oct01 p075-096 cme · ment of hallux valgus. 4) to be aware of the role of faulty footwear in the...

OCTOBER 2001 • PODIATRY MANAGEMENTwww.podiatrymgt.com 75

do not undergo surgery. Addition-ally, the major role of inadequatetight fitting footwear in the devel-opment of hallux valgus is well es-tablished and accepted by all.1-5

This Continuing Podiatric MedicalEducation Article will focus on hal-lux valgus/bunion deformity and

its non-surgical management withspecial emphasis on the role offootwear in the development andtreatment of this common foot ail-ment.

Hallux valgus is an angular out-ward deviation of the proximal

Continued on page 76

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Following this article, an answer sheet and full set of instructions are provided (p. 94).—Editor

Most of the literature onhallux valgus/bunion de-formity is devoted to sur-

gical correction, although mostpeople with this common problem

By Ellen Sobel, D.P.M., Ph.D., C.Ped.,and Steven J. Levitz, D.P.M.

Objectives

1) To be able to identify andevaluate the hallux abductovalgusdeformity and associated pedalconditions

2) To know the current theoryof etiology and pathomechanics ofhallux valgus.

3) To know the results of recentempirical studies of the manage-ment of hallux valgus.

4) To be aware of the role offaulty footwear in the develop-ment of hallux valgus deformity.

5) To know the pedorthic man-agement of hallux valgus and tobe cognizant of the 10 rules forproper shoe fit.

6) To be familiar with all aspectsof non-surgical management ofhallux valgus and associated de-formities.

Continuing

Medical Education

Hallux ValgusAssessment and

conservative management, and the role

of faulty footwear.

Building YourFOOTWEAR PRACTICE

have observed an increas-ing incidence of bunionsas they have changedfrom traditional sandalsto leather footwear.23

In contrast Gottschalket al . 24 reported fromSouth Africa that halluxvalgus was present inboth urban and ruralAfricans. Similarly Barni-cot and Hardy16 observedthat hallux valgus didoccur in barefootedAfricans in both sexes.The conclusions thatmust be drawn from thesedata are that hallux val-gus and bunions do seemto occur in nonshod indi-viduals, but much less fre-quently than personswearing shoes. As Myer-son notes, approximately4 percent of the worldpopulation develops hal-lux valgus deformity, re-gardless of type of foot-wear or lack thereof.25

Many authors havedescribed the relationship betweenpronation and hallux valgus.26-37

However, this does not mean thatthe relationship is necessari ly

causal. Inman36

felt that prona-tion was a predis-posing factor tothe developmentof hallux valgusonly if significantheel valgus wasp r e s e n t o nweight bearing,but not if thearch alone wassimply flattened.M o r e r e c e n t l yKilmartin and

Wallace38 found that there was noassociation in arch height betweenchildren with hallux valgus andunaffected children. Similarly,other recent studies have found noassociation between hallux valgusand pronation.39,40

Hypermobility of the first rayhas been considered to be one ofthe causative factors of hallux val-gus.1,41 An average of 4.2º of mo-tion has been reported to be pre-sent in the normal first metatarso-

cuneiform joint.42 Clinical signs offirst ray hypermobility have tradi-tionally included the presence of adorsal bunion, callus beneath thesecond metatarsal head and arthri-tis of the first and second metatar-socuneiform joint. Radiographical-ly cortical hypertrophy along themedial border of the secondmetatarsal shaft has been thoughtto be diagnostic of first ray hyper-mobility.

In one recent study hypermo-bility of the first ray was assessedby increased thickness of the medi-al cortex at the midshaft of the sec-ond metatarsal on x-ray.42 In thisstudy there was found to be nocorrelation between clinically in-creased range of motion of the firstmetatarsocuneiform joint and 2ndmetatarsal medial cortical thick-ness, placing into doubt whetherincreased 2nd metatarsal medialcortical thickening is a valid indi-cator of clinical hypermobility ofthe first ray.

First ray hypermobility may ac-tually be a result of hallux valgusrather than an etiology of the con-dition. In a quantitative assess-

phalanx of the hallux occurringin 2 to 15 percent of the U.S. popu-lation.6-8 A bunion is any osseous-cartilaginous enlargement of themedial eminence often combinedwith swelling of the soft tissues.9

EtiologyShoes are the most important

extrinsic factor in the developmentof hallux valgus1-5,10,11 and the majorcause of forefoot pain.5 It has beensaid that perfectly healthy feet aregenerally found only in youngchildren and peoples that go bare-foot.12 In a survey of 905 cases,bunions occurred in females tentimes more frequently than males,suggesting that females, who wearfashionable footwear more thanmen, developed hallux valgus andbunions due to the footwear.13

Coughlin and Thompson14 notedthe extremely high prevalence ofbunions in women in the fourththrough sixth decade of life, onceagain suggesting that stylish con-stricting footwear causes halluxvalgus.

Hallux valgus is found almostexclusively in societies where shoesare worn.15-20 Yet many individualswear fashionablefootwear and hal-lux valgus doesnot develop.15

Shine21 examined3,515 people onthe island of St.H e l e n a a n dfound that theincidence of hal-lux valgus was 2percent in thosewho went bare-foot, and in thoseshod for 60 years,48 percent of the women had hal-lux valgus and 16 percent of themen had hallux valgus. Sim-Fookand Hodgson19 compared 107 bare-foot and 118 shoe-wearing Chinesein Hong Kong and found that hal-lux valgus occurred in 2 percent ofbarefoot people and 33 percent ofpeople who wore shoes. SimilarlyMaclennan22 found only a 2 per-cent incidence of hallux valgus in1,256 non-shoe wearing NewGuinean natives. The Japanese

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76 www.podiatrymgt.comPODIATRY MANAGEMENT • OCTOBER 2001

Hallux valgus is anangular outward

deviation of the proximalphalanx of the halluxoccurring in 2 to 15percent of the U.S.

population.

Figure 1. End stage hallux valgus. Tight extensorhallucis longus results in hyperextension of thehallux.

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ligamentous laxity has been re-ported to be associated with halluxvalgus.44

The association between halluxvalgus and metatarsus primusvarus is controversial. Lapidus at-tr ibuted the r igid metatarsusprimus varus to the medial slopeof the metatarsocuneiformjoint.45He considered the apex ofthe metatarsus primus varus defor-mity to be the medial metatarso-

cuneiform joint. He observedthat the intermetatarsal angleof a fetus is approximately 32˚and reduces to 6.2˚ in normaladults. Therefore, he assumedthat a high IM angle resultedfrom an arrest in develop-ment that congenitally pre-disposed patients to develophallux valgus deformity. 45

Hardy and Clapham46 found a .71correlation between the occur-rence of metatarsus primus varusand hallux valgus.46

Truslow47 was the first to theo-rize that metatarsus primus varuswas a congenital abnormalitywhich resulted in hallux valguswhen the individual began wearingshoes. However, studies by Hardyand Clapham46 and Craigmile30

seemed to disprove this theory.The fact that in children the inter-metatarsal (IM) angle remains sta-ble for long periods of time whilethe hallux abductovalgus angle isfound to increase until a certainthreshold hallux valgus angle isreached, and then both the IM andhallux valgus angles both increaserapidly,46,48 seems to indicate that

ment of sagittal plane motion ofthe first ray, Klaue et al.43foundthat the mean dorsal displacementat the metatarsal base averaged 2.6millimeters in patients with halluxvalgus and 1.5 millimeters in thecontrol group, suggesting that pa-tients with hallux valgus tend tohave an increased passive exten-sion of the first ray. Generalized

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Figure 2A. Hallux valgus deformity. Figure 2B. Significant pronation, part of hallux valgus deformity.

Figure 2C. Ankle equinus, frequently associated with hallux valgus.Figure 2D. Forefoot supinatus withcallosity under 2nd metatarsal head.

hallux valgus precedes metatarsusprimus adductus. It would appearthat once the medial capsule of theMTPJ is overstretched by a largehallux valgus angle, a longitudinalforce on the tip of the toe easilyproduces metatarsus primusvarus.49

Multifactorial inheritance isthought to be the mode of trans-mission in hallux valgusdeformity50 with a positive familyhistory in 63 per-cent of patientswith hallux val-gus.46 Coughlin51

noted maternaltransmission inthe majority ofjuvenile halluxvalgus patientswith variablepenetrance.

PathomechanicsThe pathomechanical process

begins with wearing narrow,pointy, short, and possibly highheeled shoes for many years. Creepdeformation forces resulting fromthe shoe produce a slow deforma-tion over time resulting in stretch-ing of the abductor hallucis musclewith the proximal phalanx of thehallux starting to drift laterally andabducting. The normal forces ofwalking with forefoot pronationstretch the medial collateral liga-ment and capsular structures andpush the hallux into a valgus posi-tion.40

After a certain threshold degreeof abductus and valgus of the hal-lux is reached, a retrograde forcefrom the distorted position of thehallux pushes the first metatarsalinto a varus position and off thesesamoids. The sesamoid bones arelocated within the two tendons ofthe flexor hallucis brevis and func-tion similarly to the patella, serv-ing as a fulcrum to add mechanicaladvantage to the pull of the FHBand FHL during toe-off . Thesesamoids are firmly attached tothe adductor hallucis and the deeptransverse metatarsal ligament andinsert on the plantar lateral base ofthe proximal phalanx and do notfollow the medial migration of the

Hallux Valgus... balance the joint, FHL ten-dinitis may result. 52 Finallywhen the lateral collateral liga-ment and sesamoid ligaments aredisrupted and the entire joint cap-sule weakens, dislocation of themetatarsophalangeal joint occurswith end stage hallux valgus defor-mity.25

Usually less than 50 percent ofthe metatarsal will articulate withthe proximal phalanx. The clinicalappearance of the medial promi-nence is due to the displacementof the hallux laterally uncoveringthe medial aspect of the metatarsalhead. The metatarsal head hyper-trophies laterally and an overlyinginflammatory bursa can occur (thebunion). During the propulsive pe-riod of gait individuals with halluxvalgus widen the forefoot, increas-ing deformity with each step, incontrast with the forefoot narrow-ing with propulsion in people whodo not have hallux valgus.53

More than 50 percent of theweight-bearing force during gaitpasses through the first metatar-sophalangeal joint.9 Gait analysis ofthe individual with hallux valgusreveals that the great toe has a di-minishing role in weight bearing ofthe forefoot.54 As the hallux abduc-tus angle increases, the pressure be-neath the hallux decreases.55-57 Thecenter of pressure is a mathematicalrepresentation of the summation of

first metatarsal. With medial mi-gration of the first metatarsal head,the medial joint capsule becomesattenuated and the abductor hallu-cis tendon is pulled plantarwardbecoming a flexor. Adduction ofthe first metatarsal with an increas-ing intermetatarsal angle results ina wide splayed forefoot.25

Shoe friction and irritation ofthe medial collateral ligament ofthe first metatarsophalangeal jointlead to chronic inflammation ofthe overlying bursa and further

proliferation offibrotic and os-teoblastic activi-ty. As the defor-mity progressesthe axis of pull ofthe adductor hal-lucis, the flexorhallucis brevis,extensor hallucislongus, and theabductor hallucisall become later-

alized, increasing the abductorforce on the hallux. The halluxmay be held in extension awayfrom the ground due to the bow-string effect of the extensor hallu-cis longus (Figure 1). With prona-tion and hypermobility of the firstmetatarsal the f lexor hallucislongus muscle contracts to plantarflex the great toe and balance thefirst metatarsophalangeal joint.With increased use of the FHL to

Continuing

Medical Education



Hallux valgus is found almost

exclusively in societies where shoes are worn.

Figure 2E. In spite of severe hallux valgus, pronation, ankle equinus, and fore-foot supinatus, the heel is straight.

Clinical PresentationPatients with hallux valgus gen-

erally complain of pain in the firstmetatarsophalangeal joint mostly

when walking intight shoes. Theclinical presenta-tion of halluxvalgus is unmis-takable, with se-vere deformity(Figure 2A), sig-nificant prona-tion (Figure 2B),ankle equinus(Figure 2C), andforefoot supina-tus with callosityunder the second

metatarsal head (Figure 2D), yetthe weight bearing heel positionremains relatively straight (Figure

forces through which load on thefoot acts in the stance phase ofgait.55 There is acharacteristic lat-eral shifting ofthe center of pres-sure in patientswith hallux val-gus which is simi-lar to the centerof pressure mea-surements of pa-tients who haveundergone halluxa m p u t a t i o n s . 5 4

The effectivenessof various treat-ments can be determined by thereestablishment of the weight bear-ing of the first MTP joint utilizingin-shoe plantar pressure devices.

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TABLE 1DIFFERENTIAL DIAGNOSIS OF HALLUX VALGUS

(Adapted from Williams RC: J Musculoskel Med, 1991)

DISEASE CLINICAL FEATURE LABORATORY/IMAGING

Gout Men 40 to 70 years Serum uric acid level elevated Acute monoarthritis of 1st MTPJ in 75% of patientsShould not last more than 1 week Urate crystals in leukocytes Skin may peel over toe attack;

Radiographic changes occur 7-10 years after first attack

Infection Red hot, swollen joint Synovial fluidshows leukocytosisSeptic arthritis Gram stain may be positive

Joint fluid/blood cultures positiveBone scan may be positive

Osteoarthritis Affects multiple MTP joints Exostoses;Enlarged but not warm and tender Interphalangeal narrowing on x-rayPainful passive range of motion ESR normal

Hallux rigidus Clinically no motion at MTP joint Marked bony overgrowthNo acute redness or warmth Ankylosis on x-ray with hallux rigidusdorsal bunion

Hallux valgus Generally symmetrical Stage 4 hallux valgus with with Fibular deviation of all digits completed subluxated joint on x-rayRheumatoid May be more severe than isolated Severe deformity with ankylosisArthritis hallux valgus demonstrated on x-ray

Loss of passive range of motion of joint may be clinical indicator

Hallux valgus General presentation of Signs of systemic neuromuscular with Hallux valgus disease, I.e., spasticityneuromuscular more severedisease

Figure 3. Gouty arthritis with swellingof 1st metatarsophalangeal joint phys-ically appears as bunion deformity.

In one recent studyhypermobility of the first

ray was assessed byincreased thickness of the

medial cortex at themidshaft of the secondmetatarsal on x-ray.


hallux valgus does seem quite simple from thepresentation of obvious clinical deformity. Perhapsthe early inflammatory stage where hallux valgus and

bunion deformi-ty may resemblegouty arthritisand infection aremost problemat-ic. Enlargementof the firstmetatarsopha-langeal jointwith acutemonoarthritis ofthe first metatar-s o p h a l a n g e a ljoint is also pre-sent in gout (fig-ure 3).62,63 Pa-tients presentwith intensepain, heat, ery-thema, andswelling of the1st metatar-s o p h a l a n g e a ljoint.64 Exquisite

Continuing

Medical Education2E). It should be kept in mind that empirical studieshave found the normal weight bearing calcanealstance position of the heel to be about 5º valgus.58,59

Patients with severe bunion deformity frequentlydevelop callosities under the lesser metatarsal headsbecause of a lack of weight bearing of the first ray.Callus may also develop under the second, third, orfourth metatarsophalangeal heads. Hammer digitswith overlapping or underlapping digits result fromthe laterally deviated hallux. Painful corns resultfrom the shoe upper. Soft corns commonly occurwith bunions between the first and second toes andeven between the lesser toes because more pressure isplaced on the toes from the hallux valgus deformity.Hallux rigidus is a common problem associated withthe bunion. Sesamoid pain is common with the pro-gression of bunions. As the first metatarsal migratesand the sesamoids are no longer in place, incongruityand osteochondrosis of the sesamoids develop.

In bunion patients who have excessive pronationwith heel valgus, associated Achilles tendon tightnessincreases the valgus forces on the hallux duringpropulsion. Excessive pronation presenting withbunion deformity may also be associated with poste-rior tibial tendinitis and peroneal spasm.52 Arthritismay rarely develop in the first metatarsal cuneiformjoint as a result of instability of the first metatarsal.52

Stress fractures can occur in the second or thirdmetatarsals during pronation as stresses are trans-ferred to the second and third metatarsals and the lat-eral fibula. Increased pressure between the lateralmetatarsals may also result in Morton’s Neuroma.

RadiographicCriteria

According toGerbert’s Textbookof Bunion Surgery,the normal halluxabductus angle is10-15˚60 and thenormal inter-metatarsal angle is8-12˚.60 However,significant halluxvalgus can existwith an inter-metatarsal angle of8-12˚.61 Therefore,some favor a morestringent criteriaand values of 9 orhigher are consid-ered to be abnor-mal.6,15,18

DifferentialDiagnosis

At first glancethe diagnosis of

Hallux Valgus...

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Figure 4A. Early gouty arthritis. Jointsurface intact.

Figure 4B. Late gouty arthritis. Joint isdestroyed.

rence of disease, tophi may developand calcify.

The articular surfaces of jointsare generally spared in early gout(Figure 4A), but advanced joint dis-

ease produces a narrowed jointspace much like that in osteoarthri-tis (Figure 4B). If gouty arthritislasts for too long or does not re-spond to nonsteroidal anti-inflam-matory medication, the diagnosisof gout becomes less certain (SeeCase Presentation Figure 5A/B). Theintense inflammatory responsemay resemble a cellulitic process.There may be desquamation of theoverlying skin and blood tests willreveal a mild peripheral leukocyto-sis with an infectious process.

Hallux rigidus with osteoarthri-tis of the first metatarsophalangealjoint may present with a dorsalbunion (Figure 6A/B). Passive dor-siflexion of the 1st MTPJ is restrict-ed or absent. Osteoarthritis of the1st MTPJ produces pain during pas-sive and/or active motion, andcompression over the bunion areaproduces minimal tenderness.

Compression of the medial dorsaldigital sensory nerve may produce

one week. Non-steroidal anti-inflam-matory medication will reduce symp-toms within two to three days.64 Ra-diographs reveal only soft tissueswelling or osteopenia.65With recur-

tenderness is present dorsally andlaterally with inflammation and gen-erally resolves spontaneously within

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Figure 5A/B. Case Presentation. This 55 year old male presented with a 2-week history of pain and swelling in dorsum ofthe left foot (Figure 5A). The patient had hallux valgus deformity of the left foot only and a history of gouty arthritis. Theproblem failed to resolve after 2 weeks and in fact showed some signs of increased pain and swelling after he walked onit. There was no history of trauma; however, plain radiographs revealed fracture of the 2nd metatarsal (Figure 5B). Unilat-eral hallux valgus did not account for this patient’s pain and swelling. Similarly, although the patient had a history ofgouty arthritis, the pain and swelling was lasting 2 weeks without showing signs of improvement, which is unusual forgout. Although this patient had no history of trauma, plain radiographs revealed a healing fracture of the secondmetatarsal which might have become more symptomatic with walking on the foot.

Continued on page 84Figure 6A. Dorsal bunion.Figure 6B. Osteoarthritis of the firstmetatarsal phalangeal joint.

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ly bilateral and presents with sublux-ation of the first metatarsopha-langeal joint and fibular deviation(Figure 7). After a while the bones ofthe foot in rheumatoid arthritis maybecome entirely fused (Figure 8). SeeTable 1 for a summary of the differ-ential diagnosis for hallux valgus.

Management of Hallus Valgusand Foot Orthoses—CurrentResearch

There are only three recent em-

pirical studies which involve ran-domized clinical trials dealing withthe effect of foot orthoses on theprogression of hallux valgus andthe relief of symptoms.

One prospective randomizedclinical trial evaluated the effect ofFunctional Foot orthoses on theprogression of the hallux valgusangle in adults with rheumatoidarthritis.67 Fifty rheumatoid arthri-tis patients in the treatment groupwore Rohadur functional foot or-thoses with appropriate posts, and52 patients with rheumatoidarthritis in the control group woreplacebo leather unposted orthoses.After wearing the foot orthoses forthe 3-year study period, 5 patientswearing the functional foot or-thoses versus 12 patients wearingthe leather orthoses demonstratedprogression of the hallux valgusdeformity on x-ray. Progression ofhallux valgus deformity was de-fined as a 5˚ increase or more in

the hallux valgus angle. Those au-thors concluded that foot orthosesslowed the progression of halluxvalgus deformity in patients withrheumatoid arthritis.67

In the only randomized clinicaltrial on the effect of functionalfoot orthotics on the progressionof hallux valgus in healthy chil-dren, 93 children with hallux val-gus aged 9-10 years were followedfor a three year period.48 Approxi-mately half were randomly as-signed to wearing a functionalposted foot orthosis for 3 years andthe remaining half served as thecontrol group. At the end of the

tenderness along the dorsal-medialaspect of the foot which results in aradiating or “shooting” pain thattravels toward the toe or ankle.

Skin irritation is usually fromshoes and will resolve as soon asthe shoes are removed.

Hallux valgus is the most com-mon foot deformity in rheumatoidarthritis.66 Hallux valgus associatedwith rheumatoid arthritis is frequent-

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Multifactorial inheritance is thought

to be the mode oftransmission

in hallux valgusdeformity with a

positive family history in63 percent of patients

with hallux valgus.

Figure 8. Bilateral hallux valgus with complete fusion of all joints associatedwith rheumatoid arthritis.

Figure 7. Bilateral hallux valgus with joint subluxation and fibular deviation as-sociated with rheumatoid arthritis.

three year study period the 1stmetatarsophalangeal angle in-creased approximately 2˚ in thecontrol group and 2.5˚ in the treat-ment group. However, the differ-ence between the control andtreatment group was not signifi-cant. In the nonaffected foot thehallux valgus angle increased ap-proximately 4˚ in both the treatedand the control group, which wasa highly significant difference. Itshould be noted that the inter-metatarsal angle remained thesame over the entire three-yearstudy period. During the study,hallux valgus developed in the un-affected feet of children with uni-lateral deformity, despite the use ofthe orthosis.48

A recent randomized controlledtrial published in the Journal of theAmerican Medical Association (May

Hallux Valgus... year. Patients were randomlyassigned to surgery (distalchevron osteotomy), orthosis, ora one-year period of watchful wait-ing (control group).

At the time of 6-month follow-up, patients in the surgery and or-thosis group had less pain andwere more satisfied with the treat-ment than in the non-treated con-trol group. At the time of 1-yearfollow-up, pain intensity decreasedmore in the surgical than in the or-thotic group or the control group.The number of painful days, cos-metic disturbance, and footwearproblems were least in the surgicalgroup and functional status andsatisfaction with treatment werebest in the surgical group.68 The au-thors concluded that foot orthoseswere effective for short term reliefin the mild to symptomaticbunion patients, but that surgical

16, 2001) compared the effective-ness of surgery, orthotic treatmentand no treatment in patients withmild to moderate hallux valgus.68

There were approximately 70 adultpatients in each of the threegroups who were followed for one

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Medical Education



The effectiveness of various treatments

can be determined by the reestablishment of the weight bearing of the first MTP joint

utilizing in-shoe plantar pressure

devices.

TABLE 210 RULES FOR PROPER SHOE FIT

[Adapted from the Pedorthic Footwear Association (PFA), the National Shoe Retailers Association (NSRA) and the American Orthopaedic Foot and Ankle Society (AOFAS)]

1) The patient should not select a shoe by SIZE since sizes vary according to style and shoe company. The shoe mustbe selected according to fit.

2) The shoe should be similar to the shape of the foot.

3) The size of the foot increases with age so foot size should be measured periodically. The Brannock device is usedto measure the length of the foot from heel to toe, the width of the foot and the arch length. The arch length(heel-to-ball length) is measured from the heel to the first metatarsal head. The shoe size is based on the archlength, not the overall length of the foot, because the arch length ends at the first metatarsal head which is thewidest part of the foot.

4) Both feet should be measured and the shoe is fit to the largest foot.

5) Shopping for a new pair of shoes should be done at the end of the day when feet are the largest.

6) The patient should be standing during the fitting/measuring process.

7) There should be 3/8 inch to 1/2 inch from the longest toe to the end of the shoe.

8) Shoes should not feel tight when purchased and be expected to be “broken in.” The ball of the foot should fitsnugly into the widest part (ball pocket) of the shoe.

9) There should not be heel slippage.

10) The patient should walk in the shoes before purchasing them.

with longitudinal arch support andmedial forefoot posting.

Shoe WearThe pedorthic objectives for re-

lief of hallux valgus include reliev-ing direct medialpressure over thebunion and ad-dressing transfermetatarsalgia inthe lesserm e t a t a r s a l s .S y m p t o m a t i cpronation shouldalso be ad-dressed. Bunionpain may becaused by directpressure over

the medial eminence or painoriginating from joint motion.If the pain is due to direct pres-sure over the bunion then thepatient will have no difficultyambulating barefoot. Wide

roomy shoes will be most helpfulwhen the pain is caused by directpressure over the medial eminence.Shoes can be stretched to relievepressure. Remember that it is nec-essary to leave shoes overnight fora proper stretching procedure. Ifthe problem is coming from withinthe joint, a stiff-soled shoe or rock-er bottom sole may help to by-passthe painful metatarsophalangealjoint.

The typical women’s foot has awide forefoot and narrow heel. Theaverage women’s foot is 3-1/4 to 3-3/4 inches wide. The width of thefashion shoe is usually not morethan 3 inches wide (Figure 9A/B). A

management was ultimatelymore beneficial.

Foot orthoses are helpful for as-sociated transfer metatarsalgia, topad metatarsalcallosities and tolimit excessivep r o n a t i o n .Sanders andHegemeir70 havesuggested foot or-thoses for halluxvalgus patientswith instability ofthe first metatar-s o c u n e i f o r mjoint. They statethat these pa-tients complain of generalized footpain with activity, and incorrectlyassume that the pain is due to theirbunion. They suggest full lengthfoot orthoses fabricated from tril-aminar or multilaminar materials

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Figure 9A. Fashion shoes with narrow forefoot and square pointy low toebox.

Figure 9B. This shoe is too narrow for thispatient even though it is a low heeled ox-ford blucher shoe.

Figure 10A. Shoe with cutout for bunion. Figure 10B. Shoe with cutout for overlapping toe.

Compression of themedial dorsal digitalsensory nerve mayproduce tenderness

along the dorsal-medialaspect of the foot.

combination last provides for anarrow rearfoot and a wide fore-foot to prevent heel slippage. Fi-nally, sometimes it is necessary tocut a hole into the shoe (Figure10A/B). See Table 2 for the 10 rules

Hallux Valgus... heel, and 76 percent for a 3-1/4 inch heel.71

Bunion SplintsBunion splints are an under-uti-

lized yet highly effective treatmentfor hallux valgus bunion deformity.Although no splint will actually cor-rect hallux valgus deformity,stretching and realignment of thefirst MTPJ performed by the splintmay provide the patient with dra-matic symptomatic relief. The clas-sic latex bunion shield may be spe-cially molded to the patient’s foot toaccommodate a bunion deformity(Figure 11). There are a number ofcommercial bunion splints whichpad the bunion, straighten the hal-lux valgus deformity and can beused at night for sleeping and evenduring the day as long as the halluxvalgus deformity is at least partiallyflexible. Some come with attachedtoe splinting and toe spacers. A toespacer between the first and secondtoe is often necessary since the ab-

for Proper Shoe Fit.The heel height should be low

(Table 3). By the age of 16, over 50percent of girls wear heels some ofthe time. As compared with noheel, forefoot pressure increases by22 percent when wearing a 3/4-inch heel, 57 percent for a 2-inch

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TABLE 3THE HEIGHT OF THE HEEL OF THE SHOE

(Adapted from Sander M, Hagemeir KW: Conservative treatment and

shoewear options for hallux valgus.Foot Ankle Clin 2(4): 639-53, 1997, December.)

Flat Shoe 3/4 inch heel height or less

Low Heel 3/4 inch heel height to 1-3/4 inch heel height

Mid Heel 1-3/4 inch heel height to 2-1/4 inch heel height

High Heel 2-1/4 inch or higher

to splint hammer digits and tailor’sbunions (Figure 14).

Pedifix’s Hallux Valgus Soft-Splint™ also provides comfortableand effective post-op splinting. It is

designed for ambulatory or non-am-bulatory use after bunion surgery tomaintain ideal hallux positioningand constant MP joint alignment(Figure 17).

Debridement of associated digi-tal corns andplantar callositiesshould be donep e r i o d i c a l l y .Foam, rubber, orsilicone toesleeves (Silipos)are used to sepa-rate or cushioncontact pointsbetween the hal-lux and the sec-ond toe (Figure15). Corn padsand metatarsalpads can be usedfor associated de-formities of thedigits and plantarc a l l o s i t i e s .

Metatarsal pads have been shown toreduce pressure under the metatarsalheads in 100 percent of asymp-tomatic female volunteers.73 Similar-ly in another study of the effect ofmetatarsal pads on plantar weightbearing pressure in asymptomaticindividuals, walking with insoleswith metatarsal pads resulted inpeak load decreases in the forefootregion and peak load increases inthe midfoot region under themetatarsal shafts.74 Also availablefrom Silipos is their soft paddedBunion Shield, which is excellentfor both daytime and nighttime use.

Physical therapy may consist ofsuperficial and deep heat treatmentsuch as ultrasound and exercises tostretch the toe twice daily for oneminute per foot (10 to 15 repeti-tions) for the first month, then oncedaily for 3 months. Intraarticular in-jection for patients with painfulrange of motion are a final option (1ml of 50 percent corticosteroid and1 percent lidocaine) prior to surgicalintervention.

There has recently been empha-sis on clinical staging of hallux val-gus.75 Garrow and associates75 feltthat since hallux valgus is the mostinstantly recognizable deformity ofthe foot, they developed a stagingsystem based on clinical photoalone. Table 3 reviews the authors’clinical staging for hallux valgus de-formity and management for eachof the associated four clinical stages.

For more information aboutthese products mentioned in thepreceding article, circle the corre-sponding number on the readerservice card in this magazine.

Apex Bunion Shield—Circle #148Jacoby Bunion Splint (Angus)—

Circle #149Apex Night Splint—Circle #150Darco Abductor Splint—Circle

#151Silipos Bunion Shield—Circle

#152Silipos Toe Sleeve—Circle #153Pedifix SoftSplint—Circle #155 �

References1 American College of Foot and Ankle Or-

thopedics and Medicine (ACFAOM): PreferredPractice Guidelines Prescription Custom FootOrthoses. 1998.

2 American College of Foot and Ankle Sur-

ducted hallux pushes against thesecond digit. Apex Foot Health In-dustries has combined a relativelythick soft foam toe spacer with asoft bunion pad for accommodationof hallux valgus and bunion defor-mity (Figure 12). The popular JacobyBunion Splint from Angus Market-ing is commonly used for patientswith Hallux Valgus (Figure 16).

The hallux valgus night splint(also from Apex) (Figure 13) placesthe hallux in a 1st class lever systemwhich stretches and adducts the de-viated hallux. We have found thatmany patients with deformity findrelief by wearing the splint at night.This splint has also been reported tobe effective postoperatively afterbunion surgery.72 Darco Internation-al, Inc. has a very comfortable clothbunion splint which not only exertsa corrective force on the hallux, butcomes with adjustable velcro straps

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Figure 11.Latex bunion shield.

Figure 12. Hallux valgus bunion shield with large toe spacer. (Apex Foot HealthIndustries)

Wide roomy shoes will be most helpful

when the pain is causedby direct pressure overthe medial eminence.

Shoes can be stretched to relieve pressure.

14 Coughlin MJ, ThompsonFM: The high price of high-fashionfootwear. In instructional Course Lec-tures, The American Academy of Or-thopaedic Surgeon. Vol. 44, pp.371-7. Rose-mont, Illinois, The American Academy of Or-thopaedic Surgeons, 1995.

15 Coughlin MJ: Hallux valgus Causes,Evaluation, and Treatment. Postgraduate Medi-cine 75(5): 174-87, 1984, April.

16 Barnicot NA, Hardy RH: The position ofthe hallux in West Africans. J Anat 80: 356-61,1955.

17 Engle ET, Morton DJ: notes on foot dis-orders among natives of the Belgian Congo. JBone joint Surg 13: 311-8, 1931.

18 Johnson PH: The Bunion. J ArkansasMed Soc 78: 235-7, 1981.

19 Sim-Fook L, Hodgson AR: A comparisonof foot forms among the non-shoe and shoe-wearing Chinese population. J Bone Joint Surg(Am) 40: 1058-62, 1958.

20 Wells LH: the foot of the South Africannative. Amer J phys Anthropol 15: 185-289,1931.

21 Shine IB Incidence of hallux valgus in apartially shoe-wearing community. BritishMedical Journal I(2): 1648-50, 1965.

22 Maclennan R: Prevalence of hallux val-gus in a Neolithic New Guinea population.Lancet 1: 1398, 1966.

23 Kato T, Watanabe S: The etiology of hal-lux valgus in Japan. Clin Orthop 157: 78-81,1981.

24 Gottschalk FAB, Sallis JG, Solomon L,Beighton PH: J bone Joint Surg 61B: 254, 1979.

25 Myerson M, Edwards WHB: The etiolo-gy and pathogenesis of hallux valgus. FootAnkle Clin 2: 583, 1997.

26 Hauser EDW. Diseases of the Foot. W.B.Saunders Company, Philadelphia, 1941. Chap-ter 6, p. 119.

27 Root ML, Orien WP, Weed JH: Normal

geons (ACFAS): Preferred Practice Guidelines.Hallux Valgus in the Healthy Adult. Pp. 1-24,1992.

3 Coughlin MJ: The high cost of fashion-able footwear. J Musculosklet Med 40-53, De-cember, 1994.

4 Mann RA, Coughlin MJ: Adult halluxvalgus. In Mann RA, Coughlin MJ, eds. Surgeryof the Foot and Ankle. St. Louis, Mo: Mosby-Yearbook; 1993.

5 Rudicel SA: Evaluating and managingforefoot problems in women. J MusculoskelMed 16: 562-67, 1999.

6 Coughlin M: Hallux valgus J Bone JointSurg 78A: 932-66, 1996.

7 Mann RA: Disorders of the first metatar-sophalangeal joint. J Am Acad Orthop Surg 3:34-43, 1995.

Hallux Valgus... 8 Hurwitz S: Evaluating bunions, offeringrelief. J Musculoskel Med 14: 52-64, 1997.

9 Nork SE, Coughlin RR: How to examinea foot and what to do with a bunion. PrimaryCare 23(2): 281-97, 1996.

10 Frey CC, Shereff MJ: Tendon injuriesabout the ankle in athletes. Clin Sport med 7(1):103-118, 1988.

11 Friedman SL: “Palliative Care,” In JMRobbins: Primary Podiatric Medicine. W.B.Saunders Company, Philadelphia, 1994, Chap-ter 13, 167-82.

12 Snijder CJ: “Biomechanics of Footgear,Hallux Valgus, and Splayfoot. Chapter 22. pp.564-582. In Disorders of the Foot and Ankle edby M Jahss, Churchill Livingstone, New York,1991.

13 Mann RA, Coughlin MJ: Hallux valgusetiology, anatomy, treatment and surgical con-siderations. Clin Orthop 157: 31-41, 1981.

Continuing

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Figure 14. Hallux valgus abductor splint with attachments for splinting hammerdigit and Tailor’s bunion (Darco International, Inc.).

Figure 13. Hallux valgus abductory night splint. (Apex Foot Health Industries)

Figure 15. Soft silicone toe sleeve (Silipos,Inc.)

95-9, 1938.32 Joplin RJ: Sling procedure for correction

of splay-foot, metatarsus primus varus, and hal-lux valgus. J Bone Joint Surg 32A 779-85, 1950.

33 Mayo CH: The surgical treatment ofbunion. Minnesota Med 3: 326-331, 1920.

34 Rogers WA, Joplin RJ: Hallux valgus,weak foot and theKeller operation: anend-result study. SurgClin N Amer 27: 1295-1302, 1947.

35 Stein HC:Hallux valgus. SurgGynec Obstet 66: 889-898, 1938.

36 Inman VT:Hallux valgus: A reviewof etiologic factors. Or-thop Clin NA 5(1): 59-66, 1974. January.

37 Donley BG,Tisdel CL, Sferra JJ et al.

Diagnosingand treatinghallux valgus:A conservativeapproach for ac o m m o np r o b l e m .Cleveland ClinJ Med 64(9):469-74, Octo-ber, 1997.

38 Kil-martin TE,Wallace WA:The signifi-cance of pesplanus in juvenile hallux valgus. Foot Ankle 13:53, 1992.

39 Saragas NP, Becker PJ: comparative radio-graphic analysis of parameters in feet with andwithout hallux valgus. Foot Ankle Int 16: 139,1995.

and Abnormal Function of the Foot. ClinicalBiomechanics Volume II. Clinical Biomechan-ics Corporation, Los Angeles, California, 1977.

28 Greenberg GS: Relationship of hallux ab-ductus angle and first metatarsal angle to severi-ty of pronation. J AmPodiatry Assoc 69: 29-34, 1979.

29 Holstein A: Hal-lux valgus: an acquireddeformity of the foot incerebral palsy. FootAnkle 1: 33-8, 1980.

30 Craigmile DA:Incidence, origin, andprevention of certainfoot defects. Br Med J 2:729-52, 1953.

31 Galland WI, Jor-dan H: Hallux valgusSurg Gynec Obstet 66:

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TABLE 4CLINICAL STAGING OF HALLUX VALGUS DEFORMITY

AND TREATMENT

STAGE I: Inflammatory

Pain, heat, swelling, erythemaVery little deviation of the toe, but large medial prominence at the MTP jointPain from inflammation of small bursa formed over the medial eminenceThickening of the bursal wall accentuates the prominenceMust be distinguished from gout, infection, inflammation

STAGE II: Mild Deformity

Asymptomatic The proximal phalanx begins to drift laterally and into valgus position No associated lateral subluxation of the sesamoid bones on radiographCongruent MTP joint

STAGE III: Moderate Deformity

The first metatarsal head is pushed into a position of varus, off the sesamoidsLateral sesamoid is displaced about 75% from beneath metatarsal headMedial capsular structures are stretched while the lateral structures become increasingly contractedSome loss of MTP joint congruity

STAGE IV: Severe Deformity

Significant metatarsus primus varusComplete dislocation of the sesamoids Pronation of the great toeOverlapping of the second toeMarked soft tissue contractureCongruity at the metatarsophalangeal joint completely lostOften associated with rheumatologic or neuromuscular disease

Figure 16. The popular jacoby BunionSplint from Angus Marketing

Figure 17. Pedifix’s SoftSplint™

Circle #48

a result of flexion forces in hallux valgus. Footankle 13: 515, 1992.

54 Holmes GB: Gait analysis in hallux valgus.Foot Ankle Clin 2(4): 627-38, 1997, December.

55 Hutton WC, Dhanendran M: The me-chanics of normal and hallux valgus feet: Aquantitative study. Clin orthop 157: 7-13, 1981.

56 Stokes IAF, Hutton WC, Evans MJ: Theeffects of hallux valgus and Keller’s operationon the load-bearing function of the foot duringwalking. Acta OrthopBelg 41: 695-704, 1975.

57 Stokes IAF, Hut-ton WC, Stott JRR, et al:Forces under the halluxvalgus foot before andafter surgery. Clin Or-thop 142: 64-72, 1979.

58 Sobel E, Levitz S,Caselli M, Brentnall Z,Tran MQ: Natural histo-ry of the rearfoot angle:Preliminary values in150 children. FootAnkle Inter 20(2): 119-125, 1999.

59 Sobel E, Levitz SJ, Caselli M, et al:Reevaluation of the relaxed calcanealstance position. J Amer Podiatr Med Assoc89(5): 258-64, 1999, May.

60 Hass M: “Radiographic and Biomechani-cal Considerations of Bunion Surgery.” Chapter2, pp. 23-90. In Textbook of Bunion Surgery, edby J Gerbert & TH Sokoloff, Futura PublishingCompany, Mount Kisco, New York, 1981.

61 Ruch JA, Banks AS. “Evaluation of thedeformity of hallux abducto valgus.” Chapter5, Part 2, pp. 144-150. In ComprehensiveTextbook of Foot Surgery, Vol. 1, ed by EDMcGlamry, Williams & Wilkins, Baltimore,1987.

62 Agudelo CA, Wise CA: Diagnosis andmanagement of complicated gout. Bull RheumDis 47: 25, 1998.

63 Williams RC: Toe pain: Is it podagra orsomething else: J Musculoskel Med 31-42, 1991.

40 Alvarez R, Haddad RJ, Gould N, et al:The simple bunion: Anatomy at the metatar-sophalangeal joint of the great toe. Foot Ankle4: 229, 1984.

41 Myerson MS, Badekas A: Hypermobilityof the first ray. 5(3): 469-84, 2000.

42 Prieskorn DW, Mann RA, Fritz G: Radio-graphic assessment of the second metatarsal:Measure of first ray hypermobility. Foot Ankle17(6): 331-3, 1996, June.

43 Klaue K, Hansen ST, Masquelet AC: Clin-ical, quantitative assessment of first tarsometatr-sal mobility in the sagittal plane and its relationto hallux valgus deformity. Foot Ankle Int 15: 9,1994.

44 Carl A, Ross S, Evanski P, et al: Hyper-mobility in hallux valgus. Foot Ankle 8: 264,1988.

45 Lapidus PW: The author’s bunion opera-tions from 1931-1969. Clin Orthop 1960.

46 Hardy RH, Clapham JCR: Observationson hallux valgus J Bone Joint Surg 33B: 376-91,1951.

47 Truslow W: Metatarsus primus varus orhallux valgus? J Bone Joint Surg 7: 98-108,1925.

48 Kilmartin TE, Barrington RL: Acontrolled prospective trial of a foot or-thosis for juvenile hallux valgus. J BoneJoint Surg 76B: 210-14, 1994.

49 Wilson DW: Treatment of hallux val-gus and bunion. Br J Hospital Med Dec, 548-558, 1980.

50 Sobel E, Giorgini R: Helping childrenwith genetic foot disorders. Podiatry Today 11:36-46, 1998.

51 Coughlin MJ: Roger A. Mann Award. Ju-venile hallux valgus: etiology and treatment.Foot Ankle Int 16: 682, 1995.

52 Baxter DE: Treatment of bunion defor-mity in the athlete. Orthop Clin NA 25(1): 33-9, 1994, January.

53 Sanders AP, Snijders CJ, Van Linge B:Medial deviation of the first metatarsal head as

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Drs. Levitz and Sobel are professors inthe Department of Orthopedics,NYCPM.

64 Bibbo C, Lin SS: Crystallinearthropathies Gout and Calcium pyrophos-phate deposition disease (CPPDD) Foot AnkleClin 4(2): 275-91, 1999, June.

65 Uri DS, Dalinka MK: Imaging ofarthropathies: Crystal disease. Radio Clin NorthAm 34: 359-74, 1996.

66 Sobel E, Caselli MA, McHale KA: Pedalmanifestations of musculoskeletal disease. ClinPodiatr Med Surg 15(3): 435-80, 1998, July.

67 Budiman-Mak E,Conrad KJ, Roach KE etal.: Can foot orthosesprevent hallux valgusdeformity in rheuma-toid arthritis. A ran-domized clinical trial. JClin Rheumatol 1:1995.

68 Torkki M, Malmi-vaara A, Seitsalo S, et al:Surgery vs orthosis vswatchful waiting forhallux valgus A ran-domized controlled

trial. JAMA 285(19) 2474-80, 2001, May 16,2001.

69 Sobel E, Levitz SJ, Caselli MA: Orthoses inthe treatment of rearfoot problems. J Am PodiatrMed Assoc 89(5): 220-33, 1999, May

70 Sanders M, Hagemeir KW: Conservativetreatment and shoewear options for hallux val-gus. Foot ankle Clin 2(4): 639-53, 1997.

71 Snow R, Williams K, Holmes G:The effects of wearing high-heeled shoeson pedal pressure in women. Foot ankle13: 85-92, 1992.

72 Donatto KC, Rightor N, Ambrosia RD:Custom-Molded Orthotics in Postoperativehallux valgus immobilization. Orthopedics15(4): 449-51, 1992, April.

73 Holmes GB, Timmerman L: Aquantitative assessment of the effect ofmetatarsal pads on plantar pressures.Foot Ankle 11: 141-5, 1990.

74 Chang AH: Abu-Faraj ZU, Harris GF, etal: Multistep measurement of plantar pressurealterations using metatarsal pads. Foot Ankle Int15(12): 654-60, 1994.

75 Garrow AP, Papageorgiou A, SilmanAJ, et al: The grading of hallux valgus TheManchester Scale. J Am Podiatr Med Assoc91(2): 74-8, 2001, February.

Bunion splints are an underutilized, yet highly effective

treatment for hallux valgus bunion

deformity.

6) The most common EXTRINSICetiologic factor producing halluxvalgus deformity is:

A) pronationB) hypermobility of the first rayC) shoesD) genetics

7) The fact that in children theintermetatarsal angle remains stablefor long periods of time while thehallux abductovalgus angle is foundto increase until a certain thresholdhallux valgus angle is reached, andthen both the IM and hallux valgusangles both increase rapidly, wouldseem to:

A) Prove that a highintermetatarsal angle is the causeof hallux valgusB) Disprove that a highintermetatarsal angle is the causeof hallux valgusC) Prove that the a highintermetatarsal angle is inverselyproportional to the hallux valgusangleD) Prove that the intermetatarsalangle is not related to the halluxvalgus angle

8) The cause of the laterally displacedsesamoids in hallux valgus deformityis:

A) Drifting of the fibularsesamoidB) Dislocation of the 1stmetatarsophalangeal jointC) Medial migration of the firstmetatarsal headD) The abducted position of thehallux

9) The clinical appearance of themedial prominence in bunion/halluxvalgus deformity is due to:

A) Displacement of the halluxlaterally uncovering the medialaspect of the metatarsal headB) Dislocation of the 1stmetatarsophalangeal jointC) Inflammatory arthritisD) Bursitis

10) What were the findings of therecent randomized controlled trialpublished in the Journal of theAmerican Medical Association (May16, 2001) comparing theeffectiveness of surgery, orthotictreatment and no treatment in

1) What is the percent of adults withhallux valgus in the United States?

A) Less than 1 percentB) 2 to 15 percentC) 25 to 33 percentD) 50 to 75 percent

2) What is the relationship betweenwearing shoes, wearing fashionablefootwear and development of halluxvalgus?

A) Bunions are NEVER found inindividuals who are unshod.B) Bunions are ONLY found inindividuals who wear fashionablefootwear.C) Bunions are found much morefrequently in individuals whowear fashionable footwear, butalso occur with much lessfrequency in individuals who donot wear fashionable foot wear,but do not occur in unshodindividuals.D) Bunions are found much morefrequently in individuals whowear fashionable footwear, butalso occur with much lessfrequency in individuals who donot wear fashionable foot wear,and also occur to some extent inunshod individuals.

3) In hallux valgus deformity, what isthe most common position of theheel when the patient is standing?

A) 5˚ of valgusB) Significant heel valgusC) Significant heel varusD) The greater the hallux valgusdeformity the more heel valgus ispresent

4) It has been observed that as theJapanese have changed fromtraditional sandals to leather footwear,the incidence of hallux valgus has:

A) IncreasedB) DecreasedC) Remained the sameD) There is no data pertaining tothis subject

5) What is the cause of the widenedsplayed foot deformity in halluxvalgus?

A) PronationB) High hallux valgus angle withsubluxationC) High intermetatarsal angleD) Forefoot pronation

patients with mild to moderate halluxvalgus?

A) No treatment (watchfulwaiting) was equally effective inpain reduction as compared tofoot orthoses and surgery for mildto moderate bunion patients.B) Foot orthoses were the mosteffective treatment in patientswith mild to moderate buniondeformity as compared to surgicaltreatment and the control group(no treatment).C) Surgical management was themost effective treatment inpatients with mild to moderatebunion deformity as compared tosurgical treatment and thecontrol group (no treatment).D) Foot orthoses and surgicalmanagement were equallyeffective in treatment in patientswith mild to moderate buniondeformity with both modalitiesmore effective than the controlgroup (no treatment).

11) A shoe last that might be helpfulto a patient with a bunion deformitywould be:

A) Board lastB) Slip lastC) Chukka bootD) Combination last

12) What is the effect on pressure inthe forefoot when wearing a 2-inchhigh heeled shoe?

A) Forefoot pressure is notaffectedB) Forefoot pressure is reducedC) Forefoot pressure is increasedapproximately 22 percentD) Forefoot pressure is increasedapproximately 50 percent

13) Foot orthoses have been found toslow the progression of hallux valgusdeformity in people with rheumatoidarthritis.

A) TrueB) False

14) A shoe with a heel heightbetween 1-3/4 inches and 2-1/4inches would be considered:

A) Flat shoeB) Low heelC) Mid heelD) High heel

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15) Which would be INCORRECT as to shoe wear?A) Both feet should be measured and the shoe is fitto the largest foot.B) The ball of the foot should fit snugly into thewidest part (ball pocket) of the shoe.C) The patient should be sitting during thefitting/measuring process.D) There should be 3/8 inch to 1/2 inch from thelongest toe to the end of the shoe.

16) Which is NOT in the differential for hallux valgusdeformity?

A) Gouty arthritisB) Osteoarthritis of the 1st metatarsophalangeal jointC) Compression of the medial plantar nerveD) Infection

17) A review of recent empirical studies on therelationship of pronation and hallux valgus reveals that:

A) Pronation is one of the main causes of halluxvalgusB) It is unknown whether excessive pronation is anextrinsic cause of hallux valgusC) There is no correlation between subtalar jointpronation and hallux valgusD) Pronation of the subtalar joint results inhypermobility of the first ray which leads to halluxvalgus deformity

18) According to recent literature what is the role of ahypermobile 1st ray in the etiology of hallux valgusdeformity?

A) Hypermobility of the 1st ray is a pre-existing factorand a major cause of hallux valgusB) Hypermobility of the 1st ray is not the cause, butmay actually be a result of hallux valgusC) It is not clear whether a hypermobile 1st ray is thecause of the result of hallux valgusD) It has recently become known that a hypermobile1st ray is neither the cause nor the result of halluxvalgus deformity

19) What is the indication and main function of thebunion splint?

A) To correct a rigid deformity to be used at nightonlyB) For accommodation and realignment of flexibledeformity and postoperativelyC) To correct a flexible deformity and relieve pain inrigid deformityD) Hallux valgus splints can only be used at night andpostoperatively

20) Which is generally NOT part of the clinicalpresentation of severe hallux valgus deformity?

A) Forefoot supinatusB) Heel valgus of 5˚C) Pronated foot typeD) Plantarflexed first ray

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A B C D

Degree____________________________

Additional comments and suggestions for future exams:

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EXAM #11/2001Hallux Valgus(Sobel/Levitz)

1. A B C D

2. A B C D

3. A B C D

4. A B C D

5. A B C D

6. A B C D

7. A B C D

8. A B C D

9. A B C D

10. A B C D

11. A B C D

12. A B C D

13. A B C D

14. A B C D

15. A B C D

16. A B C D

17. A B C D

18. A B C D

19. A B C D

20. A B C D

Circle:


oct01 p075-096 cme · ment of hallux valgus. 4) to be aware of the role of faulty footwear in the...

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