In adults with mild‑to‑moderate hallux valgus, is physical therapy alone adequate, or are night splints and corrective insoles the preferred first‑line treatment?

Hallux Valgus: Conservative Management Strategy

For adults with mild-to-moderate hallux valgus, physical therapy combined with footwear modifications and orthotic insoles should be the first-line treatment, as splints and corrective devices cannot correct the deformity but can help control symptoms. 1, 2

Evidence-Based Conservative Approach

Primary Treatment Components

Non-operative treatment cannot correct hallux valgus deformity but effectively controls symptoms through a combination of interventions. 1, 2

• Footwear modifications are essential, requiring foot-conforming shoes that avoid bruising and prevent forced progression of the deformity 2
• Custom orthotic insoles improve functional stabilization and redistribute pressure away from the bunion 1, 2
• Physical therapy and foot gymnastics provide functional stabilization of the foot through active strengthening exercises 2

Role of Splints and Night Devices

The evidence does not support splints or corrective positioning devices as standalone treatments for structural correction. 1

• Toe pads and positioning devices may be used as adjunctive measures for symptom relief, not deformity correction 3
• Night splinting can be added as an adjunctive measure to the overall conservative regimen 4

Comprehensive Conservative Protocol

The staged approach prioritizes outpatient consultation and physiotherapy at the forefront, with additive analgesic or anti-inflammatory medication as needed. 2

• Manual therapies and physiotherapy should be adopted based on existing pathology and pressure symptoms 2
• NSAIDs for pain management during symptomatic flares 2
• Activity modifications to reduce stress on the first metatarsophalangeal joint 3

Treatment Algorithm

Stage 1 (Initial 3-6 months):

• Implement foot-conforming footwear immediately 2
• Prescribe custom orthotic insoles for functional stabilization 1, 2
• Initiate supervised physical therapy with foot strengthening exercises 2
• Add NSAIDs for symptomatic relief as needed 2

Stage 2 (If symptoms persist after conservative trial):

• Reassess deformity severity with weight-bearing radiographs 1
• Consider surgical consultation when conservative measures fail to control symptoms 5, 2

Critical Evidence Regarding Effectiveness

One medium-quality trial demonstrated that surgery (distal chevron osteotomy) is more effective than conservative treatment for pain reduction in the first year (mean difference -15.00,95% CI -22.79 to -7.21). 5

However, this does not negate the importance of an adequate conservative trial first, as:

• Conservative treatment remains the appropriate initial approach for symptom control 1, 2
• Surgery is reserved for patients who fail conservative management with the goal of pain relief and improved quality of life 3

Common Pitfalls to Avoid

• Do not promise structural correction with conservative measures—patient education must emphasize symptom control, not deformity reversal 1, 2
• Avoid relying solely on splints or corrective devices without addressing footwear, orthotics, and functional strengthening 1, 2
• Do not delay surgical referral indefinitely in patients with persistent, disabling symptoms despite 3-6 months of appropriate conservative care 5, 2