Efficacy of foot orthoses as nonoperative treatment for hallux valgus: A 2-year follow-up study

The impact of corrective exercises, kinesiology taping, and mechanical correction on pain and foot shape in women with hallux valgus

Background

This study aimed to assess the effect of corrective exercises and exercises supplemented by kinesiology taping or an orthosis on pain and foot alignment in women with hallux valgus (HV).

Methods

Eighty-two women with HV were randomly divided into groups: E (n = 24) who exercised for 12 weeks; EKT (n = 18) who exercised and used kinesiology taping on HV; EMC (n = 15) who performed exercise and used an orthosis to correct their big toe position; and CHV (25 women with HV without therapy). Additional control group C: (n = 31) women with normal hallux. The Wejsflog index, Clarke's angle, alpha and beta angles, and pain intensity in the big toe area were assessed at the beginning and after therapy.

Results

The Wejsflog index was significantly lower in women with HV and increased significantly after therapy in the E and EKT groups. Clarke's angle did not differ between women with and without HV, and Clarke's angle did not change after therapy. The HV angle decreased significantly in groups E and EKT but was still significantly greater than that in group C. The fifth toe varus angle did not differ between women with and without HV and decreased significantly in the right foot after therapy in group E. Pain in the HV area decreased significantly in all groups undergoing therapy.

Conclusion

Women with HV have a greater forefoot width, but their longitudinal arch and fifth toe position do not differ. Exercises significantly reduce pain and improve hallux alignment. Combining exercises with kinesiology taping or an orthosis does not increase the therapeutic effect. Although the observed effects of conservative therapy are promising, it should be remembered that long-term effects have not been studied.

Trial registration

The Australian New Zealand Clinical Trials Registry (ACTRN12621000902897).

Research progress in the etiology and minimally invasive therapy of hallux valgus

Hallux valgus (HV) is the most common foot deformity. It has various pathogenic factors that make its pathogenesis challenging to understand. As the disease progresses, patients experience amplified pain and decreased activities, significantly affecting their quality of life. At present, clinics offer several conservative and surgical treatments that must be selected based on patient condition and disease progression. Surgical treatment is frequently the only method available to patients with HV to delay disease progression and correct the deformity after conservative treatment fails. In recent years, minimally invasive surgical treatments have gained significant attention and developed rapidly due to their well-known advantages, such as safety, efficiency, and quick recovery time. The number of literature that provides a systematic review of the subject must be increased. This review tracks recent advancements, summarizing the etiological mechanism, epidemiology, diagnosis, and treatment of HV. In addition, it emphasizes typical surgical therapies and focuses on the progress of minimally invasive treatment from the first generation to the current fourth generation. This review will serve as a systematic basis for the clinical treatment of HV and provide a reference material for future research.

Radiographic and Patient-Reported Outcomes for First Tarsometatarsal Arthrodesis Using an Intramedullary Nail for Hallux Valgus Deformity A Consecutive Case Series

BACKGROUND

First tarsometatarsal (TMT) arthrodesis is one of the most common procedures performed each year for the correction of hallux valgus deformity, and nonunion rates for first TMT arthrodesis are commonly reported to be between 4% and 15%. The purpose of this study was to evaluate the effectiveness of an intramedullary nail system in patients requiring first TMT arthrodesis.

METHODS

An ambispective, multisurgeon, consecutive case series was conducted, in which retrospective and prospective collection of patient-reported outcome measure (PROM) and radiologic data were conducted. Patients who underwent first TMT arthrodesis from July 2019 to July 2022 for hallux valgus deformity with an intramedullary nail system and had adequate records for a minimum of 3 months postoperation (±4 weeks) were included.

RESULTS

Seventy patients were included in the final analysis, with a median prospective PROM follow-up of 1.6 years. There was an overall union rate of 91.4% (64/70 patients). Nine patients required secondary procedures: 4 hardware removals and 5 nonunion revisions. Collected PROMs and radiologic data showed significant improved from preoperative to prospective follow-up (P < .01).

CONCLUSION

First TMT arthrodesis using an intramedullary nail system result in nonunion rates and PROMs comparable to other techniques currently being used.

LEVELS OF EVIDENCE

Level IV: Retrospective Case Series.

The efficacy of shoes modification and orthotics in hallux valgus deformity: a comprehensive review of literature

Hallux valgus (HV) is a frequent forefoot deformity affecting about 23% of adults and 35.7% of people over 65. The exact etiology is not fully understood. The first ray plays a significant role in walking cause it bears the principal amount of weight and maintains the position of the medial arch. Several factors that deteriorate the integrality of the first ray, such as foot deformities, restrictive footwear, and pes planus, may be ascribed to the HV occurrence. Before any surgical correction, conservative treatment should always be initiated first. Currently, there is no consensus that conservative management by shoe modification and foot orthoses could correct the pathology or terminate the clinical worsening of the condition.From a careful analysis of the literature, proper footwear should be a shoe with an adequate length, wide toe box, cushioned sole, and a lowered heel to not increase the load on the metatarsal heads and cause pain. Personalized 3D printed customized toe spreaders may be applied in patients with HV, improving symptoms and bringing pain relief. Compensating the subtalar joint hyperpronation through foot orthoses plays a fundamental role in the HV development, preventing or at least controlling the condition's progress; this, along with weight reduction and regular physical activity.Data obtained suggest that dynamic foot orthoses prefer a biomechanical type with 3/4-length, which is less likely to negatively affect the dorsal or medial pressures, which instead were noted to increase with the sulcus- and full-length orthoses.Although some studies suggest that foot orthoses would favor the correction of HV deformity, results have been very variable and just in few studies appear to correct HV or reduce its progression, improving symptoms and bringing pain relief. In the case of HV surgical correction, orthoses seem to maintain the correct position acquired over time.

Biomechanical evaluation of 3D-printed joint-type orthosis for hallux valgus

BACKGROUND

Orthoses play an important role in the conservative treatment of hallux valgus (HV) with different therapeutic effects. In this study, a new HV orthosis was developed using three-dimensional (3D) printing technology. In addition, its kinematic effect was evaluated using motion analysis.

METHODS

Seventeen participants with an HV angle of >20° were included in the study. The first metatarsophalangeal abduction angle before and after the orthosis was measured statically. Subsequently, dynamic first metatarsophalangeal abduction, dorsiflexion angle and ground reaction force with and without the orthosis were recorded and calculated during walking using a Vicon motion analysis system and force plates. The patients' comfort scales were determined after the motion analysis.

RESULTS

The angular corrections of the orthosis in the first metatarsophalangeal abduction were 14.6° and 6.3° under static and dynamic conditions, respectively. Reduced hallux dorsiflexion was observed with the orthosis in the early stance phase. However, no significant changes in ground reaction forces were observed.

CONCLUSION

The results of our study confirm the potential of the 3D-printed HV orthosis in the static and dynamic correction of deformities while ensuring patient comfort with minimal impact on hallux kinematics, suggesting the potential of our design for long-term use.

Correction effects of peroneus longus contraction on hallux valgus radiographic parameters

BACKGROUND

Hypermobility of the first tarsometatarsal joint plays an important role in hallux valgus pathogenesis. The peroneus longus is recognized as a dynamic stabilizer of the first tarsometatarsal joint. However, the association between the peroneus longus function and the hallux valgus deformity remains unknown. This study aimed to determine the effect of peroneus longus contraction induced by electrical muscle stimulation on the correction of hallux valgus radiographic parameters in patients with hallux valgus.

METHODS

Thirty-five patients with hallux valgus (47 feet; 2 men, 33 women; mean age 64.9 years) were included. Non-weight-bearing dorsoplantar radiographs of the foot were obtained with and without electrical muscle stimulation of the peroneus longus. Radiographic parameters of hallux valgus deformities, including the hallux valgus angle, intermetatarsal angle, first metatarsal protrusion distance, and distance between the first and second metatarsal bases, were measured and compared between the two conditions.

RESULTS

All hallux valgus radiographic parameters were significantly improved by contraction of the peroneus longus. The median hallux valgus angle decreased by 13.2°. Fewer changes in the hallux valgus angle were identified in patients with severe deformity and geriatric patients.

CONCLUSIONS

Although the peroneus longus muscle has received little attention in the management of hallux valgus, our findings suggest that it has the potential to be a novel conservative approach for treating mild-to-moderate hallux valgus.

Effectiveness of footwear and foot orthoses in reducing medial metatarsophalangeal joint pressure in women with hallux valgus

BACKGROUND

Hallux valgus is a common condition where the subluxation of the first metatarsophalangeal joint and lateral deviation of the hallux at the interphalangeal joint creates difficulty with footwear fit. Footwear and foot orthoses are commonly prescribed nonsurgical treatments for hallux valgus.

RESEARCH QUESTION

Do extra-width footwear and foot orthoses influence peak pressure at the medial aspect of the metatarsophalangeal and interphalangeal joints in women with hallux valgus?

METHODS

Community-dwelling women with symptomatic hallux valgus underwent gait testing when wearing their own shoes and when wearing extra-width footwear fitted with three-quarter length, arch-contouring prefabricated foot orthoses. Peak pressure (kPa) on the medial aspect of the metatarsophalangeal and medial interphalangeal joints and on the plantar surface of the foot (hallux, lesser toes, metatarsophalangeal joint 1, metatarsophalangeal joints 2-5, midfoot and heel) were measured using the novel pedar®-X system with the pedar® pad and pedar® insole, respectively (Novel, GmbH, Munich, Germany). Paired samples t-tests were used to calculate the differences between the two conditions, and the magnitude of observed differences was calculated using Cohen's d.

RESULTS

We tested 28 participants (aged 44-80 years, mean 60.7, standard deviation 10.7). Compared to their own footwear, wearing the intervention footwear and orthoses was associated with a statistically significant decrease in pressure on the medial aspect of the metatarsophalangeal joint (58.3 ± 32.8 versus 42.6 ± 32.8, p=0.026, d=0.49), increased pressure under the midfoot (70.7 ± 25.7 versus 78.7 ± 23.6, p=0.029, d=0.33) and decreased pressure underneath the heel (137.3 ± 39.0 versus 121.3 ± 34.8, p=0.019, d=0.45).

SIGNIFICANCE

The intervention footwear and orthoses significantly decreased peak pressure on the medial aspect of the first metatarsophalangeal joint but had no significant effect on the interphalangeal joint. Further studies are required to determine whether these changes are associated with improvements in symptoms associated with hallux valgus.

Finite Element Parametric Design of Hallux Valgus Orthosis Based on Orthogonal Analysis

OBJECTIVE

To design appropriate orthosis for hallux valgus, a difficult foot condition that affects a quarter of the body's bones, we need to clarify the numerical biomechanical features, which have not been established in previous biomechanical studies. Therefore, we constructed a finite element model of the bunion foot to investigate the orthopaedic force compensation mechanism.

METHODS

A patient with moderate hallux valgus was recruited. CT imaging data in DICOM format were extracted for three-dimensional foot model reconstruction. In conjunction with the need for rapid design of bunion orthosis, a metatarsal force application sizing method based on an orthogonal test design was investigated. The orthogonal test design was used to obtain the hallux valgus angle (HVA) and the inter metatarsal angle (IMA) data for different force combinations. Based on the extreme difference analysis and analysis of variance of the test results, the influence of different force combinations on the bunion angle was quickly determined.

RESULTS

The results showed that the stress concentration occurred mainly in the first metatarsal bone. The distribution trend was in the medial and lateral middle of the bone and gradually decreased to the dorsal base of the bone body. The greatest stress occurs in the cartilage between the phalanges and metatarsals. In 25 groups of simulation experiments, HVA was reduced from 27.7° to 13°, and IMA was reduced from 12.5° to 7.3°.

CONCLUSION

Applying detailed orthopaedic force collocation to the first metatarsal column can effectively restore the mechanics and kinematics of hallux valgus, and provide a reference for the treatment of bunion valgus and the design of orthopaedic devices.

Preoperative degree of deformity and underlying disease affect the postoperative deformity of joint-preserving hallux valgus surgery

BACKGROUND

The combination of distal osteotomy with lateral dissection in joint-preserving surgery for severe hallux valgus deformity has recently begun to yield encouraging results. We examined the frequency of complications and risk factors of those for joint-preserving surgery in patients with and without rheumatoid arthritis (RA).

METHODS

A retrospective, observational study of 72 feet (27 patients with RA) was performed. The inclusion criteria were patients who underwent joint-preserving surgery for hallux valgus deformity at our hospital between January 2008 and March 2016 who could be followed up with for longer than 12 months.

RESULTS

The mean preoperative and immediate postoperative hallux valgus angles (HVA) were 41.8 and 4.4, respectively. The mean preoperative and immediate postoperative intermetatarsal angles between the first and second metatarsal bones (M1-M2A) were 14.6 and 5.8, respectively. At the final postoperative evaluation, the mean HVA was 8.8 and the mean M1-M2A was 6.4.Data were compared among the patients with complications (recurrent valgus deformity, varus deformity), and those without complications (normal HVA) at the final postoperative evaluation. The rate of RA in the varus deformity group was 71.4%, which tended to be higher than in other groups (p = .058). The mean preoperative HVA were 48.2 and 52.6 in the group of recurrent valgus deformity and varus deformity, which was higher than the normal HVA group (p = .001).

CONCLUSIONS

High preoperative HVA was a risk factor for the recurrence of valgus deformity. Most of the varus deformities were observed in the RA group with high preoperative HVA; therefore, caution should be exercised in operating on patients with severe deformity or those with RA.

LEVEL OF EVIDENCE

III.

Forefoot Function after Hallux Valgus Surgery: A Systematic Review and Meta-Analysis on Plantar Load Measurement

While hallux valgus (HV) surgeries are useful for correcting skeletal alignment problems, their effects on plantar load, which reflects forefoot functions, are less understood. The objective of this study is to conduct a systematic review and meta-analysis on the plantar load change after HV surgeries. A systematic search of Web of Science, Scopus, PubMed, CENTRAL, EMBASE, and CINAHL was performed. Studies that assessed the pre- and post-operative plantar pressure of HV patients undergoing surgeries and reported load-related parameters over the hallux, medial metatarsal, and/or central metatarsal regions were included. Studies were appraised by using the modified NIH quality assessment tool for before-after study. Studies suitable for meta-analysis were pooled with the random-effects model, using the standardized mean difference of the before-after parameters as an effect measure. Twenty-six studies containing 857 HV patients and 973 feet were included for the systematic review. Meta-analysis was conducted on 20 of them, and most studies did not favor HV surgeries. Overall, HV surgeries reduced the plantar load over the hallux region (SMD -0.71, 95% CI, -1.15 to -0.26), indicating that forefoot function worsened after surgeries. For the other five outcomes, the overall estimates were not statistically significant, indicating that surgeries did not improve them either. There was substantial heterogeneity among the studies, which in most cases could not be resolved by pre-planned subgroup analyses by surgical classification, year of publication, median age of patients, and length of follow-up. Sensitivity analysis removing lower-quality studies showed that the load integrals (impulse) over the central metatarsal region significantly increased (SMD 0.27, 95% CI, 0 to 0.53), indicating that surgeries increased the risk of transfer metatarsalgia. There is no solid evidence that HV surgeries could improve forefoot functions from a biomechanical point perspective. Currently available evidence even suggests that surgeries might reduce the plantar load over the hallux and adversely affect push-off function. The reasons behind and the effectiveness of alternative surgical methods warrant further investigation.

Race and Insurance Status Association With Receiving Orthopedic Surgeon-Prescribed Foot Orthoses

BACKGROUND

This study looked at the effect of patient demographics, insurance status, education, and patient opinion on whether various orthotic footwear prescribed for a variety of diagnoses were received by the patient. The study also assessed the effect of the orthoses on relief of symptoms.

METHODS

Chart review documented patient demographics, diagnoses, and medical comorbidities. Eligible patients completed a survey either while in the clinic or by phone after their clinic visit.

RESULTS

Of the 382 patients prescribed orthoses, 235 (61.5%) received their orthoses; 186 (48.7%) filled out the survey. Race and whether or not the patient received the orthosis were found to be significant predictors of survey completion. Race, type of insurance, and amount of orthotic cost covered by insurance were significant predictors of whether or not patients received their prescribed orthoses. Type of orthosis, diabetes as a comorbidity, education, income, sex, and diagnosis were not significant predictors of whether the patient received the orthosis. Qualitative results from the survey revealed that among those receiving their orthoses, 87% experienced improvement in symptoms: 21% felt completely relieved, 66% felt better, 10% felt no different, and 3% felt worse.

CONCLUSION

We found that white patients had almost 3 times the odds of receiving prescribed orthoses as black patients, even after controlling for type of insurance, suggesting race to be the primary driver of discrepancies, raising the question of what can be done to address these inequalities. While large, systematic change will be necessary, some strategies can be employed by those working directly in patient care, such as informing primary care practices of their ability to see patients with limited insurance, limiting blanket refusal policies for government insurance, and educating office staff on how to efficiently work with Medicare and Medicaid.

LEVEL OF EVIDENCE

Level III, comparative study.

The Influence of Short-Term Kinesiology Taping on Foot Anthropometry and Pain in Patients Suffering from Hallux Valgus

Background and Objectives: Hallux valgus, one of the most common foot disorders, contributes to the formation of pain, changes foot proportions and hinders everyday functioning. In this study we wanted to verify if kinesiology taping improves hallux valgus and affects the position as well as reducing pain. Materials and Methods: Forty feet with hallux valgus were examined and the parameters were measured at three stages: before the kinesiology taping was applied, just after its application and after a month of use. Measurements were taken with a 3D scanner and a baropodometric platform. Results: When taping was applied, the hallux valgus angle decreased statistically significantly compared with pre-taping (p < 0.01). The use of taping for a month significantly reduced this angle compared with pre-taping (p < 0.05). Parameters such as foot length, the surface of the hindfoot and forefoot and hindfoot pressure on the ground changed. A change in the hallux position due to the taping produced significant changes in the perception of pain (p < 0.001). Conclusion: Kinesiology taping acts on the hallux valgus and foot position mechanically. This makes kinesiology taping an effective method of conservative treatment for patients who are not qualified for surgery.

Finite Element Analysis of Generalized Ligament Laxity on the Deterioration of Hallux Valgus Deformity (Bunion)

Hallux valgus is a common foot problem affecting nearly one in every four adults. Generalized ligament laxity was proposed as the intrinsic cause or risk factor toward the development of the deformity which was difficult to be investigated by cohort clinical trials. Herein, we aimed to evaluate the isolated influence of generalized ligament laxity on the deterioration using computer simulation (finite element analysis). We reconstructed a computational foot model from a mild hallux valgus participant and conducted a gait analysis to drive the simulation of walking. Through parametric analysis, the stiffness of the ligaments was impoverished at different degrees to resemble different levels of generalized ligament laxity. Our simulation study reported that generalized ligament laxity deteriorated hallux valgus by impairing the load-bearing capacity of the first metatarsal, inducing higher deforming force, moment and malalignment at the first metatarsophalangeal joint. Besides, the deforming moment formed a deteriorating vicious cycle between hallux valgus and forefoot abduction and may result in secondary foot problems, such as flatfoot. However, the metatarsocuneiform joint did not show a worsening trend possibly due to the overriding forefoot abduction. Controlling the deforming load shall be prioritized over the correction of angles to mitigate deterioration or recurrence after surgery.