AOFAS Clinical Rating System
Copyright 1994 by the American Orthopaedic Foot and Ankle Society
Foot & Ankle International / Vol. 15, No. 7 / July 1994
Clinical Rating Systems for the Ankle-Hindfoot, Midfoot, Hallux and Lesser Toes
Harold B. Kitaoka, M.D.; Ian J. Alexander, M.D.; Robert S. Adelaar, M.D.; James A. Nunley, M.D.; Mark S. Myerson, M.D.; Melanie Sanders, M.D.
ABSTRACT
Four rating systems were developed by the American Orthopaedic Foot and Ankle Society to provide a standard method of reporting clinical status of the ankle and foot. The systems incorporate both subjective and objective factors into numerical scales to describe function, alignment, and pain.
Orthopaedic surgeons are faced with a bewildering number of reports in the medical literature that are a challenge to interpret and apply because no standardized evaluation scheme is universally used or accepted.
Unlike the case with hip and knee joints, few of the rating systems reported for the ankle and foot have been adopted for use by subsequent investigators.
4,6,7,12-14 Some evaluation schemes incorporate subjective and objective clinical variables into a numerical scale, such as the forefoot score for
bunionette,7-9, 15 forefoot score for bunion,6 ankle scores 1,4,5,11,13 heel score,3 tarsometatarsal 14 or resection arthroplasty.7 score, or ankle inversion injury scale,12 or into a graded nonnumerical scale, such as excellent, good, fair, and poor. Others incorporate only subjective factors into nonnumerical scale, and some include both radiologic and clinical factors. In some cases, patients are asked to rate their own result of
treatment by selecting a nonnumerical grade. Nonnumerical grading used includes categories of excellent, good, fair, poor; good, fair, poor; good, poor; good, good with reservations, failure; and successful, unsuccessful. Clinical results are often reported as individual factors without aggregation into a composite score. Sometimes nonnumerical grades are reported with limited information about what criteria were used to define each grade.A standard rating system ideally allows for the comparison of results of different methods of treatment in patients with the same disorder. It also ena
bles the surgeon to follow the progress of the patient before and at various intervals after a particular treatment.
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The purpose of this study was to develop and report a standard rating system for the foot and ankle.
MATERIALS AND METHODS
A committee of the American Orthopaedic Foot and Ankle Society reviewed published rating systems for the ankle and foot as well as systems used in the hip, knee, spine, shoulder, wrist, elbow, and hand. We considered different ways of rating, such as a global score encompassing all regions of the foot and ankle, a score for each individual joint, and a separate score for each type of operation. By consensus, four scales were developed for different anatomic regions.
Various factors thought to reflect the condition of the ankle and foot were considered as well as the relative weight of these factors, the use of nonnumerical grading (e.g., excellent, good, fair, and poor), and inclusion of radiologic variables. We decided that the scale should not require the use of sophisticated equipment, such as a force plate or foot pressure measurement system, and should not be so complex that its use by clinicians would be limited. It should also be applicable for different clinical situations, such as evaluation of patients after arthrodesis, implant arthroplasty, and ligament reconstruction.
RESULTS
We devised four grading scales, each with 100 possible points. No radiologic factors were included because we wanted the scores to be strictly clinical. We also did not assign numerical values to exce
llent, good, fair, and poor results. Both subjective and objective clinical factors constituted each scale.ignore subsequent bad blocks
It was recognized that joints of the ankle and hindfoot function as a complex. For example, inversion motion of the foot involves rotation of the subtalar, talonavic-ular, calcaneocuboid, and ankle joints. We therefore developed a combined ankle-hindfoot rating system.
The three other proposed systems were (1) midfoot, (2) hallux metatarsophalangeal-interphalangeal, and (3) lesser metatarsophalangeal-interphalangeal scales.
Ankle-Hindfoot Scale
This scale grades ankle, subtalar, talonavicular, and calcaneocuboid joint levels and may be applied to ankle replacement, ankle arthrodesis, ankle instability operations, subtalar arthrodesis, subtalar instability operations, talonavicular arthrodesis, calcaneocuboid arthrodesis, calcaneal osteotomy, calcaneus fracture, talus fracture, and ankle fracture.
This scale is a modification of a clinical scale published previously.4 A score of 100 points is possible in a patient with no pain, full range of sagittal and hindfoot motion, no ankle or hindfoot instability, go
od alignment, ability to walk more than six blocks, ability to ambulate on any walking surface, no discernible limp, no limitation of daily or recreational activities, and no assistive devices needed for ambulation. Fifty points were assigned to function, 40 to pain, and 10 to alignment. The ankle-hindfoot score is detailed in Table 1.
It is not possible to determine isolated ankle joint range of motion clinically; therefore, dorsiflexion motion and plantarflexion motion are measured with a goni-ometer and described as sagittal motion. Hindfoot motion is expressed as a percentage of normal, as in previously published reports.2 A joint that can be passively dislocated or severely subluxated is graded as definitely unstable in these systems.
TABLE 1
Ankle-Hindfoot Scale (100 Points Total)
Pain (40 points)
q None (40)
q Mild, occasional (30)
q Moderate, daily (20)
q Severe, almost always present 0
Function (50 points)
q Activity limitations, support requirement
r No limitations, no support (10)
r No limitation of daily activities, limitation of recreational activities, no support (7)
r Limited daily and recreational activities, cane (4)
r Severe limitation of daily and recreational activities, walker, crutches, wheelchair, brace 0
q Maximum walking distance, blocks
r Greater than 6 (5)
r4-6 (4)
r1-3 (2)
r Less than 1 0
q Walking surfaces
r No difficulty on any surface (5)
r Some difficulty on uneven terrain, stairs, inclines,
ladders (3)
r Severe difficulty on uneven terrain, tairs,inclines,
ladders 0
q Gait abnormality
r None, slight (8)
r Obvious (4)
r Marked 0
q Sagittal motion (flexion plus extension)
r Normal or mild restriction (30° or more) (8)
r Moderate restriction (15°-29°) (4)
r Severe restriction (less than 150) 0
q Hindfoot motion (inversion plus eversion)
r Normal or mild restriction (75%-100% normal) (6)
r Moderate restriction (25%-74% normal) (3)
r Marked restriction (less than 25% normal) 0
q Ankle-hindfoot stability (anteroposterior,varus-valgus)
r Stable (8)
r Definitely unstable 0
Alignment (10 points)
q Good, plantigrade foot, midfoot well aligned (15)
q Fair, plantigrade foot, some degree of midfoot malalignment
observed, no symptoms (8)
q Poor, nonplantigrade foot, severe malalignment,
symptoms 0
Midfoot Scale
This scale grades intercuneiform, lateral cuneiform-cuboid, naviculocuneiform, and tarsometatarsal levels and may be applied to intercuneiform arthrodesis, naviculocuneiform arthrodesis, tarsometatarsal arthrodesis, lateral cuneiform-cuboid arthrodesis, navicular fracture, cuneiform fracture, cuboid fracture, and tarsometatarsal fracture or dislocation.
This scale was modified from an ankle score published previously.4 A score of 100 points is possible in a patient with no pain, good alignment, ability to walk more than six blocks, ability to ambulate on any walking surface, no discernible limp, no limitation of daily or recreational activities, no assistive devices needed for ambulation, and no special footwear requirements. Forty-five points were assigned to function, 40 to pain, and 15 to alignment. The midfoot score is detailed in Table 2.
Because range of motion of individual intertarsal joints of the midfoot cannot be measured clinically, motion was not included in this scale.
TABLE 2
Midfoot Scale (100 Points Total)
Pain (40 points)
q None (40)
q Mild, occasional (30)
q Moderate, daily (20)
q Severe, almost always present 0
Function (45 points)
q Activity limitations, support
r No limitations, no support (10)
r No limitation of daily activities, limitation of recreational
activities, no support (7)
r Limited daily and recreational activities, cane (4)
r Severe limitation of daily and recreational activities, walker, crutches, wheelchair 0
q Footwear requirements
r Fashionable, conventional shoes, no insert required (5)
r Comfort footwear, shoe insert (3)
r Modified shoes or brace 0
q Maximum walking distance, blocks
r Greater than 6 (10)
r4-6 (7)
r1-3 (4)
r Less than 1 0
q Walking surfaces
r No difficulty on any surface (10)
r Some difficulty on uneven terrain, stairs, inclines,
ladders (5)
r Severe difficulty on uneven terrain, stairs, inclines,
ladders 0
q Gait abnormality
r None, slight (10)
r Obvious (5)
r Marked 0
Alignment (15 points)
q Good, plantigrade foot, midfoot well aligned (15)
q Fair, plantigrade foot, some degree of midfoot malalignment observed, no symptoms (8)
q Poor, nonplantigrade foot, severe malalignment, symptoms 0
Hallux Metatarsophalangeal-lnterphalangeal Scale
This scale grades first metatarsal, metatarsophalangeal (MTP) joint, proximal phalanx, distal phalanx,
and interphalangeal (IP) joint levels and may be applied to hallux valgus, hallux varus, MTP arthrosis (hallux rigidus, osteoarthrosis, traumatic or inflammatory or other arthroses), hallux valgus interphalangeus, clawtoe, mallet toe, MTP arthrodesis, cheilectomy, MTP implant arthroplasty, MTP resection arthroplasty, MTP instability or dislocation, and both intra-articular and extra-articular fractures of the metatarsal and phalanx.
This scale is a modification of a forefoot score published previously for hallux valgus surgery 6 and for resection arthroplasty surgery.10 A score of 100 points is possible in a patient with no pain, full range of MTP and IP motion, no MTP or IP instability, good alignment, no limitation of daily or recreational activities, and no footwear limitations. Forty points were assigned to pain, 45 to function, and 15 to alignment. The hallux MTP-IP score is detailed in Table 3.
TABLE 3
Hallux Metatarsophalangeal-Interphalangeal Scale (100 Paints Total)
Pain (40 points)
q None (40)
q Mild, occasional (30)
q Moderate, daily (20)
q Severe, almost always present 0
Function (45 points)
q Activity limitations
r No limitations (10)
r No limitation of daily activities, such as employment
responsibilities, limitation of recreational
activities (7)
r Limited daily and recreational activities (4)
r Severe limitation of daily and recreational

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