INTRODUCTION — Valgus malformation of the great toe, commonly known as a bunion, is a very common and potentially painful and debilitating condition of unclear etiology. This topic will provide an overview of the anatomy, pathophysiology, diagnosis, and management of hallux valgus (HV) in adults. Toe and foot injuries are discussed elsewhere. (See "Toe fractures in adults" and "Metatarsal shaft fractures" and "Overview of foot anatomy and biomechanics and assessment of foot pain in adults".)
ANATOMY AND BIOMECHANICS
Definitions and basic forefoot anatomy — By convention, toes and their respective metatarsals are numbered from one (great toe) through five (little toe). The great toe has two phalanges, while the second through fifth toes typically have three (figure 1 and figure 2 and figure 3). Tendons and ligaments insert at the bases of each phalanx. The digital artery and nerve pass together along the sides of each toe.
●Ray – The forefoot consists of five longitudinal projections, called rays, which are comprised of the metatarsal and the bones aligned with and proximal to the metatarsal, such as the cuneiforms or cuboid bones. Hallux valgus (HV) involves the first ray.
●Hallux valgus deformity – This deformity is defined as a lateral deviation of the hallux (great toe) on the first metatarsal (figure 4). The deviation of the hallux occurs primarily in the transverse plane. The deformity often also involves rotation of the toe in the frontal plane causing the toenail to face medially (ie, eversion). These two deviations have led to the use of different terms to describe the deformity. In orthopedic texts, it is often called "hallux valgus," whereas many podiatry texts prefer the term "hallux abductovalgus" (HAV). Patients are more familiar with the expression "bunion."
●Hallux abductus angle – The HA (or HV) angle is created by the bisection of the longitudinal axis of the hallux and the longitudinal axis of the first metatarsal (figure 4 and image 1). Historically, an HA angle of >15 degrees was considered abnormal, but such deformities are not always symptomatic, and in some cases, an HA angle >15 degrees occurs naturally due to the shape of the articular surfaces involved [1,2]. Contemporary research suggests an HA angle of ≥20 degrees is abnormal [3].
●Intermetatarsal angle – The angle determined by the bisection of the longitudinal axes of the first and second metatarsals (figure 4). An intermetatarsal (IM) angle <9 degrees is considered normal.
First ray anatomy — There are no muscles that originate on the first metatarsal to directly stabilize the first metatarsophalangeal (MTP) joint. The abductor and adductor hallucis muscles pass medially and laterally to the MTP joint respectively, but they are located nearer to the plantar surface (figure 5). Thus, any force pushing the proximal phalanx laterally, or the metatarsal head medially, lacks direct muscular constraint and can create a valgus deformity.
The first metatarsal is held in alignment by a splinting action of the abductor hallucis muscle medially and by the lateral pull of the peroneus longus acting at the base of the metatarsal [4]. Movement at the first MTP joint in the transverse plane is prevented by collateral ligaments running from the metatarsal epicondyles, distally and plantarly, to the proximal phalanx.
Pathophysiology of hallux valgus deformity — Increased pressure under the head of the first metatarsal (for example, due to increased subtalar pronation or a congenital plantarflexed first ray) will force the first ray to move medial-dorsally. This movement increases the HA and IM angles and places the metatarsal more medial relative to its proximal phalanx. When the muscles act to stabilize the joint during gait, the proximal phalanx is pulled against the lateral aspect of the metatarsal head which pushes the metatarsal more medially, further increasing the HA angle.
As the first metatarsal moves medially and the hallux moves laterally, the medial capsule and medial collateral ligament come under chronic strain and eventually rupture. The medial movement of the metatarsal forces the abductor hallucis muscle beneath the metatarsal. From this position, it acts solely as a plantarflexor of the proximal phalanx and contributes to the valgus rotation seen with HV deformity. Eventually, without medial stabilizing structures, the lateral joint capsule and collateral ligaments tighten and the adductor hallucis muscle acts unopposed, exacerbating the deformity [5].
Since not all cases of HV deformity become severe, there may be a threshold up to which the forces deforming the joint can be opposed by other anatomic structures. When forces greater than the threshold occur, the joint becomes deformed. It is possible that such progression occurs rapidly rather than worsening steadily over several years [1,2,6].
EPIDEMIOLOGY — The prevalence of hallux valgus (HV) deformity varies but is widely prevalent among adult populations. According to a systematic review of 78 studies involving almost 500,000 subjects, the prevalence of HV is approximately 23 percent among adults aged 18 to 65 years, 36 percent among adults over 65 years, and 30 percent among all adult females [7]. The prevalence is greater among shod compared with barefoot (unshod) populations, although the condition is twice as common among females than males in unshod populations [8-10].
ETIOLOGY — Although many theories have been proposed, the precise etiology of hallux valgus (HV) deformity is unknown [11,12]. HV deformity is likely multifactorial in origin and includes such factors as abnormal foot mechanics affecting the first ray [5,13-17], abnormal first metatarsophalangeal anatomy [18-21], joint hypermobility [22,23], and genetic influences [4]. HV is also associated with conditions such as inflammatory joint disease [24-26].
Since HV deformity occurs primarily in shod populations, affecting females in particular, poor footwear has frequently been cited as a cause. The fact that some females wear footwear that compresses their toes significantly without detrimental effects, while some males suffer from marked HV deformity despite the use of nonconfining footwear, leads many to think that footwear probably exacerbates underlying bony or mechanical abnormalities rather than acting as a primary factor.
While many studies have reported that HV is associated with a change in weightbearing pressures under the hallux and in other areas of the foot, these studies have all been observational, and therefore causal relationships cannot be determined. It remains unclear whether changes in loading are a result of the HV deformity itself or related to an underlying mechanical dysfunction that contributes to the development of the HV deformity [27].
However, it seems clear that weightbearing pressures under the foot change as HV develops, since pressure lesions (eg, calluses) develop, which were not present before the deformity developed and may not be present on the unaffected foot. One study has suggested that changes in weightbearing pressures might lead to further injuries within the foot or limb [28]. However, the precise relationship between plantar pressures and specific injuries remains unknown. There is no evidence that general gait parameters are affected by HV, but there is some evidence suggesting that severe deformity does disrupt gait and balance, particularly on uneven surfaces and among older adults, who may be put at increased risk of falling [27,29].
DIAGNOSIS
Clinical diagnosis — The diagnosis of hallux valgus (HV) can be made clinically, as it is easily recognized on physical examination (picture 1 and picture 2). The HV deformity is a lateral deviation of the hallux (great toe) on the first metatarsal (figure 4). The deviation of the hallux occurs primarily in the transverse plane. The deformity often also involves rotation of the toe in the frontal plane causing the toenail to face medially (ie, eversion/valgus).
Complications — HV can lead to a number of painful complications in or around the first metatarsophalangeal (MTP) joint, many of which may be clinically evident upon physical examination. These include [30-32]:
●Inflammation of a medial bursa protecting the joint (most common)
●Degeneration of the crista on the plantar surface of the metatarsal head (figure 5), caused by erosion as the metatarsal moves over the sesamoids
●Entrapment of the medial dorsal cutaneous nerve as it passes through the enlarged bunion area
●Hammertoe deformity of the second toe, caused by destabilizing pressure from the laterally deviated great toe
●Central metatarsalgia, caused by the patient's chronic shifting of weight from an unstable first ray onto the central rays
●Degeneration of the cartilage covering the metatarsal head
●Synovitis of the MTP joint
Imaging in select patients — For the majority of patients with HV deformity and non-severe symptoms, radiography is not performed. However, for patients with severe or refractory symptoms, radiographs may be helpful to determine the presence and extent of damage to the articular surfaces of the first metatarsophalangeal (MTP) joint. In addition, when surgery is being considered, radiographs are essential to assess the severity of the deformity and select the appropriate surgical procedure (algorithm 1 and image 1). Two weightbearing views, including a dorsoplantar (DP) plus an additional projection, such as an axial view to assess sesamoid position or rotation of the metatarsal, are typically obtained.
TREATMENT
Initial conservative management — Based upon hundreds of published studies assessing conservative and surgical treatments, there is little evidence that conservative treatments are useful for the management of hallux valgus (HV) deformity. Nevertheless, we agree with the American College of Foot and Ankle Surgeons and suggest that most patients are initially managed with conservative therapies before surgical referral is made (algorithm 1) [33]. In our clinical experience, it is possible for patients with mild symptoms to attain good symptomatic relief with footwear modifications, such as a low heel, wider toebox, or focused stretching of the shoe upper. However, patients with severe pain or dysfunction and those whose symptoms do not improve with conservative management should be referred for surgical treatment. (See 'Surgery for severe or refractory symptoms' below.)
There are few randomized trials looking at conservative treatments for HV in adults [34]. Despite the dearth of evidence, we suggest the following nonoperative treatments are considered for all patients to alleviate symptoms and possibly help prevent progression of HV deformity [33]. The choice of conservative treatment will be dependent upon anatomical and biomechanical features, such as degree of HV deformity and severity of symptoms. Nonoperative measures include:
●Footwear modification – We instruct all patients with HV deformity to wear low-heeled shoes with a wide toe box, or specially altered shoes with increased medial pocket for the first metatarsophalangeal (MTP) joint to minimize pressure on the joint. Patients may be able to adequately modify their existing footwear with a shoe box stretcher with bunion attachments.
●Orthoses – In the treatment of HV deformity, orthoses (prefabricated or custom-made) are used to improve foot mechanics (eg, reducing abnormal subtalar joint pronation) and to prevent abnormal forces from acting on the first ray complex (picture 3). It is hoped that orthoses might prevent further deterioration of the HV angle and relieve pain by improving joint function. Orthoses need to be worn in a low-heeled, well-fitting, fastening shoe (ie, non-slip-on shoe); this type of shoe may itself help support joint position and reduce discomfort.
•In subjects with rheumatoid arthritis (RA), orthoses have been shown to prevent progression of HV deformity. In a randomized controlled trial including 102 patients with active RA, treatment orthoses reduced the chance of progression of the hallux abductus (HA) angle compared with placebo orthoses over three years (adjusted odds ratio 0.27, 95% CI 0.08-0.92) [35]. However, in the same study, measures of pain, disability, and function of the foot showed little difference between the treatment and control groups. Furthermore, the majority of patients in the trial were male, and these results may not apply to women who comprise the majority of patients with HV deformity.
•In another randomized trial comparing orthoses with no treatment in patients with painful, mild to moderate HV deformity, those wearing orthoses reported improved pain scores after six months, but these improvements were not maintained thereafter [36]. At one year, the self-reported global assessment for the orthosis group was improved compared with the control group (“better,” 46 versus 24 percent; “worse,” 11 versus 34 percent). In the same study, surgery (chevron osteotomy) outperformed orthoses for all outcomes. The study did not evaluate HA angle progression.
●Splinting – Splints can be used to place the toe in a corrected position in the hope of enabling soft tissue adaptation and delaying rupture of the medial joint capsule and collateral ligament, although there is little evidence that such interventions improve long-term outcomes. The most commonly used devices are night splints (typically prefabricated/over-the-counter devices), which realign the hallux while nonweightbearing (picture 4). A splint is typically worn at night. For daytime wear, wedges can be placed between the first and second toe (toe separator).
Studies of splinting for HV are inconsistent and often limited by their small sample sizes, risk of bias, and other methodologic flaws:
•In a randomized trial including 90 patients with HV, custom-molded silicone night splints were found to reduce deformity over 12 months of wear compared with usual care, in whom the deformity increased slightly [37]. The reduction in deformity in the night splint group was approximately 3 degrees, which was less than the clinically relevant change of 5 degrees set by the study authors. Further, both the treatment and control groups had a similar reduction in pain.
•In another randomized trial, night splints were ineffective in reducing pain associated with HV deformity, although progression of deformity did not occur in either group over six months [38].
•Night splints were more effective in reducing deformity and pain than a toe separator, but they were less effective than exercises in another small study [39]. However, the mean decrease in HA angle was approximately 2 degrees, which was within the range of measurement error.
•In a three-month observational study of 30 patients comparing night splints with a toe separator attached to a semi-rigid insole, the use of night splints was not associated with a reduction in pain, while the toe separator/insole was [40]. There were nonsignificant reductions in the HA and intermetatarsal (IM) angles in both groups. The reduction of pain in the insole group was felt to be possibly attributable to the change in footwear.
•In an observational study including 30 individuals with HV, traditional night splints were compared with a custom slipper-splint containing a toe separator that could be worn day or night. Although there was a small reduction in the HV angle in the custom slipper-splint group after one year, the changes were not significant [41,42].
●Stretching and/or mobilization/manipulation – Mobilization involves slow repeated movements within the range of motion, stretching involves applying sustained pressure to take the joint to its end of range of motion, and manipulation involves the rapid movement of the joint beyond the current range of motion.
Manipulation/mobilizations are undertaken by trained professionals such as physical therapists, chiropractors, and podiatrists. These are undertaken in a supervised clinical setting and then maintained by the patient at home through further stretching and specific exercises.
•A randomized controlled trial including 56 females with moderately symptomatic HV compared mobilization, exercise, and toe splinting with no treatment [43]. At 12 months, the treatment group had improvements in pain, functional, and strength scores compared with the control group. In addition, the HV angle improved by approximately 7 degrees in the treatment group at 12 months’ follow-up compared with the control group, where the deformity remained static.
•Two small preliminary studies also suggest that graded mobilization and manipulation may be associated with improved pain and function in the short term, but further study of long-term effects is needed [44,45].
●Bunion pads – Medial bunion pads applied to the overlying skin can prevent skin irritation due to friction.
●Ice – Ice can be applied to the area after activity as needed (for 15 to 20 minutes, not applied directly to the skin to avoid skin injury) to reduce inflammation.
●Analgesics – If necessary, systemic analgesics can be used after activity or when there is pain that is not responsive to rest or topical ice. We advise the use of nonsteroidal antiinflammatory drugs (NSAIDs) if tolerated and there are no contraindications (eg, ibuprofen 400 to 600 mg orally every eight hours as needed, or acetaminophen 325 to 1000 mg orally every eight hours as needed). These medications should be taken at the lowest effective dose and for the shortest period of time. (See "Nonselective NSAIDs: Overview of adverse effects" and "Approach to the management of chronic non-cancer pain in adults", section on 'Pharmacologic therapy' and "Acetaminophen (paracetamol) poisoning in adults: Pathophysiology, presentation, and evaluation".)
Surgery for severe or refractory symptoms — The decision to consider surgery is based primarily upon the severity of symptoms, such as pain and difficulty with ambulation; neither the clinical or radiographic appearance of the deformity plays a significant role in this decision. We suggest that patients with severe pain or dysfunction (eg, pain or difficulty with ambulation) and those with refractory symptoms despite a conservative treatment regimen should be referred to a foot surgeon (algorithm 1). Although there is no required duration of conservative therapy, some guidelines suggest a trial of at least three months [46].
Both orthopedic and podiatric specialist foot surgeons, as well as nonspecialists, perform operations to repair HV deformity. No study has compared the results of surgery based on who performed the procedure, however, we advise that patients be referred to a foot surgery specialist with experience repairing HV deformity.
Procedures — Approximately 150 surgical procedures for the correction of HV deformity have been described. Most surgical procedures are undertaken using an open approach that results in a dorsal scar of 3 to 5 cm. In addition, there are minimally invasive procedures that use direct imaging techniques and involve correction of the deformity through a small incision, leaving a scar of only 1 cm.
No matter which surgical approach is employed, all procedures involve one of the following techniques:
●Arthrodesis – Fusing the MTP joint or the metatarsocuneiform joint in a corrected position.
Fusion of the first MTP joint is rarely performed unless there is severe degeneration of the joint and good function is unlikely to be regained were only joint position corrected. The procedure is usually reserved for older patients. Walking on a fused MTP joint alters foot mechanics during gait and can cause secondary hyperkeratoses to develop. A study of 81 patients treated with first MTP arthrodesis reported success in relieving joint pain, improving walking distance, and improving appearance after a minimum follow-up of 24 months [47].
Fusion at the metatarsocuneiform joint (Lapidus procedure) is used when the mobility of the first ray is excessive. A study of 87 patients found that the Lapidus procedure combined with a soft tissue correction was successful in reducing the HA and IM angles as well as improving the American Orthopaedic Foot and Ankle Society (AOFAS) functional score [48]. Eighty-four percent of patients considered the surgery satisfactory.
●Arthroplasty – Removing the joint or replacing the joint with an implant.
The most frequently described operation involving removal of the metatarsal joint surface is called the Keller’s arthroplasty. Joint replacement arthroplasty involves removing either just the metatarsal joint surface or both the metatarsal and proximal phalanx joint surfaces and replacing the joint surface/s with a prosthetic joint implant.
In a study comparing Keller's arthroplasty with arthrodesis, 75 percent of arthroplasty patients were completely satisfied postoperatively, and 88 percent experienced complete pain relief [47]. However, 12 percent experienced an increase in pain. In addition, some patients needed up to 30 months before experiencing improvement. Overall, there was little difference in outcomes between the arthroplasty and arthrodesis groups. In a small study comparing Keller's arthroplasty with distal metatarsal osteotomy, there were larger residual HA and IM angles in the arthroplasty group, but there were similar overall satisfaction and pain relief between groups [49].
●Osteotomy – Cutting the first metatarsal and realigning the bone in a less adducted position.
The bone cut made during an osteotomy varies in shape and position, depending upon the surgical strategy. As an example, a straight cut is used in the Wilson osteotomy, whereas a wedge-shaped cut is used in the chevron osteotomy. The cut may be made near the neck of the metatarsal (distal osteotomy), in the shaft (scarf osteotomy), or near the base (proximal osteotomy). Although a greater degree of correction is possible through proximal osteotomies, these procedures require larger dissections and have higher complication rates. Generally, the surgeon tries to minimize metatarsal shortening and to maintain the metatarsal's plantar-flexed position. The chevron osteotomy has been studied most closely.
In a randomized trial including 209 patients that compared chevron osteotomy with treatment with orthosis or no treatment, osteotomy outperformed both nonoperative alternatives [36]. At 12-month follow-up, the HA and IM angles in the osteotomy group were within normal range, and 80 percent of patients were satisfied with their treatment. Nevertheless, 61.5 percent of the surgical patients still had "moderate" footwear problems, and half had experienced some pain within the previous six months. The surgery group also had the highest foot care costs and took the greatest number of sick days. In trials comparing chevron with other types of osteotomies, the chevron has done as well as [50,51] or outperformed its comparison procedure [52] either in terms of correction of deformity or in reduced adverse outcomes; the chevron procedure was often the less technical procedure performed in these comparisons.
●Bunionectomy – Removing the prominent side of the metatarsal head.
This procedure is rarely performed alone and is typically included with other surgical procedures.
●Tenotomy/soft tissue procedure – Reconstructing the soft tissue (eg, tendons) to pull the bones into a corrected position.
The McBride procedure, an example of such a procedure, involves detaching the adductor tendon from the proximal phalanx and transferring it to the neck of the first metatarsal. These procedures can be performed in conjunction with a bony procedure such as an osteotomy.
One study including 31 patients compared transposition of the adductor hallucis muscle to the lateral metatarsal head (modified McBride procedure) with leaving the tendon detached, and there was no difference in HA or IM angles [53]. In another small study comparing chevron-Akin osteotomy with a distal soft tissue reconstruction plus Akin osteotomy, the soft tissue reconstruction did not correct the HA and IM angles as successfully as the osteotomy alone, but patient satisfaction did not differ significantly [54].
A study including 84 patients compared chevron osteotomy with chevron osteotomy plus adductor tenotomy and found little difference in mechanical correction and no difference in patient satisfaction [55]. Another study comparing chevron osteotomy with and without soft tissue release also reported no difference in HA or IM angles at one-year follow-up [56].
A 2018 systematic review, including 229 studies of a wide range or surgical procedures and outcomes, identified that arthrodesis and arthroplasty procedures had higher percentages of negative outcomes [57]. Recurrence of the HV deformity occurred in 5 percent of cases (average across all the surgical procedures) and postoperative metatarsalgia developed in a similar percentage of patients.
Minimally invasive, or percutaneous, surgery is used with increasing frequency. One small prospective study comparing minimally invasive surgery with open scarf osteotomy found no difference in the degree of correction of the deformity, but the minimally invasive approach resulted in a shorter scar and reduced surgical time [58]. In a randomized control trial comparing the chevron osteotomy with a minimally invasive procedure involving a distal V-shaped osteotomy, no differences in pain, functional, or radiographic outcomes were found [59]. Patient satisfaction was greater for the minimally invasive procedure in the first nine months following the procedure, but there was no difference in satisfaction after this time [59]. These results are consistent with those of other studies included in a systemic review of minimally invasive hallux valgus surgery [60]. Well-performed randomized trials are needed to confirm these results.
Postoperative recovery
Timing — Recovery from surgery depends upon the particular procedure undertaken. If a bony procedure such as an osteotomy is performed, healing corresponds to the time to complete bony union. Observational studies suggest that bony union following such procedures consistently occurs at around six to seven weeks postoperatively even when early weightbearing is allowed [61,62]. However, external factors such as smoking may impair healing and increase the time required [63].
The time needed to return to work also generally coincides with the bone healing time. In a study of 89 patients who underwent osteotomy for HV, the average time to return to work was six weeks, whereas the return to sport was eight weeks [64]. It is likely that functional and cosmetic improvement continue after surgery for at least one year. In a separate study of 59 patients who underwent osteotomy for HV, measures of postoperative patient satisfaction showed continued improvement from 6 to 12 months [65].
Patient expectations — Managing patients’ surgical expectations is important. Patient satisfaction does not necessarily correlate with surgical outcome as determined by radiographic parameters (ie, HA and IM angles) [66].
Patients should be educated that the hallux will not be straight after the operation. Patients should understand that 10 to 25 degrees of valgus angulation is normal at the MTP joint, and that resolution of postoperative pain and swelling may require several months [67].
In addition, they should be informed that they will not necessarily be able to fit into narrower shoes postoperatively; otherwise, they may be dissatisfied if this expectation is not met. One study found that only 2 of 52 patients could wear smaller shoes after their procedure despite a postoperative reduction in foot width [68].
TREATMENTS OF UNPROVEN BENEFIT — There are a variety of treatments for hallux valgus (HV) of unclear or unproven benefit that we do not recommend.
●Botulinum toxin – One randomized control trial compared botulinum toxin type A injections with saline injections and found no difference in outcome for hallux abductus (HA) angle, function, or pain at six months post-treatment [69].
●Marigold ointment – In a single small trial, marigold ointment was effective in reducing pain, soft tissue swelling, and the HA angle when applied to the bunion area over an eight-week period [70]. However, the trial had methodologic limitations which limit the applicability of the results.
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topic (see "Patient education: Bunion (The Basics)")
SUMMARY AND RECOMMENDATIONS
●Anatomy and pathophysiology – Hallux valgus (HV) deformity (bunion) is defined as a lateral deviation of the hallux (great toe) on the first metatarsal (figure 4). The deviation of the hallux occurs primarily in the transverse plane. The deformity often also involves rotation of the toe in the frontal plane causing the toenail to face medially (ie, eversion). Since not all cases of HV deformity become severe, there may be a threshold up to which the forces deforming the joint can be opposed by other anatomic structures. When forces greater than the threshold occur, the joint becomes deformed. (See 'Definitions and basic forefoot anatomy' above and 'Pathophysiology of hallux valgus deformity' above.)
●Diagnosis – The diagnosis of HV can be made clinically, as it is easily recognized on physical examination (picture 1 and picture 2). For the majority of patients with HV deformity and nonsevere symptoms, radiography is not performed. However, for patients with severe or refractory symptoms, radiographs may be helpful to determine the presence and extent of damage to the articular surfaces of the first metatarsophalangeal (MTP) joint. In addition, when surgery is being considered, radiographs are essential to assess the severity of the deformity and select the appropriate surgical procedure (algorithm 1 and image 1). Two weightbearing views, including a dorsoplantar (DP) plus an additional projection, such as an axial view, are typically obtained. (See 'Diagnosis' above.)
●Initial conservative management – In most patients, we suggest initial management with nonoperative therapies rather than surgical referral (algorithm 1) (Grade 2C). Although there is little published evidence that conservative treatments are useful for the management of HV deformity, it is our clinical experience that patients with mild symptoms can attain good symptomatic relief with interventions such as footwear modifications, orthoses, splinting, stretching, mobilization, and/or manipulation, as well as the use of ice, analgesics, and bunion pads. (See 'Initial conservative management' above.)
●Surgical referral for severe or refractory symptoms – The decision to consider surgery is based primarily upon the severity of symptoms, such as pain and difficulty with ambulation; neither the clinical or radiographic appearance of the deformity plays a significant role in this decision. We suggest that patients with severe pain or dysfunction, and those with refractory symptoms despite a conservative treatment regimen, should be referred to a foot surgeon (Grade 2C). Although there is no required duration of conservative therapy, some guidelines suggest a trial of at least three months.
●Recovery and patient expectations – Recovery from surgery depends upon the particular procedure undertaken. If a bony procedure such as an osteotomy is performed, healing corresponds to the time to complete bony union; this occurs at around six to seven weeks postoperatively even when early weightbearing is allowed. In addition, patients should be educated that the hallux will not be straight after the operation. Patients should understand that 10 to 25 degrees of valgus angulation is normal at the MTP joint, and that resolution of postoperative pain and swelling may require several months. They should also be informed that they will not necessarily be able to fit into narrower shoes postoperatively; otherwise, they may be dissatisfied if this expectation is not met.
