intervention. Certain radiographic ndings seem to resonate with patients, but
other ndings, although useful to the surgeon, will be relatively
meaningless to patients. The radiographic changes in stage IV are
extensive and obvious even to the untrained observer, which leads to
patients easily understanding why they have a stiff and painful toe
with a large lump. Other radiographic ndings such as subchondral
cysts, attening of the subchondral bone plate, a long rst metatarsal,
or rst ray elevatus will not be intrinsically clear to the patient
regarding why their toe is stiff and painful. Despite extensive preoperative consultation addressing what might or might not be found in
surgery regarding the condition of the cartilage, the patient could
walk away with the perception that the surgeon does not know what
is wrong. Denitive radiographic ndings and descriptions such as
bone on bone arthritis and bone spur impingement are terms
familiar to most adults and can be easily understood when demonstrated on radiographs. Although clearly visible in stage IV HL/HR,
these ndings are often not demonstrated on standard radiographic
views for stage II and stage III HL/HR. Despite the surgeon knowing
that dorsal bone spurs will impinge with forced dorsiexion, causing
pain and limited range of motion (ROM), the patient might not understand. The surgeon might also predict that the dorsal cartilage will
be compromised owing to the presence of crepitus and pain with

dorsiexion or attening of the subchondral bone plate; however, the

patient is left with ambiguity. It has been causally noted that the LAT
SD view increases patients understanding of their HL/HR condition.
This simple, inexpensive, functional test is able to demonstrate joint
space narrowing with bone on bone arthritis and bone spur
impingement at the upper third of the joint in patients with midterm
HL/HR despite the appearance of a normal joint space on standard
radiographs. Patients commonly remark Oh, I get it when shown
this view.
The clinical application of the LAT SD view in HL/HR has received
little attention in the published data. A series of 5 patients with stage II
or stage III HL/HR are presented to depict the clinical applications of
this radiographic view, including objective measurement of the
maximum rst MPJ dorsiexion, conrmation of a bony block at end
range of dorsiexion, the presence or absence of joint space narrowing
at the dorsal third of the rst MPJ, evaluation of excursion of the
sesamoid apparatus during dorsiexion, a patient understanding tool,
an intraoperative assessment of procedure effectiveness, and objective
comparison of maximum dorsiexion before and after surgery.
Case Reports
The cases of 5 typical patients from our practice with stage II or
stage III HL/HR (9) are presented to depict different scenarios in which
the LAT SD view can be uniquely useful from a clinical standpoint. It
has been our experience that the LAT SD view seems to have the

T.J. Boffeli, R.C. Collier / The Journal of Foot & Ankle Surgery xxx (2014) 18

greatest utility in midterm disease; therefore, our examples have

focused on this particular group of patients.
Patient 1
Patient 1 was a 61-year-old female with stage II HL/HR involving
joint pain, dorsal bump pain, and limited ROM. The standard anteroposterior and lateral views showed a reasonable joint space and an
elevated and long rst metatarsal. The preoperative LAT SD view
documented very restricted dorsiexion but an intact joint space on
the upper third of the rst MPJ (Fig. 2). The intraoperative viewing of
the joint surface conrmed intact cartilage on the upper third of the
joint. This patient underwent distal metatarsal decompression
osteotomy with cheilectomy. The utility of the LAT SD view is shown
in Fig. 3 to document limited preoperative and improved 6-week and
4-year postoperative functional dorsiexion. The patient could visually see how the joint mobility had been restricted preoperatively and
how joint mobility had improved after distal metatarsal osteotomy
with cheilectomy. The surgeon can also measure the amount of dorsiexion pre- and postoperatively for objective documentation
purposes.
Patient 2
Patient 2 was a 58-year-old male with stage II HL/HR involving
smooth and unrestricted preoperative ROM yet chronic joint
discomfort. The preoperative LAT SD view showed normal dorsiexion ROM and maintenance of the joint space at the dorsal third of
the rst MPJ. He underwent cheilectomy with intraoperative observation of intact cartilage on the dorsal third of the metatarsal head
and a central stellate cartilage lesion in the middle third of the joint
(Fig. 4). These intraoperative ndings were predicted from the
complete preoperative history and radiographic workup. This case

demonstrates the limited ability of the LAT SD view to predict the

condition of the cartilage under these circumstances. Central lesions
with at least a portion of intact dorsal cartilage will therefore lead to a
false-negative result. Negative ndings from the LAT SD examination
with unexplained joint pain with activity or ROM should raise suspicion for a central stellate lesion.
Patient 3
Patient 3 was a 57-year-old female with stage III HL/HR involving
dorsal bump pain and pain on ROM. Standard anteroposterior and
lateral views showed an intact joint space despite clinical evidence
of advanced arthritis. The patient could see the dorsal spur; however, the cause of her pain was not inherently obvious on the standard radiographs. She experienced an Oh, I get it moment when
shown her LAT SD view, which clearly demonstrated bone spur
impingement with end ROM and a lack of joint space, with bone on
bone at the upper third of the joint (Fig. 5). She agreed to either
cheilectomy or fusion, with the nal procedure selection determined
from intraoperative inspection of the joint surface. She ultimately
underwent rst MPJ fusion. The complete preoperative workup
allowed the surgeon and patient to be prepared and avoid surprises
at surgery.
Patient 4
Patient 4 was a 62-year-old female with stage II HL/HR involving
dorsal bump pain, joint pain, and restricted dorsiexion and plantar
exion ROM. The LAT SD view conrmed the lack of excursion of the
sesamoid apparatus as a potential component cause of the restricted
mobility (Fig. 6). This preoperative nding allowed the surgeon to
predict that cheilectomy might relieve the bump pain but that frozen
or arthritic sesamoids would likely prevent improved postoperative

Fig. 4. Patient 2 demonstrates normal joint space on lateral and lateral hallux stress dorsiexion view, despite joint pain with range of motion. Patient 2 was 58-year-old male with stage II
hallux limitus/rigidus and smooth range of motion yet chronic joint discomfort. A normal joint space was noted on the (A) lateral and (B) anteroposterior radiographs. (C) The lateral hallux
stress dorsiexion view showed maintenance of the joint space at the upper third of the metatarsophalangeal joint indicating at least partially intact cartilage on the upper third of the
metatarsal head. (D) Intraoperative appearance of rst metatarsal cartilage with a central stellate lesion (arrow) but otherwise intact cartilage.

T.J. Boffeli, R.C. Collier / The Journal of Foot & Ankle Surgery xxx (2014) 18

Fig. 5. Patient 3 is an example of the lateral hallux stress dorsiexion view demonstrating a bony block at the end range of dorsiexion and a lack of joint space at the upper third of the metatarsal
phalangeal joint. Patient 3 was 57-year-old female with stage III hallux limitus/rigidus involving bump pain and pain on range of motion. Standard (A) lateral and (B) anteroposterior views showing
an intact joint space despite clinical evidence of advanced arthritis. (C) Lateral hallux stress dorsiexion view demonstrating a bony block at the end range of dorsiexion and a lack of joint space on
the upper third of the joint. (D) Intraoperative appearance of cartilage with loss of the upper third (arrow), which was predicted from the lateral hallux stress dorsiexion ndings.

Fig. 6. Patient 4 demonstrates frozen sesamoids. In this case, the utility of the lateral hallux stress dorsiexion view for examining excursion of the sesamoid apparatus is shown because
this view is a functional weightbearing examination. Note the lack of movement of the sesamoids (solid arrows) between the (A) lateral and (B) lateral hallux stress dorsiexion radiographs. This depiction of frozen sesamoids should increase the surgeons concern for arthritis of the sesamoid apparatus. This could warrant preoperative and intraoperative
consideration regarding cheilectomy versus fusion. (C) Intraoperative appearance of degenerative joint disease at the sesamoid articulation (dotted arrow) with the metatarsal in this
patient led to the intraoperative decision for planned rst metatarsophalangeal joint fusion.

T.J. Boffeli, R.C. Collier / The Journal of Foot & Ankle Surgery xxx (2014) 18

Fig. 7. Intraoperative utility of the lateral hallux stress dorsiexion view. A 58-year-old male with stage II hallux limitus/rigidus with dorsal bump pain and pain at the end range of dorsiexion. (A)
Intraoperative relaxed position lateral view demonstrating joint space narrowing and periarticular bone spurs. (B) Intraoperative lateral hallux stress dorsiexion (LAT SD) view demonstrating the
lack of joint space on the dorsal third of the joint. Intraoperative appearance conrmed lack of intact cartilage on the dorsal third of the joint and the patient underwent a cheilectomy. When
performing a cheilectomy, multiple variables are considered including the extent of remaining healthy cartilage, prevention of future dorsal impingement and maintaining enough bone for possible
future arthrodesis procedures. The LAT SD view was useful to evaluate the mechanics of the joint after cheilectomy to conrm that an appropriate amount of dorsal metatarsal bone had been
removed. Intraoperative imaging of the (C) preoperative LAT SD and (D) postoperative LAT SD views can be printed and given to the patient to demonstrate the effectiveness of the procedure.

ROM. From the intraoperative appearance of degenerative joint disease

at the sesamoid articulation with the metatarsal, an intraoperative
decision was made to proceed with the planned MPJ fusion.
Patient 5
Patient 5 was a 58-year-old male with stage II HL/HR involving
dorsal bump pain and pain at the end range of dorsiexion. The LAT
SD view revealed bone on bone on the dorsal third of the joint and
dorsal bone spur impingement. The intraoperative appearance of the
joint conrmed the LAT SD nding of a lack of cartilage on the dorsal
third of the joint. The patient underwent cheilectomy. When performing cheilectomy, multiple variables must be considered
regarding the extent of bone resection, including the location of the
cartilage defect, prevention of continued dorsal impingement, and

maintaining enough bone for possible future arthrodesis procedures.

The intraoperative LAT SD view was useful in this case to evaluate the
mechanics of the joint after cheilectomy (Fig. 7). The combination of
standard and LAT SD intraoperative views were used to conrm that
enough dorsal metatarsal bone had been removed to allow improved
dorsiexion yet prevent excessive bone resection that would limit
future conversion to rst MPJ fusion. The intraoperative LAT SD images of the preoperative and postoperative cheilectomy (Fig. 7C and
D) can be printed and given to the patient to demonstrate the effectiveness of the procedure.
Discussion
The present case series details the clinical utility of the LAT SD view
for evaluating midterm HL/HR. The current published data on HL/HR

Table 1
Summary of clinical utility of lateral hallux stress dorsiexion view in hallux limitus/rigidus
Observation on LAT SD view

Clinical utility of observation

Other radiographic views

with same utility

Refer to
gures cited

Joint space present at upper third of rst MPJ

At least a portion of cartilage remains on

upper third of rst metatarsal head
Cartilage is absent on the upper third of rst metatarsal head

None

Figs. 2 to 4

Visible on standard lateral view in

stage IV HL/HR
None
None

Figs. 5 to 8

None

Fig. 6

None

Fig. 7

Lack of joint space at upper third of rst MPJ

Restricted rst MPJ dorsiexion
Comparison of pre- and postoperative
dorsiexion
Frozen sesamoids
Lack of bone spur impingement
with dorsiexion

Objective measurement of maximum rst MPJ dorsiexion

Allows patient to observe improvement in dorsiexion
from the procedure; allows objective measurement and
documentation for the surgeon
Predicts limited mobility of sesamoids, raising concern for minimal
improvement of ROM after surgery
Intraoperative tool to ensure appropriate amount of bone
resection obtained

Abbreviations: HL, hallux limitus; HR, hallux rigidus; LAT SD, lateral hallux stress dorsiexion; MPJ, metatarsophalangeal joint; ROM, range of motion.

Figs. 2, 3, and 6
Fig. 3

T.J. Boffeli, R.C. Collier / The Journal of Foot & Ankle Surgery xxx (2014) 18
Table 2
Value of the lateral stress dorsiexion view for prediction of intraoperative ndings
Findings on Preoperative AP and
Lateral Radiograph

Findings LAD SD View

Prediction of Intraoperative
Findings based on radiographs

Intraoperative Findings

Patient
Example

Intact joint space at the rst MPJ

Joint space maintained at the

upper third of the joint
Joint space maintained at the
upper third of the joint

Intact cartilage on upper third of

the metatarsal head
Intact cartilage on upper third of
the metatarsal head

Intact joint space despite clinical

evidence of advanced arthritis

Absent joint space at the upper

third of the joint

Full thickness defect of joint cartilage

on the upper third of the metatarsal head

Arthritic changes to the sesamoid

complex may or may not be visible

Lack of movement of the sesamoids

when compared to the lateral radiograph

Frozen and arthritic sesamoids

Intact cartilage on upper third

of the metatarsal head
Intact cartilage on upper third
of the metatarsal head with
central stellate lesion
Full thickness defect of joint
cartilage on the upper third
of the metatarsal head
Lack of excursion of sesamoid
apparatus, DJD between
sesamoids and metatarsal

Intact joint space at the rst MPJ

Abbreviations: AP, anteroposterior; DJD, degenerative joint disease; LAT SD, lateral hallux stress dorsiexion; MPJ, metatarsophalangeal joint.

Fig. 8. The lateral hallux stress dorsiexion view can be a tool for patient understanding of hallux limitus/hallux rigidus. Standard weightbearing anteroposterior and lateral radiographs
will demonstrate ndings the physician can use to help stage hallux limitus/rigidus, including irregular joint space narrowing, attening of the metatarsal head, and dorsal spurring. These
ndings might not resonate in the same manner to the patient. However, we have causally observed that showing the patient a functional weightbearing radiograph such as (A) the lateral
stress dorsiexion view demonstrating bone spur impingement, bone on bone arthritis, and restricted dorsiexion improves the patients understanding of the joint condition. (B)
Note how these ndings cannot be visually demonstrated on the standard lateral view.

have primarily focused on the etiology, staging, procedure selection

criteria, and procedure outcomes (2,6,11,19). Taranto et al (18)
demonstrated the reliability of the method used to obtain the LAT SD
radiograph and measurement of the rst MPJ dorsiexion angle. This
simple, reproducible, and inexpensive weightbearing view provides a
functional representation of the maximum rst MPJ dorsiexion,
radiographic assessment of the joint space on the upper third of the
joint, determination of presence or absence of bone spur impingement
at the end range of dorsiexion, an assessment of sesamoid excursion
with hallux dorsiexion, an intraoperative assessment of procedure
effectiveness, and a preoperative to postoperative comparison of the
maximum rst MPJ dorsiexion. The clinical utility of these ndings
are listed in Table 1. It has also been our casual observation that patients
have been better able to understand their HL/HR condition when
shown the LAT SD view (Fig. 8).
In our experience, the LAT SD view is a useful tool for patient
understanding and setting appropriate expectations in the workup of
HL/HR. Findings consistent with HL/HR on standard weightbearing
radiographs are useful to the surgeon in diagnosing and staging the
condition; however, these ndings will not always be clear to the
patient. When shown their LAT SD view with clear evidence of bone
spur impingement and bone on bone occurring after only 20! of
dorsiexion, the patients have frequently remarked Oh, I get it.
Patients frequently have an inherent understanding of bone on
bone, because this term is commonly used to describe other arthritic
joints such as hips and knees. Having a visual representation of this
bone on bone is a benecial tool for patient education. Patients with
HL/HR frequently ask how they will be able to walk if their rst MPJ
has been fused. The LAT SD view can be used to demonstrate that they
have already been walking without functional dorsiexion. After
seeing this radiograph, the patient is often more involved and
comfortable with the decision to undergo a joint fusion procedure.
Furthermore, this view can be used to enable patient understanding
in the postoperative period. A comparison of the preoperative LAT SD

view with the postoperative LAT SD view can provide a clear representation of the change in motion after surgical intervention.
Regarding preoperative planning, the LAT SD view seems to provide the most utility in evaluating midterm disease. Accurate staging
is important for appropriate preoperative planning, procedure selection, and patient education. Previous investigators have demonstrated
that early degenerative arthritis of the MPJ occurs at the upper third of
the joint (1417). However, standard weightbearing views cannot
accurately assess joint space narrowing in the upper third of the MPJ
when the central third of the cartilage has remained intact, which is
often the case with midterm HL/HR. The LAT SD view provides
additional insight regarding the condition of the cartilage on the
dorsal third of the MPJ, which is important in the patients with
midterm disease. The more tools the surgeon has to obtain preoperative information about the condition of the cartilage in HL/HR, the
better one can predict the intraoperative ndings, which, in turn,
results in improved preoperative planning, procedure selection, patient education and understanding, and shared decision making. A
summary of the value of the LAT SD for prediction of intraoperative
ndings are listed in Table 2.
The present study was limited by the small population size and
retrospective nature of the study. A prospective study is currently
underway with intent to conrm our observations regarding the
various clinical utilities of the LAT SD view for evaluating midterm HL/
HR. To bring awareness of the utility of the LAT SD view, we reported
the present case series to show that the LAT SD view is a simple test
that provides useful clinical information about multiple factors that
inuence procedure selection and patient understanding of HL/HR.
References
1. Gould N. Hallux rigidus: cheilotomy or implant. Foot Ankle 1:315320, 1981.
2. Coughlin MJ, Shurnas PS. Hallux rigidus: grading and long term results of operative treatment. J Bone Joint Surg Am 85A:20722088, 2003.

T.J. Boffeli, R.C. Collier / The Journal of Foot & Ankle Surgery xxx (2014) 18

3. Mann RA, Coughlin MJ. Hallux valgus: etiology, anatomy, treatment, and surgical
considerations. Clin Orthop 157:3141, 1981.
4. McMaster MJ. The pathogenesis of hallux rigidus. J Bone Joint Surg 60B:8287, 1978.
5. Myerson M, Edwards WHB. The etiology and pathogenesis of hallux valgus. Foot
Ankle Clin 2:583598, 1997.
6. Oloff LM, Jhala-Patel G. A retrospective analysis of joint salvage procedures for
grades III and IV hallux rigidus. J Foot Surg 47:230236, 2008.
7. OMalley MJ, Basran HS, Gu Y, Sayres S, Deland JT. Treatment of advanced stages of
hallux rigidus with cheilectomy and phalangeal osteotomy. J Bone Joint Surg Am
95A:606610, 2013.
8. Shereff MJ, Beijani FJ, Kummer FJ. Kinematics of the rst metatarsophalangeal
joint. J Bone Joint Surg Am 63:392398, 1968.
9. Drago JJ, Oloff L, Jacobs AM. A comprehensive review of hallux limitus. J Foot Surg
23:213220, 1984.
10. Regnauld B. Hallux rigidus. In: The Foot, pp. 345359, edited by B Regnauld,
Springer-Verlag, Berlin, 1986.
11. Roukis TS, Jacobs PM, Dawson DM, Erdmann BB, Ringstrom JB. A prospective
comparison of clinical, radiographic and intraoperative features of hallux rigidus:
short-term follow-up and analysis. J Foot Surg 41:158165, 2002.

12. Unger K, Rahimi F, Bareither D, Muehleman C. The relationship between articular

cartilage degeneration and bone changes of the rst metatarsal phalangeal joint. J
Foot Surg 39:2433, 2000.
13. Gamble FO, Yale I. Joint diseases. In: Clinical Foot Roentgenology, Krieger Publishing,
New York, 1975, p. 64.
14. Hattrup SJ, Johnson KA. Subjective results of hallux rigidus following treatment
with cheilectomy. Clin Orthop Relat Res 226:182191, 1988.
15. Moberg EA. Simple operation for hallux rigidus. Clin Orthop Relat Res 142:5556,1979.
16. Shurnas PS, Coughlin MJ. Arthritic conditions of the foot. In: Surgery of the Foot and
Ankle, pp. 805921, edited by MJ Coughlin, RA Mann, CL Saltzman, Mosby Elsevier,
Philadelphia, 2007.
17. Weinfeld SB, Schon LC. Hallux metatarsophalangeal arthritis. Clin Orthop Relat Res
349:919, 1998.
18. Taranto MJ, Taranto J, Bryant A, Singer KP. Radiographic investigation of angular
and linear measurements including rst metatarsophalangeal joint dorsiexion
and rearfoot to forefoot axis angle. J Foot Ankle Surg 44:190199, 2005.
19. Beertema W, Draijer WF, van Os JJ, Pilot P. A retrospective analysis of surgical
treatment in patients with symptomatic hallux rigidus: long-term follow-up. J
Foot Ankle Surg 45:244251, 2006.