What is the initial management for hallux valgus?

Initial Management of Hallux Valgus

Conservative management with properly fitting footwear and orthotic devices should be the initial treatment for hallux valgus before considering surgical intervention. 1

Understanding Hallux Valgus

Hallux valgus is a common forefoot deformity affecting approximately 23% of adults and 35.7% of people over 65. It involves lateral deviation of the great toe (hallux) with medial deviation of the first metatarsal, often resulting in a prominent medial eminence ("bunion").

Assessment and Diagnosis

• Evaluate for:

  • Pain at the first metatarsophalangeal joint
  • Visible lateral deviation of the great toe
  • Prominence of the medial aspect of the first metatarsal head
  • Difficulty with footwear
  • Decreased range of motion in the first metatarsophalangeal joint
  • Secondary deformities (hammertoes, calluses)

• Document specific deformity characteristics and functional impact to guide appropriate management 2

• Assess for erythema, warmth, or signs of skin breakdown which can indicate pre-ulcerative signs 2

Initial Management Algorithm

Step 1: Footwear Modifications

• Recommend shoes with:
  • Adequate length (1-2 cm longer than the foot)
  • Wide, rounded toe box
  • Low heel height
  • Cushioned sole
  • Internal width equal to foot width at metatarsal phalangeal joints 2
• Avoid narrow, pointed, or high-heeled shoes that compress the forefoot

Step 2: Orthotic Devices

• Consider the following options:
  • Toe spacers or separators (personalized 3D printed customized toe spreaders may improve symptoms) 1
  • Metatarsal pads to redistribute pressure
  • Dynamic foot orthoses (preferably biomechanical type with 3/4-length) 1
  • Cushioning insoles to reduce pressure on affected areas

Step 3: Pain Management

• NSAIDs may be used to reduce pain and swelling 3
• Ice application for acute pain or post-activity discomfort
• Activity modification to reduce symptoms

Step 4: Physical Therapy and Exercises

• Toe exercises to maintain joint mobility and strengthen intrinsic foot muscles
• Stretching exercises for the Achilles tendon and plantar fascia
• Regular physical activity with appropriate footwear 1

When to Consider Referral for Surgical Evaluation

Surgery should be considered when conservative measures fail to provide adequate symptom relief. The evidence shows that surgery, specifically distal chevron osteotomy of the first metatarsal, is more effective than conservative treatment for pain reduction in the first year following surgery 4.

Indications for surgical referral include:

• Persistent pain despite 3-6 months of conservative management
• Progressive deformity
• Difficulty with footwear despite accommodative measures
• Development of secondary deformities or complications

Important Considerations and Caveats

• Conservative treatment can only relieve symptoms but cannot correct the deformity or halt its progression 5
• Weight reduction may help control the condition's progress by reducing pressure on the forefoot 1
• Patients should be educated about proper footwear selection and regular foot inspection 2
• Post-surgical orthoses may help maintain correction achieved through surgery 1

Special Populations

• For diabetic patients or those with circulatory issues:
  • More frequent monitoring is necessary
  • Assess for loss of protective sensation using 10-g monofilament testing 3, 2
  • Document pedal pulses to evaluate vascular status 2
  • Consider referral to foot care specialists for ongoing preventive care 3

By following this structured approach to the initial management of hallux valgus, clinicians can effectively address symptoms, potentially slow progression, and determine appropriate timing for surgical intervention when necessary.