Hallux Valgus: Difference between revisions

m (Removed protection from "Hallux Valgus")
No edit summary
 
(25 intermediate revisions by 5 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  ==
== Introduction ==
[[File:Bunion (cropped).png|right|frameless]]
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 the most common foot deformity<ref name=":1">Mortka K, Lisiński P. Hallux valgus—a case for a physiotherapist or only for a surgeon? Literature review. Journal of physical therapy science. 2015;27(10):3303-7.</ref>.
* It is a progressive foot deformity in which the first [[Foot Anatomy|metatarsophalangeal]] (MTP) joint is affected and is often accompanied by significant functional disability and [[Foot Pain|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><ref name="Nix" /> and reduced quality of life<ref name=":3">González-Martín C, Alonso-Tajes F, Pérez-García S, Seoane-Pillado MT, Pértega-Díaz S, Couceiro-Sánchez E et al. Hallux valgus in a random population in Spain and its impact on quality of life and functionality. Rheumatol Int. 2017;37(11):1899-1907.</ref><ref name=":3" />  
* This joint is gradually subluxed (lateral deviation of the MTP joint) resulting in abduction of the first metatarsal while the phalanges adduct<ref name="Menz" /><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 the development of soft tissue and bony prominence on the medial side of what is called a bunion <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)<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" />
* There is a high prevalence of hallux valgus in the overall population (23% of adults aged 18-65 years and 35.7% of adults over 65 years of age)
* There is a higher prevalence in women (females 30% - males 13%) and the elderly (35.7%)<ref>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 (1a).</ref><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><span style="font-size: 13.28px;"> </span>[[Image:1757-1146-3-21-2.jpg|1x2px]]
* It is more common in individuals with flat feet or hammer toes<ref name=":3" /><br>
{{#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>


== Clinically Relevant Anatomy   ==
== Clinically Relevant Anatomy ==
[[File:Foot inferior.png|thumb|Plantar surface of the foot]]


[[Image:Hallux valgus anatomy.jpg|right|500x500px]]  
=== 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 Hallux or first toe is the medio-distal part of the foot. 
=== Joints ===
* Formed by the first metatarsal (articulates with two sesamoid bones), the first proximal phalanx and the first distal phalanx. 
The hallux metatarsophalangeal joint (MPJ) is a synovial joint. Three joints are part of this system:
* Formed by three bones instead of four, unlike the other toes who have an extra bone called the intermediate phalanx.
The Hallux (first toe) has three synovial joints. 
# Tarsometatarsae joint - situated between the medial cuneïforme bone and the first metatarsal, it does not allow a lot of movement.
# Metatarsophalangeal joint - connects the first metatarsal and the first proximal phalanx. The joint allows flexion and extension of the first toe and a small ab- and adduction towards the centre of the second toe. It is also reinforced by ligaments (lig. metatarsophalangae collateralia and lig. Metatarsophalangae plantaria). 
# Interphalangae joint - connection between the two phalanges of the first toe. This joint only allows flexion and extension and it is also reinforced by ligaments (lig. Interphalangae collateralia and lig. Interphalangae plantaris).
Two sesamoid bones articulate with the first metatarsal bone. These sesamoid bones: 
* Protect the tendons of [[Flexor Hallucis Brevis]] FHB (embedded in the tendon of the FHB muscle) 
* Main function helping FHB generate more force by extending its levers.
Muscles acting on joint:  


M. [[Tibialis Anterior|tibialis anterior]], M. [[Extensor Hallucis Longus|extensor hallucis longus]], M. [[Peroneus longus and brevis tests|peroneus longus]], M. [[flexor hallucis longus]], M.[[extensor Hallucis Brevis]], M. abductor hallucis, M. flexor hallucis brevis, M. adductor hallucis, M. interossei dorsales I, [[Plantar Fasciitis|aponeurosis plantaris]]. <ref>SCHÜNKE et al, Prometheus lernatlas der anatomie - allgemeine anatomie und bewegungssystem (tweede druk), Georg Thieme Verlag, Stuttgart, 2005, 600p</ref><ref>Internet, Bunion, (http://emedicine.medscape.com/article/1235796-overview#a11), 2016-11-11.</ref>
* [[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]]


Hallux Valgus Angle
=== 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>''' ===
* 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.<br>


== Epidemiology & Etiology  ==
* 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]]


Etiology is not well established - certain factors have been considered to play a role in the development of hallux valgus;
=== 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]].


*Gender (10x more frequent in women)
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>
*Footwear (tight pointed shoes) Wearing tight shoes and/or heeled shoes between 20 and 39 years of age can be crucial in the development of hallux valgus in later years.
*Congenital deformity or predisposition
*Chronic [[Achilles Tendinopathy|achilles]] tightness
*[[Pes Planus|Severe flatfoot]]
*Hypermobility of the first metatarsocunieform joint
*Systemic disease
*Possible that abnormal muscle insertions are partly responsible for hallux valgus
*Hallux valgus is also associated with hip and knee OA and is inversely associated with a higher BMI. <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 &amp; research. 2013;65(9):1515-1521. doi:10.1002/acr.22040. (Levels of evidence: 2B)</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 &amp; research. 2015;67(6):791-798. doi:10.1002/acr.22517. (Levels of evidence: 2A)</ref><ref>Barnish MS, Barnish J. High-heeled shoes and musculoskeletal injuries: a narrative systematic review. BMJ Open. 2016;6(1):e010053. doi:10.1136/bmjopen-2015-010053.</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. doi:10.1093/gerona/glw004.(Levels of evidence: 3)</ref><ref>MOL, W. et STRIKWERDA, R., Compendium orthopedie, De tijdstroom, Lochum, 1977, 343p. (p.232-234).</ref>
== Clinical Presentation  ==
[[File:Hallux valgus angle 2.jpg|right|frameless]]In this foot deformity:
* Distal end of the first metatarsal drifts medially and the proximal phalanx deviates laterally.
* First MTP becomes subluxed, leading to a lateral deviation of the hallux and medial displacement of the distal end of the first metatarsal
* Bony enlargement of the first metatarsal head <ref name="Menz" />.&nbsp;
Mechanism behind this hallux valgus formation
* Starts with the stretching of the abductor hallucis muscle (for example as a result of wearing tight shoes).
* Base of the first proximal phalanx (PP) starts to lateralise and abducts.
* During gait, the forefoot is turned into pronation, which stretches the medial collateral ligament and the capsular structures of the first MTP joint.
* First MTP joint consists of multiple bones, ligaments, sesamoid bones and nearby muscles,  all influencing other structures as they move or stretch.
* Once a threshold degree of valgus of the first PP is reached, the first metatarsal bone starts his way into a varus position.
* Hallux is pushed into a valgus position.
* Capsule gets weaker and the abductor hallucis tendon turns into a flexor of the hallux.
* As the condition progresses multiple muscles tend to worsen the situation as their axis of pull is lateralized.  
As a bunion appears, friction is raised when shoes are worn.  
* There may be irritation of the MCL ligament of the first MTP joint, which leads to inflammation and calcification of the joint.  
* This worsens the pain and bunion size.  
* In an early stage, this leads to tenderness of the bunion due to footwear.
* The skin over the bunion is hard, warm and red. Later on, the patient may have other complaints due to osteoarthritis.  
* The bunion keeps moving medially and the pain gets worse. <ref name="Glasoe" /> <ref name="Dimonte" />
[[File:Hallux Valgus.png|right|frameless|443x443px]]
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:''' 
=== 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 bodyweight 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
*The 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 <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:'''
* 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 <ref name="Dimonte" />
*[[Pain Behaviours|Pain]] (primary symptom) <ref name="T" />


== 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>
[[Image:Manchester-Scale.png|400px|right|frameless]][[X-Rays|Radiographs]] - used to determine the Hallux Valgus Angle (The angle created between the lines that longitudinally bisect the proximal phalanx and the first metatarsal)  
* Footwear (tight, pointed shoes)
* Angle is greater than 15°, hallux valgus is diagnosed<ref name=":1" />.  
** 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>
* 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" />
It is not always possible or necessary to take radiographs to determine the severity of hallux valgus. Therefore, the Manchester scale was developed <ref name="Menz" />.
* The Manchester scale consists of standardized photographs of four types of hallux valgus: none, mild, moderate and severe. Research has shown that this scale is reliable in terms of both re-test and inter-tester reliability (kappa values of 0.77 and 0.86). &nbsp;
* In the study by Roddy et al (2007) <ref name="Roddy" />, the authors developed a tool that consists of five photographs instead of four. 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>. Both scales (the four-level classification or dichotomised scale) can be used to determine the severity of hallux valgus<ref name="H" />.
Physical examination should be performed with the patient both seated and standing. Take note of: 
* Deformity during weight bearing (generally accentuated).
* Presence of pes planus and/or contracture of the Achilles tendon 
* Height of the longitudinal arch and hallux, with its relation to the lesser toes <ref name="T" />.


== Differential Diagnosis ==
* Congenital deformity
Hallux valgus can be confused with other diseases or injuries during diagnosis. In the early stages, the redness and pain can be confused with an inflammation, infection or gout of the first MTP joint. 
* Anatomical and biomechanical factors, such as
* [[Gout|Gout]] Pain suddenly appears while onset is gradual with hallux valgus. As well, semi uric acid level can be tested to differentiate between the two (since it is increased in patients with gout).
** long first metatarsal
* [[Hallux Rigidus]] can be confused with hallux valgus 
** rounded joint  
* [[Septic (Infectious) Arthritis|Septic arthritis]] i(red and swollen).
** metatarsus primus varus
* [[Turf toe|Turf toe]] can be confused with hallux valgus. <ref>SOBEL, E., Hallux valgus, assessment and conservative management and the role of faulty footwear, October 2001, (http://podiatrym.com/cme/oct01.pdf).</ref><ref>Internet, Gout, 2016-12-08, (http://www.webmd.com/arthritis/tc/gout-topic-overview#1)</ref><ref>Ashman CJ, Klecker RJ, Yu JS (2001) Forefoot pain involving the metatarsal region: differential diagnosis with MR imaging. Radiographies 21:1425–1440.</ref><ref>Jeremy J., McCormick, MD, Robert B. Anderson, MD -Turf Toe: Anatomy, Diagnosis, and Treatment, Clin Sports Med. 2010 Apr;29(2):313-23 (Levels of evidence : A)</ref><ref>MCRAE, R., Clinical Orthopaedic Examination, Churchill Livingstone, Edinburgh, 2010, 323p (p.236-238).</ref>
* Chronic [[Achilles Tendon|Achilles tendon]] tightness
* [[Arthritis|Arthropathy]]<ref>http://patient.info/doctor/hallux-rigidus</ref>Surgical or traumatic
* 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]]


== Management / Interventions  ==
== Clinical Presentation ==


=== Non-operative treatment  ===
=== 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:


[[Image:Hallux valgus1.jpg|right|250x250px]]
* 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


==== Prevention  ====
<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>


A hereditary factor or predisposition (for example as a result of a generalized ligamentous laxity) is not preventable but other things are. For example, wearing shoes that fit properly (not too tight) and avoiding high heels can be important factors in preventing hallux valgus.<ref>Coşkun G, Talu B, Bek N, et al. Effects of hallux valgus deformity on rear foot position, pain, function, and quality of life of women. J Phys Ther Sci 2016; 28:781–787. (Levels of evidence: 2B)</ref>&nbsp;
=== Signs and Symptoms ===


==== Treatment  ====
* 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


The first treatment option is non-operative care:
== Pre-operative Management ==


*Adjustment of footwear to 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 toe box
* Patient education regarding recovery time
*The condition of pes planus may be helped by an orthosis. Severe pes planus can lead to a recurrence of hallux valgus following surgery.


*Achilles tendon contracture may require stretching or even lengthening <ref name="T" />
<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>


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>. 
== 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:


=== Operative treatment  ===
* 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


If non-operative treatment fails, surgery could be considered <ref name="T" />.  Before an operation is chosen, the severity of the hallux valgus has to be determined. In order to do that, a weight bearing plain film radiography is used.
'''Goals:'''


There are about a hundred thirty one different surgical techniques. Many surgeons combine one or two techniques depending on the severity of the condition and the history of the patient. Below are a few examples of Hallux Valgus correction techniques:
# To maintain a flexible first MTP joint
# To  preserve the normal weight-bearing pattern of the forefoot


*'''Austin/Chevron Procedure&nbsp;<br>'''This procedure is frequently used for mild deformities. The osteotomy is in a "V" shape, a sagittal saw is used in a medial to lateral direction inside the first metatarsal head. The loose fragment is then placed differently to correct the first metatarsal angle. The fragment is fixated with pins or screws.
'''Outcomes:'''
*'''Reverdin Procedure'''<br> A wedge is removed from the head of the first metatarsal head in order to get a better organisation of the articular cartilage. The wedge is situated on the dorsal side and medially based. In some cases, the surgeon decides that is necessary to rotate the articular cartilage. A screw or K-wire is used for fixation.
*'''Scarf Procedure'''<br>When the deformity is moderate to severe, the scarf procedure is a frequently used option. The osteotomy is longitudinal, in a medial to lateral direction, inside the shaft. The capital piece is moved more to the lateral side and stabilized with two screws.
*'''Closing Base Wedge Procedure'''<br>Base procedures are mostly used for severe deformities, so is this one. A wedge is made in the proximal metatarsal, on lateral side. When the wedge is removed, the distal part is translated to the lateral side causing the gap to close and the first metatarsal to align with the second. The minimum fixation is a bicortical screw.
*'''Lapidus Arthrodesis'''<br>This is another option when a severe deformity is observed. By removing a piece of the articular cartilage of the medial cuneiform and the base of the first metatarsal, a fusion between the two is created. The fixation can be external, by the use of a plate or screws.
*'''Akin Procedure'''<br>An extra correction can be constructed when a wedge is made on the medial side of the first proximal phalanx. The gap is closed by pushing the distal part to the medial side and fixating it. The similarities with the closing base wedge procedure stand out.
*'''First Metatarsal Joint fusion''' in cases of midfoot instability<ref name=":0" />
*'''First Metatarsal-Phalangeal Joint Arthrodesis'''<br>The permanent elimination of motion is the reason that this procedure is one of the last options to treat a significant deformity. Most of the time, there is another component that motivates the choice of this joint destructive procedure: degenerative arthrose or an unstable joint. The proximal phalanx is correctly positioned towards the first metatarsal and is then fixated through the joint with screws, plates or crossing K-wires.&nbsp;<ref>Meyr, A. et al. A pictorial review of reconstructive ankle and foot surgery: hallux abductovalgus. Journal of Radiology Case Reports. 2015; 9(6): 29-43. Geraadpleegd op 23 november 2016 via: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4638376/ fckLR(Levels of evidence: 2C)</ref>&nbsp;<ref>MOL, W. et STRIKWERDA, R., Compendium orthopedie, De tijdstroom, Lochum, 1977, 343p. (p.232-234).</ref><ref>HAMBLEN, D.L. et SIMPSON, A.H.R.W., Adam’s outline of orthopaedics (14th edition), Churchill livingstone, Edinburgh, 2010, 485p. (p454-457)</ref>


=== Post-operative Management  ===
* 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


For all surgical procedures, the patient is allowed to ambulate in a post-operative shoe immediately after surgery. Patients need to wear a post-op shoe and compressive dressings from 6- 8 weeks. Long-term follow-up has shown equally positive outcomes after Chevron osteotomy for both patients both younger and older than 50 years of age.
== Post-operative Management ==
'''General Guidelines:'''


Physiotherapy is beneficial after the corrective operation <ref>Hawson ST. Physical Therapy Post–Hallux Abducto Valgus Correction. Clinics in Podiatric Medicine and Surgery. 2014 Apr 1;31(2):309-22.</ref>(research in this area needs to be developed, the availability of many surgical techniques makes it difficult to run proper clinical trials)<ref name=":0">Simpson H. Hallux Valgus Surgery and Physiotherapy course. Physioplus 2020</ref>.
* At least six weeks of non-weight bearing
* Immobilisation in a modified shoe
* [[Oedema Assessment|Oedema]] management


Hallux valgus correction can be very complicated
=== Physiotherapy ===
* Especially if it was associated with instability which can be caused by bony or soft tissue abnormality.
<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>
* When combined with midfoot fusion (cases of 1st ray instability) the post-operative recovery might be challenging<ref name=":0" />.
* Patient's beliefs should be addressed prior to the surgery because many patients get frustrated and disappointed when quick recovery is not met<ref name=":0" />.
It is important to discuss the '''post-operative complication'''s with the patient prior to the operation and explain to them that they will experience the following<ref name=":0" />:
* Six weeks of non-weightbearing
* Discomfort
* immobilization in a modified shoe
* Swelling might last up to six months
* You can provide the patient with reading resources to make sure they understand the surgery and its complications.
* The postoperative management shouldn't be exclusive on managing pain and restoring local mobility. It should have a wider view to assess and manage any other associated issues<ref name=":0" />.
=== Key Rehabilitation Principals<ref name=":0" />: ===
'''Gait'''


Gait deficits can result from the immobilization in the modifiable shoe or plaster of Paris for at least six weeks. 
==== Fixing Gait ====
* Restoring the gait, [[balance]] and the associated deficits is a key component to successful rehabilitation.
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>
* One of the gait deficits that are often present following hallux valgus correction is when patients adopt a 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 preventing other injuries in the long term<ref>Schuh R, Hofstaetter SG, Adams Jr SB, 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. Physical therapy. 2009 Sep 1;89(9):934-45.</ref>.
[[File:Tandam walk.gif|right|frameless]]To facilitate loading the first metatarsal you can use the following techniques:
* Ask your patient to walk with one foot directly in front of the other. This encourages using the tibial rotation to bring that first toe down to the floor otherwise, the patient might lose their balance and fall over.
* Manual techniques to restore soft tissue balance. Techniques such as midfoot and forefoot mobilizations, Plantar Fascia release and Achilles tendon lengthening can all be utilized. 
* Foot orthoses can also be used to relieve weight-bearing stresses&nbsp;<ref name="Dimonte" />
'''To address gait deficits:'''
* Look at gait
* Film it
* Address and correct gait
* Do it over and over and make sure your patient is confident
[[File:Metatarsal doming.gif|right|frameless]]'''Strength Deficits'''


Weakness of the intrinsic foot muscles<ref name=":2">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.</ref> occurs following a period of immobilization. Additionally, the patients might have had previous imbalance prior to the surgery so it's important to assess, retrain and re-educate the foot core. 
'''Goal:'''


The targeted muscles for strengthening are<u><ref name=":2" />:</u>
# To restore gait as closely as possible back to normal
* The intrinsics:abductor hallucis, adductor hallucis, and the flexor hallucis brevis. 
* The extrinsics being the tibialis posterior and fibularis longus 
Simply, ask the patient to create a dome by their foot from a seated position by pressing the toes down and shortening the foot with isometric holds. We can progress this exercise by 
* Asking the patient to press the first toe down and lift the other four toes up then switch around, press the four toes down and lift the big toe up. 
* 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 dome of the foot. 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.
{{#ev:youtube|G2OyCOS3c_I|}}<ref>Active Foot Arch Strengthening Therapeutic Exercise | Pro Physio . Available from:https://www.youtube.com/watch?v=G2OyCOS3c_I[last accessed 09/07/2020]</ref>
'''Once the patient manages to do it well in sitting, progress into these positions:'''
* Standing
* Standing on one foot
* Walking
* Step Up
* Step Down
A useful way to improve the control of the movement is to film the patient from behind and from the front so they can see and compare. Alternatively, they can do it in front of a mirror, have the patient walk up and down, to the mirror and back, so they can see what's happening and how are they doing it. And keep correcting them.


'''Improve Plantar flexion push-off'''
'''Strategies:'''


It's important to think of exercises that can improve the functional push-off rather than performing the foot exercises from sitting by progressing simple foot exercises from sitting to weight-bearing position.
* 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


<u>Example of exercises and techniques:</u>
==== Check the Foot Core ====
* Standing over the edge of a box or a step with the exercise band and ask them to push through it.  
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>
* Walking with an exercise band underneath the toes and pulling it up. So the patient pushes their toes down into the band as they walk off, pressing down to push their foot off.
* Soft tissue work is important as well such as releasing the toe extensors as they 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's useful to lengthen, release and stretch them by asking the patient to stand over the edge and drop their heels down. You can put cotton wool between the toes to stretch them out.  
'''Second toe mobility and flexibility'''


Assess the second toe, you want it to be sitting nicely next to the big toe. Stretching might be helpful if needed but avoid overstretching. In some cases, the toe alignment might be disturbed if the surgery wasn't successful.
* the intrinsics: abductor hallucis, adductor hallucis, and the flexor hallucis brevis
* the extrinsics: tibialis posterior and fibularis longus


'''[[Pain Assessment|Pain Management]]'''  
'''Goal:'''


This can be a challenge following the operation especially the pain that is due to scar healing (a strong bony pain would be concerning).
# To strengthen the foot core
* Desensitising techniques to help manage pain 
* TENS machine can also help with managing the pain. 
* Discuss the medications with the surgeon and the patient about medication.
* Familiarize yourself with the surgical technique to avoid using a technique that could disturb the bone healing such as mobilizing a scarf osteotomy
* Sesamoid mobilization can be used - performs grade III joint mobilizations 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. <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>
<br>The following is a suggested post-operative rehabilitation programme:


'''PHASE I - Pain Relief. Minimise Swelling &amp; Injury Protection<ref name="p1" />'''  
[[File:Metatarsal doming.gif|thumb|Doming exercise]]
'''Strategies:'''


Pain is the main reason that patients seek treatment for a bunion.&nbsp;Inflammation is best eased using ice therapy, techniques (e.g. soft tissue massage, acupuncture, unloading taping techniques) or exercises that unload the inflamed structures. Anti-inflammatory medications may help. Orthotics can also be used to offload the bunion.  
* 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.


'''PHASE II - Restoring Normal ROM &amp; Posture<ref name="p1" />'''
{{#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>


As pain and inflammation settle, the focus of treatment turns to restoring normal toe and foot joint range of motion and muscle length.
==== Planter Push-Off ====
'''Goal:'''


Treatment may include;
# To improve the functional push-off


*joint mobilisation (abduction and flexion) and alignment techniques (between the first and the second metatarsal)
'''Strategies:'''
*massage
*muscle and joint stretches
*taping
*bunion splint or orthotic
*bunion stretch and soft tissue release. (see reference for video)<ref>Internet, Youtube: Bunion stretch and soft tissue release; 2012-08-01, (https://www.youtube.com/watch?v=q5Ov6LMISvU)</ref>


'''PHASE III - Restore Normal Muscle Control &amp; Strength<ref name="p1">http://physioworks.com.au/injuries-conditions-1/foot-bunion</ref>'''
* 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.


A foot posture correction Program to assist you to regain your normal foot posture.
* Second toe mobility and flexibility
[[File:Elastic band dorsiflexion.jpg|right|frameless]]
{{#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>
'''Dorsiflexion Strengthening with Elastic Resistance Band'''


The ankle dorsiflexion exercise strengthens the ankle and lower leg muscles. The patient is positioned in long-sitting. The centre of the resistance band is placed on the top of the forefoot with the toes slightly pointed. The ends of the band are either held by an assistant or secured against an immovable object (e.g. a table leg). The patient then dorsiflexes the ankle, pulling "towards their nose," working against the resistance of the band.
==== Address the Pain ====
[[File:Towel toe curl.jpg|right|frameless]]
'''Goal:'''
'''Towel curls''' The patient spreads out a small towel on the floor, curling his/her toes around it and pulling the towel towards them.


'''Toes spread out (TSO)''' A possible causative factor of the hallux valgus is the muscle imbalance between the abductor hallucis and the adductor hallucis. Strengthening the abductor muscle can prevent a hallux valgus and can be helpful to correct the deformity in an early stage. The toes-spread-out (TSO) exercise is an efficient way to train abductor hallucis. <ref>KIM, M; et al. Comparison of muscle activities of abductor hallucis and adductor hallucis between the short foot and toe-spread-out exercises in subjects with mild hallux valgus. Journal of Back and Musculoskeletal Rehabilitation. 26, 2, 163-168, Apr 2013. (levels of evidence: 5)</ref> (Level of evidence 1: 5) (Level of evidence 2: 5)&nbsp;
# To reduce pain and restore normal toe and foot joint range of motion and muscle length


'''PHASE IV - Restoring Full Function'''  
'''Strategies:'''


The goal of this stage of rehabilitation is to return the patient to his/her desired activities. Everyone has different demands for their feet that will determine what specific treatment goals need to be achieved.  
* [[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.'''''


'''PHASE V - Preventing a Recurrence'''  
==== Match the Shoe ====
'''Goal:'''


Bunions will deform further with no attention and bunion-associated pain has a tendency to return. The main reason is biomechanical.
# To provide needed support for sensitive and swollen foot


In addition to muscle control, the physiotherapist should assess foot biomechanics and may recommend either a temporary off-the-shelf orthotic or refer for a custom-made orthotic. High heeled shoes and shoes with tight or angular toe boxes should be avoided.
'''Strategies:'''


{| width="100%" cellspacing="1" cellpadding="1"
* Ask the patient what shoes they see themselves wearing
|-
* Assess the shoe the patient is currently wearing
| {{#ev:youtube|q5Ov6LMISvU|380}} (Level of evidence 5)<ref>Correct Toes. Bunion Stretch and Soft Tissue Release. Available from: http://www.youtube.com/watch?v=q5Ov6LMISvU [last accessed 08/01/17]</ref>
* The worn shoe may no longer be suitable - its shape may have changed to accommodate the pre-operative foot posture
| {{#ev:youtube|zRIilSqwALU|380}} (Level of evidence 5)<ref>Integrated Health. Hallux valgus. Available from: http://www.youtube.com/watch?v=zRIilSqwALU [last accessed 08/01/17]</ref>
* 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


=== Foot-wear following the operation ===
[[File:Shoe.jpg|right|frameless|400x400px]]
What should I wear after the operation? This is often an emotional topic for the patients and often, patients' and surgeons' expectations don't match at all. 
* Surgeons would expect patients to wear a wide and very stable shoe. 
* Important to discuss and inform the patient that their foot is going to be sensitive, swollen, and will need support for at least six months so it's important to find a suitable and nice-looking shoe that doesn't aggravate the pain. 
* Ideally, find a shoe with a slightly wider toe box, a good solid heel structure that is not too high (doesn't have to be flat).
* Ask your patient: what shoes do you see yourself wearing? Or what would you like to wear? Ask the patient to bring in some of your shoes and discuss their foot position and possible effects of the shoes on their feet (Worn-out shoes may no longer be suitable because it has adapted to the shape and the weight of their previous foot posture). 
* Investing in a good pair of shoes that will provide comfort and support is important (familiarize yourself with the available brands to help your patients select proper footwear). 
* Friction from the scar might be an issue - advice the patient to wear Silk socks or silky stockings in the beginning and pick shoes that can give some stretch. The patient can rub the soft part of soap on their sock and shoe to improve lubrication<ref name=":0" />.


== References  ==
== References  ==
Line 286: Line 219:
[[Category:Conditions]]
[[Category:Conditions]]
[[Category:Course Pages]]
[[Category:Course Pages]]
[[Category:Physioplus Content]]

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, Andeela Hafeez, Jolien Rottie, Rachael Lowe, Jess Bell, Bradley Svoboda, Kim Jackson, Admin, Morgane Michiels, 127.0.0.1, Kristin Zumo, Khloud Shreif, Tarina van der Stockt, WikiSysop, Tinne Tielemans, Wanda van Niekerk and Evan Thomas

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"