What is the treatment for hallux valgus?

Treatment of Hallux Valgus

For symptomatic hallux valgus, surgical correction with distal chevron osteotomy is the most effective treatment, providing superior pain relief and functional outcomes compared to conservative management or no treatment. 1, 2

Conservative Management (First-Line for Mild Symptoms)

Conservative treatment provides symptomatic relief but does not correct the deformity itself. 3, 4

Footwear Modifications

• Prescribe therapeutic footwear with sufficient width at the metatarsophalangeal joints to accommodate the bunion deformity 5
• Ensure shoes are 1-2 cm longer than the foot with adjustable features and firm support 5
• Use open-backed shoes to reduce pressure on inflamed areas 6, 5
• Avoid barefoot walking both indoors and outdoors 6, 5

Orthotic Interventions

• Consider custom or prefabricated orthoses to redistribute pressure and reduce pain 5
• Use cushioning insoles to reduce pressure on the medial aspect of the foot 5
• Apply felted foam in combination with appropriate footwear when other offloading devices are unavailable 6

Pain and Inflammation Management

• Use NSAIDs for pain and inflammation control if not contraindicated 6
• Apply ice to reduce inflammation in reddened areas 5
• Consider topical analgesics as an alternative for patients who cannot tolerate oral NSAIDs 5

Physical Therapy

• Implement stretching exercises targeting the plantar fascia and Achilles tendon 6
• Prescribe strengthening exercises and gait education 5
• Modify activities to reduce pressure on affected joints 5

Additional Measures

• Recommend weight loss if indicated to reduce pressure on the affected foot 6
• Educate patients on daily foot inspection, proper washing and drying, and appropriate nail care 5

Important caveat: Conservative treatment with orthoses provides only short-term symptomatic relief (up to 6 months) and does not prevent progression of the deformity. 1, 4

Surgical Management (Definitive Treatment for Persistent Pain)

Surgery is indicated when pain persists despite conservative management. 3

Distal Chevron Osteotomy (Preferred for Mild-to-Moderate Deformity)

Distal chevron osteotomy is the gold standard for hallux valgus angles ≤35 degrees, demonstrating superior outcomes compared to conservative treatment or no treatment. 1, 3, 2

• At 1 year post-surgery, pain intensity decreases by 19 points more than controls (95% CI: -28 to -10) 1
• 83% of surgical patients report improvement at 1 year compared to 24% in control groups (number needed to treat: 1.7) 1
• Results in good or very good outcomes in 85% of patients and satisfactory results in an additional 10% 3
• Provides better walking speed compared to other osteotomy techniques 2

Proximal Osteotomy (For Severe Deformity)

Severe deformities require a soft-tissue procedure at the first metatarsophalangeal joint combined with proximal first metatarsal osteotomy. 3

• Indicated when conservative measures fail and deformity is severe 3
• No significant difference in outcomes between proximal chevron and other proximal osteotomy techniques 2

Keller's Arthroplasty vs. Arthrodesis (For Advanced Disease)

In elderly patients or those with osteoarthritis, resection arthroplasty (Keller's) is preferred; arthrodesis is reserved for physically active patients. 3

• Keller's arthroplasty has less impact on walking ability compared to arthrodesis 4
• Distal osteotomy preserves joint range of motion better than Keller's arthroplasty 4

Post-Operative Rehabilitation

• Patients can usually bear full weight while wearing a flat surgical shoe immediately after surgery 3
• Early weightbearing is not detrimental to final outcomes 4
• Continuous passive motion appears to improve range of motion and accelerate early recovery 4

Monitoring and Follow-Up

• Regular podiatric assessment every 3-6 months, especially in elderly patients 5
• Monitor for signs of ulceration, particularly in patients with risk factors such as redness or inflammation 5
• Assess for peripheral neuropathy, as decreased sensation increases ulceration risk 5
• Evaluate vascular status by checking pedal pulses to ensure adequate circulation 5

Critical pitfall: 25-33% of patients remain dissatisfied even after successful surgical correction with improved angles and reduced pain, highlighting the importance of realistic pre-operative counseling. 4