Hallux Valgus: Difference between revisions

No edit summary
No edit summary
 
(148 intermediate revisions by 18 users not shown)
Line 1: Line 1:
<div class="editorbox">
<div class="editorbox">
'''Original Editors ''' - [[User:Bradley Svoboda|Bradley Svoboda]]  
'''Original Editors ''' - [[User:Bradley Svoboda|Bradley Svoboda]]


'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}  
'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}
</div>  
</div>  
== Definition<br> ==
== Introduction ==
Hallux Valgus is considered one of the most common foot deformities,<ref>Mortka K, Lisiński P. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4668189/pdf/jpts-27-3303.pdf Hallux valgus-a case for a physiotherapist or only for a surgeon? Literature review.] J Phys Ther Sci. 2015 Oct;27(10):3303-7</ref> and is described as “lateral deviation of the hallux and its consequent distancing from the median axis of the body”.<ref name=":3">Cavalheiro CS, Arcuri MH, Guil VR, Gali JC. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7006535/pdf/1809-4406-aob-28-01-12.pdf HALLUX VALGUS ANATOMICAL ALTERATIONS AND ITS CORRELATION WITH THE RADIOGRAPHIC FINDINGS.] Acta Ortop Bras. 2020 Jan-Feb;28(1):12-15.</ref> Treatment for hallux valgus ranges from conservative to surgical management.<ref>Wojcik B, Fabiś M, Zadroźna K, Małek A, Iwaniszyn-Zapołoch K, Remjasz K,Aleksandrowicz J, Siedlecki W. Hallux valgus treatment and new methods. Journal of Education, Health and Sport [online]. 2022;12( 9): 614–620. [last access 18.02.2023]</ref> There are about 131 different surgical techniques. However, no method is available thus far that sufficiently corrects all hallux valgus deformities.<ref name=":1">Joseph TN, Mroczek KJ. Decision making in the treatment of hallux valgus. Bull NYU Hosp Jt Dis. 2007;65(1):19-23. </ref> This article will discuss pre and post-operative hallux valgus management principles.


Hallux valgus is a progressive foot deformity in which the first metatarsophalangeal (MTP) joint is affected and is often accompanied by significant functional disability and foot pain<ref name="Menz">Radiographic validation of the Manchester scale for the classification of hallux valgus deformity, Menz HB et al, Rheumatology 2005;44:1061–1066 (1B)</ref><sup>,</sup><ref name="Nix">Prevalence of hallux valgus in the general population: a systematic review and meta-analysis. Nix S., Smith M., Vicenzino B. Journal of Foot and Ankle Research 2010, 3:21 (1B)</ref>. This joint is gradually subluxed (lateral deviation of the MTP joint) resulting in an resulting in an abduction of the first metatarsal while the phalanges adduct.<ref name="Menz">Radiographic validation of the Manchester scale for the classification of hallux valgus deformity, Menz HB et al, Rheumatology 2005;44:1061–1066 (1B)</ref>,<ref name="H">Validity of self-assessment of hallux valgus using the Manchester scale, Menz H et al, Musculoskeletal Disorders 2010, 11:215 (1A)</ref>. This often leads to development of soft tissue and bony prominence on the medial side of what is called a bunion&nbsp;<ref name="Glasoe">Hallux Valgus and the First Metatarsal Arch Segment: A Theoretical Biomechanical Perspective. Glasoe W et al, Phys Ther. 2010;90:110–120. (3A)</ref> (exostosis on the dorsomedial aspect of the first metatarsal head&nbsp;<ref name="T">Decision Making in the Treatment of Hallux Valgus, Joseph T, Mroczek K. Bulletin of the NYU Hospital for Joint Diseases 2007;65(1):19-23 19 (4)</ref> ). At a late stage, these changes lead to pain and functional deficit: i.e. impaired gait (lateral and posterior weight shift, late heel rise, decreased single-limb balance, pronation deformity) <ref name="H">Validity of self-assessment of hallux valgus using the Manchester scale, Menz H et al, Musculoskeletal Disorders 2010, 11:215 (1A)</ref>. There is a high prevalence of hallux valgus in the overall population (23% in adults aged 18-65 years and 35.7% in elderly people aged over 65 years). It has a higher prevalence in women (females 30% - males 13%).and the elderly (35,7%) <ref name="Nix">Prevalence of hallux valgus in the general population: a systematic review and meta-analysis. Nix S., Smith M., Vicenzino B. Journal of Foot and Ankle Research 2010, 3:21 (1B)</ref>. <br>
== Clinically Relevant Anatomy ==
[[File:Foot inferior.png|thumb|Plantar surface of the foot]]


== Clinically Relevant Anatomy<br>  ==
=== Bones ===
The [[Metatarsals|first metatarsal]], proximal phalanx, and distal phalanx form the hallux or first toe. In addition, two [[Sesamoid|sesamoid bones]] (medial and lateral) contribute to the first metatarsophalangeal joint. Their dorsal surface articulates with the plantar aspect of the first metatarsal head and is contained within the [[Flexor Hallucis Brevis|flexor hallucis brevis]] muscle tendon. The first metatarsal head is responsible for good static and dynamic weight bearing. The sesamoid bones protect the tendons of the flexor hallucis brevis and help generate more force by extending its levers.


The angle created between the lines that longitudinally bisect the proximal phalanx and the first metatarsal is known as the hallux valgus angle.&nbsp; Less than 15 degrees is considered normal.&nbsp; Angles of 20 degrees and greater are considered abnormal.&nbsp;&nbsp; An angle &gt;45-50 degrees is considered severe.<br>
=== Joints ===
The hallux metatarsophalangeal joint (MPJ) is a synovial joint. Three joints are part of this system:


== Mechanism of Injury / Pathological Process<br>  ==
* [[Foot Anatomy|Tarsometatarsal joint]] -located between the medial cuneiform bone and the first metatarsal.
* [[Foot Anatomy|Metatarsophalangeal joint]] - connects the first metatarsal and the first proximal phalanx.
* [[Foot Anatomy|Interphalangeal joint]] - situated between the two phalanges of the first toe.
[[File:Ligaments of the foot plantar aspect Primal.png|thumb|Ligaments of the foot plantar aspect]]


The exact etiology is not well established, however, certain factors have been considered to play a role in the development of hallux valgus.&nbsp; Gender(10x more frequent in women), shoewear (tight pointed shoes), congenital deformity or predisposition, chronic achilles tightness, severe flatfoot, hypermobility of the first metatarsocunieform joint, and systemic disease.  
=== Ligaments'''<ref>Hallinan JTPD, Statum SM, Huang BK, Bezerra HG, Garcia DAL, Bydder GM, Chung CB. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7337226/pdf/rg.2020190145.pdf High-Resolution MRI of the First Metatarsophalangeal Joint: Gross Anatomy and Injury Characterization.] Radiographics. 2020 Jul-Aug;40(4):1107-1124.</ref>''' ===


== Clinical Presentation  ==
* The intersesamoid ligament (ISL) links two sesamoids and indirectly connects the [[Flexor Hallucis Brevis|flexor hallucis brevis]] (FHB), [[Abductor Hallucis|abductor hallucis]], and [[Adductor Hallucis|adductor hallucis]] tendons.
* Sesamoid phalangeal ligaments (SPLs) are the thickest first MTPJ ligaments. They protect the sesamoids from subluxation when high tensile forces act upon them while walking or running.
* Metatarsosesamoid ligaments (MTSLs), or suspensory ligaments, are part of the plantar plate complex. They assist with stabilising the sesamoids.
* Medial and lateral metatarsophalangeal ligaments (collateral ligaments) attach at the peripheral sesamoids. They are not part of the plantar plate complex but play an essential role as static stabilisers when applying valgus or varus forces.
[[File:Intrinsic foot muscles.png|thumb|Intrinsic foot muscles]]


In this foot deformity, the medial eminence becomes prominent as the distal end of the first metatarsal drift medially and the proximal phalanx deviates laterally. The first MTP becomes subluxed, what leads to a lateral deviation of the hallux, medial displacement of the distal end of the first metatarsal and bony enlargement of the first metatarsal head <ref name="Menz">Radiographic validation of the Manchester scale for the classification of hallux valgus deformity, Menz HB et al, Rheumatology 2005;44:1061–1066 (1B)</ref>. With progression, the pull of the adductor hallucis tendon and the intermetatarsal ligament cause the sesmoids to erode the cristae underneath the first metatarsal cuasing the sesmoids to sublux laterally. <br>
=== Muscles ===
The following muscles act on the first MTP joint: [[Tibialis Anterior|tibialis anterior]], [[Extensor Hallucis Longus|extensor hallucis longus]], [[Peroneus (Fibularis) Longus Muscle|peroneus longus]], flexor hallucis longus, extensor hallucis brevis, [[Abductor Hallucis|abductor hallucis]], [[Flexor Hallucis Brevis|flexor hallucis brevis]], [[Adductor Hallucis|adductor hallucis]], [[Dorsal Interossei of the Foot|dorsal interossei]], and [[Aponeurosis|aponeurosis plantaris]].


'''[[Image:Hallux Valgus.png|thumb|right]]<br>Figure 1: '''Hallux valgus is a disruption of the normal alignment of the metatarsophalangeal joint. The hallux abducts while the first metatarsocuneiform segments adduct. The severity of the hallux deformity is measured by (A) hallux valgus angle and (B) intermetatarsal 1-2 angle&nbsp;<ref name="Glasoe">Hallux Valgus and the First Metatarsal Arch Segment: A Theoretical Biomechanical Perspective. Glasoe W et al, Phys Ther. 2010;90:110–120. (3A)</ref>  
The muscle responsible for the motion control at the first MPJ is [[Extensor Hallucis Brevis|extensor hallucis brevis]], abductor hallucis, flexor hallucis brevis, and adductor hallucis. The abductor hallucis contributes to the abduction and flexion of the first MPJ. In addition to the foot's intrinsic muscles, the flexor hallucis longus contributes to the flexion of the distal phalanx of the hallux and the extensor hallucis longus to its extension.<ref>J.S. Kawalec JS. 12 - Mechanical testing of foot and ankle implants. Editor(s): Friis E. Mechanical Testing of Orthopaedic Implants. Woodhead Publishing 2017: pages 231-253</ref>


A common problem in people with hallux valgus (pre-operative), is one or more disorders in their [http://www.physio-pedia.com/index.php?title=Gait_Cycle gait pattern] due to the deformity of the first metatarsophalangeal joint. Dysfunctions that may be present: <br>
=== Motion ===
The primary motion of the metatarsophalangeal joint is flexion and extension with minimal abduction and adduction. The collateral ligaments limit mediolateral movement in the joint.<ref>Mojica MN, John S. Early JS.19 - Foot Biomechanics. Editor(s): Webster JB, Murphy DP. Atlas of Orthoses and Assistive Devices (Fifth Edition),Elsevier, 2019: 216-228.e1.</ref>
[[File:Hallux valgus angle 2.jpg|thumb|Hallux Valgus Angle]]


*Gait deviations in the midstance (middle stage) and the propulsion phase (late stance). As the body weight moves forward on a foot on the ground, the patient will tend to keep his weight on the lateral border of the foot. This leads to a lateral and posterior weight shift
==== Hallux Valgus Angle ====
*Patient has also a pronation deformity
*Patient is unable to supinate his / her foot and will tend to keep his body weight on the lateral border of the foot which results in a late heel rise
*The period of single-limb support will be diminished&nbsp;<ref name="Dimonte">Pathomechanics, Gait Deviations, and Treatment of the Rheumatoid Foot: a clinical report. Dimonte P et al. Physical therapy 1982: Vol 62(8): 1148 – 1156 (5)</ref>


When a physical examination is executed, the following indications could be present:<br>
* The angle created between the lines that longitudinally bisect the proximal phalanx and the first metatarsal.
* Less than 15° is considered normal. Angles of 20° and greater are considered abnormal. An angle of 45-50° is considered severe.


*Lateral deviation of the MTP joint
== Epidemiology and Aetiology ==
*Swelling of first MTP joint
Hallux Valgus deformity is a complex condition. It has a familial tendency that depends on autosomal dominant inheritance's transmission with incomplete penetrance.<ref name=":3" /> Other aetiologic factors include the following:  
*Shortening of flexor hallucis brevis muscle
*Tenderness of hallux
*Weakness of hallux abductor muscles&nbsp;<ref name="Dimonte">Pathomechanics, Gait Deviations, and Treatment of the Rheumatoid Foot: a clinical report. Dimonte P et al. Physical therapy 1982: Vol 62(8): 1148 – 1156 (5)</ref>
*Pain (primary symptom) <ref name="T">Decision Making in the Treatment of Hallux Valgus, Joseph T, Mroczek K. Bulletin of the NYU Hospital for Joint Diseases 2007;65(1):19-23 19 (4)</ref><br><br>


== Diagnostic Procedures  ==
* Gender (more common in women than men (ratio of 15:1)<ref>Kakwani M, Kakwani R. Current concepts review of hallux valgus. Journal of Arthroscopy and Joint Surgery. 2021;8(3):222-30.</ref>
* Footwear (tight, pointed shoes)
** Menz et al. found that wearing constrictive footwear "between the ages of 20 and 39 years may be a critical period for the development of hallux valgus in later life"<ref>Menz HB, Roddy E, Marshall M, Thomas MJ, Rathod T, Peat GM, Croft PR. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5106851/ Epidemiology of shoe wearing patterns over time in older women: associations with foot pain and hallux valgus]. J Gerontol A Biol Sci Med Sci. 2016 Dec;71(12):1682-7. </ref>


One of the procedures to determine hallux valgus is the use of radiographs. Here we look at the hallux abductus angle. This is the angle formed between the longitudinal bisections of the first metatarsal and the proximal phalanx. When we have an angle less than 15°, there is no sign of hallux valgus. If the angle is greater than 15°, there is a sign of hallux valgus. An angle of 45-50 ° is considered serious. The degree of displacement of the sesamoids and the level of osteoarthritic change within the first MTP joint should be considered as well.<ref name="Menz">Radiographic validation of the Manchester scale for the classification of hallux valgus deformity, Menz HB et al, Rheumatology 2005;44:1061–1066 (1B)</ref>  
* Congenital deformity
* Anatomical and biomechanical factors, such as
** long first metatarsal
** rounded joint
** metatarsus primus varus
* Chronic [[Achilles Tendon|Achilles tendon]] tightness
* Severe flatfoot
* Hypermobility of the first metatarsocuneiform joint
* Systemic disease
* Abnormal muscle insertions
* Hip and knee [[osteoarthritis]]<ref>Hannan MT, Menz HB, Jordan JM, Cupples LA, Cheng C-H, Hsu Y-H. Hallux Valgus and Lesser Toe Deformities are Highly Heritable in Adult Men and Women: the Framingham Foot Study. Arthritis care & research. 2013;65(9):1515-1521. </ref><ref>Golightly YM, Hannan MT, Dufour AB, Renner JB, Jordan JM. Factors Associated with Hallux Valgus in a Community-Based Cross-Sectional Study of Adults with and without Osteoarthritis. Arthritis care & research. 2015;67(6):791-798. </ref><ref>Barnish MS, Barnish J. High-heeled shoes and musculoskeletal injuries: a narrative systematic review. BMJ Open. 2016;6(1):e010053</ref><ref>Menz HB, Roddy E, Marshall M, et al. Epidemiology of Shoe Wearing Patterns Over Time in Older Women: Associations With Foot Pain and Hallux Valgus. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences. 2016;71(12):1682-1687. </ref>
* High [[Body Mass Index|Body Mass Index (BMI)]]
[[File:Hallux valgus anatomy.jpg|thumb|Anatomy of the Hallux Valgus]]


It is not always possible or necessary to take radiographs to determine the severity of hallux valgus. Therefore, they developed a scale, called the Manchester scale <ref name="Menz">Radiographic validation of the Manchester scale for the classification of hallux valgus deformity, Menz HB et al, Rheumatology 2005;44:1061–1066 (1B)</ref>.The Manchester scale consists of standardized photographs of four types of hallux valgus: none, mild, moderate and severe. Research has shown that this test is reliable in terms of both re-test and inter-tester reliability (kappa values of 0.77 and 0.86). In the study by Roddy et al (2007) <ref name="Roddy">Validation of a self-report instrument for assessment of hallux valgus. Roddy E et al. Osteoarthritis Cartilage 2007, 15:1008-1012. (2B)</ref>, they have developed a tool that exists of 5 photographs, instead of 4 photographs which is the case in the Manchester scale. Each photograph had a hallux valgus angle increased with 15 °. This tool had a good retest reliability (kappa = 0.82) and is also a good tool to use to determine hallux valgus severity <ref name="Roddy">Validation of a self-report instrument for assessment of hallux valgus. Roddy E et al. Osteoarthritis Cartilage 2007, 15:1008-1012. (2B)</ref>. So we can use both scales (the four-level classification or dichotomised scale) to determine the severity of hallux valgus <ref name="H">Validity of self-assessment of hallux valgus using the Manchester scale, Menz H et al, Musculoskeletal Disorders 2010, 11:215 (1A)</ref>.<br>Physical examination should be performed with the patient both seated and standing. During weight bearing, the deformity is generally accentuated. During examination, the presence of pes planus and contracture of the Achilles tendon should be evaluated. The height of the longitudinal arch and hallux, with its relation to the lesser toes, are also examined <ref name="T">Decision Making in the Treatment of Hallux Valgus, Joseph T, Mroczek K. Bulletin of the NYU Hospital for Joint Diseases 2007;65(1):19-23 19 (4)</ref>.<br>
== Clinical Presentation ==


== Outcome Measures  ==
=== Biomechanical Factors<ref name=":3" /> ===
Hallux valgus pathology is consistent with bone deviation and destabilisation of the muscle group around the joint. The following process may occur in stages or parallel:


add links to outcome measures here (see [[Outcome Measures|Outcome Measures Database]])
* Initial injury relates to the failure of the medial sesamoid and the medial collateral ligaments
* Medial deviation of the first metatarsal head
* Valgus deformity of the proximal phalanx while its base is fixed to the sesamoid, transverse ligament and adductor hallucis tendon
* The lateral arching of the extensor and flexor hallucis longus tendons increases valgus deformity
* The adductor hallucis tendon pulls the phalanx in pronation, causing dislocation of the phalanx base
* First metatarsophalangeal joint rotates medially with pronation and becomes unstable


== Management / Interventions<br> ==
<blockquote>The end result is lateral deviation and lateral rotation of the hallux with medial deviation and lateral rotation of the first metatarsal. </blockquote>{{#ev:youtube|L_orU3MgOVw|400}} <ref>Biomechanix Foot and Knee Clinic. Hallux Valgus. Available from: http://www.youtube.com/watch?v=L_orU3MgOVw [last accessed 08/01/17]</ref>


=== Non-operative treatment  ===
=== Signs and Symptoms ===


The first treatment option is non operative care:<br>  
* Joint inflammation
* Initial pain and tenderness of the bunion with footwear
* Alteration in the skin over the bunion: it becomes hard, warm and red
* Bony enlargement of the first metatarsal head<ref>Menz HB, Munteanu SE. Radiographic validation of the Manchester scale for the classification of hallux valgus deformity. Rheumatology (Oxford). 2005 Aug;44(8):1061-6.</ref>
* Progression in pain as the bunion size increases
* [[Gait Deviations|Gait deviations]] in the midstance (middle stage) and the propulsion phase (late stance).
** As the bodyweight moves forward on a foot on the ground, the patient will tend to keep their weight on the lateral border of the foot
** Lateral and posterior weight shift
** Late heel rise due to body weight shifted on the lateral border of the foot
** Reduced time in single-limb support <ref name=":4">Dimonte P, Light H. Pathomechanics, gait deviations, and treatment of the rheumatoid foot: a clinical report. Phys Ther. 1982 Aug;62(8):1148-56.</ref>
* Foot pronation deformity
* Weakness of hallux abductor muscles<ref name=":4" />
* Shortening of flexor hallucis brevis muscle


*Adjustment to footwear help in eliminating friction at the level of the medial eminence (bunion), e.g., patients should be provided of a shoe with a wider and deeper tip
== Pre-operative Management ==
*The condition of pes planus may be helped by an orthosis. A sever pes planus condition can lead to a recurrence of hallux valgus following surgery.
*Achilles tendon contracture may require stretching or even lengthening <ref name="T">Decision Making in the Treatment of Hallux Valgus, Joseph T, Mroczek K. Bulletin of the NYU Hospital for Joint Diseases 2007;65(1):19-23 19 (4)</ref>


This type of treatment can be applied in the early stage when the secondary contractures of the soft tissues and the alterations of the articular surfaces have not become permanent <ref name="Day">Hallux valgus. F. DAY, M.D., Canad. M. A. J. April 16, 1957, vol. 76 (5)</ref>.
* Patient education regarding recovery time


'''PHASE I - Pain Relief. Minimise Swelling &amp; Injury Protection<ref name="1">http://physioworks.com.au/injuries-conditions-1/foot-bunion</ref>'''
<blockquote>“I think it would be useful if you know of a patient that is thinking about having the surgery, discuss it with them, give them the stuff to read and make sure that they understand what they are letting themselves in for.” ''Helene Simpson'' <ref name=":6">Simpson H. Hallux Valgus. Plus Course 2020</ref><br></blockquote>


Pain is the main reason that you seek treatment for bunion. Analgesics may help.  
== Operative Treatment ==
Despite many surgical procedures for treating hallux valgus, no single method can correct all deformities.<ref name=":1" /> The surgeons decide about the type of procedure based on the results of their assessment which includes:


Inflammation it best eased via ice therapy and techniques or exercises that deload the inflammed structures. Anti-inflammatory medications may help.
* Close observation for an increased hallux valgus angle
* Increased intermetatarsal (IM) angle
* Pronation of the first toe
* Increased distal metatarsal articular angle (DMAA)
* Enlarged medial eminence
* Subluxation of the sesamoids


Your physiotherapist will use an array of treatment tools to reduce your pain and inflammation.
'''Goals:'''


These include: ice, electrotherapy, acupuncture, deloading taping techniques, soft tissue massage and orthotics to off-load the bunion.
# To maintain a flexible first MTP joint
# To  preserve the normal weight-bearing pattern of the forefoot


'''PHASE II - Restoring Normal ROM &amp; Posture<ref name="1">http://physioworks.com.au/injuries-conditions-1/foot-bunion</ref>'''  
'''Outcomes:'''


As your pain and inflammation settles, your physiotherapist will turn their attention to restoring your normal toe and foot joint range of motion and muscle length.  
* According to a study by Hernandez-Castillejo et al.,<ref>Hernández-Castillejo LE, Martínez Vizcaíno V, Garrido-Miguel M, Cavero-Redondo I, Pozuelo-Carrascosa DP, Álvarez-Bueno C. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8023907/pdf/IORT_91_1764193.pdf Effectiveness of hallux valgus surgery on patient quality of life: a systematic review and meta-analysis]. Acta Orthop. 2020 Aug;91(4):450-456.</ref> hallux valgus surgery decreased patient perception of pain and increased Quality of Life in the physical and social domains
* Goh et al.<ref>Goh GS, Tay AY, Thever Y, Koo K. Effect of age on clinical and radiological outcomes of hallux valgus surgery. Foot & Ankle International. 2021 Jun;42(6):798-804.</ref> concluded that age did not influence the perioperative, functional, or subjective outcomes following hallux valgus surgery, but older patients may be at higher risk of recurrence


Treatment may include joint mobilisation and alignment techniques, massage, muscle and joint stretches, taping, a bunion splint or orthotic.
== Post-operative Management ==
'''General Guidelines:'''


'''PHASE III - Restore Normal Muscle Control &amp; Strength<ref name="1">http://physioworks.com.au/injuries-conditions-1/foot-bunion</ref>'''
* At least six weeks of non-weight bearing
* Immobilisation in a modified shoe
* [[Oedema Assessment|Oedema]] management


a Foot Posture Correction Program to assist you to regain your normal foot posture.  
=== Physiotherapy ===
<blockquote>Look at the patient as a WHOLE: "fix the gait, check on the foot core, plantar push-off, shoe wear, make sure you address the pain, look at the whole kinetic chain and make sure you also match it to the shoes at the bottom." Helene Simpson <ref name=":6" /></blockquote>


<u>Strengthing exercise:</u>  
==== Fixing Gait ====
After hallux valgus correction, patients may adopt the habit of walking on the side of their foot to avoid loading the recently operated big toe. This needs to be addressed to ensure good balance and stability and to prevent other injuries in the long term.<ref>Schuh R, Hofstaetter SG, Adams SB Jr, Pichler F, Kristen KH, Trnka HJ. [https://academic.oup.com/ptj/article/89/9/934/2737642?login=false Rehabilitation after hallux valgus surgery: importance of physical therapy to restore weight bearing of the first ray during the stance phase.] Phys Ther. 2009 Sep;89(9):934-45.</ref>


'''Ankle Dorsiflexion with Band<ref name="2">http://www.everydayhealth.com/foot-health/8-foot-exercises-for-bunions.aspx</ref>'''  
'''Goal:'''


The ankle dorsiflexion exercise strengthens the ankles and lower leg muscles.Sit on the floor with your legs straight to begin. Place your hands on the floor at your sides and use your arms to hold your back straight. Place the center of the band on the top of your forefoot with your toes slightly pointed. Have a friend sit on the floor in front of you and hold the ends of the band at floor level. Next, pull your toes away from your friend and the ends of the band. You should get resistance from the band if your workout partner is holding it tight. Point your toes slightly to complete an ankle dorsiflexion.
# To restore gait as closely as possible back to normal


'''Towel curls.''' You can strengthen your toes by spreading out a small towel on the floor, curling your toes around it, and pulling it toward you. Repeat five times. Khan says that gripping objects with your toes like this can help keep your foot flexible.<ref>http://www.everydayhealth.com/foot-health/8-foot-exercises-for-bunions.aspx</ref>
'''Strategies:'''


'''PHASE IV - Restoring Full Function'''
* Look, film, address, correct. Repeat as necessary to ensure the patient's confidence in their gait
* Facilitate loading the first metatarsal
** Walk with a patient, one foot directly in front of the other
** Forefoot mobilisation strategies, including plantar fascia lengthening, Achilles tendon lengthening


During this stage of your rehabilitation is aimed at returning you to your desired activities. Everyone has different demands for their feet that will determine what specific treatment goals you need to achieve. For some it be simply to walk around the block. Others may wish to run a marathon or return to a labour-intensive activity.  
==== Check the Foot Core ====
Targeted muscles for strengthening are:<ref>Glasoe WM. [https://www.jospt.org/doi/epdf/10.2519/jospt.2016.6704 Treatment of progressive first metatarsophalangeal hallux valgus deformity: a biomechanically based muscle-strengthening approach.] Journal of orthopaedic & sports physical therapy. 2016 Jul;46(7):596-605.</ref>


'''PHASE V - Preventing a Recurrence'''
* the intrinsics: abductor hallucis, adductor hallucis, and the flexor hallucis brevis
* the extrinsics: tibialis posterior and fibularis longus


Bunions will deform further with no attention. Plus, the bunion pain associated does have a tendency to return. The main reason is biomechanical.
'''Goal:'''


In addition to your muscle control, your physiotherapist will assess your foot biomechanics and may recommend either a temporary off-the shelf orthotic or refer you to a podiatrist for custom made orthotics. You should avoid wearing high heel shoes and shoes with tight or angular toe boxes.
# To strengthen the foot core


=== <br>Operative treatment  ===
[[File:Metatarsal doming.gif|thumb|Doming exercise]]
'''Strategies:'''


If non-operative treatment fails surgery could be considered <ref name="T">Decision Making in the Treatment of Hallux Valgus, Joseph T, Mroczek K. Bulletin of the NYU Hospital for Joint Diseases 2007;65(1):19-23 19 (4)</ref>. <br>There are several surgical procedures that we can apply depending on the severity of the injury:<br>
* Ask the patient to create a dome with their foot from a seated position by pressing the toes down and shortening the foot with isometric holds.
* Ask the patient to press the first toe down and lift the other four toes, then switch around, push the four toes down and lift the big toe.
* Add some resistance using an exercise band (put the band underneath and press down on it while pulling the band up with both hands). This exercise is called 'foot core plus'.
* Ask the patient to do the same exercise while maintaining the foot dome. A further step would be to get the toes down, the first ray down, and then they can start lifting the heel all the time, maintaining a good foot posture.
* Progress into standing, standing on one foot, walking, stepping up, stepping down.


*For mild cases: distal soft tissue procedure
{{#ev:youtube|v=pmqBTq3HIJw|300}}<ref>Align Therapy. Strengthening the Foot Core! Available from: https://www.youtube.com/watch?v=pmqBTq3HIJw [last accessed 24/02/2023]</ref>
*Hallux angle &lt; 30 °: Chevron osteotomy
*Hallux &lt; 25 °: Akin procedure
*Age &gt; 65 year: Keller arthoplasty
*Arhrodesis (the most common)


=== Post-operative physiotherapy  ===
==== Planter Push-Off ====
'''Goal:'''


As a result of the gait disturbances (see non-operative treatment), objectives for physical therapy could be:<br>
# To improve the functional push-off


*Adjusted footwear with wider and deeper tip
'''Strategies:'''
*Increase extension of MTP joint
*Relieve weight-bearing stresses (orthosis)&nbsp;<ref name="Dimonte">Pathomechanics, Gait Deviations, and Treatment of the Rheumatoid Foot: a clinical report. Dimonte P et al. Physical therapy 1982: Vol 62(8): 1148 – 1156 (5)</ref>
*<u>Sesamoid Mobilization</u>:*The physical therapist performs grade III joint mobilizations on the medial and lateral sesamoid of the affected first MPJ. He / she places 1 thumb on the proximal aspect of the sesamoid en applies a force from proximal to distal that causes the sesamoid to reach the end range of motion = distal glides. These are performed with large-amplitude rhythmic oscillations. No greater than 20° of movement of the MPJ is allowed during the technique.<sup><ref name="J">The effects of sesamoid mobilization, flexor hallucis strengthening, and gait training on reducing pain and restoring function in individuals with hallux limitus: a clinical trial. Shamus J, Shamus E, Gugel RN, et al. J Orthop Sports Phys Ther. 2004;80:769–780. 2B</ref> </sup>
*Strengthening of the M. Peroneus Longus&nbsp;<ref name="Schuh">Rehabilitation after hallux valgus surgery: importance of physical therapy to restore weight bearing of the first ray during the stance phase. Schuh R, Hofstaetter SG, Adams SB Jr, et al. Phys Ther. 2009;89:934–945. (2C)</ref>
*Gait Training <ref name="J">The effects of sesamoid mobilization, flexor hallucis strengthening, and gait training on reducing pain and restoring function in individuals with hallux limitus: a clinical trial. Shamus J, Shamus E, Gugel RN, et al. J Orthop Sports Phys Ther. 2004;80:769–780. 2B</ref>. During gait training, we can train the different phases:


#Stance phase: could be trained by performing a heel-strike in its physiological position at the lateral aspect of the heel.  
* Exercises
#Stance phase could be followed by weight bearing of the first metatarsal during midstance and terminal stance, with training of active push-off by the hallux flexors, the flexor digitorum longus and brevis muscles, and the lumbrical muscles&nbsp;<ref name="Schuh">Rehabilitation after hallux valgus surgery: importance of physical therapy to restore weight bearing of the first ray during the stance phase. Schuh R, Hofstaetter SG, Adams SB Jr, et al. Phys Ther. 2009;89:934–945. (2C)</ref><br>During gait training, verbal cues could be provided .
** Standing over the edge of a box or a step with an exercise band - ask the patient to push through the band.
** Walking with an exercise band underneath the toes and pulling it up - the patient pushes their toes down into the band as they walk, pressing down to push their foot off.
** Soft tissue work is also essential, such as releasing the toe extensors. These muscles get stiff and lose the ability to slide smoothly through the extensor retinaculum in line with the syndesmosis.
** Heel raises to strengthen the plantar flexors, and if they are tight, it is helpful to lengthen, release and stretch them by asking the patient to stand over the edge of a step and to drop their heels down. You can put cotton wool between the toes to stretch them.


These objectives should ensure that pain is reduced and function is restored. <ref name="J">The effects of sesamoid mobilization, flexor hallucis strengthening, and gait training on reducing pain and restoring function in individuals with hallux limitus: a clinical trial. Shamus J, Shamus E, Gugel RN, et al. J Orthop Sports Phys Ther. 2004;80:769–780. 2B</ref><br>Physiotherapists should contain an expanded program, including whirlpool, [http://www.physio-pedia.com/index.php?title=Ultrasound_therapy ultrasound], ice, [http://www.physio-pedia.com/index.php/Transcutaneous_Electrical_Nerve_Stimulation_(TENS) electrical stimulation,] MTJ mobilizations and exercises. This is more effective than a physical therapy alone. The combination will result in a increase in ROM MTP joint, strength and function and also a decrease in pain <ref name="J">The effects of sesamoid mobilization, flexor hallucis strengthening, and gait training on reducing pain and restoring function in individuals with hallux limitus: a clinical trial. Shamus J, Shamus E, Gugel RN, et al. J Orthop Sports Phys Ther. 2004;80:769–780. 2B</ref>.&nbsp;
* Second toe mobility and flexibility
{{#ev:youtube|v=h2kaEOd3GcI|300}}<ref>Northwest Foot & Ankle. Toe Extensor Stretch with Dr Ray McClanahan. Available from: https://www.youtube.com/watch?v=h2kaEOd3GcI [last accessed 24/02/2023]</ref>


<br>Post -op Rehabiliatation Considerations <br>
==== Address the Pain ====
'''Goal:'''


*For all surgical procedures, the patient is allowed to ambulate in a post-operative shoe immedidately after surgery.
# To reduce pain and restore normal toe and foot joint range of motion and muscle length
*Patients come out of surgery needing to wear a post-op shoe and compressive dressings for 8 weeks
*Long term follow up has shown equally positive outcomes after Chevron osteotomy for both patients both younger and older than 50.


== Differential Diagnosis<br>  ==
'''Strategies:'''


add text here relating to the differential diagnosis of this condition<br>  
* [[Desensitization|Desensitising]] techniques
* [[Transcutaneous Electrical Nerve Stimulation (TENS)|Transcutaneous electrical nerve stimulation]] (TENS)
* Medication review with the surgeon and the patient
* Therapists need a good understanding of surgical techniques to avoid using techniques that could disturb bone healing, such as mobilising a scarf osteotomy
* Sesamoid mobilisation: grade III joint mobilisations on the medial and lateral sesamoid of the affected first MPJ.
** One thumb is placed on the proximal aspect of the sesamoid and is used to apply a force from proximal to distal that causes the sesamoid to reach the end range of motion (distal glides). These are performed with large-amplitude rhythmic oscillations. No greater than 20° of movement of the MPJ should be allowed during the technique.<ref>Shamus J, Shamus E, Gugel RN, Brucker BS, Skaruppa C. [https://www.jospt.org/doi/epdf/10.2519/jospt.2004.34.7.368 The effect of sesamoid mobilization, flexor hallucis strengthening, and gait training on reducing pain and restoring function in individuals with hallux limitus: a clinical trial]. J Orthop Sports Phys Ther. 2004 Jul;34(7):368-76.</ref> '''NOTE''': '''''Always check operative protocol before choosing intervention. This technique is not suitable if a surgical procedure with fusion has been done.'''''


== Key Evidence  ==
==== Match the Shoe ====
'''Goal:'''


Connor et al showed a statistically significant limitation in ROM ffor the physical therapy group alone compared to the group that also had CPM.&nbsp; No differences in groups likelihood of developing complications.&nbsp; CPM group discontinued oral analgesics more quickly as well as returned to wearing conventional shoewear in a significantly shorter time period.<br>
# To provide needed support for sensitive and swollen foot


Torkki et al compared surgery, orthoses, and watchful waiting.&nbsp; They found surgical interventions was superior to those obtained with orthosis or watchful waiting., although the use of orthosis did provide some short-term relief.
'''Strategies:'''


== Resources <br>  ==
* Ask the patient what shoes they see themselves wearing
* Assess the shoe the patient is currently wearing
* The worn shoe may no longer be suitable - its shape may have changed to accommodate the pre-operative foot posture
* A wider toe box and sound, solid heel structure can be useful
* Do not wear flat leather sole shoes
* Wearing silk socks or silky stockings can prevent friction and protect the scar


Ferrari J, Higgins JPT, Prior TD.&nbsp; Interventions for treating hallux valgus(abductovalgus) and bunions(Review).&nbsp; Cochrane Database of Systematic Reviews 2004, issue 1. Art. No: CD 000964. DOI: 10.1002/14651858.CD000964.pub.2.


Torkki M, malvivaara A, Seitsalo S, Hoikka V, laippala P, Paavolainen P.&nbsp; Surgery v. orthosis vs. watchful waiting for hallux valgus.&nbsp; JAMA. 2001;285(19);2474-2480.
== References   ==
 
== References<br> ==


<references />  
<references />  


 
[[Category:Foot]]
 
[[Category:Musculoskeletal/Orthopaedics|Orthopaedics]]
[[Category:Foot]]
[[Category:Foot - Conditions]] 
[[Category:Conditions]]
[[Category:Course Pages]]

Latest revision as of 11:10, 11 August 2023

Original Editors - Bradley Svoboda

Top Contributors - Laura Ritchie, Van Horebeek Erika, Mariam Hashem, Ewa Jaraczewska, Lucinda hampton, Rachael Lowe, Jess Bell, Bradley Svoboda, Andeela Hafeez, Jolien Rottie, Admin, Kim Jackson, Morgane Michiels, 127.0.0.1, Kristin Zumo, Khloud Shreif, Wanda van Niekerk, Evan Thomas, Tarina van der Stockt, WikiSysop and Tinne Tielemans

Introduction[edit | edit source]

Hallux Valgus is considered one of the most common foot deformities,[1] and is described as “lateral deviation of the hallux and its consequent distancing from the median axis of the body”.[2] Treatment for hallux valgus ranges from conservative to surgical management.[3] There are about 131 different surgical techniques. However, no method is available thus far that sufficiently corrects all hallux valgus deformities.[4] This article will discuss pre and post-operative hallux valgus management principles.

Clinically Relevant Anatomy[edit | edit source]

Plantar surface of the foot

Bones[edit | edit source]

The first metatarsal, proximal phalanx, and distal phalanx form the hallux or first toe. In addition, two sesamoid bones (medial and lateral) contribute to the first metatarsophalangeal joint. Their dorsal surface articulates with the plantar aspect of the first metatarsal head and is contained within the flexor hallucis brevis muscle tendon. The first metatarsal head is responsible for good static and dynamic weight bearing. The sesamoid bones protect the tendons of the flexor hallucis brevis and help generate more force by extending its levers.

Joints[edit | edit source]

The hallux metatarsophalangeal joint (MPJ) is a synovial joint. Three joints are part of this system:

Ligaments of the foot plantar aspect

Ligaments[5][edit | edit source]

  • The intersesamoid ligament (ISL) links two sesamoids and indirectly connects the flexor hallucis brevis (FHB), abductor hallucis, and adductor hallucis tendons.
  • Sesamoid phalangeal ligaments (SPLs) are the thickest first MTPJ ligaments. They protect the sesamoids from subluxation when high tensile forces act upon them while walking or running.
  • Metatarsosesamoid ligaments (MTSLs), or suspensory ligaments, are part of the plantar plate complex. They assist with stabilising the sesamoids.
  • Medial and lateral metatarsophalangeal ligaments (collateral ligaments) attach at the peripheral sesamoids. They are not part of the plantar plate complex but play an essential role as static stabilisers when applying valgus or varus forces.
Intrinsic foot muscles

Muscles[edit | edit source]

The following muscles act on the first MTP joint: tibialis anterior, extensor hallucis longus, peroneus longus, flexor hallucis longus, extensor hallucis brevis, abductor hallucis, flexor hallucis brevis, adductor hallucis, dorsal interossei, and aponeurosis plantaris.

The muscle responsible for the motion control at the first MPJ is extensor hallucis brevis, abductor hallucis, flexor hallucis brevis, and adductor hallucis. The abductor hallucis contributes to the abduction and flexion of the first MPJ. In addition to the foot's intrinsic muscles, the flexor hallucis longus contributes to the flexion of the distal phalanx of the hallux and the extensor hallucis longus to its extension.[6]

Motion[edit | edit source]

The primary motion of the metatarsophalangeal joint is flexion and extension with minimal abduction and adduction. The collateral ligaments limit mediolateral movement in the joint.[7]

Hallux Valgus Angle

Hallux Valgus Angle[edit | edit source]

  • The angle created between the lines that longitudinally bisect the proximal phalanx and the first metatarsal.
  • Less than 15° is considered normal. Angles of 20° and greater are considered abnormal. An angle of 45-50° is considered severe.

Epidemiology and Aetiology[edit | edit source]

Hallux Valgus deformity is a complex condition. It has a familial tendency that depends on autosomal dominant inheritance's transmission with incomplete penetrance.[2] Other aetiologic factors include the following:

  • Gender (more common in women than men (ratio of 15:1)[8]
  • Footwear (tight, pointed shoes)
    • Menz et al. found that wearing constrictive footwear "between the ages of 20 and 39 years may be a critical period for the development of hallux valgus in later life"[9]
  • Congenital deformity
  • Anatomical and biomechanical factors, such as
    • long first metatarsal
    • rounded joint
    • metatarsus primus varus
  • Chronic Achilles tendon tightness
  • Severe flatfoot
  • Hypermobility of the first metatarsocuneiform joint
  • Systemic disease
  • Abnormal muscle insertions
  • Hip and knee osteoarthritis[10][11][12][13]
  • High Body Mass Index (BMI)
Anatomy of the Hallux Valgus

Clinical Presentation[edit | edit source]

Biomechanical Factors[2][edit | edit source]

Hallux valgus pathology is consistent with bone deviation and destabilisation of the muscle group around the joint. The following process may occur in stages or parallel:

  • Initial injury relates to the failure of the medial sesamoid and the medial collateral ligaments
  • Medial deviation of the first metatarsal head
  • Valgus deformity of the proximal phalanx while its base is fixed to the sesamoid, transverse ligament and adductor hallucis tendon
  • The lateral arching of the extensor and flexor hallucis longus tendons increases valgus deformity
  • The adductor hallucis tendon pulls the phalanx in pronation, causing dislocation of the phalanx base
  • First metatarsophalangeal joint rotates medially with pronation and becomes unstable

The end result is lateral deviation and lateral rotation of the hallux with medial deviation and lateral rotation of the first metatarsal.

[14]

Signs and Symptoms[edit | edit source]

  • Joint inflammation
  • Initial pain and tenderness of the bunion with footwear
  • Alteration in the skin over the bunion: it becomes hard, warm and red
  • Bony enlargement of the first metatarsal head[15]
  • Progression in pain as the bunion size increases
  • Gait deviations in the midstance (middle stage) and the propulsion phase (late stance).
    • As the bodyweight moves forward on a foot on the ground, the patient will tend to keep their weight on the lateral border of the foot
    • Lateral and posterior weight shift
    • Late heel rise due to body weight shifted on the lateral border of the foot
    • Reduced time in single-limb support [16]
  • Foot pronation deformity
  • Weakness of hallux abductor muscles[16]
  • Shortening of flexor hallucis brevis muscle

Pre-operative Management[edit | edit source]

  • Patient education regarding recovery time

“I think it would be useful if you know of a patient that is thinking about having the surgery, discuss it with them, give them the stuff to read and make sure that they understand what they are letting themselves in for.” Helene Simpson [17]

Operative Treatment[edit | edit source]

Despite many surgical procedures for treating hallux valgus, no single method can correct all deformities.[4] The surgeons decide about the type of procedure based on the results of their assessment which includes:

  • Close observation for an increased hallux valgus angle
  • Increased intermetatarsal (IM) angle
  • Pronation of the first toe
  • Increased distal metatarsal articular angle (DMAA)
  • Enlarged medial eminence
  • Subluxation of the sesamoids

Goals:

  1. To maintain a flexible first MTP joint
  2. To  preserve the normal weight-bearing pattern of the forefoot

Outcomes:

  • According to a study by Hernandez-Castillejo et al.,[18] hallux valgus surgery decreased patient perception of pain and increased Quality of Life in the physical and social domains
  • Goh et al.[19] concluded that age did not influence the perioperative, functional, or subjective outcomes following hallux valgus surgery, but older patients may be at higher risk of recurrence

Post-operative Management[edit | edit source]

General Guidelines:

  • At least six weeks of non-weight bearing
  • Immobilisation in a modified shoe
  • Oedema management

Physiotherapy[edit | edit source]

Look at the patient as a WHOLE: "fix the gait, check on the foot core, plantar push-off, shoe wear, make sure you address the pain, look at the whole kinetic chain and make sure you also match it to the shoes at the bottom." Helene Simpson [17]

Fixing Gait[edit | edit source]

After hallux valgus correction, patients may adopt the habit of walking on the side of their foot to avoid loading the recently operated big toe. This needs to be addressed to ensure good balance and stability and to prevent other injuries in the long term.[20]

Goal:

  1. To restore gait as closely as possible back to normal

Strategies:

  • Look, film, address, correct. Repeat as necessary to ensure the patient's confidence in their gait
  • Facilitate loading the first metatarsal
    • Walk with a patient, one foot directly in front of the other
    • Forefoot mobilisation strategies, including plantar fascia lengthening, Achilles tendon lengthening

Check the Foot Core[edit | edit source]

Targeted muscles for strengthening are:[21]

  • the intrinsics: abductor hallucis, adductor hallucis, and the flexor hallucis brevis
  • the extrinsics: tibialis posterior and fibularis longus

Goal:

  1. To strengthen the foot core
Doming exercise

Strategies:

  • Ask the patient to create a dome with their foot from a seated position by pressing the toes down and shortening the foot with isometric holds.
  • Ask the patient to press the first toe down and lift the other four toes, then switch around, push the four toes down and lift the big toe.
  • Add some resistance using an exercise band (put the band underneath and press down on it while pulling the band up with both hands). This exercise is called 'foot core plus'.
  • Ask the patient to do the same exercise while maintaining the foot dome. A further step would be to get the toes down, the first ray down, and then they can start lifting the heel all the time, maintaining a good foot posture.
  • Progress into standing, standing on one foot, walking, stepping up, stepping down.

[22]

Planter Push-Off[edit | edit source]

Goal:

  1. To improve the functional push-off

Strategies:

  • Exercises
    • Standing over the edge of a box or a step with an exercise band - ask the patient to push through the band.
    • Walking with an exercise band underneath the toes and pulling it up - the patient pushes their toes down into the band as they walk, pressing down to push their foot off.
    • Soft tissue work is also essential, such as releasing the toe extensors. These muscles get stiff and lose the ability to slide smoothly through the extensor retinaculum in line with the syndesmosis.
    • Heel raises to strengthen the plantar flexors, and if they are tight, it is helpful to lengthen, release and stretch them by asking the patient to stand over the edge of a step and to drop their heels down. You can put cotton wool between the toes to stretch them.
  • Second toe mobility and flexibility

[23]

Address the Pain[edit | edit source]

Goal:

  1. To reduce pain and restore normal toe and foot joint range of motion and muscle length

Strategies:

  • Desensitising techniques
  • Transcutaneous electrical nerve stimulation (TENS)
  • Medication review with the surgeon and the patient
  • Therapists need a good understanding of surgical techniques to avoid using techniques that could disturb bone healing, such as mobilising a scarf osteotomy
  • Sesamoid mobilisation: grade III joint mobilisations on the medial and lateral sesamoid of the affected first MPJ.
    • One thumb is placed on the proximal aspect of the sesamoid and is used to apply a force from proximal to distal that causes the sesamoid to reach the end range of motion (distal glides). These are performed with large-amplitude rhythmic oscillations. No greater than 20° of movement of the MPJ should be allowed during the technique.[24] NOTE: Always check operative protocol before choosing intervention. This technique is not suitable if a surgical procedure with fusion has been done.

Match the Shoe[edit | edit source]

Goal:

  1. To provide needed support for sensitive and swollen foot

Strategies:

  • Ask the patient what shoes they see themselves wearing
  • Assess the shoe the patient is currently wearing
  • The worn shoe may no longer be suitable - its shape may have changed to accommodate the pre-operative foot posture
  • A wider toe box and sound, solid heel structure can be useful
  • Do not wear flat leather sole shoes
  • Wearing silk socks or silky stockings can prevent friction and protect the scar


References[edit | edit source]

  1. ↑ Mortka K, Lisiński P. Hallux valgus-a case for a physiotherapist or only for a surgeon? Literature review. J Phys Ther Sci. 2015 Oct;27(10):3303-7
  2. ↑ 2.0 2.1 2.2 Cavalheiro CS, Arcuri MH, Guil VR, Gali JC. HALLUX VALGUS ANATOMICAL ALTERATIONS AND ITS CORRELATION WITH THE RADIOGRAPHIC FINDINGS. Acta Ortop Bras. 2020 Jan-Feb;28(1):12-15.
  3. ↑ Wojcik B, Fabiś M, Zadroźna K, Małek A, Iwaniszyn-Zapołoch K, Remjasz K,Aleksandrowicz J, Siedlecki W. Hallux valgus treatment and new methods. Journal of Education, Health and Sport [online]. 2022;12( 9): 614–620. [last access 18.02.2023]
  4. ↑ 4.0 4.1 Joseph TN, Mroczek KJ. Decision making in the treatment of hallux valgus. Bull NYU Hosp Jt Dis. 2007;65(1):19-23.
  5. ↑ Hallinan JTPD, Statum SM, Huang BK, Bezerra HG, Garcia DAL, Bydder GM, Chung CB. High-Resolution MRI of the First Metatarsophalangeal Joint: Gross Anatomy and Injury Characterization. Radiographics. 2020 Jul-Aug;40(4):1107-1124.
  6. ↑ J.S. Kawalec JS. 12 - Mechanical testing of foot and ankle implants. Editor(s): Friis E. Mechanical Testing of Orthopaedic Implants. Woodhead Publishing 2017: pages 231-253
  7. ↑ Mojica MN, John S. Early JS.19 - Foot Biomechanics. Editor(s): Webster JB, Murphy DP. Atlas of Orthoses and Assistive Devices (Fifth Edition),Elsevier, 2019: 216-228.e1.
  8. ↑ Kakwani M, Kakwani R. Current concepts review of hallux valgus. Journal of Arthroscopy and Joint Surgery. 2021;8(3):222-30.
  9. ↑ Menz HB, Roddy E, Marshall M, Thomas MJ, Rathod T, Peat GM, Croft PR. Epidemiology of shoe wearing patterns over time in older women: associations with foot pain and hallux valgus. J Gerontol A Biol Sci Med Sci. 2016 Dec;71(12):1682-7.
  10. ↑ Hannan MT, Menz HB, Jordan JM, Cupples LA, Cheng C-H, Hsu Y-H. Hallux Valgus and Lesser Toe Deformities are Highly Heritable in Adult Men and Women: the Framingham Foot Study. Arthritis care & research. 2013;65(9):1515-1521.
  11. ↑ Golightly YM, Hannan MT, Dufour AB, Renner JB, Jordan JM. Factors Associated with Hallux Valgus in a Community-Based Cross-Sectional Study of Adults with and without Osteoarthritis. Arthritis care & research. 2015;67(6):791-798.
  12. ↑ Barnish MS, Barnish J. High-heeled shoes and musculoskeletal injuries: a narrative systematic review. BMJ Open. 2016;6(1):e010053
  13. ↑ Menz HB, Roddy E, Marshall M, et al. Epidemiology of Shoe Wearing Patterns Over Time in Older Women: Associations With Foot Pain and Hallux Valgus. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences. 2016;71(12):1682-1687.
  14. ↑ Biomechanix Foot and Knee Clinic. Hallux Valgus. Available from: http://www.youtube.com/watch?v=L_orU3MgOVw [last accessed 08/01/17]
  15. ↑ Menz HB, Munteanu SE. Radiographic validation of the Manchester scale for the classification of hallux valgus deformity. Rheumatology (Oxford). 2005 Aug;44(8):1061-6.
  16. ↑ 16.0 16.1 Dimonte P, Light H. Pathomechanics, gait deviations, and treatment of the rheumatoid foot: a clinical report. Phys Ther. 1982 Aug;62(8):1148-56.
  17. ↑ 17.0 17.1 Simpson H. Hallux Valgus. Plus Course 2020
  18. ↑ Hernández-Castillejo LE, Martínez Vizcaíno V, Garrido-Miguel M, Cavero-Redondo I, Pozuelo-Carrascosa DP, Álvarez-Bueno C. Effectiveness of hallux valgus surgery on patient quality of life: a systematic review and meta-analysis. Acta Orthop. 2020 Aug;91(4):450-456.
  19. ↑ Goh GS, Tay AY, Thever Y, Koo K. Effect of age on clinical and radiological outcomes of hallux valgus surgery. Foot & Ankle International. 2021 Jun;42(6):798-804.
  20. ↑ Schuh R, Hofstaetter SG, Adams SB Jr, Pichler F, Kristen KH, Trnka HJ. Rehabilitation after hallux valgus surgery: importance of physical therapy to restore weight bearing of the first ray during the stance phase. Phys Ther. 2009 Sep;89(9):934-45.
  21. ↑ Glasoe WM. Treatment of progressive first metatarsophalangeal hallux valgus deformity: a biomechanically based muscle-strengthening approach. Journal of orthopaedic & sports physical therapy. 2016 Jul;46(7):596-605.
  22. ↑ Align Therapy. Strengthening the Foot Core! Available from: https://www.youtube.com/watch?v=pmqBTq3HIJw [last accessed 24/02/2023]
  23. ↑ Northwest Foot & Ankle. Toe Extensor Stretch with Dr Ray McClanahan. Available from: https://www.youtube.com/watch?v=h2kaEOd3GcI [last accessed 24/02/2023]
  24. ↑ Shamus J, Shamus E, Gugel RN, Brucker BS, Skaruppa C. The effect of sesamoid mobilization, flexor hallucis strengthening, and gait training on reducing pain and restoring function in individuals with hallux limitus: a clinical trial. J Orthop Sports Phys Ther. 2004 Jul;34(7):368-76.
Retrieved from "https://www.physio-pedia.com/index.php?title=Hallux_Valgus&oldid=339967"