Design: Single-centre, randomised superiority trial
Population: 90 adults ≥40 with symptomatic hallux rigidus
Primary outcome: Walking pain (0–10) at 12 months
Effect: 1.3 vs 5.7; difference −5.0 (95% CI −6.1 to −3.9)

A single-centre Finnish trial randomised 90 adults aged 40 or over with radiographically confirmed first metatarsophalangeal joint osteoarthritis, symptoms for over a year and walking pain of 4 or more out of 10, to arthrodesis or watchful waiting. It was published in Annals of Internal Medicine in August and is the first randomised comparison against the natural course.

At 12 months, mean walking pain was 1.3 after arthrodesis and 5.7 with watchful waiting (adjusted difference −5.0 points, 95% CI −6.1 to −3.9). The prespecified minimal important difference was 1.7 points.

The effect is large and clearly clinically meaningful. For a patient with persistent pain despite footwear changes, referral for surgery is reasonable rather than indefinite conservative care.

Confirm the diagnosis with weight-bearing radiographs.
Try stiff-soled or rocker-bottom footwear and analgesia first.
Refer patients with pain persisting beyond a year for surgical opinion.
Explain that fusion removes big-toe movement but relieves pain.

Why it matters

It gives randomised evidence that surgery, not time, relieves painful hallux rigidus.

The statistics, in plain English

A 5-point difference on a 10-point pain scale is about three times the smallest change patients notice, and the whole interval is well beyond it. The trial was unblinded and single-centre, which can inflate pain-score differences, but not plausibly by this much.