H a l l u x Val g u s

Paul J. Hecht, MD*, Timothy J. Lin, MD

KEYWORDS
 Bunion  Hallux valgus  Metatarsus primus varus

KEY POINTS
 Hallux valgus is a common progressive forefoot deformity that affects women more
commonly than men.
 Tight-fitting and high-heeled shoes, gender, and genetics seem to be the most important
predisposing factors.
 Treatment consists of footwear modification and surgical procedures, depending on the
patient’s symptoms and the severity of the deformity.
 Radiographic evaluation must include weight-bearing radiographs.

INTRODUCTION

Hallux valgus is the most common problem of the forefoot in adults.1 The deformity of
hallux valgus is progressive, and involves several stages, but begins with lateral devi-
ation of the great toe (hallux) and medial deviation of the first metatarsal (metatarsus
primus varus).2 In its later stages, hallux valgus involves progressive subluxation of the
first metatarsophalangeal (MTP) joint.1 The cause of hallux valgus has been debated
for years, but is likely associated with genetic predisposition, restrictive footwear,
other foot deformities such as pronation of the hindfoot3 and pes planus (flatfoot),1
hypermobility, contracture of the Achilles tendon, and neuromuscular disorders
such as cerebral palsy and stroke.4,5 No association has been made between hallux
valgus and either obesity or occupation (except for ballet dancing).1,6,7
Adults are more commonly affected than children, although juvenile hallux valgus
does occur. Women are diagnosed more frequently than men, with a ratio as high
as 15:1 in some studies,8 and require surgery more often, which is thought to be asso-
ciated with differential use of tight-fitting and high-heeled shoes. Women also tend to
have higher rates of ligamentous laxity and different bony anatomy that may play a
role.9

Disclosures: None.
Department of Orthopaedic Surgery, Dartmouth Hitchcock Medical Center, One Medical Center
Drive, Lebanon, NH 03756, USA
* Corresponding author.
E-mail address: paul.j.hecht@hitchcock.org

Med Clin N Am 98 (2014) 227–232

http://dx.doi.org/10.1016/j.mcna.2013.10.007 medical.theclinics.com
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228 Hecht & Lin

Symptoms of hallux valgus include poor-fitting shoes, plantar foot pain, medial first
MTP joint pain, deep MTP aching pain from joint degeneration, and pain with weight
bearing.
Management of hallux valgus generally begins with conservative (nonoperative)
treatment, especially in juvenile hallux valgus, the elderly, or patients with significant
comorbidities. Conservative modalities include avoidance of tight-fitting, high-heeled
shoes; wearing wide-toed soft footwear; use of various inserts/pads; and physical
therapy. Surgical correction is indicated in situations of failed nonoperative manage-
ment, progressive, painful deformity, and disruption of lifestyle and/or activity.

DIAGNOSIS

Evaluation of the patient with suspected hallux valgus should include a thorough
history, including any pertinent family history; physical examination; and radiologic
examination with weight-bearing radiographs. History should focus on duration of
symptoms, activity modification, footwear, and types of any previous interventions.
Physical examination must include observation of gait, alignment, and range of motion
of the first MTP joint and of both lower extremities, and examination of the bare feet
both with weight bearing and without. Special attention should be paid to type and
wear pattern of footwear; specific areas of pain and tenderness; the presence of cal-
luses or corns; deformities of the lesser toes, midfoot, or hindfoot; laxity of the first ray
(from the great toe to the hindfoot); the presence of a large bunion; and the presence or
absence of Achilles tightness.

PATHOGENESIS/PROGRESSION

The first ray bears a significant amount of weight as it maintains the position of the
medial arch.10 Any deformity that disrupts the integrity of the first ray can lead to
hallux valgus.5 As seen in Table 1,5 there is a series of steps in the progression of
hallux valgus, but the steps are not necessarily followed in a specific order. Because
the medial structures of the first MTP joint are weak, including the medial collateral
ligament and the medial sesamoid bone, they tend to fail first.11 The metatarsal
head eventually drifts medially, the proximal phalanx shifts into valgus, the bursa of
the medial eminence becomes inflamed and prominent, and the extensor hallucis
longus and flexor hallucis longus tendons bowstring laterally, exaggerating the
deformity.5,12,13

Table 1
The multiple steps that are involved in the progression of hallux valgus (not necessarily in
order)

Potential Causes of Hallux Valgus

Extrinsic Factors Intrinsic Factors
Footwear (high heels, narrow shoes) Genetics
Excess weight bearing Sex (female>male)
Ligamentous laxity
Other foot deformities (pes planus, hindfoot
pronation, metatarsus primus varus)
Age
Neuromuscular disorders (eg, cerebral palsy, stroke)

Data from Perera AM, Mason L, Stephens MM. The pathogenesis of hallux valgus. J Bone Joint Surg
Am 2011;93(17):1650–61.
 Hallux Valgus 229

CLASSIFICATION

Severity of hallux valgus is typically based on symptoms and radiologic assessment

using weight-bearing radiographs and is described as mild, moderate, or severe.
Two angles of importance in the assessment of radiologic severity of hallux valgus
are the hallux valgus angle (HVA; normal <15 )2 and intermetatarsal angle (IMA; normal
<9 ).4 Classification of hallux valgus is based on the HVA and IMA, and this is summa-
rized in Fig. 1 and Table 2.

TREATMENT
Nonoperative Treatment
Conservative interventions should be used before surgical intervention, and should be
the mainstay of treatment in juvenile hallux valgus,14 the elderly, and patients with
severe neuropathy or other comorbidities that make them poor surgical candidates.
The goal of conservative management should be to decrease severity of symptoms
and avoid lifestyle/activity modifications because there is no evidence to show that
nonoperative therapies have the ability to correct the hallux valgus deformity.
Patients should first be counseled to avoid using tight-fitting or high-heeled foot-
wear. They should be advised to seek out soft, wide-toed footwear in order to attempt
to slow progression. Various inserts have been used in order to alleviate pain,
including hallux valgus splints, bunion shields (Fig. 2), toe spacers, and night splints.
However, orthotics have not been shown to prevent or slow progression of hallux
valgus.15 In one recent study published in 2013 by Reina and colleagues16 there

Fig. 1. Mild to moderate hallux valgus. HVA is 30 and the IMA is 11 . The first MTP joint is
congruent, but there is a large exostosis over the medial aspect of the first metatarsal head
that is associated with an overlying soft tissue prominence.
230 Hecht & Lin

Table 2
The classification of hallux valgus based on standing anteroposterior (AP) radiographs

Radiographic Classification of Hallux Valgus

Subluxation of Lateral Sesamoid
HVA ( ) IMA ( ) on AP View (%)
Normal <15 <9 —
Mild <20 11 <50
Moderate 20–40 <16 50–75
Severe >40 16 >75

was no difference in progression of radiographic severity of hallux valgus (measured

by HVA and IMA) in 54 women randomized to custom-made orthotics versus no treat-
ment at 12-month follow-up. Given the unpredictability of outcome with regard to
activity tolerance and pain after surgical correction, patients who are able to maintain
a high level of sport or activity should prolong surgery until this is not the case.
Over-the-counter antiinflammatory medications, acetaminophen, and (rarely) injec-
tions may be used to alleviate pain.

Operative Treatment
Preoperative counseling is important when considering operative correction. Patients
should be warned of the possibility of persistent pain, continued need for footwear
modification, and risk of recurrence, as well as general risks of surgery and anesthesia.
More than 140 surgical procedures have been described to correct hallux valgus,
but no single procedure has been shown to lead to improved outcomes. Procedures
are generally grouped into categories, each of which is used as indicated based on
severity of disease with respect to radiographic parameters, presence or absence
of significant first MTP joint degeneration, and whether or not the deformity is
passively correctable by the examiner. General categories include distal soft tissue
procedures, first metatarsal osteotomies, proximal phalanx osteotomies, arthrodesis
(fusion), and resection arthroplasties. Some combination of these procedures is
commonly used to treat patients.
Juvenile hallux valgus is best treated conservatively for as long as possible, given
the increased risk of recurrence, shown to be as high as 40% to 60% in one series

Fig. 2. A bunion shield used in the conservative treatment of hallux valgus.

 Hallux Valgus 231

of 21 bunions in 13 adolescents treated operatively.17 There is also a higher risk of

overcorrection with surgical management in skeletally immature patients.18

SUMMARY

Hallux valgus is a common foot problem whose cause and progression is multifacto-
rial, complex, and poorly known. It is likely related primarily to genetic predisposition
and use of tight, constrained footwear. Hallux valgus shows a predilection toward
women, although this may also be related to differences in shoe preferences between
sexes. It is a progressive disorder with no treatment known to slow or stop progres-
sion. Shoe inserts can be used as a conservative measure with unpredictable efficacy.
Surgery is indicated in healthy individuals when nonoperative measures fail, although
outcomes from surgery are not always predictable. Adverse effects of surgery include
infection and recurrence. Many procedures have been described in the literature,
including soft tissue and bony reconstruction of the first ray. The procedure that is indi-
cated depends on the severity of the deformity.

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