Continuing Education Activity

Hallux valgus is a complex forefoot deformity characterized by malalignment of the first ray, most commonly involving the great toe and first metatarsophalangeal joint. Deformity severity varies widely and does not consistently correlate with symptom burden. Symptomatic presentations commonly include pain, erythema, and irritation over the medial eminence, as well as functional limitations affecting ambulation and prolonged standing. Diagnosis relies on careful clinical examination combined with weight-bearing imaging to assess angular deformity and associated articular surface involvement. Initial management emphasizes conservative strategies, including accommodative footwear, over-the-counter or custom orthotics, protective padding, and night splints to reduce symptoms and limit progression. Many patients experience symptom improvement with appropriate nonoperative care. Persistent pain or functional impairment despite conservative measures may warrant surgical correction, with contemporary techniques demonstrating favorable long-term outcomes.

Through this course, the participant develops a comprehensive understanding of biomechanical factors, clinical evaluation, and imaging interpretation relevant to the management of hallux valgus. Instruction emphasizes individualized treatment selection, integrating symptom severity, functional impact, and patient goals rather than radiographic findings alone. Collaboration within an interprofessional team enhances patient outcomes by aligning care among clinicians, physical therapists, podiatrists, orthotists, and rehabilitation specialists. Coordinated communication supports accurate diagnosis, consistent patient education, optimized postoperative recovery, and long-term prevention strategies, promoting evidence-based care across the treatment continuum.

Objectives:

• Assess patient history, physical examination findings, gait mechanics, and functional limitations to determine clinical impact and treatment priorities.
• Describe the key elements involved in obtaining a thorough history, performing a focused physical exam, and conducting an appropriate clinical and radiographic evaluation of hallux valgus.
• Implement appropriate conservative interventions, including orthoses, padding, splints, and activity modification, in the early stages of disease.
• Communicate the importance of a multidisciplinary team approach to the evaluation, management, and long-term care of patients with symptomatic hallux valgus, with particular attention to its impact on patient outcomes.

Introduction

Hallux valgus, commonly referred to as a bunion or juanete, is one of the most prevalent forefoot deformities (see Image. Clinical Bunion Presentation). Hallux valgus is characterized by a lateral deviation of the proximal phalanx of the great toe and a medial deviation of the first metatarsal head, which further results in the adduction of the first metatarsal, a condition known as metatarsus primus varus. The precise etiology of hallux valgus remains unproven; it is generally believed to be multifactorial. The medical literature indicates that the condition is more prevalent in women than in men, with reported ratios as high as 15:1, and is often associated with prolonged use of narrow, poorly fitted shoes, especially high-heeled footwear. This is generally regarded as aggravative versus causative.[1][2]

Diagnosis of hallux valgus deformity is primarily clinical and based on the characteristic deformity with the great toe contracted towards the second digit. Tenderness over the medial bone eminence is common and often associated with a restricted and painful range of motion of the first metatarsophalangeal joint. Radiographic imaging, particularly in weight-bearing, is important for evaluating angular deformity and assessing the joint for incongruence and potential degenerative changes (see Image. Radiographic Hallux Valgus).

Initial management should focus on measures to alleviate symptoms and slow the progression of the deformity. Conservative treatments include ice, stretching, wider shoes, functional and firm orthotic/supportive devices, prescription or over-the-counter nonsteroidal anti-inflammatory drugs, cryotherapy, foot pads or toe spacers, taping, night splints, home or in-clinic physical therapy, and steroid injections. When appropriate treatments fail to provide desired relief or halt the progression of the deformity, or when the deformity compromises the patient's function, surgical management should be considered.

This determines if the patient is a good candidate for surgical correction of the deformity. Surgical outcomes are generally favorable with high patient satisfaction, especially with recent advances in surgical technique and hardware fixation. These focus on proper procedures and candidate selection, simplification of procedures, reproducibility, and more rapid recovery with fewer complications.[1][3][4]

Etiology

The etiology of hallux valgus is now recognized as multifactorial, with triplanar biomechanical influences. This is influenced by intrinsic (foot imbalances) and extrinsic (trauma or ill-fitting footwear) factors.[4] Contributing factors include genetic predisposition, structural and biomechanical abnormalities of the first ray, and environmental factors such as footwear and physical demand. Other factors can include anatomic variations such as a shortened or dorsiflexed first metatarsal, flexible or rigid forefoot varus, pes planovalgus or lateral peritalar subluxation (flatfoot disorder), equinus resulting in forefoot overloading, and first-ray or great-toe hypermobility.[5] 

Systemic and connective tissue disorders may predispose individuals to hallux valgus.[2] Inflammatory and autoimmune conditions such as rheumatoid arthritis, psoriatic arthritis, and gouty arthritis can lead to joint destruction and ligamentous laxity. Similarly, connective tissue disorders such as Marfan syndrome, Ehlers-Danlos syndrome, as well as chromosomal conditions such as Down syndrome, demonstrate higher rates of hallux valgus, likely due to collagen abnormalities and ligamentous imbalances.[5] Neuromuscular conditions, particularly those that lead to muscular imbalances such as cerebral palsy, stroke, and myelomeningocele, can create foot imbalances and influence the development of hallux valgus due to malformation of the firray. While restrictive shoes with narrow, short toe boxes or high heels have traditionally been associated with hallux valgus, contemporary evidence suggests that ill-fitting footwear is more an aggravating than a causative factor.

Recent advances in imaging, combined with biomechanical and genetic research, have further refined the understanding of hallux valgus as a complex triplanar deformity involving the transverse, sagittal, and coronal planes.[6] Weight-bearing computed tomography scans and 3-dimensional (3D) reconstruction studies demonstrate that the first metatarsal not only deviates medially but also pronates and dorsiflexes, resulting in lateral displacement of the sesamoid apparatus and instability of the first ray. This rotational component is now recognized as a significant factor that can be addressed surgically to optimize outcomes compared with traditional surgical methods, thereby reducing recurrence of deformity.[7][6] Regarding the genetic component of hallux valgus, studies have suggested a familial clustering and several heritable traits, including variations in collagen composition, first metatarsal joint morphology, and first metatarsal head shape, that may influence joint function.[8] Modern gait studies suggest that the formation of hallux valgus is influenced by a failure of the dynamic stabilizer function of the abductor hallucis and peroneus longus tendons in maintaining proper first ray alignment.[9]

Collectively, these insights support a multifactorial, 3D analysis of patients with hallux valgus, in which genetic, structural (intrinsic), and mechanical factors dynamically and irreversibly influence one another over time. A greater understanding of how these mechanisms influence the position and function of the great toe joint has led to the development of advanced corrective surgical techniques, including improved arthrodesis of the first metatarsocuneiform joint and minimally invasive bunion procedures. The main goals are to restore alignment of the great toe joint and first ray in all 3 planes, while reducing recurrence rates and promoting faster recovery with fewer complications.[10][11]

Epidemiology

Hallux valgus is a relatively common condition, occurring in approximately 23% of adults aged 18 to 65 and in 36% of adults older than 65.[11][12] Hallux valgus demonstrates a distinct sex-based prevalence, occurring more frequently in women, with reported rates as high as 30% in some cohort studies.[13] Epidemiological study results show a higher prevalence of hallux valgus among shoe-wearers than among habitually barefoot individuals. Although footwear, including heels, may aggravate the condition, it is now considered more an exacerbating factor than a direct cause. Interestingly, even in barefoot populations, women exhibit twice the prevalence of hallux valgus compared with men, supporting the conclusion that its development is primarily influenced by intrinsic anatomic imbalances and genetic predisposition rather than by extrinsic factors such as shoewear.[14][15]

Pathophysiology

The pathophysiology of hallux valgus is multifactorial, reflecting a complex interplay among bony alignment, soft-tissue balance, and dynamic loading forces.[16] Current understanding includes degradation of capsular and ligamentous restraints and instability of the first ray at the first tarsometatarsal joint, leading to the triplanar deformity described above.[17] Regarding alignment, the function of the first ray is normally guided by coordinated activity of the peroneus longus proximally and laterally, and medially by the abductor hallucis brevis, which stabilizes the first ray dynamically and statically against the ground during gait. The collateral ligaments and plantar capsule help maintain joint congruency and stabilize the joint in the transverse plane. When excessive or prolonged plantar pressures occur, often associated with first ray hypermobility or abnormal pronation and instability, the first metatarsal tends to displace medially and dorsally, while the proximal phalanx deviates plantarly and pronates, resulting in a triplanar deformity.

This malalignment progressively stretches and weakens the medial capsule and supporting ligaments, whereas the adductor hallucis and lateral capsule pull laterally at the attachment of the plantar sesamoid apparatus, thereby further accentuating the deformity. Over time, the contracted sesamoid apparatus subluxes laterally along with the out-of-plane rotation of the metatarsal complex, leading to greater joint incongruency and mechanical inefficiency of the flexor hallucis brevis attached to the sesamoids and base of the proximal phalanx. Recent advances in imaging, including weight-bearing computed tomography scans, have confirmed that hallux valgus is a true triplanar deformity with abnormal positioning in all 3 planes.[18] This evolving understanding of deformity and multi-level instability has fundamentally changed surgical correction and contributed to greatly improved long-term surgical outcomes.[19]

History and Physical

History

Hallux valgus deformity most commonly presents with a chronic, progressive onset. Patients typically report gradual widening of the forefoot, accompanied by pain, swelling, and irritation or redness over the medial aspect of the first metatarsal head. The proximal phalanx pronates and deviates laterally, while the first metatarsal head deviates medially, producing the characteristic bunion prominence. Patients typically present with a chronic onset of sharp or deep pain at the metatarsophalangeal joint, exacerbated by ambulation and by certain shoes that rub/irritate the area. Some patients report secondary pain beneath the second metatarsal head due to first ray instability in the sagittal plane and overload of the second metatarsal head.

Over time, the frequency and intensity of pain increase, often paralleling the progression of hallux valgus deformity. This progression is also typically marked by a visible increase in the severity of the deformity and by greater difficulty in finding properly fitting shoes. Patients may also report tingling, numbness, and burning along the dorsomedial aspect of the great toe joint, consistent with compression of a branch of the medial dorsal cutaneous nerve.

Common signs associated with hallux valgus and the associated mechanisms include:

• Increased medial bunion prominence over the first metatarsal head, leading to friction, skin and nerve irritation, and underlying bursitis as the body attempts to pad/cushion the area
• Crowding or overlapping of the adjacent toes, resulting in callus and corn formation
• Transfer pressure across the lesser metatarsals, particularly the second, causing metatarsalgia, predisposing to disruption or injury of the second metatarsal and toe plantar plate, and ultimately resulting in a complex hammer toe deformity and contracture

Additional sequelae include blisters, ulceration, interdigital keratosis, and irritated skin adjacent to the deformity.[20] These symptoms can lead to functional limitations, gait alterations, and reduced quality of life.

Physical Examination

A comprehensive physical examination of the bilateral feet and ankles is essential to assess the severity of the deformity and identify contributing factors, such as biomechanical defects or soft-tissue imbalances. This should include both non-weight-bearing and weight-bearing assessments.

General biomechanical assessment

The examination should include an evaluation of the forefoot and rearfoot alignment, first-ray mobility, and subtalar and midtarsal joint flexibility. Key findings to document include:

• Forefoot or rearfoot varus/valgus alignment
• First-ray hypermobility or instability at the tarsometatarsal joint
• Pes planovalgus or pes cavus deformity
• Achilles and gastrocnemius tightness (equinus)
• Resting calcaneal stance position (inverted, everted, or neutral)
• Tibial torsion assessment
• Gait evaluation for compensatory pronation or lateral column overloading

Non-weight-bearing exam

• Hallux position: Assess the transverse plane relationship relative to the second digit (underlapping, overlapping, or neutral).
• First metatarsophalangeal joint inspection: Evaluate the medial eminence prominence, range of motion, congruency, quality of motion (noting any crepitus or limitation hinting at arthritic adaptation), and any signs of inflammation or bursitis.
• Range of motion: Measure active and passive range of motion. Normal values are 15° of dorsiflexion and 65 to 75° of plantarflexion. Assess for pain, crepitus, or mechanical block.
• Axis of motion: Determine whether or not the great toe joint is congruent or deviated, suggesting subluxation.

Weight-bearing exam

Weight-bearing assessment reveals the extent of the deformity and any compensatory biomechanics. Things to observe are:

• Hallux abduction, metatarsal head prominence, and rotation of the hallux (frontal plane pronation).
• Assess the first ray alignment and stability, checking for hypermobility or elevation.
• Evaluate hallux purchase (ground contact of the distal phalanx) and metatarsophalangeal joint dorsiflexion under load.
• Note any other associated findings such as metatarsus primus varus, metatarsus adductuctus, cross-over second toe deformity, or predislocation syndrome, or lesser toe contractures.

Evaluation

Laboratory Assessment

Routine laboratory testing is not typically indicated in the evaluation of hallux valgus unless there is clinical suspicion of an underlying metabolic, inflammatory, or systemic condition. When appropriate, laboratory studies may include the following:

• Rheumatoid factor and antinuclear antibody testing to evaluate for autoimmune or connective tissue disorders.
• C-reactive protein and erythrocyte sedimentation rate to assess for systemic inflammatory activity.
• Serum uric acid levels are evaluated in the context of gouty arthropathy.
• Complete blood count to screen for systemic infection or anemia.

If osteomyelitis or deep infection is suspected, particularly in cases of ulceration, failed prior surgical intervention, or for an immunocompromised patient, advanced imaging such as magnetic resonance imaging, single-photon emission computed tomography scan, or a white blood cell-labeled radionuclide bone scan may be considered to evaluate for osseous involvement or soft-tissue abscess formation, especially if surgical intervention is being considered.[21]

Imaging Modalities

While the diagnosis of hallux valgus is primarily clinical, imaging is necessary to quantify the deformity, assess joint integrity, and guide surgical planning. Weight-bearing radiography remains the gold standard.[22]

• Anteroposterior view: Demonstrates the hallux valgus angle (HVA) and the intermetatarsal angle (IMA). The sesamoid position should be viewed. The presence of metatarsus adductus and articular congruency of the first metatarsophalangeal joint should also be noted, as these would affect surgical planning.[23]
• Lateral view: Assess for first ray elevation or plantarflexion, dorsal exostosis, and sagittal plane alignment
• Oblique projection: Provides information on bone stock, trabecular pattern, and cortical continuity.
• Sesamoid axial view: Evaluate the sesamoid position and integrity of the crista. This also helps to assess for subluxation or arthritic changes.

Radiographic classification and severity

Radiographic classification helps determine the extent of the deformity and is often used to guide the appropriate surgical approach when necessary. Severity is typically defined by the HVA and IMA (see Table. Hallux Valgus Severity Classification).

Table

Table. Hallux Valgus Severity Classification.

*Adapted from standard radiographic hallux valgus assessments [22]

Additional radiographic parameters to assess include distal metatarsal articular angle, proximal articular set angle, hallux interphalangeal angle, metatarsus adductus angle (Engle angle), and sesamoid position grading (Hardy and Clapham).[24][25]

Weight-bearing computed tomography and virtual surgical planning

Advancements in technology have enabled more modern assessments that incorporate weight-bearing computed tomography scan data, which are then converted into a 3-dimensional model that provides a more accurate representation of the deformity morphology and better insight into its biomechanical implications.[26] This allows the functional load-bearing of the foot to better demonstrate the true nature of the deformity, quantify the frontal plane rotation of the first metatarsal, evaluate the sesamoid position, assess joint congruity and instability, and aid in advanced preoperative and virtual surgical planning (VSP). See Image. Anatomic 3D Modeling of Foot Deformity. 

VSP allows the surgeon to accurately measure the deformity and "rehearse" the corrective osteotomies to identify the optimal technique to correct the deformity.[26] The 3D data derived from VSP can then be used to create patient-specific cutting guides to achieve the correction rehearsed during the VSP session.[27] While there is currently no literature reviewing the use of patient-specific cutting guides for the correction of complex bunion deformities, the United States Food and Drug Administration has approved this approach, and several companies are actively developing this technology to bring it to market, with the aim of making surgical intervention more predictable and reproducible.

Treatment / Management

Initial management of hallux valgus should focus on addressing symptoms and slowing the progression of deformity, rather than on permanent correction. The American College of Foot and Ankle Surgeons and the American Orthopaedic Foot and Ankle Society recommend initial conservative therapeutic measures before considering surgical intervention. Surgical treatments are typically reserved for progressive conditions and for patients who do not respond to conservative measures. Nonoperative strategies are most appropriate for mild-to-moderate deformities or for patients who are poor surgical candidates.

Nonoperative Treatment Modalities

• Footwear modification: The use of wide-toe-box shoes with stretchable uppers helps reduce pressure and friction at the medial eminence, and the avoidance of high-heeled footwear.
• Orthotic intervention: The use of custom or over-the-counter medial arch supports and first ray stabilizing orthoses can be used to redistribute pressure and stabilize the first ray
• Pharmacologic and topical therapies: Short courses of nonsteroidal anti-inflammatory drugs, topical analgesics, and anti-inflammatories or cryotherapy can manage inflammation, bursitis, and capsulitis, often associated with hallux valgus deformities
• Activity modification: Reducing high-impact or prolonged weight-bearing activities is recommended to allow inflammation to subside. Avoidance of activities known to aggravate the condition should also be considered.
• Padding and splinting: Bunion pads, toe spacers, taping, and night splints may help to alleviate localized irritation. Splints may give relief, but are not considered corrective.

While these measures can improve function and comfort, results of studies typically show that conservative measures do not reverse or halt the progression of the deformity. The primary goals, therefore, are relief of symptoms, improved shoeware tolerance, and quality of life.

Surgical Intervention

Surgical management of hallux valgus is indicated when conservative measures fail to alleviate the patient's symptoms or when the deformity causes functional limitations, difficulty with shoe selection, or secondary pathologies, such as digital deformities, metatarsalgia, or recurrent bursitis. There has been a substantial evolution in the approach to bunion correction over recent years. Traditional procedures, including distal and proximal metatarsal osteotomies (such as Chevron, Scarf, or closing base wedge techniques) and first tarsometatarsal joint fusion via the Lapidus procedure, have demonstrated predictable outcomes in the literature when appropriately indicated.

However, these techniques primarily address deformity in the transverse plane and are limited in their ability to correct the rotational component of hallux valgus. As a result, unrecognized or untreated first ray instability may lead to undercorrection of the deformity and an increased risk of recurrence.[28] At this time, the most significant advances in bunion correction have centered on incorporating triplanar correction into the surgical approach. See Image. Traditional Bunion Procedures.

Traditional osteotomies

As mentioned above, conventional approaches typically employ an osteotomy of the first metatarsal, in which either a wedge is removed or the bone is shifted into a less adducted position. The cut varies in position and shape depending on the surgical strategy. For example, a Wilson osteotomy utilizes a straight cut, while a Chevron osteotomy uses a wedge-shaped cut.

The location of the cut may occur near the base of the metatarsal (proximal osteotomy), in the shaft (scarf osteotomy), or in the neck (distal osteotomy). Until recently, the Chevron osteotomy was the most commonly used approach for bunion correction.[29] Although Chevron osteotomy is the gold standard, results from more recent studies have demonstrated that traditional osteotomies that don't account for frontal-plane/triplanar correction have recurrence rates ranging from 20% to 60%.[29][30]

Arthroplasty procedures

Arthroplasty of the first metatarsophalangeal joint aims to relieve pain while preserving joint mobility. This approach is typically reserved for low-demand or older adults with advanced degenerative changes of the great toe joint, prior failed corrective procedures, or contraindications to osteotomy or fusion. Surgical options include hemiarthroplasty (with or without resurfacing implants), total joint arthroplasty, and interpositional or resection arthroplasty, such as the modified Keller procedure.

Hemiarthroplasty replaces a single articular surface, most commonly the base of the proximal phalanx, and emphasizes preservation of joint length with minimal bone resection. This technique is generally favored when degenerative changes are confined to one side of the joint. Total joint arthroplasty involves resurfacing both sides of the joint; however, long-term survivorship data remain inconsistent, with relatively high complication rates, including implant loosening and instability, often necessitating revision surgery.[31][32] Interpositional arthroplasty and the Keller resectional arthroplasty are performed in patients with severe hallux rigidius who require pain relief but wish to maintain joint motion. The Keller arthroplasty remains the most commonly used motion-sparing technique for advanced arthritic changes. However, in the presence of hallux valgus, the toe position can be unpredictable, leading to transfer metatarsalgia, hallux shortening, or a cock-up toe deformity. See Image. Implant Arthroplasty of the Great Toe.

Soft-tissue rebalancing procedures

Soft-tissue rebalancing is integral to most hallux valgus reconstructive procedures but can also be performed as a primary corrective procedure in mild deformities or as an adjunct to bony realignment. The modified McBride procedure, for example, focuses on releasing the adductor hallucis tendon, the fibular sesamoidal ligament, and tightening the medial capsular ligament. The goal is to restore balance of the great toe joint in the transverse plane while fine-tuning the sesamoid position under the metatarsal head. However, excessive lateral soft-tissue release or overtightening medially can result in joint stiffness, hallux interphalangeal flexion, metatarsophalangeal (MTP) joint extension, medial drift, and hallux varus. Currently, soft-tissue techniques are used adjunctively and should complement, rather than replace, bony correction.[33] See Image. Soft-Tissue Rebalancing of the Great Toe.

Arthrodesis procedures

The first MTP joint can be fused in a corrected position, a procedure generally reserved for patients with severe deformity, marked joint instability, or advanced arthritic changes.[34] This has traditionally been performed when the joint is severely degenerated, and regaining function is unlikely.[35] Although this approach is generally reserved for older patients, it may also be considered in younger individuals, particularly when managing a previously failed bunion correction without infection, or when treating a severe deformity with instability and an elevated intermetatarsal angle.[34]

Postoperatively, up to 81% of patients report pain relief and improved ambulation. However, nonunion rates have been reported as high as 20%. Patients may also experience limitations with footwear, particularly difficulty wearing heels, metatarsalgia during weight-bearing or transfers, and stiffness of the first MTP joint. See Image. Great Toe Joint Fusion in Hallux Valgus.

Another arthrodesis option is fusion of the first tarsometatarsal (TMT) joint, commonly referred to as the Lapidus procedure. Traditionally, the Lapidus procedure was often reserved for cases of hypermobility of the first ray and severely increased hallux valgus and first intermetatarsal angles. The first TMT joint is considered the center of rotational angulation, or the apex of the deformity, and several studies have suggested more reliable, longer-term results regarding recurrence rates versus traditional osteotomies for the correction of hallux valgus.[36] More recently, arthrodesis at this level has been modified to address triplanar hallux valgus deformity and has demonstrated improved functional outcomes, reduced recurrence rates, and earlier return to weight-bearing activities.[37] 

Newer Generation Bunion Techniques

Instrumented triplanar lapidus

Recent advances in understanding hallux valgus as a true triplanar deformity have led to the development of surgical techniques that emphasize triplanar anatomic correction. These approaches are supported by modern instrumentation designed to assist surgeons in accurately restoring the position of the first metatarsal relative to the second, as well as by cutting guides that improve the reproducibility of optimal correction across surgeons with varying levels of experience.[6][32] This approach restores alignment of the great toe (and sesamoid) across the transverse, sagittal, and coronal planes.

As a result, the modified and instrumented Lapidus, which addresses the triplanar nature of the deformity, has become widely accepted and yields improved results compared with more traditional Lapidus techniques.[38] This approach, combined with newer anatomically designed hardware, has also been shown to allow much earlier weight-bearing (typically within 1 to 2 weeks) compared with the traditional Lapidus (6 to 8 weeks of non-weight-bearing). Prospective multicenter data of up to 4 years have demonstrated sustained angular correction, bony union at 6 to 7 weeks, and higher patient satisfaction rates.[4] See Image. Triplanar Lapidus Correction.

Minimally invasive surgery

Another significant, relatively recent advancement in the correction of hallux valgus came with the renewed interest in percutaneous corrective techniques. While minimally invasive surgery (MIS) is not new, a more recent emphasis on achieving triplanar correction with this approach has led to MIS gaining traction due to the correction being achieved through smaller incisions with less soft-tissue dissection and faster recovery times compared to more "open" traditional techniques. Additionally, this approach preserves both the first MTP and first TMT joints without requiring fusion.[10] 

The newer minimally invasive techniques are increasingly popular. Results from a study comparing the traditional open osteotomy approach with the MIS Chevron osteotomy found no significant difference in surgical success. However, surgical time was shorter and scar size smaller with the minimally invasive procedure. In addition, a randomized controlled trial comparing open versus MIS osteotomies found that clinical and radiographic outcomes were similar between the 2 treatment groups.[39]

Rotational controlled hybrid techniques

Several groups are investigating emerging hybrid methods that combine the stability of open fixation with soft-tissue preservation. Rotational control of the metatarsal head is now considered critical in ensuring the proper alignment and function of the sesamoid apparatus, which acts as a pulley system of the great toe. This realignment further emphasizes the evolution of hallux valgus from the more traditional 2-dimensional to a newer 3-dimensional correction philosophy.

Another area of interest, as mentioned above, is the development of patient-specific instrumentation; the incorporation of weight-bearing computed tomography scan to further elucidate the nature of the deformity; the use of 3-dimensional modeling for VSP; and the use of customized cutting guides. These advancements are aimed at optimally correcting the true deformity, reducing recurrence rates, leveling surgical skill among surgeons, improving the reproducibility and predictability of outcomes, and enhancing patient satisfaction (see Image. Patient-Specific Solution and Virtual Surgical Planning in Hallux Valgus). This patient-specific approach will likely focus on patients with more severe hallux valgus deformities, particularly those with significant metatarsus adductus, in which the optimal position of the first metatarsal depends on the simultaneous correction of the metatarsus adductus.[34]

Differential Diagnosis

Conditions to consider when evaluating patients with a possible hallux valgus deformity include:

• Osteoarthrosis
• Hallux rigidus/limitus
• Turf toe
• Gout
• Septic arthritis
• Metatarsus adductus
• Skew foot
• Trauma
• Peripheral neuropathy
• Peripheral vascular disease
• Avascular necrosis
• Bursitis
• Sesamoiditis
• Ganglionic cyst
• Stress fracture or stress reaction
• Diffuse idiopathic skeletal hyperostosis
• Tendonitis
• Contusion
• Simple exostosis
• Osteochondroma [40]

Staging

Root et al divided hallux valgus deformity into 4 stages, as outlined below:

• Stage 1: Lateral displacement of the hallux at the MTP joint.
• Stage 2: Progression of the hallux abduction (hallux pressing against the second toe).
• Stage 3: Increased intermetatarsal angle, possibly associated with second hammertoe deformities.
• Stage 4: Partial or complete hallux dislocation at the MTP joint.[41]

Prognosis

The overall prognosis for hallux valgus deformity is favorable. Patients should initially undergo a trial of conservative treatment. Surgery may be considered if pain and functional limitations persist despite nonsurgical management. Postoperative recovery depends on the procedure. With any bone procedure, such as an osteotomy, healing takes around 6 to 7 weeks (corresponding to the complete bony union). If the patient is a smoker, the healing may take longer.[42] Patients typically return to work approximately 6 to 12 weeks postoperatively. Improvement has been shown to take up to 1 year postoperatively.[43] 

Postsurgical complications vary depending on the surgical procedure and technique. The more common complications include osseous nonunion, hematoma, numbness, hardware failure, osteomyelitis, cellulitis, avascular necrosis, hallux varus, limited joint range of motion, and recurrence.[44] Recurrence rates for hallux valgus correction vary by procedure, ranging from 10% to 47%. This variability is multifactorial and often reflects anatomic predisposition, patient adherence to postoperative instructions, medical comorbidities, and suboptimal surgical technique or procedure selection.[45]

Complications

Progressive hallux valgus deformities can result in several secondary issues, including:

• Bursitis of the great toe joint (most common)
• Second toe hammertoe deformity
• Plantar plate disruption and cross-over second toe deformity
• Degenerative disease of the metatarsal head
• Central metatarsalgia
• Medial dorsal cutaneous nerve or branch entrapment
• Sesamoiditis or fracture
• Complex regional pain syndrome
• Degenerative arthritis of the first ray or surrounding joints
• Neuroma
• Stress fracture or reaction
• Freiberg disease
• Plantar plate rupture or predislocation syndrome
• MTP joint synovitis [46]

Postoperative and Rehabilitation Care

Postoperative care is primarily determined by the type of procedure performed. A dressing is typically applied during surgery to protect the site, provide mild compression, and help maintain alignment of the corrected toe. Patients should rest, ice, and elevate the limb to reduce postoperative swelling. Sutures are generally removed 2 to 3 weeks after surgery, depending on the procedure. Weight-bearing restrictions vary by procedure but are typically recommended for the initial 2 weeks postoperatively. Non-weight-bearing splints may be indicated for more advanced procedures, such as midfoot fusion.

Newer postoperative protocols emphasize early protected weight-bearing, functional rehabilitation, and real-time outcome tracking using patient-reported outcome measures.[40] Modern fixation devices, including low-profile titanium plates, purpose-designed minimally invasive screws, intramedullary plates, and compressive bone staple systems, enhance construct stability and facilitate accelerated recovery. Postsurgical imaging is typically obtained at 1 week to confirm correction and again at 6 weeks and 3 months to monitor healing and guide activity progression during rehabilitation.

Long-term monitoring is intended to identify underlying etiologic factors and to minimize the risk of recurrence of hallux valgus. Identified contributing factors should be addressed, and postsurgical patients may benefit from orthotic devices, particularly in conditions that accelerate joint degeneration, such as rheumatoid arthritis. By effectively managing these factors, long-term surgical outcomes can be optimized. Strategies to prevent recurrence focus on achieving first-ray stability, sesamoid recentering, and comprehensive triplanar correction.

Deterrence and Patient Education

Hallux valgus, commonly known as a bunion, is a very common painful forefoot condition. Hallux valgus occurs when the big toe gradually shifts toward the smaller toes, creating a visible bump on the medial aspect of the foot. This area may become red, swollen, and painful, especially when wearing tight or narrow shoes. While there is no single cause of bunions, they occur more frequently in women and often become symptomatic in individuals who regularly wear high heels or shoes with a narrow toe box. Other contributing factors include foot structure, inherited genetic traits, and certain medical conditions.

A physical examination is typically sufficient to diagnose a bunion, although x-rays or other imaging studies may be used to assess the severity of the deformity and to guide treatment planning. Initial management generally begins with nonsurgical options such as wearing wider, more supportive shoes, using orthotic inserts or pads, anti-inflammatory medications, icing, padding, and night splints to reduce discomfort and slow progression. When conservative measures do not provide adequate relief, surgical intervention may be recommended to realign the toe and relieve pain. Most patients recover well following surgery, with bone healing typically occurring within 6 to 7 weeks.[47] Total recovery time varies with the surgical technique and individual factors, although many patients return to light activities or work within 6 to 12 weeks.

Tobacco use is an important consideration, as smoking has been shown to delay bone and tissue healing and increase the risk of complications such as delayed union or wound infection. Patients are strongly encouraged to quit smoking prior to surgery and to avoid tobacco use during recovery to optimize outcomes.[43] While improvement is often noted within the initial months, healing and final results may continue to progress for up to 1 year following surgery. Patience, proper wound care, and adherence to postoperative instructions are essential for a successful recovery.

Enhancing Healthcare Team Outcomes

Management of hallux valgus is optimized through coordinated interprofessional collaboration that prioritizes patient-centered care, safety, and evidence-based decision-making. Primary care clinicians are often the initial point of contact and play a critical role in early recognition, risk stratification, patient education, and timely referral. Radiologists contribute by providing accurate interpretation of weight-bearing imaging to assess the severity of deformity and joint integrity. Physical therapists address biomechanical contributors, gait abnormalities, and postoperative rehabilitation, emphasizing functional restoration and recurrence prevention. Surgeons evaluate candidacy for operative correction, select appropriate procedures based on the characteristics of the deformity and the patient's goals, and obtain informed consent through shared decision-making.

Advanced clinicians and nurses reinforce education, monitor wound healing, assess for complications such as infection or nonunion, and coordinate transitions of care. Pharmacists and pain specialists support multimodal analgesia strategies that minimize opioid exposure while maintaining adequate pain control, thereby enhancing safety and recovery. Ethical practice requires transparent communication regarding risks, benefits, alternatives, and realistic expectations for recovery and long-term outcomes. Clear documentation, structured handoffs, and consistent messaging across disciplines reduce care fragmentation and improve adherence. Through effective interprofessional communication, coordinated rehabilitation planning, and shared accountability for outcomes, the healthcare team enhances functional recovery, reduces the risk of recurrence, and promotes optimal long-term outcomes for patients with hallux valgus.

This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare-affiliated entity. The views expressed in this publication represent those of the author and do not necessarily represent the official view of HCA Healthcare or any of its affiliated entities. 

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Disclosure: Adam Perler declares no relevant financial relationships with ineligible companies.

Disclosure: Michael Dixon declares no relevant financial relationships with ineligible companies.

Disclosure: Farhan Alvi declares no relevant financial relationships with ineligible companies.