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Home , Ankylosis, Blucher shoe, Bunion, Valgus deformity

MedicalContinuing Education Building Your PRACTICE

Objectives

1) To be able to identify and evaluate the hallux abductovalgus deformity and associated pedal conditions

2) To know the current theory of etiology and pathomechanics of hallux valgus.

3) To know the results of recent Hallux Valgus empirical studies of the manage- ment of hallux valgus.

Assessment and 4) To be aware of the role of conservative management, faulty footwear in the develop- ment of hallux . and the role of faulty footwear. 5) To know the pedorthic man- agement of hallux valgus and to be cognizant of the 10 rules for proper fit.

6) To be familiar with all aspects of non-surgical management of hallux valgus and associated de- formities.

Welcome to Management’s CME Instructional program. Our journal has been approved as a sponsor of Continu- ing Medical Education by the Council on Podiatric Medical Education. You may enroll: 1) on a per issue basis (at $15 per topic) or 2) per year, for the special introductory rate of $99 (you save $51). You may submit the answer sheet, along with the other information requested, via mail, fax, or phone. In the near future, you may be able to submit via the Internet. If you correctly answer seventy (70%) of the questions correctly, you will receive a certificate attesting to your earned credits. You will also receive a record of any incorrectly answered questions. If you score less than 70%, you can retake the test at no additional cost. A list of states currently honoring CPME approved credits is listed on pg. 94. Other than those entities currently accepting CPME-approved cred- it, Podiatry Management cannot guarantee that these CME credits will be acceptable by any state licensing agency, hospital, managed care organization or other entity. PM will, however, use its best efforts to ensure the widest acceptance of this program possible. This instructional CME program is designed to supplement, NOT replace, existing CME seminars. The goal of this program is to advance the knowledge of practicing . We will endeavor to publish high quality manuscripts by noted authors and researchers. If you have any questions or comments about this program, you can write or call us at: Podiatry Management, P.O. Box 490, East Islip, NY 11730, (631) 563-1604 or e-mail us at [email protected]. Following this article, an answer sheet and full set of instructions are provided (p. 94).—Editor

By Ellen Sobel, D.P.M., Ph.D., C.Ped., do not undergo surgery. Addition- its non-surgical management with and Steven J. Levitz, D.P.M. ally, the major role of inadequate special emphasis on the role of tight fitting footwear in the devel- footwear in the development and ost of the literature on opment of hallux valgus is well es- treatment of this common ail- hallux valgus/ de- tablished and accepted by all.1-5 ment. Mformity is devoted to sur- This Continuing Podiatric Medical Hallux valgus is an angular out- gical correction, although most Education Article will focus on hal- ward deviation of the proximal people with this common problem lux valgus/bunion deformity and Continued on page 76

www.podiatrymgt.com OCTOBER 2001 • PODIATRY MANAGEMENT 75 Hallux Valgus... have observed an increas- Continuing ing incidence of phalanx of the hallux occurring as they have changed Medicalin Education 2 to 15 percent of the U.S. popu- from traditional lation.6-8 A bunion is any osseous- to leather footwear.23 cartilaginous enlargement of the In contrast Gottschalk medial eminence often combined et al.24 reported from with swelling of the soft tissues.9 South Africa that hallux valgus was present in Etiology both urban and rural are the most important Africans. Similarly Barni- extrinsic factor in the development cot and Hardy16 observed of hallux valgus1-5,10,11 and the major that hallux valgus did cause of forefoot pain.5 It has been occur in barefooted said that perfectly healthy feet are Africans in both sexes. generally found only in young The conclusions that children and peoples that go bare- must be drawn from these foot.12 In a survey of 905 cases, data are that hallux val- bunions occurred in females ten gus and bunions do seem times more frequently than males, to occur in nonshod indi- suggesting that females, who wear viduals, but much less fre- fashionable footwear more than quently than persons men, developed hallux valgus and wearing shoes. As Myer- bunions due to the footwear.13 son notes, approximately Coughlin and Thompson14 noted 4 percent of the world the extremely high prevalence of population develops hal- bunions in women in the fourth lux valgus deformity, re- Figure 1. End stage hallux valgus. Tight extensor through sixth decade of life, once gardless of type of foot- hallucis longus results in hyperextension of the again suggesting that stylish con- wear or lack thereof.25 hallux. stricting footwear causes hallux Many authors have valgus. described the relationship between cuneiform .42 Clinical signs of Hallux valgus is found almost pronation and hallux valgus.26-37 first ray hypermobility have tradi- exclusively in societies where shoes However, this does not mean that tionally included the presence of a are worn.15-20 Yet many individuals the relationship is necessarily dorsal bunion, callus beneath the wear fashionable causal. Inman36 second metatarsal head and arthri- footwear and hal- felt that prona- tis of the first and second metatar- lux valgus does tion was a predis- socuneiform joint. Radiographical- not develop.15 Hallux valgus is an posing factor to ly cortical hypertrophy along the Shine21 examined angular outward the development medial border of the second 3,515 people on of hallux valgus metatarsal shaft has been thought the island of St. deviation of the proximal only if significant to be diagnostic of first ray hyper- Helena and phalanx of the hallux heel valgus was mobility. found that the present on In one recent study hypermo- incidence of hal- occurring in 2 to 15 weight bearing, bility of the first ray was assessed lux valgus was 2 percent of the U.S. but not if the by increased thickness of the medi- percent in those population. arch alone was al cortex at the midshaft of the sec- who went bare- simply flattened. ond metatarsal on x-ray.42 In this foot, and in those More recently study there was found to be no shod for 60 years, Kilmartin and correlation between clinically in- 48 percent of the women had hal- Wallace38 found that there was no creased range of motion of the first lux valgus and 16 percent of the association in arch height between metatarsocuneiform joint and 2nd men had hallux valgus. Sim-Fook children with hallux valgus and metatarsal medial cortical thick- and Hodgson19 compared 107 bare- unaffected children. Similarly, ness, placing into doubt whether foot and 118 shoe-wearing Chinese other recent studies have found no increased 2nd metatarsal medial in Hong Kong and found that hal- association between hallux valgus cortical thickening is a valid indi- lux valgus occurred in 2 percent of and pronation.39,40 cator of clinical hypermobility of barefoot people and 33 percent of Hypermobility of the first ray the first ray. people who wore shoes. Similarly has been considered to be one of First ray hypermobility may ac- Maclennan22 found only a 2 per- the causative factors of hallux val- tually be a result of hallux valgus cent incidence of hallux valgus in gus.1,41 An average of 4.2º of mo- rather than an etiology of the con- 1,256 non-shoe wearing New tion has been reported to be pre- dition. In a quantitative assess- Guinean natives. The Japanese sent in the normal first metatarso- Continued on page 78

76 PODIATRY MANAGEMENT • OCTOBER 2001 www.podiatrymgt.com Circle #13 Hallux Valgus... has been re- Hardy and Clapham46 found a .71 Continuing ported to be associated with hallux correlation between the occur- ment of sagittal plane motion of valgus.44 rence of metatarsus primus varus Medicalthe Education first ray, Klaue et al.43found The association between hallux and hallux valgus.46 that the mean dorsal displacement valgus and metatarsus primus Truslow47 was the first to theo- at the metatarsal base averaged 2.6 varus is controversial. Lapidus at- rize that metatarsus primus varus millimeters in patients with hallux tributed the rigid metatarsus was a congenital abnormality valgus and 1.5 millimeters in the primus varus to the medial slope which resulted in hallux valgus control group, suggesting that pa- of the metatarsocuneiform when the individual began wearing tients with hallux valgus tend to joint.45He considered the apex of shoes. However, studies by Hardy have an increased passive exten- the metatarsus primus varus defor- and Clapham46 and Craigmile30 sion of the first ray. Generalized mity to be the medial metatarso- seemed to disprove this theory. cuneiform joint. He observed The fact that in children the inter- that the intermetatarsal angle metatarsal (IM) angle remains sta- of a fetus is approximately 32˚ ble for long periods of time while and reduces to 6.2˚ in normal the hallux abductovalgus angle is adults. Therefore, he assumed found to increase until a certain that a high IM angle resulted threshold hallux valgus angle is from an arrest in develop- reached, and then both the IM and ment that congenitally pre- hallux valgus angles both increase disposed patients to develop rapidly,46,48 seems to indicate that hallux valgus deformity.45 Continued on page 79

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

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

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Hallux Valgus... first metatarsal. With medial mi- balance the joint, FHL ten- gration of the first metatarsal head, dinitis may result.52 Finally hallux valgus precedes metatarsus the medial joint capsule becomes when the lateral collateral liga- primus adductus. It would appear attenuated and the abductor hallu- ment and sesamoid ligaments are that once the medial capsule of the cis tendon is pulled plantarward disrupted and the entire joint cap- MTPJ is overstretched by a large becoming a flexor. Adduction of sule weakens, dislocation of the hallux valgus angle, a longitudinal the first metatarsal with an increas- metatarsophalangeal joint occurs force on the tip of the easily ing intermetatarsal angle results in with end stage hallux valgus defor- produces metatarsus primus a wide splayed forefoot.25 mity.25 varus.49 Shoe friction and irritation of Usually less than 50 percent of Multifactorial inheritance is the medial collateral ligament of the metatarsal will articulate with thought to be the mode of trans- the first metatarsophalangeal joint the proximal phalanx. The clinical mission in hallux valgus lead to chronic of appearance of the medial promi- deformity50 with a positive family the overlying bursa and further nence is due to the displacement history in 63 per- proliferation of of the hallux laterally uncovering cent of patients fibrotic and os- the medial aspect of the metatarsal with hallux val- teoblastic activi- head. The metatarsal head hyper- gus.46 Coughlin51 Hallux valgus ty. As the defor- trophies laterally and an overlying noted maternal is found almost mity progresses inflammatory bursa can occur (the transmission in the axis of pull of bunion). During the propulsive pe- the majority of exclusively the adductor hal- riod of gait individuals with hallux juvenile hallux in societies where lucis, the flexor valgus widen the forefoot, increas- valgus patients hallucis brevis, ing deformity with each step, in with variable shoes are worn. extensor hallucis contrast with the forefoot narrow- penetrance. longus, and the ing with propulsion in people who abductor hallucis do not have hallux valgus.53 Pathomechanics all become later- More than 50 percent of the The pathomechanical process alized, increasing the abductor weight-bearing force during gait begins with wearing narrow, force on the hallux. The hallux passes through the first metatar- pointy, short, and possibly high may be held in extension away sophalangeal joint.9 Gait analysis of heeled shoes for many years. Creep from the ground due to the bow- the individual with hallux valgus deformation forces resulting from string effect of the extensor hallu- reveals that the great toe has a di- the shoe produce a slow deforma- cis longus (Figure 1). With prona- minishing role in weight bearing of tion over time resulting in stretch- tion and hypermobility of the first the forefoot.54 As the hallux abduc- ing of the abductor hallucis muscle metatarsal the flexor hallucis tus angle increases, the pressure be- with the proximal phalanx of the longus muscle contracts to plantar neath the hallux decreases.55-57 The hallux starting to drift laterally and flex the great toe and balance the center of pressure is a mathematical abducting. The normal forces of first metatarsophalangeal joint. representation of the summation of walking with forefoot pronation With increased use of the FHL to Continued on page 80 stretch the medial collateral liga- ment and capsular structures and push the hallux into a valgus posi- tion.40 After a certain threshold degree of abductus and valgus of the hal- lux is reached, a retrograde force from the distorted position of the hallux pushes the first metatarsal into a varus position and off the sesamoids. The sesamoid are located within the two tendons of the flexor hallucis brevis and func- tion similarly to the , serv- ing as a fulcrum to add mechanical advantage to the pull of the FHB and FHL during toe-off. The sesamoids are firmly attached to the adductor hallucis and the deep transverse metatarsal ligament and insert on the plantar lateral base of the proximal phalanx and do not Figure 2E. In spite of severe hallux valgus, pronation, ankle equinus, and fore- follow the medial migration of the foot supinatus, the heel is straight.

www.podiatrymgt.com OCTOBER 2001 • PODIATRY MANAGEMENT 79 Hallux Valgus... Clinical Presentation Continuing Patients with hallux valgus gen- forces through which load on the erally complain of pain in the first Medicalfoot Education acts in the stance phase of metatarsophalangeal joint mostly gait.55 There is a when walking in characteristic lat- tight shoes. The eral shifting of clinical presenta- the center of pres- In one recent study tion of hallux sure in patients hypermobility of the first valgus is unmis- with hallux val- takable, with se- gus which is simi- ray was assessed by vere deformity lar to the center increased thickness of the (Figure 2A), sig- of pressure mea- nificant prona- surements of pa- medial cortex at the tion (Figure 2B), tients who have midshaft of the second ankle equinus undergone hallux metatarsal on x-ray. (Figure 2C), and amputations.54 forefoot supina- The effectiveness tus with callosity of various treat- under the second ments can be determined by the metatarsal head (Figure 2D), yet reestablishment of the weight bear- the weight bearing heel position Figure 3. Gouty with swelling ing of the first MTP joint utilizing remains relatively straight (Figure of 1st metatarsophalangeal joint phys- in-shoe plantar pressure devices. Continued on page 81 ically appears as bunion deformity.

TABLE 1 OF HALLUX VALGUS (Adapted from Williams RC: J Musculoskel Med, 1991)

DISEASE CLINICAL FEATURE LABORATORY/IMAGING Men 40 to 70 years Serum uric acid level elevated Acute of 1st MTPJ in 75% of patients Should 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 leukocytosis Gram stain may be positive Joint fluid/blood cultures positive scan may be positive Affects multiple MTP Exostoses; Enlarged but not warm and tender Interphalangeal narrowing on x-ray Painful passive range of motion ESR normal Clinically no motion at MTP joint Marked bony overgrowth No acute redness or warmth on x-ray with hallux rigidus dorsal bunion Hallux valgus Generally symmetrical Stage 4 hallux valgus with with Fibular deviation of all digits completed subluxated joint on x-ray Rheumatoid May be more severe than isolated Severe deformity with ankylosis Arthritis 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 , I.e., spasticity neuromuscular more severe disease

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Hallux Valgus... hallux valgus does seem quite simple from the presentation of obvious clinical deformity. Perhaps 2E). It should be kept in mind that empirical studies the early inflammatory stage where hallux valgus and have found the normal weight bearing calcaneal bunion deformi- stance position of the heel to be about 5º valgus.58,59 ty may resemble Patients with severe bunion deformity frequently gouty arthritis develop callosities under the lesser metatarsal heads and infection are because of a lack of weight bearing of the first ray. most problemat- Callus may also develop under the second, third, or ic. Enlargement fourth metatarsophalangeal heads. Hammer digits of the first with overlapping or underlapping digits result from metatarsopha- the laterally deviated hallux. Painful corns result langeal joint from the shoe upper. Soft corns commonly occur with acute with bunions between the first and second and monoarthritis of even between the lesser toes because more pressure is the first metatar- placed on the toes from the hallux valgus deformity. sophalangeal Hallux rigidus is a common problem associated with joint is also pre- the bunion. Sesamoid pain is common with the pro- sent in gout (fig- gression of bunions. As the first metatarsal migrates ure 3).62,63 Pa- and the sesamoids are no longer in place, incongruity tients present and osteochondrosis of the sesamoids develop. with intense In bunion patients who have excessive pronation pain, heat, ery- with heel valgus, associated Achilles tendon tightness thema, and increases the valgus forces on the hallux during swelling of the propulsion. Excessive pronation presenting with 1st metatar- bunion deformity may also be associated with poste- sophalangeal rior tibial tendinitis and peroneal spasm.52 Arthritis Figure 4A. Early gouty arthritis. Joint joint.64 Exquisite may rarely develop in the first metatarsal cuneiform surface intact. Continued on page 82 joint as a result of instability of the first metatarsal.52 Stress fractures can occur in the second or third metatarsals during pronation as stresses are trans- ferred to the second and third metatarsals and the lat- eral fibula. Increased pressure between the lateral metatarsals may also result in Morton’s Neuroma.

Radiographic Criteria According to Gerbert’s Textbook of Bunion Surgery, the normal hallux abductus angle is 10-15˚60 and the normal inter- metatarsal angle is 8-12˚.60 However, significant hallux valgus can exist with an inter- metatarsal angle of 8-12˚.61 Therefore, some favor a more stringent criteria and values of 9 or higher are consid- ered to be abnor- mal.6,15,18

Differential Diagnosis At first glance Figure 4B. Late gouty arthritis. Joint is the diagnosis of destroyed. Circle #80 www.podiatrymgt.com OCTOBER 2001 • PODIATRY MANAGEMENT 81 Hallux Valgus... one week. Non-steroidal anti-inflam- rence of disease, tophi may develop Continuing matory medication will reduce symp- and calcify. tenderness is present dorsally and toms within two to three days.64 Ra- The articular surfaces of joints Medicallaterally Education with inflammation and gen- diographs reveal only soft tissue are generally spared in early gout erally resolves spontaneously within swelling or osteopenia.65With recur- (Figure 4A), but advanced joint dis-

Figure 5A/B. Case Presentation. This 55 year old male presented with a 2-week history of pain and swelling in dorsum of the left foot (Figure 5A). The patient had hallux valgus deformity of the left foot only and a history of gouty arthritis. The problem failed to resolve after 2 weeks and in fact showed some signs of increased pain and swelling after he walked on it. 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 of gouty arthritis, the pain and swelling was lasting 2 weeks without showing signs of improvement, which is unusual for gout. Although this patient had no history of trauma, plain radiographs revealed a healing fracture of the second metatarsal which might have become more symptomatic with walking on the foot.

ease produces a narrowed joint space much like that in osteoarthri- tis (Figure 4B). If gouty arthritis lasts for too long or does not re- spond to nonsteroidal anti-inflam- matory medication, the diagnosis of gout becomes less certain (See Case Presentation Figure 5A/B). The intense inflammatory response may resemble a cellulitic process. There may be desquamation of the overlying skin and blood tests will reveal a mild peripheral leukocyto- sis with an infectious process. Hallux rigidus with osteoarthri- tis of the first metatarsophalangeal joint may present with a dorsal bunion (Figure 6A/B). Passive dor- siflexion of the 1st MTPJ is restrict- ed or absent. Osteoarthritis of the 1st MTPJ produces pain during pas- sive and/or active motion, and compression over the bunion area produces minimal tenderness. Compression of the medial dorsal Figure 6B. Osteoarthritis of the first digital sensory nerve may produce Figure 6A. Dorsal bunion. metatarsal phalangeal joint. Continued on page 84

82 PODIATRY MANAGEMENT • OCTOBER 2001 www.podiatrymgt.com Circle #72 Hallux Valgus... ly bilateral and presents with sublux- pirical studies which involve ran- Continuing ation of the first metatarsopha- domized clinical trials dealing with tenderness along the dorsal-medial langeal joint and fibular deviation the effect of foot orthoses on the Medicalaspect Education of the foot which results in a (Figure 7). After a while the bones of progression of hallux valgus and radiating or “shooting” pain that the foot in may the relief of symptoms. travels toward the toe or ankle. become entirely fused (Figure 8). See One prospective randomized Skin irritation is usually from Table 1 for a summary of the differ- clinical trial evaluated the effect of shoes and will resolve as soon as ential diagnosis for hallux valgus. Functional Foot orthoses on the the shoes are removed. progression of the hallux valgus Hallux valgus is the most com- Management of Hallus Valgus angle in adults with rheumatoid mon in rheumatoid and Foot Orthoses—Current arthritis.67 Fifty rheumatoid arthri- arthritis.66 Hallux valgus associated Research tis patients in the treatment group with rheumatoid arthritis is frequent- There are only three recent em- wore Rohadur functional foot or- thoses with appropriate posts, and 52 patients with rheumatoid arthritis in the control group wore placebo leather unposted orthoses. After wearing the foot orthoses for the 3-year study period, 5 patients wearing the functional foot or- thoses versus 12 patients wearing the leather orthoses demonstrated progression of the hallux valgus deformity on x-ray. Progression of hallux valgus deformity was de- fined as a 5˚ increase or more in

Multifactorial inheritance is thought to be the mode of transmission in hallux valgus

Figure 7. Bilateral hallux valgus with joint subluxation and fibular deviation as- deformity with a sociated with rheumatoid arthritis. positive family history in 63 percent of patients with hallux valgus.

the hallux valgus angle. Those au- thors concluded that foot orthoses slowed the progression of hallux valgus deformity in patients with rheumatoid arthritis.67 In the only randomized clinical trial on the effect of functional foot on the progression of hallux valgus in healthy chil- dren, 93 children with hallux val- gus aged 9-10 years were followed for a three year period.48 Approxi- mately half were randomly as- signed to wearing a functional posted foot orthosis for 3 years and the remaining half served as the Figure 8. Bilateral hallux valgus with complete fusion of all joints associated control group. At the end of the with rheumatoid arthritis. Continued on page 85

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Hallux Valgus... 16, 2001) compared the effective- year. Patients were randomly ness of surgery, orthotic treatment assigned to surgery (distal three year study period the 1st and no treatment in patients with chevron ), orthosis, or metatarsophalangeal angle in- mild to moderate hallux valgus.68 a one-year period of watchful wait- creased approximately 2˚ in the There were approximately 70 adult ing (control group). control group and 2.5˚ in the treat- patients in each of the three At the time of 6-month follow- ment group. However, the differ- groups who were followed for one up, patients in the surgery and or- ence between the control and thosis group had less pain and treatment group was not signifi- were more satisfied with the treat- cant. In the nonaffected foot the ment than in the non-treated con- hallux valgus angle increased ap- The effectiveness trol group. At the time of 1-year proximately 4˚ in both the treated of various treatments follow-up, pain intensity decreased and the control group, which was more in the surgical than in the or- a highly significant difference. It can be determined thotic group or the control group. should be noted that the inter- by the reestablishment The number of painful days, cos- metatarsal angle remained the metic disturbance, and footwear same over the entire three-year of the weight bearing problems were least in the surgical study period. During the study, of the first MTP joint group and functional status and hallux valgus developed in the un- satisfaction with treatment were affected feet of children with uni- utilizing in-shoe best in the surgical group.68 The au- lateral deformity, despite the use of plantar pressure thors concluded that foot orthoses the orthosis.48 were effective for short term relief A recent randomized controlled devices. in the mild to symptomatic trial published in the Journal of the bunion patients, but that surgical American Medical Association (May Continued on page 86

TABLE 2 10 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 must be 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 used to 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 arch length, not the overall length of the foot, because the arch length ends at the first metatarsal head which is the widest 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 fit snugly 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.

www.podiatrymgt.com OCTOBER 2001 • PODIATRY MANAGEMENT 85 Hallux Valgus... with longitudinal arch support and roomy shoes will be most helpful Continuing medial forefoot posting. when the pain is caused by direct management was ultimately pressure over the medial eminence. Medicalmore Education beneficial. Shoe Wear Shoes can be stretched to relieve Foot orthoses are helpful for as- The pedorthic objectives for re- pressure. Remember that it is nec- sociated transfer metatarsalgia, to lief of hallux valgus include reliev- essary to leave shoes overnight for pad metatarsal ing direct medial a proper stretching procedure. If callosities and to pressure over the the problem is coming from within limit excessive bunion and ad- the joint, a stiff-soled shoe or rock- pronation. Compression of the dressing transfer er bottom sole may help to by-pass Sanders and medial dorsal digital metatarsalgia in the painful metatarsophalangeal Hegemeir70 have the lesser joint. suggested foot or- sensory nerve may metatarsals. The typical women’s foot has a thoses for hallux produce tenderness Symptomatic wide forefoot and narrow heel. The valgus patients pronation should average women’s foot is 3-1/4 to 3- with instability of along the dorsal-medial also be ad- 3/4 inches wide. The width of the the first metatar- aspect of the foot. dressed. Bunion fashion shoe is usually not more socuneiform pain may be than 3 inches wide (Figure 9A/B). A joint. They state caused by direct Continued on page 87 that these pa- pressure over tients complain of generalized foot the medial eminence or pain pain with activity, and incorrectly originating from joint motion. assume that the pain is due to their If the pain is due to direct pres- bunion. They suggest full length sure over the bunion then the foot orthoses fabricated from tril- patient will have no difficulty aminar or multilaminar materials ambulating barefoot. Wide

Figure 9B. This shoe is too narrow for this Figure 9A. Fashion shoes with narrow forefoot and square pointy low toe patient even though it is a low heeled ox- box. ford blucher shoe.

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

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Hallux Valgus... for Proper Shoe Fit. heel, and 76 percent for a 3- The heel height should be low 1/4 inch heel.71 combination last provides for a (Table 3). By the age of 16, over 50 narrow rearfoot and a wide fore- percent of girls wear heels some of Bunion Splints foot to prevent heel slippage. Fi- the time. As compared with no Bunion splints are an under-uti- nally, sometimes it is necessary to heel, forefoot pressure increases by lized yet highly effective treatment cut a hole into the shoe (Figure 22 percent when wearing a 3/4- for hallux valgus bunion deformity. 10A/B). See Table 2 for the 10 rules inch heel, 57 percent for a 2-inch Although no splint will actually cor- rect hallux valgus deformity, stretching and realignment of the TABLE 3 first MTPJ performed by the splint may provide the patient with dra- THE HEIGHT OF THE HEEL OF THE SHOE matic symptomatic relief. The clas- sic latex bunion shield may be spe- (Adapted from Sander M, Hagemeir KW: cially molded to the patient’s foot to Conservative treatment and accommodate a bunion deformity shoewear options for hallux valgus. (Figure 11). There are a number of Foot Ankle Clin 2(4): 639-53, 1997, December.) commercial bunion splints which pad the bunion, straighten the hal- lux valgus deformity and can be used at night for sleeping and even Flat Shoe 3/4 inch heel height or less during the day as long as the hallux Low Heel 3/4 inch heel height to 1-3/4 inch heel height valgus deformity is at least partially flexible. Some come with attached Mid Heel 1-3/4 inch heel height to 2-1/4 inch heel height toe splinting and toe spacers. A toe spacer between the first and second High Heel 2-1/4 inch or higher toe is often necessary since the ab- Continued on page 88

Circle #84 www.podiatrymgt.com OCTOBER 2001 • PODIATRY MANAGEMENT 87 Hallux Valgus... to splint hammer digits and tailor’s Metatarsal pads have been shown to Continuing bunions (Figure 14). reduce pressure under the metatarsal ducted hallux pushes against the Pedifix’s Hallux Valgus Soft- heads in 100 percent of asymp- Medicalsecond Education digit. Apex Foot Health In- Splint™ also provides comfortable tomatic female volunteers.73 Similar- dustries has combined a relatively and effective post-op splinting. It is ly in another study of the effect of thick soft foam toe spacer with a metatarsal pads on plantar weight soft bunion pad for accommodation bearing pressure in asymptomatic of hallux valgus and bunion defor- individuals, walking with insoles mity (Figure 12). The popular Jacoby Wide roomy shoes with metatarsal pads resulted in Bunion Splint from Angus Market- will be most helpful peak load decreases in the forefoot ing is commonly used for patients region and peak load increases in with Hallux Valgus (Figure 16). when the pain is caused the midfoot region under the The hallux valgus night splint by direct pressure over metatarsal shafts.74 Also available (also from Apex) (Figure 13) places the medial eminence. from Silipos is their soft padded the hallux in a 1st class lever system Bunion Shield, which is excellent which stretches and adducts the de- Shoes can be stretched for both daytime and nighttime use. viated hallux. We have found that to relieve pressure. Physical therapy may consist of many patients with deformity find superficial and deep heat treatment relief by wearing the splint at night. such as ultrasound and exercises to This splint has also been reported to stretch the toe twice daily for one be effective postoperatively after designed for ambulatory or non-am- minute per foot (10 to 15 repeti- bunion surgery.72 Darco Internation- bulatory use after bunion surgery to tions) for the first month, then once al, Inc. has a very comfortable cloth maintain ideal hallux positioning daily for 3 months. Intraarticular in- bunion splint which not only exerts and constant MP joint alignment jection for patients with painful a corrective force on the hallux, but (Figure 17). range of motion are a final option (1 comes with adjustable velcro straps Debridement of associated digi- ml of 50 percent corticosteroid and tal corns and 1 percent lidocaine) prior to surgical plantar callosities intervention. should be done There has recently been empha- periodically. sis on clinical staging of hallux val- Foam, rubber, or gus.75 Garrow and associates75 felt silicone toe that since hallux valgus is the most sleeves (Silipos) instantly recognizable deformity of are used to sepa- the foot, they developed a staging rate or cushion system based on clinical photo contact points alone. Table 3 reviews the authors’ between the hal- clinical staging for hallux valgus de- lux and the sec- formity and management for each ond toe (Figure of the associated four clinical stages. 15). Corn pads For more information about and metatarsal these products mentioned in the pads can be used preceding article, circle the corre- for associated de- sponding number on the reader formities of the service card in this magazine. Figure 11.Latex bunion shield. digits and plantar Apex Bunion Shield—Circle #148 callosities. Jacoby Bunion Splint (Angus)— Circle #149 Apex Night Splint—Circle #150 Darco Abductor Splint—Circle #151 Silipos Bunion Shield—Circle #152 Silipos Toe Sleeve—Circle #153 Pedifix SoftSplint—Circle #155 I

References 1 American College of Foot and Ankle Or- thopedics and Medicine (ACFAOM): Preferred Practice Guidelines Prescription Custom Foot Orthoses. 1998. Figure 12. Hallux valgus bunion shield with large toe spacer. (Apex Foot Health 2 American College of Foot and Ankle Sur- Industries) Continued on page 89

88 PODIATRY MANAGEMENT • OCTOBER 2001 www.podiatrymgt.com MedicalContinuing Education

Hallux Valgus... 8 Hurwitz S: Evaluating bunions, offering 14 Coughlin MJ, Thompson relief. J Musculoskel Med 14: 52-64, 1997. FM: The high price of high-fashion geons (ACFAS): Preferred Practice Guidelines. 9 Nork SE, Coughlin RR: How to examine footwear. In instructional Course Lec- Hallux Valgus in the Healthy Adult. Pp. 1-24, a foot and what to do with a bunion. Primary tures, The American Academy of Or- 1992. Care 23(2): 281-97, 1996. thopaedic Surgeon. Vol. 44, pp.371-7. Rose- 10 3 Coughlin MJ: The high cost of fashion- Frey CC, Shereff MJ: Tendon mont, Illinois, The American Academy of Or- able footwear. J Musculosklet Med 40-53, De- about the ankle in athletes. Clin Sport med 7(1): thopaedic Surgeons, 1995. cember, 1994. 103-118, 1988. 15 Coughlin MJ: Hallux valgus Causes, 11 4 Mann RA, Coughlin MJ: Adult hallux Friedman SL: “Palliative Care,” In JM Evaluation, and Treatment. Postgraduate Medi- valgus. In Mann RA, Coughlin MJ, eds. Surgery Robbins: Primary Podiatric Medicine. W.B. cine 75(5): 174-87, 1984, April. of the Foot and Ankle. St. Louis, Mo: Mosby- Saunders Company, Philadelphia, 1994, Chap- 16 Barnicot NA, Hardy RH: The position of Yearbook; 1993. ter 13, 167-82. the hallux in West Africans. J Anat 80: 356-61, 5 Rudicel SA: Evaluating and managing 12 Snijder CJ: “Biomechanics of Footgear, 1955. forefoot problems in women. J Musculoskel Hallux Valgus, and Splayfoot. Chapter 22. pp. 17 Engle ET, Morton DJ: notes on foot dis- Med 16: 562-67, 1999. 564-582. In Disorders of the Foot and Ankle ed orders among natives of the Belgian Congo. J 6 Coughlin M: Hallux valgus J Bone Joint by M Jahss, Churchill Livingstone, New York, Bone joint Surg 13: 311-8, 1931. Surg 78A: 932-66, 1996. 1991. 18 Johnson PH: The Bunion. J Arkansas 7 Mann RA: Disorders of the first metatar- 13 Mann RA, Coughlin MJ: Hallux valgus Med Soc 78: 235-7, 1981. sophalangeal joint. J Am Acad Orthop Surg 3: etiology, anatomy, treatment and surgical con- 19 Sim-Fook L, Hodgson AR: A comparison 34-43, 1995. siderations. Clin Orthop 157: 31-41, 1981. of 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 African native. Amer J phys Anthropol 15: 185-289, 1931. 21 Shine IB Incidence of hallux valgus in a partially shoe-wearing community. British Medical 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. Foot Ankle Clin 2: 583, 1997. 26 Hauser EDW. of the Foot. W.B. Saunders Company, Philadelphia, 1941. Chap- ter 6, p. 119. 27 Root ML, Orien WP, Weed JH: Normal Continued on page 90

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

Figure 14. Hallux valgus abductor splint with attachments for splinting hammer Figure 15. Soft silicone toe sleeve (Silipos, digit and Tailor’s bunion (Darco International, Inc.). Inc.) www.podiatrymgt.com OCTOBER 2001 • PODIATRY MANAGEMENT 89 Hallux Valgus... 95-9, 1938. Diagnosing Continuing 32 Joplin RJ: Sling procedure for correction and treating and Abnormal Function of the Foot. Clinical of splay-foot, metatarsus primus varus, and hal- hallux valgus: MedicalBiomechanics Education Volume II. Clinical Biomechan- lux valgus. J Bone Joint Surg 32A 779-85, 1950. A conservative ics Corporation, Los Angeles, California, 1977. 33 Mayo CH: The surgical treatment of approach for a 28 Greenberg GS: Relationship of hallux ab- bunion. Minnesota Med 3: 326-331, 1920. common ductus angle and first metatarsal angle to severi- 34 Rogers WA, Joplin RJ: Hallux valgus, problem. ty of pronation. J Am weak foot and the Cleveland Clin Podiatry Assoc 69: 29- Keller operation: an J Med 64(9): 34, 1979. end-result study. Surg 469-74, Octo- 29 Holstein A: Hal- Clin N Amer 27: 1295- ber, 1997. lux valgus: an acquired 1302, 1947. 38 Kil- deformity of the foot in 35 Stein HC: martin TE, Hallux valgus. Surg Wallace WA: cerebral palsy. Foot Figure 17. Pedifix’s Gynec Obstet 66: 889- The signifi- Ankle 1: 33-8, 1980. SoftSplint™ 30 Craigmile DA: 898, 1938. cance of pes Incidence, origin, and 36 Inman VT: planus in juvenile hallux valgus. Foot Ankle 13: prevention of certain Hallux valgus: A review 53, 1992. foot defects. Br Med J 2: of etiologic factors. Or- 39 Saragas NP, Becker PJ: comparative radio- 729-52, 1953. thop Clin NA 5(1): 59- graphic analysis of parameters in feet with and 31 Galland WI, Jor- 66, 1974. January. without hallux valgus. Foot Ankle Int 16: 139, dan H: Hallux valgus Figure 16. The popular jacoby Bunion 37 Donley BG, 1995. Surg Gynec Obstet 66: Splint from Angus Marketing Tisdel CL, Sferra JJ et al. Continued on page 92

TABLE 4 CLINICAL STAGING OF HALLUX VALGUS DEFORMITY AND TREATMENT

STAGE I: Inflammatory Pain, heat, swelling, erythema Very little deviation of the toe, but large medial prominence at the MTP joint Pain from inflammation of small bursa formed over the medial eminence Thickening of the bursal wall accentuates the prominence Must 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 radiograph Congruent MTP joint

STAGE III: Moderate Deformity The first metatarsal head is pushed into a position of varus, off the sesamoids Lateral sesamoid is displaced about 75% from beneath metatarsal head Medial capsular structures are stretched while the lateral structures become increasingly contracted Some loss of MTP joint congruity

STAGE IV: Severe Deformity Significant metatarsus primus varus Complete dislocation of the sesamoids Pronation of the great toe Overlapping of the second toe Marked soft tissue Congruity at the metatarsophalangeal joint completely lost Often associated with rheumatologic or neuromuscular disease

90 PODIATRY MANAGEMENT • OCTOBER 2001 www.podiatrymgt.com Circle #48 Hallux Valgus... a result of flexion forces in hallux valgus. Foot 64 Bibbo C, Lin SS: Crystalline Continuing ankle 13: 515, 1992. Gout and Calcium pyrophos- 40 Alvarez R, Haddad RJ, Gould N, et al: 54 Holmes GB: Gait analysis in hallux valgus. phate deposition disease (CPPDD) Foot Ankle MedicalThe Education simple bunion: Anatomy at the metatar- Foot Ankle Clin 2(4): 627-38, 1997, December. Clin 4(2): 275-91, 1999, June. sophalangeal joint of the great toe. Foot Ankle 55 Hutton WC, Dhanendran M: The me- 65 Uri DS, Dalinka MK: Imaging of 4: 229, 1984. chanics of normal and hallux valgus feet: A arthropathies: Crystal disease. Radio Clin North 41 Myerson MS, Badekas A: Hypermobility quantitative study. Clin orthop 157: 7-13, 1981. Am 34: 359-74, 1996. of the first ray. 5(3): 469-84, 2000. 56 Stokes IAF, Hutton WC, Evans MJ: The 66 Sobel E, Caselli MA, McHale KA: Pedal 42 Prieskorn DW, Mann RA, Fritz G: Radio- effects of hallux valgus and Keller’s operation manifestations of musculoskeletal disease. Clin graphic assessment of the second metatarsal: on the load-bearing function of the foot during Podiatr Med Surg 15(3): 435-80, 1998, July. Measure of first ray hypermobility. Foot Ankle walking. Acta Orthop 67 Budiman-Mak E, 17(6): 331-3, 1996, June. Belg 41: 695-704, 1975. Conrad KJ, Roach KE et 43 Klaue K, Hansen ST, Masquelet AC: Clin- 57 Stokes IAF, Hut- al.: Can foot orthoses ical, quantitative assessment of first tarsometatr- ton WC, Stott JRR, et al: Bunion splints prevent hallux valgus sal mobility in the sagittal plane and its relation Forces under the hallux deformity in rheuma- to hallux valgus deformity. Foot Ankle Int 15: 9, valgus foot before and are an underutilized, toid arthritis. A ran- 1994. after surgery. Clin Or- yet highly effective domized clinical trial. J 44 Carl A, Ross S, Evanski P, et al: Hyper- thop 142: 64-72, 1979. Clin Rheumatol 1: mobility in hallux valgus. Foot Ankle 8: 264, 58 Sobel E, Levitz S, treatment for 1995. 1988. Caselli M, Brentnall Z, hallux valgus bunion 68 Torkki M, Malmi- 45 Lapidus PW: The author’s bunion opera- Tran MQ: Natural histo- vaara A, Seitsalo S, et al: tions from 1931-1969. Clin Orthop 1960. ry of the rearfoot angle: deformity. Surgery vs orthosis vs 46 Hardy RH, Clapham JCR: Observations Preliminary values in watchful waiting for on hallux valgus J Bone Joint Surg 33B: 376-91, 150 children. Foot hallux valgus A ran- 1951. Ankle Inter 20(2): 119- domized controlled 47 Truslow W: Metatarsus primus varus or 125, 1999. trial. JAMA 285(19) 2474-80, 2001, May 16, hallux valgus? J Bone Joint Surg 7: 98-108, 59 Sobel E, Levitz SJ, Caselli M, et al: 2001. 1925. Reevaluation of the relaxed calcaneal 69 Sobel E, Levitz SJ, Caselli MA: Orthoses in 48 Kilmartin TE, Barrington RL: A stance position. J Amer Podiatr Med Assoc the treatment of rearfoot problems. J Am Podiatr controlled prospective trial of a foot or- 89(5): 258-64, 1999, May. Med Assoc 89(5): 220-33, 1999, May thosis for juvenile hallux valgus. J Bone 60 Hass M: “Radiographic and Biomechani- 70 Sanders M, Hagemeir KW: Conservative Joint Surg 76B: 210-14, 1994. cal Considerations of Bunion Surgery.” Chapter treatment and shoewear options for hallux val- 49 Wilson DW: Treatment of hallux val- 2, pp. 23-90. In Textbook of Bunion Surgery, ed gus. Foot ankle Clin 2(4): 639-53, 1997. gus and bunion. Br J Hospital Med Dec, 548- by J Gerbert & TH Sokoloff, Futura Publishing 71 Snow R, Williams K, Holmes G: 558, 1980. Company, Mount Kisco, New York, 1981. The effects of wearing high-heeled shoes 50 Sobel E, Giorgini R: Helping children 61 Ruch JA, Banks AS. “Evaluation of the on pedal pressure in women. Foot ankle with genetic foot disorders. Podiatry Today 11: deformity of hallux abducto valgus.” Chapter 13: 85-92, 1992. 36-46, 1998. 5, Part 2, pp. 144-150. In Comprehensive 72 Donatto KC, Rightor N, Ambrosia RD: 51 Coughlin MJ: Roger A. Mann Award. Ju- Textbook of Foot Surgery, Vol. 1, ed by ED Custom-Molded Orthotics in Postoperative venile hallux valgus: etiology and treatment. McGlamry, Williams & Wilkins, Baltimore, hallux valgus immobilization. Orthopedics Foot Ankle Int 16: 682, 1995. 1987. 15(4): 449-51, 1992, April. 52 Baxter DE: Treatment of bunion defor- 62 Agudelo CA, Wise CA: Diagnosis and 73 Holmes GB, Timmerman L: A mity in the athlete. Orthop Clin NA 25(1): 33- management of complicated gout. Bull Rheum quantitative assessment of the effect of 9, 1994, January. Dis 47: 25, 1998. metatarsal pads on plantar pressures. 53 Sanders AP, Snijders CJ, Van Linge B: 63 Williams RC: Toe pain: Is it podagra or Foot Ankle 11: 141-5, 1990. Medial deviation of the first metatarsal head as something else: J Musculoskel Med 31-42, 1991. 74 Chang AH: Abu-Faraj ZU, Harris GF, et al: Multistep measurement of plantar pressure alterations using metatarsal pads. Foot Ankle Int 15(12): 654-60, 1994. 75 Garrow AP, Papageorgiou A, Silman AJ, et al: The grading of hallux valgus The Manchester Scale. J Am Podiatr Med Assoc 91(2): 74-8, 2001, February.

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

92 PODIATRY MANAGEMENT • OCTOBER 2001 www.podiatrymgt.com MedicalContinuing Education

EXAMINATION

See answer sheet on page 95.

1) What is the percent of adults with 6) The most common EXTRINSIC patients with mild to moderate hallux hallux valgus in the United States? etiologic factor producing hallux valgus? A) Less than 1 percent valgus deformity is: A) No treatment (watchful B) 2 to 15 percent A) pronation waiting) was equally effective in C) 25 to 33 percent B) hypermobility of the first ray pain reduction as compared to D) 50 to 75 percent C) shoes foot orthoses and surgery for mild D) genetics to moderate bunion patients. 2) What is the relationship between B) Foot orthoses were the most wearing shoes, wearing fashionable 7) The fact that in children the effective treatment in patients footwear and development of hallux intermetatarsal angle remains stable with mild to moderate bunion valgus? for long periods of time while the deformity as compared to surgical A) Bunions are NEVER found in hallux abductovalgus angle is found treatment and the control group individuals who are unshod. to increase until a certain threshold (no treatment). B) Bunions are ONLY found in hallux valgus angle is reached, and C) Surgical management was the individuals who wear fashionable then both the IM and hallux valgus most effective treatment in footwear. angles both increase rapidly, would patients with mild to moderate C) Bunions are found much more seem to: bunion deformity as compared to frequently in individuals who A) Prove that a high surgical treatment and the wear fashionable footwear, but intermetatarsal angle is the cause control group (no treatment). also occur with much less of hallux valgus D) Foot orthoses and surgical frequency in individuals who do B) Disprove that a high management were equally not wear fashionable foot wear, intermetatarsal angle is the cause effective in treatment in patients but do not occur in unshod of hallux valgus with mild to moderate bunion individuals. C) Prove that the a high deformity with both modalities D) Bunions are found much more intermetatarsal angle is inversely more effective than the control frequently in individuals who proportional to the hallux valgus group (no treatment). wear fashionable footwear, but angle also occur with much less D) Prove that the intermetatarsal 11) A shoe last that might be helpful frequency in individuals who do angle is not related to the hallux to a patient with a bunion deformity not wear fashionable foot wear, valgus angle would be: and also occur to some extent in A) Board last unshod individuals. 8) The cause of the laterally displaced B) Slip last sesamoids in hallux valgus deformity C) Chukka 3) In hallux valgus deformity, what is is: D) Combination last the most common position of the A) Drifting of the fibular heel when the patient is standing? sesamoid 12) What is the effect on pressure in A) 5˚ of valgus B) Dislocation of the 1st the forefoot when wearing a 2-inch B) Significant heel valgus metatarsophalangeal joint high heeled shoe? C) Significant heel varus C) Medial migration of the first A) Forefoot pressure is not D) The greater the hallux valgus metatarsal head affected deformity the more heel valgus is D) The abducted position of the B) Forefoot pressure is reduced present hallux C) Forefoot pressure is increased approximately 22 percent 4) It has been observed that as the 9) The clinical appearance of the D) Forefoot pressure is increased Japanese have changed from medial prominence in bunion/hallux approximately 50 percent traditional sandals to leather footwear, valgus deformity is due to: the incidence of hallux valgus has: A) Displacement of the hallux 13) Foot orthoses have been found to A) Increased laterally uncovering the medial slow the progression of hallux valgus B) Decreased aspect of the metatarsal head deformity in people with rheumatoid C) Remained the same B) Dislocation of the 1st arthritis. D) There is no data pertaining to metatarsophalangeal joint A) True this subject C) Inflammatory arthritis B) False D) 5) What is the cause of the widened 14) A shoe with a heel height splayed foot deformity in hallux 10) What were the findings of the between 1-3/4 inches and 2-1/4 valgus? recent randomized controlled trial inches would be considered: A) Pronation published in the Journal of the A) Flat shoe B) High hallux valgus angle with American Medical Association (May B) Low heel subluxation 16, 2001) comparing the C) Mid heel C) High intermetatarsal angle effectiveness of surgery, orthotic D) High heel D) Forefoot pronation treatment and no treatment in Continued on page 94 www.podiatrymgt.com OCTOBER 2001 • PODIATRY MANAGEMENT 93 Continuing EXAMINATION PM’s Medical Education (cont’d) CPME Program

Welcome to the innovative Continuing Education 15) Which would be INCORRECT as to shoe wear? A) Both feet should be measured and the shoe is fit Program brought to you by Podiatry Management to the largest foot. Magazine. Our journal has been approved as a B) The ball of the foot should fit snugly into the widest part (ball pocket) of the shoe. sponsor of Continuing Medical Education by the C) The patient should be sitting during the Council on Podiatric Medical Education. fitting/measuring process. D) There should be 3/8 inch to 1/2 inch from the longest toe to the end of the shoe. Now it’s even easier and more convenient

16) Which is NOT in the differential for hallux valgus to enroll in PM’s CE program! deformity? You can now enroll at any time during the year A) Gouty arthritis B) Osteoarthritis of the 1st metatarsophalangeal joint and submit eligible exams at any time during your C) Compression of the medial plantar nerve enrollment period. D) Infection PM enrollees are entitled to submit ten exams 17) A review of recent empirical studies on the published during their consecutive, twelve–month relationship of pronation and hallux valgus reveals that: A) Pronation is one of the main causes of hallux enrollment period. Your enrollment period begins valgus with the month payment is received. For example, B) It is unknown whether excessive pronation is an extrinsic cause of hallux valgus if your payment is received on September 1, 2000, C) There is no correlation between subtalar joint your enrollment is valid through August 31, 2001. pronation and hallux valgus If you’re not enrolled, you may also submit any D) Pronation of the subtalar joint results in hypermobility of the first ray which leads to hallux exam(s) published in PM magazine within the past valgus deformity twelve months. CME articles and examination 18) According to recent literature what is the role of a questions from past issues of Podiatry Man- hypermobile 1st ray in the etiology of hallux valgus agement can be found on the Internet at deformity? A) Hypermobility of the 1st ray is a pre-existing factor http://www.podiatrymgt.com/cme. All lessons and a major cause of hallux valgus are approved for 1.5 hours of CE credit. Please read B) Hypermobility of the 1st ray is not the cause, but may actually be a result of hallux valgus the testing, grading and payment instructions to de- C) It is not clear whether a hypermobile 1st ray is the cide which method of participation is best for you. cause of the result of hallux valgus D) It has recently become known that a hypermobile Please call (631) 563-1604 if you have any ques- 1st ray is neither the cause nor the result of hallux tions. A personal operator will be happy to assist you. valgus deformity Each of the 10 lessons will count as 1.5 credits; 19) What is the indication and main function of the thus a maximum of 15 CME credits may be bunion splint? A) To correct a rigid deformity to be used at night earned during any 12-month period. only B) For accommodation and realignment of flexible deformity and postoperatively The Podiatry Management Magazine C) To correct a flexible deformity and relieve pain in CPME program is approved by the Council on rigid deformity D) Hallux valgus splints can only be used at night and Podiatric Education in all states where credits postoperatively in instructional media are accepted. This arti- 20) Which is generally NOT part of the clinical cle is approved for 1.5 Continuing Education presentation of severe hallux valgus deformity? Hours (or 0.15 CEU’s) for each examination A) Forefoot supinatus B) Heel valgus of 5˚ successfully completed. C) Pronated foot type D) Plantarflexed first ray PM’s CME program is valid in all states See answer sheet on page 95. except Kentucky, Pennsylvania, and Texas.

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Continuing ENROLLMENT FORM & ANSWER SHEET (cont’d)

Medical Education

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

Circle: 1. A B C D 11. A B C D 2. A B C D 12. A B C D 3. A B C D 13. A B C D 4. A B C D 14. A B C D 5. A B C D 15. A B C D 6. A B C D 16. A B C D 7. A B C D 17. A B C D 8. A B C D 18. A B C D 9. A B C D 19. A B C D 10. A B C D 20. A B C D

LESSON EVALUATION

Please indicate the date you completed this exam ______How much time did it take you to complete the lesson? ______hours ______minutes How well did this lesson achieve its educational objectives? ______Very well ______Well ______Somewhat ______Not at all What overall grade would you assign this lesson? A B C D Degree______Additional comments and suggestions for future exams: ______

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