Table 2.

2003 Coughlin and Shurnas classification

Grade	Dorsiflexion	X-rays	Clinical findings
0	40-60°	Normal	No pain Only moderate stiffness
1	30-40°	Dorsal osteophyte Minimal joint space narrowing Minimal periarticular sclerosis, minimal flattening of metatarsal head	Mild intermittent pain evoked at maximum degrees of ROM Mild stiffness
2	10-30°	Dorsal, lateral, and possibly medial osteophytes giving flattened appearance to metatarsal head No more than ¼ if dorsal joint space involved on lateral radiograph, mild-to-moderate joint-space narrowing and sclerosis, sesamoids not usually involved	Moderate-to-severe pain and stiffness that may be constant Pain occurs just before maximum dorsiflexion and maximum plantar flexion on examination
3	< 10°	Same as in grade 2 but with substantial narrowing, possibly periarticular cystic changes, more than ¼ of dorsal joint space involved on lateral radiograph, sesamoids enlarged and/or cystic and/or irregular	Nearly constant pain and substantial stiffness at extremes of range of motion but not at mid-range
4	< 10°	Same as grade 3	Same criteria as grade 3 but there is definite pain at mid-range of passive motion