Hallux valgus represents one of the most frequent foot deformities in the adult population and is a leading cause of pain and functional limitation of the forefoot. Although often considered exclusively an aesthetic issue, it is actually a progressive pathology that, if neglected, can significantly compromise quality of life, alter gait biomechanics, and promote the onset of further toe deformities.

What is hallux valgus?

Hallux valgus is a complex and progressive deformity of the first ray of the foot, characterized by a three-dimensional alteration of bone alignment and soft tissues primarily involving the metatarsophalangeal joint of the big toe.

From an anatomical perspective, the deformity is characterized by the medial deviation of the first metatarsal (metatarsus primus varus) and the simultaneous lateral deviation and, often, pronation of the hallux.

This configuration leads to a progressive increase in the intermetatarsal angle (IMA) between the first and second metatarsals and the hallux valgus angle (HVA), which are fundamental parameters for classifying the severity of the deformity.

The progression of the pathology involves a loss of normal joint congruity of the first metatarsophalangeal joint, with progressive subluxation of the proximal phalanx relative to the head of the first metatarsal.

From a pathophysiological standpoint, hallux valgus involves not only the bone structures but also the joint capsule, collateral ligaments, plantar plate, and the musculo-tendinous apparatus. The deviation of the hallux alters the balance between the forces exerted by the extensor hallucis longus, flexor hallucis longus, and adductor hallucis tendons, which transition from physiological stabilizers to progressive deforming forces, contributing to the evolution of the pathology in a true biomechanical vicious cycle.

The medial bony prominence commonly referred to as a “bunion” does not represent a new bone growth, but rather the head of the first metatarsal becoming progressively more prominent following the medial deviation of the metatarsal itself. Bursitis can develop on this prominence due to conflict with footwear, causing the pain, redness, and inflammation frequently reported by patients.

As the deformity progresses, the alteration in plantar load distribution leads to overloading of the lateral metatarsal heads, favoring the onset of metatarsalgia (pain under the ball of the foot), plantar callosities, and secondary toe deformities, such as hammer toe or claw toe. In more advanced cases, degenerative arthritic phenomena of the first metatarsophalangeal joint may also appear, with a progressive reduction in joint range of motion and further impairment of foot function.

Grades of hallux valgus

The severity of the deformity is assessed clinically and radiographically, and three forms are distinguished:

Causes of hallux valgus

The origin of hallux valgus is multifactorial. In most patients, there is no single cause, but rather a combination of several predisposing factors, the main ones being:

• genetic predisposition and family history;
• constitutional ligamentous laxity;
• flat feet;
• hypermobility of the first metatarsal;
• biomechanical alterations of plantar support;
• rheumatoid arthritis and other inflammatory diseases;
• neurological pathologies;
• trauma.

Tight or high-heeled footwear does not generally represent the primary cause of the deformity, but it can accelerate its progression and aggravate symptoms in predisposed individuals.

Women are affected with a significantly higher frequency than men, likely due to a combination of anatomical, hormonal, and cultural factors.

Symptoms

In the early stages, hallux valgus can be completely asymptomatic. As the deformity progresses, the following frequently appear:

• pain in the inner region of the foot;
• pain under the ball of the foot (metatarsalgia);
• redness and inflammation of the bony prominence (“bunion”);
• overlapping toes;
• second toe deformity (hammer toe);
• appearance of callosities;
• difficulty wearing shoes;
• reduced ability to walk for long periods;
• worsening of quality of life;
• pain even at rest in more advanced cases.

Diagnosis

Diagnosis is conducted through clinical evaluation by a specialist supported by diagnostic imaging. The orthopedic specialist evaluates:

• foot morphology;
• joint mobility and stability of the first ray/metatarsal;
• the presence of callosities and any associated deformities;
• evoked pain.

Diagnostic imaging supports the specialist in the diagnosis; the fundamental examination remains the weight-bearing foot X-ray, which is indispensable for evaluating:

• the extent of the deformity;
• the presence of osteoarthritis;
• joint congruity;
• pre-operative data and measurements for surgical planning.

In some cases, other diagnostic tests such as CT or MRI may be requested, especially in the presence of associated pathologies.

Conservative treatments

The goal of conservative (non-surgical) therapy is to reduce symptoms, slow the progression of the pathology, and improve the patient’s quality of life since, to date, no conservative treatment is capable of definitively correcting the bone deformity.

The first therapeutic intervention concerns the patient’s daily use of appropriate footwear: shoes should have a wide toe box, soft upper, low heel, and sufficient space for the forefoot.

The use of medical devices such as custom orthotics, spacers, and braces can improve load distribution and reduce pain, especially in patients with associated biomechanical alterations, but since they do not correct the deformity, they do not modify the evolution of the pathology.

Physiotherapy and pharmacological therapy can be helpful, but their main effect concerns symptom control rather than anatomical correction.

When is surgery indicated?

When, in the presence of a radiologically confirmed biomechanical alteration, conservative therapy is not effective in reducing symptoms, there is a progression in the deformity, or associated deformities occur and pain limits daily activities resulting in significant functional limitation, then surgical treatment should be considered.

The primary goal of surgical treatment is not to improve the aesthetics of the foot, but to restore its function and reduce pain.

Main surgical techniques for hallux valgus correction

Surgical correction of hallux valgus must be personalized based on the patient’s anatomical and functional characteristics and the stage of the pathology’s progression. No single technique is universally superior: the choice depends on the severity of the deformity, the width of the intermetatarsal angle, the presence of osteoarthritis or hypermobility of the first ray, the patient’s age and functional demands, as well as the surgeon’s experience.

Currently, over 150 surgical procedures have been described, many of which represent variations of the most established techniques.

Distal first metatarsal osteotomy (Chevron)

The Chevron osteotomy is one of the most widely used procedures for treating mild to moderate hallux valgus. It consists of performing a “V” shaped osteotomy at the level of the head of the first metatarsal, which is then translated laterally to restore the correct alignment of the first ray. Stabilization is generally achieved using one or two compression screws.

The procedure offers high mechanical stability, allows for relatively early mobilization, and presents a low risk of postoperative stiffness of the first metatarsophalangeal joint. Clinical results are generally very satisfactory. The main limitation of the technique is its reduced capacity to correct particularly severe deformities or those characterized by a marked increase in the intermetatarsal angle.

Scarf osteotomy

The Scarf osteotomy represents one of the reference techniques for the treatment of mild to moderate hallux valgus and, in selected cases, even for more significant deformities, often in association with other corrective procedures. The technique involves a Z-shaped diaphyseal osteotomy of the first metatarsal, which allows the metatarsal to be translated, rotated, and, if necessary, shortened or lengthened, enabling a three-dimensional correction of the deformity.

The osteotomy is stabilized using two dedicated screws. Key advantages include the high stability of the fixation, the ability to achieve extensive corrections, the maintenance of the first metatarsal length, and the possibility of allowing early protected weight-bearing. Numerous studies have demonstrated excellent clinical and radiographic results even in the long term. The main limitation is the technical complexity of the procedure, which requires a significant learning curve and consolidated experience in foot surgery.

Proximal first metatarsal osteotomies

Proximal osteotomies are primarily indicated for patients with moderate or severe hallux valgus associated with a marked increase in the intermetatarsal angle.

The osteotomy is performed at the base of the first metatarsal, allowing for a more proximal correction of the bone axis and effective realignment of the entire first ray. Stabilization is then achieved using plates, screws, or other fixation systems.

These procedures allow for greater corrections compared to other techniques and generally guarantee stable and lasting results. The main disadvantages are greater technical complexity, the need for careful preoperative planning, and generally longer bone consolidation times.

Lapidus arthrodesis

Lapidus arthrodesis consists of the fusion of the joint between the first metatarsal and the first cuneiform (cuneometatarsal joint), eliminating hypermobility of the first ray and simultaneously correcting the deformity.

It is indicated especially for patients with marked instability of the first tarsometatarsal joint, severe deformities, recurrences after previous surgeries, or a significant increase in the intermetatarsal angle.

After preparing the joint surfaces, they are stabilized using plates and/or screws until bone fusion is achieved.

The main advantages of the procedure are the high stability of the correction, the reduced probability of recurrence, and the ability to effectively correct even very significant deformities. Disadvantages include generally longer consolidation times dictated by the need to achieve complete bone fusion and a more demanding postoperative recovery compared to other techniques.

Minimally Invasive Surgery (MIS) techniques

Osteotomies are performed through skin incisions of just a few millimeters, using specific motorized burrs under fluoroscopic guidance. Depending on the technique used, the correction can be stabilized with screws or, in selected cases, without fixation devices.

The main advantages include less soft tissue trauma, smaller incisions, reduced postoperative pain, faster functional recovery, and a better aesthetic result for scars. However, it is important to emphasize that the success of minimally invasive surgery depends heavily on the surgeon’s experience, requires accurate intraoperative radiographic control, and is indicated only after a careful study of the case and the patient’s general condition.

The latest scientific evidence shows that, when performed by expert operators with correct indications, minimally invasive techniques offer clinical and radiographic results comparable to those of traditional surgery, with the potential advantage of less surgical aggression.

Realistic benefits and possible risks of hallux valgus surgery

The primary goal of hallux valgus surgery is to restore foot function, reduce pain, and correct the deformity, allowing the patient to regain a more physiological gait and a better quality of life. The surgery is not an aesthetic procedure but a functional treatment aimed at restoring the correct biomechanical balance of the first ray and the forefoot.

When the surgical indication is appropriate and the technique is chosen based on the patient’s anatomical characteristics, clinical results are generally very satisfactory. Most patients report a significant reduction in pain, an improved ability to walk and perform normal daily activities, as well as greater ease in wearing common footwear.

Correcting the alignment of the big toe also allows for improved distribution of plantar loads, reducing the risk of overloading the other toes and the onset of metatarsalgia.

Among the most frequently observed benefits are:

• significant reduction or disappearance of pain;
• correction of the deformity and improvement of the alignment of the big toe;
• slowing or prevention of the progression of secondary forefoot deformities;
• improvement of foot functionality during walking;
• recovery of a more natural and efficient gait;
• greater tolerance for wearing everyday footwear;
• improvement in quality of life and patient satisfaction.

Modern case series report satisfaction rates of 85-90%, especially when preoperative planning is accurate, patient expectations are realistic, and the rehabilitation path is followed correctly. However, it is important to emphasize that full recovery takes time: residual swelling can persist for several months, and the final result is generally evaluable between six and twelve months after surgery.

Like any surgical procedure, hallux valgus correction involves possible complications, although their incidence is relatively low when the surgery is performed by expert surgeons in specialized centers and in compliance with established surgical and perioperative protocols.

Complications can be divided into early and late. Early complications include surgical wound infection, hematoma, bleeding, thromboembolic complications, and delays in soft tissue healing. More rarely, bone consolidation problems may occur, such as delayed union or non-union (pseudoarthrosis), especially in procedures involving proximal osteotomies or arthrodesis.

Late complications include stiffness of the first metatarsophalangeal joint, sensory alterations due to irritation or injury of small cutaneous nerve branches, persistent pain, recurrence of the deformity, overcorrection with the development of hallux varus, and, more rarely, loosening or breakage of the fixation devices used to stabilize the osteotomy or arthrodesis.

It is important to remember that no surgical technique is completely free from the risk of recurrence. The latter can depend on numerous factors, including the initial severity of the deformity, the presence of hypermobility of the first ray, neurological or rheumatological pathologies, an incorrect choice of surgical technique, or the natural evolution of foot biomechanics over time.

For this reason, the success of the operation does not depend exclusively on the surgical act, but on a combination of factors including a correct indication, accurate preoperative planning, the execution of the most appropriate technique, the patient’s cooperation in the postoperative period, and an adequate rehabilitation path.

Clear communication between the surgeon and the patient regarding the realistic goals of the surgery represents one of the fundamental elements for achieving high levels of clinical satisfaction.

Villa Stuart’s expertise in the surgical treatment of hallux valgus

Hallux valgus is a frequent and progressive pathology that, if not adequately treated, can compromise foot functionality and significantly impact quality of life.

Modern foot surgery now has numerous techniques capable of effectively correcting the deformity, but the true determining factor for the success of the treatment is not the existence of a “best” technique, but rather the ability to identify the most suitable one for the individual patient. Hallux valgus surgery requires specific skills, consolidated experience in foot and ankle surgery, and a multidisciplinary approach that accompanies the patient from diagnosis to full functional recovery.

In this context, Orthopedics and Traumatology at Villa Stuart represents one of the reference points in Rome and among the most prestigious orthopedic centers at national and international levels. The team dedicated to foot and ankle surgery handles a high number of cases each year, from simple cases to the most complex deformities and surgical revisions, adopting the most modern techniques validated by international scientific literature, including minimally invasive procedures when clinically indicated.

The goal is not only to correct the deformity but to restore a stable, functional, and painless foot to the patient, allowing them to return to their daily and sporting activities as quickly as possible and in the best safety conditions. The high level of specialization, the use of advanced technologies, personalized surgical planning, and a structured rehabilitation path make Villa Stuart a center of excellence in orthopedic foot surgery, recognized for the quality of care, clinical experience, and attention to the patient.

Relying on a highly specialized center means being able to count not only on the best therapeutic options available but also on a care path built on the individual characteristics of each patient, with the goal of achieving a lasting functional result and a concrete improvement in quality of life.

To learn more, watch the episode where Dr. Fabrizio Forco discussed the topic “Hallux valgus: how to relieve pain” on UnoMattina at this link