MedicalContinuing Education Building Your FOOTWEAR 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 valgus deformity. 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 shoe fit. 6) To be familiar with all aspects of non-surgical management of hallux valgus and associated de- formities. Welcome to Podiatry 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 podiatrists. 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 foot ail- hallux valgus/bunion 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 bunions phalanx of the hallux occurring as they have changed Medicalin Education 2 to 15 percent of the U.S. popu- from traditional sandals 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 Shoes 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 joint.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... ligamentous laxity 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.