Conservative Management of Hallux Valgus

Original Editor - Wanda van Niekerk based on the course by Helene Simpson

Top Contributors - Wanda van Niekerk and Jess Bell  

Introduction

Hallux valgus is a common foot disorder. It is a painful deformity at the first metatarsophalangeal joint that is characterised by progressive lateral deviation of the hallux (great toe) and medial deviation of the first metatarsal bone. Its causes are multifactorial. It can disrupt the function of the foot during gait and balance, and it can negatively influence quality of life in persons with this disorder. This page will focus specifically on the conservative management of hallux valgus.

Read more:

• Clinically Relevant Anatomy
• Clinical Presentation of Hallux Valgus
• Epidemiology and Aetiology of Hallux Valgus

Conservative Management

Aims of Management

Hallux valgus is a progressive condition that cannot be fixed with conservative management. The aims of conservative management are:

• patient education
• pain management
• management of the deformity
• stop or slow down the progression of the deformity
• delay surgical intervention
• manage individuals with hallux valgus for whom surgery is not an option

Patient Education

Establish the patient's understanding of hallux valgus and explain the condition to the patient:

• do they understand the underlying mechanisms?
• do they understand the condition?

Patient education is an important part of any healthcare intervention. It is a way for rehabilitation professionals to communicate essential information. It improves patient self-efficacy and self-management skills and has also been shown to improve clinical outcomes such as pain and function.

Pain Management

• Transcutaneous electrical nerve stimulation (TENS):
  • protocols for chronic pain management (different currents, different application times) may be beneficial in providing symptomatic pain relief for individuals with hallux valgus. Johnson et al. reported "moderate - certainty" evidence that pain is reduced with TENS. It is also an affordable treatment.
• Investigate underlying medical causes and refer to a rheumatologist when necessary:
  • consider condition such as psoriatic arthritis, cholesterol, diabetes, gout, rheumatoid arthritis, connective tissue disorders
  • bilateral issues, uncontrollable pain, symptoms not resolving with rest or treatment should be referred to the relevant healthcare professional
• Non-steroidal anti-inflammatories (NSAIDs) may help with pain relief
• As reported by Hurn et al., over-the-counter orthotic devices may reduce pain in the intermediate term

Shoes

Ask the patient to bring along all their shoes to a consultation and assess these shoes. When looking at shoes, consider:

• which shoes work for the patient
• which shoes help the patient
• which shoes are easiest to walk in
• which shoes are most problematic
• which shoes the patient likes to wear
• which shoes the patient has to wear

Shoe Advice

Research has highlighted that certain design features (i.e. elevated heel and a restrictive toe box) in shoes may be a cause of foot pain. Biomechanical studies have found that heel elevation in shoes can:

• increase pressure under the metatarsal heads
• limit first metatarsophalangeal joint motion
• increase Achilles tendon stiffness

Shoes with a restrictive or narrow toe box can:

• increase pressure on the medial side of the foot and between the toes

These changes may add to foot pain over time.

There is also research exploring the relationship between wearing shoes with elevated heels and hallux valgus and wearing shoes with a narrow toe box and hallux valgus. Menz et al. found no association between hallux valgus and heel height of footwear worn, but did find a significant association between wearing shoes with a restrictive or narrow toe box between the ages of 20 to 39 years and the development of hallux valgus later on.

Shoes that are generally better to wear may include:

• shoes that prevent hyperextension of the big toe
• wedges with a wide toe box
• running shoe or trainer with strong midfoot and wide toe box

Taping

Kinesiology taping

Kinesiology taping may reduce pain in people with hallux valgus. It has been reported that correcting the position of the big toe can have a positive effect on foot function. Using kinesiology tape can also influence dynamic parameters of the foot, such as increasing the support surface under the head of the first metatarsal and the lateral surface of the heel during gait. This may be helpful for patients who are not yet ready to consider surgery or who are unable to have surgery. Please watch the taping technique demonstrated by Helene Simpson in the Conservative Management of Hallux Valgus course video.

Other Taping Methods

• Bayer et al. investigated the effects of taping and foot exercises on patients with hallux valgus. Participants were divided into two groups (study group - received taping and foot exercises; control group - only foot exercises). Hallux valgus angle, pain and walking ability were measured. After the eight-week treatment programme, both groups had a significant decrease in hallux valgus angle and pain. Walking ability improved in the study group. Between group comparison showed that the study group had significantly better results in hallux valgus angle, pain and walking ability. The taping technique used in this study is described as follows:
  • non allergenic, non elastic white tape used
  • anchor around the distal toe at the base of the toenail
  • anchor strip around instep and arch of foot
  • a 2 cm wide strip placed parallel to the midline of the medial aspect of the foot, from distal to proximal
  • hallux sustained in a midline position
  • place anchors again over the original anchors

• Research on the effect of corrective taping on balance is still needed. Corrective taping of hallux valgus in middle-aged adults showed a negative effect on balance when walking or climbing stairs, which may increase fall risk.
• Jeon et al. reported an improvement in hallux valgus angle and pain with 15 taping treatments in 15 participants during a four-week period.
• Akaras et al. concluded that Mulligan taping methods could be alternative treatments for hallux valgus management. In this study, the acute effects of two different rigid tape methods (Mulligan taping and athletic taping) were investigated in participants with hallux valgus deformities. The full article, including taping methods and images, is available here: The acute effects of two different rigid taping methods in patients with hallux valgus deformity.

Role of the Orthotist and Podiatrist

• Assessment of:
  • hindfoot stability
    • calcaneus dropping into inversion
  • midfoot stability
  • medial arch
• Provide pressure relieving aids such as metatarsal pads, customised spacers:
  • Kwan et al. reported that an orthotic with a toe separator or similar element that allows for anatomical alignment of the foot is essential for the reduction of the hallux valgus angle and to relieve foot pain.
  • Dynamic and static orthoses with toe separators are both effective, but static orthoses with a toe separator have a greater effect than dynamic orthoses.
  • Toe separators reduce pain through better alignment of the big toe, less stress on the overstretched ligaments and bone subluxation.
  • Patients are more satisfied with dynamic orthoses than static orthoses as the joint range of motion is not limited, mobility is maintained, and stiffness is prevented.
  • Read the full systematic review here: Hallux valgus orthosis characteristics and effectiveness: a systematic review with meta-analysis.
• Willing to reassess the patient if orthotics are not providing the necessary outcomes for the patient.
• Consider the costs of experimenting with over-the-counter inserts and getting a customised orthotic. Discuss this with the patient.

Manual Therapy

• There are conflicting results in the literature on the use of manual therapy in the conservative management of hallux valgus. Meta-analyses have shown no significant reduction in short-term pain, whereas other studies report significant pain reduction with manual therapy. These conflicting results may be caused by the diversity of interventions, participant characteristics and sample sizes.
• Remember, this joint is often hypermobile.
• A rigid first metatarsophalangeal joint can be mobilised.
• Manual therapy may be beneficial to release a stiff and overworked foot (especially when the patient starts to grip and turn the foot into supination to relieve pressure on the first metatarsophalangeal joint). This can assist in loadbearing and recruitment of the intrinsic foot muscles and/or tibialis posterior during exercises.

Exercise Therapy

A significant reduction in pain with foot exercises has been shown. Examples of exercises that can be included in an exercise programme are:

• Dome exercises (i.e. the foot core exercises) to strengthen the intrinsic foot muscles - progression is important from sitting to full weight bearing. See exercise demonstration by Helene Simpson in the Conservative Management of Hallux Valgus course video.

• Abductor hallucis activation. See exercise demonstration by Helene Simpson in the Conservative Management of Hallux Valgus course video.

• Consider the whole kinetic chain:
  • Tibialis posterior strengthening - consider the impact of tibialis posterior on the medial arch of the foot and overpronation.
    • Tibialis posterior is a local stabiliser - isometrically stabilises the medial arch under load
    • It is also a global stabiliser - resists excessive rotation (too much pronation of the foot)
    • Examples of exercises (demonstrations of these exercises can be seen here):
      • Windscreen wiper exercise
      • Modified calf raise with soft ball between ankles
      • Calf raises without a ball

• • Knee strengthening - knee and vastus medialis oblique strength to avoid knee falling in
  • Hip strengthening - strengthening of hip stabilisers to avoid medial drop

• Important: Always make sure that the inserts or shoes match the strength and rehabilitation progressions along the course of treatment.
• Gait retraining is crucial!
  • Strategies to address gait retraining include:
    • Gait assessment
    • Film the patient
    • Address and correct any gait abnormalities

Surgical Management of Hallux Valgus

If the patient's pain is getting worse, their activities of daily living are affected, and they are doing less despite all these conservative interventions, discuss the option of getting a surgical opinion! Read more on Physiotherapy after Hallux valgus surgery here.