Lateral Stress Dorsiflexion View: A Case Series Demonstrating Clinical Utility in Midterm Hallux Limitus

The lateral hallux stress dorsiflexion view is part of our standard workup for midterm hallux limitus (HL)/hallux rigidus (HR). It provides a functional radiographic examination of the first 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 dorsiflexion 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 first metatarsal phalangeal joint dorsiflexion, 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 influences 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 first metatarsal phalangeal joint dorsiflexion, confirmation of a bony block at the end range of dorsiflexion, 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 dorsiflexion before and after surgery.