Hallux Valgus

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Definition

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^1,10. 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.^1,2. This often leads to development of soft tissue and bony prominence on the medial side of what is called a bunion (exostosis on the dorsomedial aspect of the first metatarsal head⁸) ³. 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) ². 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%) ¹⁰.

Clinically Relevant Anatomy

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

Mechanism of Injury / Pathological Process

The exact etiology is not well established, however, certain factors have been considered to play a role in the development of hallux valgus.  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.

Clinical Presentation

Hallux valgus is a deformity in which the medial eminence becomes prominent as the proximal phalanx deviates laterally.  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. 

Diagnostic Procedures

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Outcome Measures

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Management / Interventions

The different surgical interventions are: Distal soft tissue procedure(for mild cases), Chevron osteotomy(hallux angles < 30 degrees), Akin procedure(hallux angles <25 degrees), Keller arthoplasty(for ages>65 years) and Arthrodesis being the most common.

Post -op Rehabiliatation Considerations

• For all surgical procedures, the patient is allowed to ambulate in a post-operative shoe immedidately after surgery.
• 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

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Key Evidence

Connor et al showed a statistically significant limitation in ROM ffor the physical therapy group alone compared to the group that also had CPM.  No differences in groups likelihood of developing complications.  CPM group discontinued oral analgesics more quickly as well as returned to wearing conventional shoewear in a significantly shorter time period.

Torkki et al compared surgery, orthoses, and watchful waiting.  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.

Resources

Ferrari J, Higgins JPT, Prior TD.  Interventions for treating hallux valgus(abductovalgus) and bunions(Review).  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.  Surgery v. orthosis vs. watchful waiting for hallux valgus.  JAMA. 2001;285(19);2474-2480.

Case Studies

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References

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