Conservative Management of Hallux Valgus

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Introduction

Hallux valgus is a common foot disorder. It is a painful deformity at the first metatarsophalangeal joint and characterised by progressive lateral deviation of the hallux (great toe) and medial deviation of the first metatarsal bone. Its causes are multifactorial and it can disrupt the function of the foot during gait and balance. Furthemore, it negatively influences 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

This is a progressive condition and it is not a condition that can 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 cases for which surgery is not an option

Patient Education

• Establish what the patient's understanding is 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 setting. It is a way for rehabilitation professionals to communicate key information, it improves patient self-efficacy and self-management skills. It is 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. 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 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 relieve
• Over the counter orthotic devices may reduce pain in the intermediate term as reported by Hurn et al.

Shoes

Ask the patient to bring along all their shoes to a consultation and assess shoes. Considerations with shoes are:

• The shoes that work for the patient
• The shoes that help the patient
• The shoes that are easiest to walk in
• The most problematic shoe
• What shoes the patient likes to wear
• What 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 medial side of the foot and between the toes

These changes may add to foot pain overtime. There are also research showing relationships between wearing shoes with elevated heels and hallux valgus as well as 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 the wearing of shoes with a restrictive or narrow toe box between the ages of 20 to 39 years and hallux valgus development later on.

Shoes that generally will be better to wear may include:

• Shoes that prevent big toe hyperextension
• Wedges with a wide toe box
• Running shoe or trainer with strong midfoot and wide toe box

Taping

Kinesio taping

Kinesiology taping may reduce pain in people with hallux valgus. A positive effect with the correction of the big toe position on function of the foot has been reported. Using kinesiology tape can also influence dynamic parameters of the foot such as increased support surface under the head of the first metatarsal and the lateral surface of the heel during gait. Therefore this may help patients who are not yet ready to consider surgery or who are unable to have surgery. Please watch the taping technique as shown by Helene Simpson in the 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 was 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. Taping technique used in this study:
  • 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
  • Anchors again over the original anchors

• There is still research needed on the effect of corrective taping on balance. Corrective taping of hallux valgus in middle-aged adults showed a negative effect on balance when walking or climbing stairs. This may thus increase fall risk.
• Jeon et al., reported an improvement in hallux valgus angle and pain in 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. Twenty two participants were included in the study and the acute effects of two different rigid tape methods (Mulligan taping and athletic taping) were investigated in participants with hallux valgus deformities. Read the full article here with the taping methods also being described and images shown: 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
• Pressure relieving aids such as metatarsal pads, customised spacer
  • Kwan et al., reported that an orthoses design with a toe separator or such an element that allows for anatomical alignment of the foot is essential for reduction of the hallux valgus angle and to relief foot pain.
  • Dynamic and static orthoses with toe separators are both effective, but a static orthoses with toe separator has a greater effect than a 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 and mobility is maintained and stiffness 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.
• Always consider the costs involved 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.
• Careful with mobilisations in a hypermobile joint.
• 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 the 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

Significant reduction in pain with foot exercises have been shown Examples of exercises that can be included are:

• Dome exercises (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 course video.

• Abductor hallucis activation. See exercise demonstration by Helene Simpson in the 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

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