1. No category

Conservative Management
of Hallux Valgus:
An Evidence-Based Review
Danielle O’Neill, DPTc
UCSF/SFSU Graduate Program
in Physical Therapy
Personal History
Introduction: Hallux Valgus
• Hallux valgus (HV)
– Abnormal angulation of the
great toe
• Medial deviation of the distal
part of the first metatarsal
• Lateral deviation of the distal
hallux
Norma
l
Hallux
Valgus
(Richardson et al., 2008)
• Bunion
– Increased prominence of the first metatarsal head with swelling
at the medial aspect of the joint (Ferrari et al., 2000; Levangie, 2005)
www.healingfeet.com
Introduction: Hallux Valgus
• Hallux valgus angle:
• Normal 5-10° lateral deviation of the hallux
(Hart et al., 2008)
• HV diagnosis made when angle is > 15°
(Ferrari et al., 2000)
• > 20° indicates a mild deformity
• > 30° = moderate deformity
• > 40° = severe deformity (Tang et al., 2002)
http://www.huffingtonpost.com/neal-m-blitz/bunion-symptoms_b_889357.html
(Richardson et al., 2008)
Hallux Valgus: Prevalence
• Hallux Valgus may develop at any time (Ferrari et al., 2000)
– Children: between 2 and 36%
(Macfarlane & Kilmartin, 2004; Ferrari, 2009; du Plessis et al., 2011)
– Adults: 4-44% of women and 2-22% of men
(Ferrari et al., 2004; Ferrari 2012)
• 15x > prevalence in a shod population than barefoot
(Tehraninasr et al., 2008)
– Dramatic  in HV following high fashion footwear after World
War II (Tehraninasr et al., 2008)
– 2x > prevalence in women in barefoot populations (Ferrari 2012)
Multifactorial Etiology of Hallux Valgus
Intrinsic Factors:
Extrinsic Factors:
• Familial history of HV
• Foot structure:
• Footwear
– Pes planus, pronation of the hindfoot,
muscle imbalance in abductor and
adductor muscles, contracture of the
Achilles tendon, connective tissue
cross linkages
• Generalized joint laxity
• Neuromuscular diseases
– Stroke or cerebral palsy
• Arthritis
• Female gender
(Bayar et al., 2011; du Plessis et al., 2011; Mirzashahi et al.,
2011; Tehraninasr et al., 2008; Brantingham et al., 2005;
Tang et al., 2002; Ferrari, 2012)
– High heels or narrow
toe boxes
• Trauma
Introduction: Clinical Problem
Hallux Valgus:
• Abductor hallucis: overlengthened
• Progressive valgus deformity
causing angulation at the first
• Lateral
subluxation
(Tehraninasr
et al., 2008) of flexor
metatarsophalangeal (MTP)
tendons at first MTP joint
• Flexors pull the hallux into
both adduction and flexion
• Adductor hallucis and flexor
hallucis brevis muscles adjust
Adductor
to shortened positions
Abductor
(Grioso, 1992)
http://www.gvle.de/kompendium/fuss/0030/0005.html
Introduction: Clinical Problem
Hallux Valgus:
•
•
•
•
•
•
•
 crowding of lesser toes   risk of hammer toe deformities
 secondary osteoarthritis (Tehraninasr et al., 2008)
Pain  impaired gait patterns (Bayar et al., 2011; Nix et al., 2010)
Difficulty selecting comfortable footwear (Bayar et al., 2011)
 balance (Nix et al., 2010)
Functional deficits
 fall risk (Pinto et al., 2008)
http://www.footphysics.co.uk
Methods of Treatment:
Surgical Intervention:
– Most common approach with
> 150 procedures (Ferrari et al.,
2000)
– Involves cutting 1st metatarsal
• May have a temporary metal pin
to hold correction
http://www.privatehealth.co.uk image
Methods of Treatment:
Unpredictable surgical outcomes
– Timing/type of surgical procedure influences success
• Up to 75% failure rates in the juvenile population
– Generalized joint laxity and hypermobility are not surgically
correctable  poor surgical outcomes (Tang et al. 2002)
– Significant risks of post-operative complications (du Plessis et al., 2011)
Post-Operative Complications
Infection
Hallux varus
over-correction
Hardware
failure
Sensory loss
at great toe
Metatarsal
mal-union
Failure to
relieve pain
Metatarsal
non-union
Worsened
pain
Avascular necrosis of
the metatarsal head
(Macfarlane & Kilmartin, 2004; Hart et al. 2008)
Deep vein
thrombosis
Evidence to Support Conservative Interventions
Surgery is costly and may carry significant complications.
The effectiveness of surgery is debatable (du Plessis et al., 2011)
Conservative treatment for symptomatic HV is a viable
alternative to surgical treatment (du Plessis et al., 2011)
Extrinsic factors: shoes should be evaluated and
modified (Tehraninasr et al., 2008)
Intrinsic factors: Restoration of an anatomically and
biomechanically functional foot (Tehraninasr et al., 2008) by correcting
intrinsic factors of the deformity (Macfarlane & Kilmartin, 2004)
Conservative Intrinsic Interventions:
Biomechanical
Taping
Toe
separators
Night
splints
Insole
and toe
separator
• May restore anatomical and biomechanical position
• Soft tissue adaptations  improvement in angle 
decreased pain
• Improved toe alignment may optimize biomechanical function
• Static and dynamic activities
• Propulsion during the gait cycle
(Bayar et al., 2011; Tehraninasr et al., 2008; Bek & Kurklu, 2002; Tang et al., 2002; )
Gait Cycle: Push Off
• Normal mechanics
coonrapidschiropractic.com
www.footankleinstitute.com
Mortier et al. 2012.
• Altered mechanics
Conservative Intrinsic Interventions:
Manual Therapy and Exercise
Joint
mobilization
(I-IV)
Joint
manipulation
(V)
Axial
joint
traction
Foot
exercises
• May break down connective tissue cross linkages   joint
alignment and mobility  improved range of motion
•  pain
• Muscle imbalance:
• Stretch the adductors
• Strengthen the abductors
• Strengthen to stabilize the tarsal and metatarsal bones
(Bayar et al., 2011; Jedynak, 2009; Brantingham et al., 2005; du Plessis et al., 2011; garymoller.com)
Relevance
PTs receive
referrals for
treatment of
hallux valgus
Cochrane Review
1999:
Conservative
interventions HV
No guidelines
exist for
conservative PT
treatment of HV
Patients will
look to PTs for
knowledge of
effectiveness of
conservative
interventions
Newly published
studies
GAP in the
literature
• Are conservative
interventions
successful in
reducing pain,
changing angles,
and improving
function in people
with HV?
Secondary
Primary
Foreground Research Question
• Is there a difference
in patient outcomes
between conservative
interventions that
change the
biomechanics of
the foot and
alignment of the
hallux versus
interventions that
do not?
Question: PICO
Population
• Adolescents and adults with
hallux valgus
• Conservative interventions:
Intervention
Comparison
• Biomechanical approach
• Exercise and manual therapy
approach
• Compared
• Within-groups (pre-post)
• Between groups (Biomechanical
vs Manual Therapy)
Outcomes
• Pain, HV angle, intermetatarsal
(IM) angle, and foot
performance
Hypotheses
Primary
Secondary
Null: There will be no
difference with conservative
intervention for each outcome
measure.
Null: There will not be a
difference in outcome measures
between the biomechanical and
manual therapy groups
Alternate: There will be a
difference in outcomes with
conservative intervention.
Alternate: There will be a
difference between
intervention groups for the
listed outcome measures.
Expected Findings
Search: 8 randomized
controlled trials, case
studies and intervention
studies.
Outcome: Conservative
interventions would be
beneficial and
biomechanical –based
interventions would be
more successful.
http://api.ning.com
• Participants with a
diagnosis of HV
• Written in English or
translated to English
where statistical data
could be used in this
review
Exclusion Criteria
Inclusion Criteria
Methods: Search Criteria
• Surgical intervention
• Data including people
with:
• Rheumatoid
arthritis (RA)
• Neurological
compromise (
sensation or
ability to rate
pain)
Methods: Search
• Databases searched:
– Through January 31, 2013
• Search terms:
– hallux valgus, hallux abductovalgus, hallux abducto valgus, or bunion
• With: physical therapy, physiotherapy, rehabilitation, taping,
conservative intervention, splinting, orthotics, manual therapy,
manipulation, or exercise
• Recursive search
Results of Search
Secondary reviewers
confirmed that the 11 studies
met the inclusion criteria
Summary of Statistical Analysis
• Extracted means and standard deviations (or p-values
and t-values)
• Calculated single group effect sizes (ESs) and 95%
confidence intervals (CIs)
• Calculated Q heterogeneity statistics
– p >0.05 fixed effect model
– p<0.05 random effects model
• Individual ESs were weighted by inverse variance to
calculate the grand ESs and 95% CIs
• Converted back to clinical units
• Z-tests used to compare effect sizes between groups
Results: Biomechanical Group
Study
Design/Gra
de
N
Intervention
Duration
du Plessis
RCT; 1b
15
Night splint
2 weeks
Tang
Intervention;
2b
31
Custom total contact insole
with toe separator
3 months
Tehraninasr RCT; 1b
15; 15
Insole with toe separator vs
Night splint
3 months
Macfarlane
Prospective
study; 2b
21 kids;
42 feet
Night splint
Average 3
years
Mirzashahi
RCT; 2b
30; 30;
30
Slipper splint vs night splint F/u every 3
and toe separator
months; total
1 year
Bayar
RCT; 1b
10
Taping and foot exercises
8 weeks
Jeon
Intervention
study; 2b
15; 24
feet
Taping
15 treatments
in 4 weeks
Demirdel
Intervention
study; 2b
17; 22
feet
Taping
During
session
Bek
RCT; 1b
15; 15
Toe separator; Night splints
3 months
Results: Biomechanical Group
Study
Intervention
Outcome
Measures
Significant
Outcomes
du Plessis
Night splint (NS)
FFI, VAS, HDF
NS= Manual Therapy
Tang
Custom total contact
insole & toe separator
HV angle, NRS-11,
WAS
 pain, HV angle, and
 WAS
Tehraninasr Insole with toe
separator vs Night
splint
VAS, HV angle, IM
angle
Insole and toe
separator  pain
Macfarlane
Night splint
HV angle, IM angle
No  HV angle; IM
angle  <1°
Mirzashahi
Slipper splint vs night
splint & toe separator
HV angle, IM angle
SS  HV angle > NS;
SS  pt satisfaction
Bayar
Taping and foot
exercises
HV angle, VAS, WAS
Taping & ex. > ex.: HV
angle, VAS, WAS
Jeon
Taping
HV angle, pain scale
 pain & HV angle
Demirdel
Taping
Foot performance:
jump tests
Sig  in the 4 jumps &
performance tests
Bek
Toe separator; Night
VAS, HVI right and
NS:  pain;
Results: Manual Therapy Group
Study
Design/Gr
ade
N
Intervention
Duration
Brantingham
Pilot study;
2b
30
Manual therapy II-V
7 weeks
du Plessis
RCT; 1b
15
Manual therapy
4 tx/2 weeks
Follow up 1 mo.
Jedynak
Case study;
4
1
Foot mobilization
Isometric exercise
3x/week/ 3 mo;
6 mo. strength
Bayar
RCT; 1b
20
Foot exercises
8 weeks
Bek
RCT; 1b
15
Manual therapy
3 months
Results: Manual Therapy Group
Study
Intervention
Outcome
Measures
Significant Outcomes
Brantingham
Manual therapy II-V;
Control: de-tuned
action potentials
NRS- 101, FFI,
HAL
 Pain manual therapy
(early & late) > control
group (late)
du Plessis
Manual therapy
FFI, VAS, HDF Pain & disability: Manual
therapy = NS; 1 mo later
MT > NS.
Jedynak
Foot mobilization
Isometric exercise
FSHQ, IM
angle, HV
angle
 pain and 
performance
Bayar
Foot exercises
HV angle,
VAS, WAS
 HV angle and pain,
< taping/ex.
Bek
Manual therapy
VAS, HVI right  pain and  correction
and left
of deformity
NRS: numeric rating scale for pain, FFI: foot function index, VAS: visual analog scale, HDF: hallux
dorsiflexion, FHSQ: foot health status questionnaire for pain and function, HVI: hallux valgus
index
Forest Plots
• Negative ES favors intervention
• CI that does not cross zero is statistically significant
• Data will be presented by outcome measure:
• Pain, HV angle, IM angle, and foot performance
• Data from the two groups:
• Biomechanical Group
• Manual Therapy and Exercise Group
Forest Plot: Pain
Biomechanical
Moderate Grand ES: -0.78 (-1.26, 0.3) model
Random effects
Manual Therapy & Exercise
Large Grand ES: -2.46 (-4.24, -0.68)
Random effects model
Forest Plot: HV Angle
Biomechanical
Moderate Grand ES: -0.63 (-1.19, -0.07)
Random effects model
Manual Therapy & Exercise
Small Grand ES: -0.42 (-1.1, 0.26)
Fixed effect model
Forest Plot: IM Angle
Biomechanical
Large Grand ES: -0.89 (-2.09, 0.31)
Random effects model
Manual Therapy & Exercise
Moderate Individual ES: 0.59 (-2.59, 1.41)
Forest Plot: Foot Performance
Biomechanical
Manual Therapy & Exercise
Positive ES favors
intervention
Large Grand ES: 1.42 (1.01, 1.82)
Fixed effect model
Large Grand ES: 1.81 (0.62, 2.99)
Random effects model
Between Groups: Z-test
Primary
Hypotheses
Secondary
Null: There will be no
difference with conservative
intervention for each outcome
measure.
Null: There will not be a
difference in outcome measures
between the biomechanical and
manual therapy groups
Alternate: There will be a
difference in outcomes with
conservative intervention.
Alternate: There will be a
difference between
intervention groups for the
listed outcome measures.
Clinically Equivalent Values
MCID in
literature
Biomechanics
Group
Manual
Therapy &
Exercise
Group
15mm on VAS
-11.6mm (VAS)
-49.04mm (VAS)
HV Angle
Not found
-2.75°
-7.87°
IM Angle
Not found
-0.09°
-2.5° **
30% change on FFI
-65.12
-41.59
Pain
Foot
Performance
65.1%
41.5%
VAS: Visual Analog Scale
FFI: Foot Function Index
** Only 1 study included
Discussion: Summary of Results
Pain
HV
IM
Foot
Successful
Angle Angle Performance Intervention?
Biomechanical
Group
✓ ✓ ✗
✓
Manual
Therapy &
Exercise
✓ ✗ ✗
✓
Biomechanical
Intervention
Manual
Therapy &
Exercise
✓
✓
Best
Patient
Outcomes
(Bayar et al., 2011)
Cost Analysis
• Cost not directly addressed in
primary studies
• Utilization of healthcare resources and
personal resources
• No cost is associated with HEP exercises
and self-manual therapy
• Equipment:
– HV splint ($20-$40)
– Toe separator ($5 for two)
– Tape ($13/roll)
http://www.vitalitymedical.com; http://www.footsmart.com
Harm & Adverse Events
• No study reported long term harm
• One study utilizing manual and manipulative
therapy had two participants report:
• Temporary discomfort or stiffness resolving
quickly without any serious consequence
(du Plessis et al., 2011)
http://www.tumblr.com/tagged/running%20on%20the%20beac
Limitations
• Search
– One researcher performed search
– Limited databases
• Articles included
– Heterogeneous
– Various intervention types with differing protocols
– Articles translated to English
• Abstract vs full-text available
Implications for Practice
• Conservative management should be attempted prior
to surgical intervention when possible.
• Conservative treatment can be successful for
improving pain and foot performance. It may help
improve HV angle.
• Patient preference and lifestyle should be considered
when making recommendations for footwear and
treatment direction.
Directions for Further Research
• More RCTs with standardized outcome
• More
RCTs
with
standardized
outcome
measures
and
blinded
control groups
and
blinded
groups
• measures
Studies that
assess
thecontrol
lower extremities
for HV
• Studies
that assess
contributing
factorsthe lower extremities for HV
factorswith use of conservative
• contributing
Long-term studies
• Long-term
with use
of conservative
interventionstudies
vs surgical
intervention
surgical
• intervention
More studiesvs
looking
at intervention
adolescent vs adult care
• More studies looking at adolescent vs adult care
Conclusions
• Conservative interventions for HV can make
significant improvements in pain and foot
performance
– Potential improvement in HV angle
• Biomechanical interventions as well as manual
therapy and exercise interventions were successful
• Clinicians may select from many interventions to
best match patient preference
Primary Article References
•
Bayar B, Erel S, Simsek IE, Sumer E, Bayar K. The effects of taping and foot exercises on patients with
hallux valgus: a preliminary study. Turk J Med Sci. 2011;41:403-409.
•
Bek N, Kurklu B. Comparison of different conservative treatment approaches in patients with
hallux valgus [Turkish]. Artroplasti Artroskopik Cerrahi. 2002;13:90–93.
Brantingham J, Guiry S, Kretzmann H, Kite V, Globe G. A pilot study of the efficacy of a conservative
chiropractic protocol using graded mobilization, manipulation and ice in the treatment of
symptomatic hallux abductovalgus bunion. Clinical Chiropractic. 2005;8:117–133.
Demirdel E, Acet S, Hekimoglu I, Polat DS, Baltaci G. The effectiveness on physical performance of
athletic taping in patients with hallux valgus. Fizyoterapi Rehabilitasyon. 2008;19.
du Plessis M, Zipfel B, Brantingham J, et al. Manual and manipulative therapy compared to night
splint for symptomatic hallux abducto valgus: An exploratory randomised clinical trial. The Foot.
2011;21:71–78.
Jedynak T. Treating hallux abducto valgus conservatively through foot mobilisation techniques and
exercise therapy. A case study. PodiatryNow. 2009:12–15.
Jeon MY, Jeong HC, Jeong MS, et al. Effects of taping therapy on the deformed angle of the foot and
pain in hallux valgus patients. J Korean Acad Nurs. 2004;34:685–692.
Macfarlane A, Kilmartin T. Conservative treatment of juvenile hallux valgus -- a seven year prospective
study. Br J Pod. 2004;7:101–105.
Mirzashahi B, Ahmadifar M, Birjandi M, Pournia Y. Comparison of designed slippers splints with the
splints available on the market in the treatment of hallux valgus. Acta Medica Iranica. 2011;50:107112.
Tang SF, Chen CP, Pan J-L, et al. The effects of a new foot-toe orthosis in treating painful hallux
valgus. Arch Med Phys Rehabil. 2002:1792-1795.
Tehraninasr A, Saeedi H, Forogh B, Bahramizadeh M, Keyhani MR. Effects of insole with toeseparator and night splint on patients with painful hallux valgus: A comparative study. Prosthet
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References
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Bayar B, Erel S, Simsek IE, Sumer E, Bayar K. The effects of taping and foot exercises on patients with
hallux valgus: a preliminary study. Turk J Med Sci. 2011;41:403-409.
Bek N, Kurklu B. Comparison of different conservative treatment approaches in patients with hallux valgus
[Turkish]. Artroplasti Artroskopik Cerrahi. 2002;13:90–93.
Brantingham J, Guiry S, Kretzmann H, Kite V, Globe G. A pilot study of the efficacy of a conservative
chiropractic protocol using graded mobilization, manipulation and ice in the treatment of symptomatic
hallux abductovalgus bunion. Clinical Chiropractic. 2005;8: 117–133.
Demirdel E, Acet S, Hekimoglu I, Polat DS, Baltaci G. The effectiveness on physical performance of athletic
taping in patients with hallux valgus. Fizyoterapi Rehabilitasyon. 2008;19.
du Plessis M, Zipfel B, Brantingham J, et al. Manual and manipulative therapy compared to night splint for
symptomatic hallux abducto valgus: An exploratory randomised clinical trial. The Foot. 2011;21:71–78.
Ferrari J. Bunions. Clin Evid (Online). 2009.
Ferrari J, Higgins JPT, Williams RL. Interventions for treating hallux valgus (abductovalgus) and bunions.
The Cochrane Database of Systematic Reviews (Complete Reviews), Issue. Art. No.: CD000964. DOI:
10.1002/14651858.CD000964. 2000.
Ferrari, J. Hallux Valgus Deformity (bunion). In: UpToDate, Eiff P (ED), UpToDate, Waltham MA, April 10,
2012. Accessed December 6, 2012.
Grioso, Jorge. Juvenile Hallux Valgus. J. Bone Joint Surg. 1992;(74-A)9:1367–1374.
Hart ES, deAsla RJ, Grottkau BE. Current concepts in the treatment of hallux valgus. Orthop Nurs.
2008;27:274–282.
Jedynak T. Treating hallux abducto valgus conservatively through foot mobilisation thechniques and
exercise therapy. A case study. PodiatryNow. 2009:12–15.
Jeon MY, Jeong HC, Jeong MS, et al. Effects of taping therapy on the deformed angle of the foot and pain in
hallux valgus patients. J Korean Acad Nurs. 2004;34:685–692.
Levangie PK. Joint structure and function: a comprehensive analysis. 4th ed. Philadelphia, PA: F.A. Davis
Co; 2005.
References
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Macfarlane A, Kilmartin T. Conservative treatment of juvenile hallux valgus -- a seven year
prospective study. Br J Pod. 2004;(7)4:101–105.
Mirzashahi B, Ahmadifar M, Birjandi M, Pournia Y. Comparison of designed slippers splints with the
splints available on the market in the treatment of hallux valgus. Acta Medica Iranica.
2011;(50)2:107-112.
Nix S, Smith M, Vicenzino B. Prevalence of hallux valgus in the general population: a systematic
review and meta-analysis. J Foot Ankle Res. 2010;3:21.
Pinto D, Smith MB, MacDonald C, Abbott JH. Effects of manual physical therapy and exercise in mild
hallux valgus: a single subject design. J. Man. Manip. Ther. 2008;(16)3:178–179.
Richardson ML, Hansen ST, Kilcoyne RF. Radiographic Evaluation of Hallux Valgus. Departments of
Radiology and Orthopaedic Surgery, University of Washington. 2008. Available at:
http://www.rad.washington.edu/academics/academic-sections/msk/teaching-materials/radiologicexhibits/radiographic-evaluation-of-hallux-valgus/?searchterm=hallux%20valgus. Accessed 6
December 2012.
Robinson A, Limbers J. Modern concepts in the treatment of hallux valgus. J Bone Joint Surg.
2005;87:1038–1045.
Tang SF, Chen CP, Pan J-L, et al. The effects of a new foot-toe orthosis in treating painful hallux
valgus. Arch Med Phys Rehabil. 2002:1792-1795.
Tehraninasr A, Saeedi H, Forogh B, Bahramizadeh M, Keyhani MR. Effects of insole with toeseparator and night splint on patients with painful hallux valgus: A comparative study. Prosthet
Orthot Int. 2008;(32)1: 79–83.
Thompson F, Coughlin M. The High Price of High-Fashion Footwear. J Bone Joint Surg Am.
1994;76:1586–1593.
Wikipedia. Hallux Valgus. Available at: http://en.wikipedia.org/wiki/Hallux_valgus. Accessed
verified 6 December 2012.
Thank you!
• Readers:
– Diane Allen, PhD, PT
– Christopher DaPrato, PT, MS, DPT, CSCS, PES
– Thomas Tsai, PT, MS, DPT
– Krista de Leon, DPTc
– Tonya Bowers, DPTc
– Kyle Nekimken
– Family and friends
• UCSF/SFSU Class of 2013
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