What are the treatment options for a patient with hallux valgus?

Treatment of Hallux Valgus

For symptomatic hallux valgus, begin with conservative management including properly fitted therapeutic footwear with adequate width at the metatarsophalangeal joints, custom orthoses for pressure redistribution, and physical therapy; reserve surgery for patients who fail conservative treatment after 3-6 months, selecting the surgical technique based on deformity severity and patient factors. 1, 2

Conservative Management (First-Line Treatment)

Footwear Modifications

• Prescribe therapeutic footwear that accommodates the bunion deformity with sufficient width at the metatarsophalangeal joints, adequate length (1-2 cm longer than the foot), adjustable features for dressings if needed, firm support with comfortable fit, and open-backed design to reduce pressure on inflamed areas 2
• Avoid tight-fitting shoes that compress the deformity or create abnormal loading patterns 1
• Refer for specialized footwear if standard shoes cannot accommodate the deformity 1

Orthotic Interventions

• Use custom or prefabricated orthoses to redistribute pressure and reduce pain 2
• Apply cushioning insoles to reduce pressure on the medial aspect of the feet 2
• Consider toe spacers for symptom relief 3
• Assess weight distribution and apply appropriate padding to reduce hyperkeratosis build-up 2

Physical Therapy and Exercise

• Implement strengthening exercises and gait training to improve functional stability 2, 4
• Manual therapy techniques have shown beneficial effects in reducing pain and improving function 4
• Functional stabilization through foot gymnastics or physiotherapy instructions 5

Pain and Inflammation Management

• Apply ice to reduce inflammation in reddened or inflamed areas 2
• Use NSAIDs for pain and inflammation management if not contraindicated 2
• Consider topical analgesics as an alternative for patients who cannot tolerate oral NSAIDs 2
• Implement rest and activity modification to reduce pressure on affected joints 2

Patient Self-Care Education

• Daily foot inspection, especially of reddened areas 2
• Regular washing with careful drying, particularly between toes 2
• Proper nail care (cutting straight across) 2
• Application of emollients for dry skin, avoiding areas between toes 2
• Avoidance of barefoot walking 2
• Daily change of seamless socks 2

Surgical Management (When Conservative Treatment Fails)

Indications for Surgery

• Surgery is indicated when symptomatic hallux valgus persists despite adequate conservative treatment (typically 3-6 months) and the patient's suffering, age, and presence of arthritis in the MTP-I joint warrant intervention 5
• Surgery may result in clinically important pain reduction (18-point reduction on 0-100 VAS scale at 12 months) compared to no treatment 6
• Surgery may result in slight functional improvement (9-point increase on 0-100 AOFAS scale at 12 months) compared to no treatment 6

Surgical Technique Selection

Simple osteotomies (such as V-shaped/Chevron osteotomy) should be preferred over complex osteotomies as they demonstrate similar pain outcomes with potentially lower reoperation rates 6

• Complex osteotomies probably result in little to no difference in pain compared with simple osteotomies but may increase reoperation rates 6
• For hallux ulcers when non-surgical offloading fails, consider joint arthroplasty in combination with an offloading device 3
• Orient surgical therapy based on the severity of pathology and postoperative mobilization possibilities 5

Important Surgical Considerations

• Recurrent deformity occurs in approximately 29% of patients, highlighting the importance of careful patient selection and surgical technique 1
• Delay surgical treatment until after skeletal maturity when possible in juvenile hallux valgus 7
• Functional support with bracing is preferred over immobilization in post-operative management 1

Monitoring and Follow-Up

• Regular podiatric assessment every 3-6 months is recommended, especially in elderly patients, to monitor for progression of deformity and development of complications 2
• Monitor for signs of ulceration, particularly in patients with risk factors such as advanced age and presence of redness 2
• Evaluate vascular status by checking pedal pulses to ensure adequate circulation 2
• Assess for peripheral neuropathy, as decreased sensation increases risk of ulceration 2

Common Pitfalls to Avoid

• Do not use conventional footwear or standard therapeutic footwear alone to treat symptomatic hallux valgus, as this is ineffective 3
• Do not assume hallux valgus is purely a surgical problem—physiotherapeutic treatment has clear evidence of benefit 4
• The presence of redness on the medial aspect suggests inflammation requiring immediate attention to prevent potential ulceration 2
• Hallux valgus can coexist with hallux rigidus (degenerative changes of the MTP-I joint), which requires different management 8