A clinical practice guideline for hallux valgus

Foot problems have been known since early mankind  and shoes have been a part of human attire from early civilization. Throughout the centuries, fashion has played an important role in the success of certain styles from being soft to hard, rigid high-fashion footwear. These footwear constrict the width of the foot especially in the forefoot compressing the toes. Improper footwear can frequently lead to deformities of the forefoot including hallux valgus, bunionettes, and hammer toes.

This review will be looking at literature related to orthotic management for deformities of the forefoot. Since there are a large number of deformities of the forefoot including the toes, and research is scarce, this review will include some of the most common such as hallux valgus, Morton’s neuroma and metatarsalgia. The literature was reviewed to identify studies that investigated the use of foot orthoses as part of conservative treatment of forefoot deformities. The focus of this review was on randomized controlled trials as they have a strong level of evidence.

Forefoot deformities including hallux valgus, Morton’s neuroma and metatarsalgia will be included with a focus on hallux valgus as it is one of the most common and has been researched the most. The review will conclude with a clinical practice guidelines outline on hallux valgus. Sources and selection criteria Randomized controlled trials and controlled clinical trials evaluating orthotic treatment of forefoot deformities were included. Excluded were studies comparing areas of surgery solely.

This review was prepared by searching the following databases: Medline 1966-present; AMED; CINAHL via Clinicians Health Channel; Cochrane library; Pubmed and Google Scholar. Key words used were “forefoot deformities”, hallux valgus”, “metatarsalgia”, “Morton’s neuroma”, “orthotics” and “foot orthoses”. The electronic search was complemented by checking of reference lists of relevant articles for additional studies reported. Summary points .Deformities of the forefoot are common and more prevalent in women than in men with problems peaking in the fourth, fifth and sixth decade of life.

Forefoot deformities are more prevalent in women where one of the reasons can be attributed to women’s tight-fitting shoes which are very narrow especially at the metatarsal heads and toe region. Hallux valgus is one of the most common deformities of the forefoot and can be challenging to treat as it can range from benign and asymptomatic to severe and disabling. There appears to be a distinct lack of quality research for common forefoot conditions. The research is scarce and there are only a handful randomised controlled trials.

Etiology Hallux valgus is one of the most common foot deformities seen by foot and ankle specialists. It is a deformity of the 1st metatarsophalangeal (MTP) joint with adduction and valgus rotation of the great toe combined with a medially prominent first metatarsal head. The treatment may be more challenging than one may initially expect, as the deformity may range from benign and asymptomatic to severe and disabling. Morton’s neuroma is a common injury of the forefoot that affects the third web space of the toes.

The pain is located at the forefoot and radiates to the toes and can be significant and burning. It is associated with pathology of the plantar digital nerve as it divides to supply the adjacent sides of the toes. The precious cause is unclear.  Meatatarsalgia, according to researchers occurs when repetitive high-pressure loading under vulnerable metatarsal heads exceeds physiologic limits. Biomechanical factors that may increase forefoot loading include tight plantarflexors, high-heeled shoes, clawed or hammertoes and dysfunction of the 1st metatarsophalangeal joint.

On examination, symptoms may reveal oedema and inflammation, pain upon palpation and end range of motion during manual muscle testing. There may be change in alignment or position of the toes, and callousing over the metatarsal heads. Results Torkki et al. compared custom-made foot orthoses with surgery and no intervention for painful hallux valgus at 6 and 12 months. At 6 months, pain intensity decreased more in the surgical group than in the control group and more in the orthosis than in the control group.

At one year follow-up, pain decreased more in the surgical group than in the control and the orthosis groups. However, all groups improved when compared with baseline. Tehraninasr et al.  compared the effects of insoles with a toe separator and night splint on patients with painful hallux valgus at 3 months. Pain reduction was statistically significant in the insole group (p<0. 05). No significant difference was found in the night splint group. Hallux valgus and intermetatarsal angles decreased however differences found were not significant.

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