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^,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.^,. 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). 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) . 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

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 . 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.

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 ³

A common problem in people with hallux valgus (pre-operative), is one or more disorders in their gait pattern due to the deformity of the first metatarsophalangeal joint. Dysfunctions that may be present:

• 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
• 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 diminished⁵

When a physical examination is executed, the following indications could be present:

• Lateral deviation of the MTP joint
• Swelling of first MTP joint
• Shortening of flexor hallucis brevis muscle
• Tenderness of hallux
• Weakness of hallux abductor muscles⁵
• Pain (primary symptom)⁸
  
  

Diagnostic Procedures

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.

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 .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) ⁴, 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. So we can use both scales (the four-level classification or dichotomised scale) to determine the severity of hallux valgus .
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.⁸

Outcome Measures

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Management / Interventions

Non-operative treatment

The first treatment option is non operative care:

• 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
• 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 ⁸.
• 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 ⁹

Operative treatment

If non-operative treatment fails surgery could be considered⁸.
There are several surgical procedures that we can apply depending on the severity of the injury:

• For mild cases: distal soft tissue procedure
• Hallux angle < 30 °: Chevron osteotomy
• Hallux < 25 °: Akin procedure
• Age > 65 year: Keller arthoplasty
• Arhrodesis (the most common)

Post-operative physiotherapy

As a result of the gait disturbances (see non-operative treatment), objectives for physical therapy could be:

• Adjusted footwear with wider and deeper tip
• Increase extension of MTP joint
• Relieve weight-bearing stresses (orthosis) ⁵
• Sesamoid Mobilization:*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.7
• Strengthening of the M. Peroneus Longus⁶
• Gait Training⁷. During gait training, we can train the different phases:

1. Stance phase: could be trained by performing a heel-strike in its physiological position at the lateral aspect of the heel.
2. 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 ^6.

During gait training, verbal cues could be provided .

These objectives should ensure that pain is reduced and function is restored. ⁷
Physiotherapists should contain an expanded program, including whirlpool, ultrasound, ice, 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^7.

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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