Hallux Valgus Conservative Treatement

Copyright 1992 by The Journal of Bone and Joint Surgery, Incorporated

VOL. 74.A, NO. 9. OCTOBER 1992 1367

Juvenile Hallux ValgusA CONSERVATIVE APPROACH TO TREATMENT*

BY JORGE A. GROISO, M.D.t. BUENOS AIRES, ARGENTINA

Investigation performed at the National Pediatric Hospital, Buenos Aires

ABSTRACT: A conservative method consisting of use

of a thermoplastic splint at night as well as passive and

active exercises was used for the treatment of hallux

valgus in fifty-six children and teen-agers who were

between one month and sixteen years old. The splint

was remodeled periodically. At the time of follow-up,

which ranged from two to six years, the metatarso-

phalangeal joint angle or the intermetatarsal angle, or

both, had improved in approximately half of the feet.

No recurrences were detected among the patients who

improved.

Deviations of the toe are frequent among children

and teen-agers. Many patients are asymptomatic, and

the deviations are often incidental findings. When symp-

toms are present, they are mild, but the deformity is

sometimes unsightly, progressive, or worrisome for the

parents.

There is a strong hereditary trait for juvenile hal-

lux valgus’5. The deformity can be found at all ages, in-

cluding the first months of life. The findings include

occasional pain over the medial eminence and a mild

deformity. The metatansophalangealjoint is usually con-

gruous, the more pronounced deformities involve pro-

nation of the toe, and malalignment of the sesamoids

is rare’9.

There are conflicting opinions about the usefulness

of conservative therapy27. However, it is advisable to

postpone operative treatment until the completion of

bone maturation, as earlier operative intervention has

been associated with a high rate of necurrence2”�#{176}22�’.

The purpose of this study was to evaluate the non-

operative treatment of juvenile hallux valgus with the

use of a thermoplastic splint at night.

Materials and Methods

This seven-year study included fifty-six patients in

whom a deviation of the great toe had been treated with

night splints and exercises. The patients were between

one month and sixteen years old. The management of

each patient was carried out over a period of two years

*At the time of publication. no benefits in any form have been

received from a commercial party related directly or indirectly to the

subject of this article. No funds were received in support of this study.

tArenales 2245-El, Buenos Aires 1124, Argentina.

or more. The maximum age at the time of the follow-up

evaluation was twenty-one years. The minimum dura-

tion of follow-up was two years from the onset of treat-

ment, and the maximum duration was six years.

The criterion for the selection of patients for treat-

ment was an obvious deviation of the toe with a radio-

graphic metatansophalangeal angle of 15 degrees or

more, or the appearance of a prominent metatarsal

head that concerned the patient or the family. The pa-

tient had to be no older than sixteen years and without

any associated congenital anomalies (neurological or

connective-tissue disease) to be included in the study.

Classification of the Patients

The patients were divided into three groups, de-

pending on the findings and on the records available.

Group A included twenty-five patients (twenty girls and

five boys) who were chosen for the study because din-

ical photographs and radiographs made before and two

years on more after treatment were available. These

patients had true hallux valgus with an initial metatar-

sophalangeal angle of at least 15 degrees’7 or an in-

terphalangeal angle of 9 degrees or more4 (Figs. 1-A

through 2-D).Group B included five patients who did not have

true hallux valgus because the metatarsophalangeal an-

gle was less than 15 degrees. The patient or family ne-

quested the treatment for correction of a prominence

on the medial side of the foot. These patients were eval-

uated in the same manner as the patients in Group A

(Figs. 3-A and 3-B).

Group C included thirty-one patients who had ap-

parent hallux valgus but for whom radiographic studies

were not available. These patients had been followed

clinically and with photographs for two years or more.

Orthotics

The use of an office-made low-temperature thermo-

plastic splint at night was the mainstay of treatment. The

splint is cut according to a pattern drawn on paper (a

paper towel or typing paper). A pre-cut splint (Alimed,

Dedham, Massachusetts) can also be used (Fig. 4-A). A

pattern is prepared over a tracing of the patient’s foot,

and the flanges that will be needed are drawn. A flange,

half of the width of the foot, is needed on both sides to

hold the splint in place, and a transverse distal flange is

�j1�

FIt;. I-A

1368 J. A. GROISO

THE JOURNAL OF BONE AND JOINT SURGERY

Figs. i-A through I-D: Case 5. a seven-year-old boy in Group A.

Fig. 1-A: Before treatment.

Fig. I-B: After two years and nine months of treatment and six years of follow-up.

Fig. 1-C: The initial radiograph of the right foot. showing a metatarsophalangeal angle of 24 degrees and an intermetatarsal angle of 11

degrees.

Fig. I -D: Radiograph of the right foot made sixteen months later. showing a metatarsophalangeal angle of I 6 degrees and an intermetatarsal

angle of 10 degrees.

necessary to push the toe in the proper direction. The

drawing is cut out of the paper and checked on the foot.

Modifications are made if needed so that the paper

template conforms to the foot as noted.

The completed template is placed on a sheet of per-

forated low-temperature thermoplastic (Alimed). andthe outline is drawn on the thermoplastic with a ball-

point pen. The thermoplastic is softened in warm water

and cut with regular scissors. It is then heated to 70

degrees Celsius in a skillet or in a special-purpose plas-

tic bag (Alimed). Once the splint is pliable, it is removed

from the hot water with plastic forceps and placed on a

cloth towel, where it is allowed to cool first on one side

and then on the other for a few minutes. When the

doctor feels that the splint is no longer too hot to be

held, it is applied on the contralateral foot. on which no

FIG. 2-A FI�. 2-B FI;. 2-C Flu. 2-D

Figs. 2-A through 2-D: Case 17. a twelve-year-old girl in Group A.


Fig. 2-B: After two years of treatment.

Fig. 2-C: The initial radiograph of the right foot. showing a metatarsophalangeal angle of 30 degrees and an intermetatarsal angle of 8

degrees.

Fig. 2-D: Radiograph of the right foot. two years and four months postoperatively. showing a metatarsophalangeal angle of I I degrees and

an intermetatarsal angle of 8 degrees.

JUVENILE HALLUX VALGUS 1369

FIG. 4-A

lit� �

- �

‘fl

FIG. 3-AFIG. 4-B

Fig. 4-A: A pre-cut splint for the treatment of hallux valgus.

Fig. 4-B: A molded splint.j[( . .

FIG. 3-B

Figs. 3-A and 3-B: An eleven-year-old girl (Group B) who had a

prominent metatarsal head.

Fig. 3-A: Initial photograph.

Fig. 3-B: Cosmetic improvement was seen two years later.

VOL. 74-A, NO. 9. OCTOBER 1992

weight is borne because the patient is lying on an exam-

ination table. It is then molded on the metatarsal area,

with mild pressure exerted on the medial and lateralsides of the foot in the region of the first and fifth

metatarsal shafts and with enough room left to prevent

pressure on the metatarsal heads.

The transverse distal flange is folded to double its

thickness and is placed on the lateral side of the toe to

produce a varus deviation at the metatarsophalangeal

joint. The ankle joint must be in mild plantar flexion to

relax the plantar fascia and the flexor tendons to in-

crease the lateral mobility of the great toe. The borders

of the flange should be rounded to prevent pressure on

the nail-bed or at the edges (Fig. 4-B).

Sometimes, when the final position is not satisfac-

tory, it may be necessary to reheat the transverse distal

flange of the splint and, while holding the metatarsals

firmly, to redirect the great toe, molding the distal part

of the splint into the corrected position. The corrective

pressure must be exerted in a medial direction proxi-

mally, avoiding the nail-bed.

The splint is held in place with a Velcro strap that

mildly compresses the forefoot. The splint is worn only

at night. A sock can be worn over the splint to help hold

it in place.

The fit of the splint is checked every three months,

and the toe section is altered if the medial mobility of

the phalanx allows for increased medial placement ofthe flange. The metatarsophalangeal joint must be in

neutral position as regards flexion and extension in or-

den to obtain the maximum stretch of the lateral struc-

tunes (the capsule, ligament, and adductor tendon).

Exercises

There are two types of passive exercises. For the

first, the metatarsals are held together and a varus lat-

eral movement of the phalanges of the great toe is per-

FIG. 5-A FIG. 5-B

Figs. 5-A and 5-B: Case 16, a twelve-year-old girl (Group A) demonstrating the program of active exercise.

Fig. 5-A: Photograph made while the patient was standing with the muscles relaxed.

Fig. 5-B: Photograph showing active contraction of the abductor hallucis muscles bilaterally.

FIG. 6-A FIG. 6-B FIG. 6-C FIG. 6-D

Figs. 6-A through 6-D: Case 1. a thirty-day-old boy in Group A.


Fig. 6-B: After application of the plantar plastic splint.

Fig. 6-C: The initial radiograph of the left foot, showing a metatarsophalangeal angle of 26 degrees and an intermetatarsal angle of 14

degrees.

Fig. 6-D: Correction after four months of treatment and five years of follow-up.

1370 J. A. GROISO


formed several times to relax the capsule. For the other

passive exercise, the plantar aspect of the first metatar-

sal head is pushed upward with the ankle dorsiflexed,

while the great toe is dorsiflexed and deviated in a varus

direction to elongate the adductor and the flexor hallu-

cis brevis.

For the active exercises, the patient stands with the

feet slightly apart and attempts to touch one great toe

with the other great toe without moving the feet (Figs.

5-A and 5-B). After several trials, most children learn

how to contract the abductor muscles, but some, mostly

in the younger age-group, cannot learn to perform this

movement, perhaps because they do not have a good

understanding of the instructions on because the abduc-

ton muscles do not have an independent voluntary con-

traction. The active and the passive exercises are done

once a day with twenty repetitions of each. It is con-

venient to start the physical routine with the help of a

physiotherapist.

If there is a contracture of the Achilles tendon, it

should be treated with stretching exercises done with

the patient standing and the knees extended to neutral.

It is advisable to continue the treatment until bone

maturation, as is recommended for the treatment of

other angular deviations in children.

When a patient has excessive pronation of the fore-

foot, he or she can be fitted with an arch support to

prevent exaggerated pressure on the medial side of the

great toe (Figs. 7-A and 7-B). Twelve patients in this

series wore arch supports.

FIG. 7-A FIG. 7-B



Figs. 7-A and 7-B: Case 9, a ten-year-old girl (Group A) who had pronation of the forefoot.

Fig. 7-A: Photograph made before treatment while the patient was standing.

Fig. 7-B: After treatment. there was improvement in the alignment of the toes and the pronation of the great toes.

Evaluation ofthe Patient

Initial photographs and radiographs were made

with the patient bearing weight. The follow-up was per-

formed with paper-copy photographs, made every four

to eight months. The follow-up radiographs, made at

least two years after treatment, were made with the

patient standing and at least six hours after the splint

had been removed. The feet were not evaluated for

metatarsus pnimus varus because it has been reported

that the alignment of the first ray is normal in patients

who have hallux valgus’5.

Group A

Results

Group A included twenty-five patients (twenty girls

and five boys) whose average age was ten years (range,

one month to sixteen years) (Table I). They were eval-

uated at a mean of three years and four months (range,

two to six years) after the start of treatment.

For the purpose of the study, the feet were consid-

ered independently of one another”. A total of forty-

eight feet (twenty-five left and twenty-three right) with

an abnormal metatarsophalangeal angle were analyzed.

A change in the angle of 2 degrees or more was

considered valid; this took into account the error of themethod according to Piggott.

The initial metatarsophalangeal angles of the forty-eight feet averaged 22 degrees (range, 15 to 35 degrees).The angle in twenty-eight feet improved (decreased) an

average of 6 degrees (range, 2 to 19 degrees). The angle

did not change in thirteen feet, and it increased an aver-

age of 5 degrees (range, 2 to 9 degrees) in seven feet.

The intermetatarsal angle was 9 degrees or more

(average, 1 1 degrees; maximum, 16 degrees) in thirty-

seven feet. The angle improved an average of 3 degrees(range, 2 to 7 degrees) in twelve feet. The angle did

not change in seventeen feet, and it increased an aver-

age of 3 degrees (range, 2 to 4 degrees) in eight feet.No conclusion can be made with regard to the influ-

ence of the rate of exact compliance with the regimen

of treatment. It was presumed that the compliance oc-

casionally was not as good as was reported because the

information provided by the parents, mostly with regard

to the prescribed exercises, varied markedly from the

information provided by the patients. It was very useful

to show the patients the photograph that had been made

at the beginning of the treatment so that they would see

the improvement. For some patients, interruption of the

use of the splint was deleterious, but for others, the

improvement that had been obtained was not affected.One interesting result was in a six-year-old girl

(Case 4) who had complied very well with the regimenof treatment. The mother had requested treatment forher daughter because the mother had severe hallux val-gus. The girl had initial improvement over a four-month

period, followed by regression of the correction as seen

nadiographically. At the most recent follow-up examina-tion, the metatarsophalangeal angle on the left was 3

degrees larger than before treatment. The metatarso-phalangeal angle on the right remained the same. Thecosmetic appearance was improved and the family waspleased with the result of the treatment.

For one patient (Case 1), use of the splint was

stopped when he was seven months old. after four

months of wear. There was no recurrence five yearsafter the cessation of treatment (Figs. 6-A through 6-D).

Two children (Cases 3 and 5) stopped wearing the splint,for psychological reasons, after at least two years of use

with six months of weaning. The radiographic angles

were less than 15 degrees at the time of follow-up. The

routine for weaning was to remove the splint one day aweek over a period of two months, then to remove it

two days a week for two months and then three days aweek for the last two months. One patient (Case 3) who

1372 J. A. GROISO

TABLE I

GROUP A

Change in

Affected

Metatarso-

phalangeal Angle*

(Degrees)

Intermetatarsal

Angle*

(Degrees)

Duration

of

Follow-

Metatarsophalangeal

Angle

(Degrees)

Change in Inter-

metarsal Angle

(Degrees)

Metatarso-

phalangeal

Congruence*

Case Age Sex Relative Left Right Left Right up Left Right Left Right Left Right

(Yrs�) (Yrs.)

1 1 mo. M 26/15 7/13 14/7 13/10 6 +11 -6 +7 +3 Dev./ Congr./

congr. congr.

2 3 F Grand- 24/22 23/22 11/10 10/7 4 +2 +1 +1 +3 Dev./ Dev./

mother dev. dev.

3 5 F Grand-mother

15/11 16115 10/10 10/12 6 +4 +6 0 -2 Dev./

congr.Dev./

congr.

4 6 F Mother 15/18 16/17 8/10 9/11 4 -3 -1 -2 -2 Congr./

congr.

CongrJ

congr.

5 7 M Grand-

mother

24/14 25/12 11/10 11/9 6 +10 +15 +1 +2 Dev./

congr.

Dev./

congr.

6 9 F Mother 19/27 29/37 10/12 10/11 2 -8 -8 -2 -1 Sublux./

sublux.

Congri

sublux.

7 9 F 35/32 20/19 10/12 9/9 3 +3 +1 -2 0 Sublux./

sublux.

Congr./

congr.

8 10 M 15/16 13/13 9/13 10/9 4 -1 0 -4 +1 Congr./

congr.

Congr./

congr.

9 10 F 24/28 28/29 13/8 14/12 4 -4 -1 +5 +2 CongrJ

congr.

Congr./

congr.

10

11

10

10

F

F

Mother

Father

23/18

16/13

23/16

16/17

8/8

8/11

7/7

7/7

2

2

+5

+3

+7

-1

0

-3

0

0

Congr./

congr.

Congr./

congr.

Dev./

congr.

Congr./

congr.

12 10 F 30/21 30/20 6/11 14/12 3 +9 +10 -5 +2 Sublux./

dev.

Sublux./

dev.

13

14

10

11

M

F

19/15

21/24

25/16

16/9

9/9

11/10

11/12

6/10

2

3

#{247}4

-3

+9

+7

0

+1

-1

-4

Dev./

congr.

Sublux./

sublux.

Congr./

congr.

Sublux./

congr.

15 11 F 20/10 17/5 10/12 9/10 2 +10 +12 -2 -1 Congr./

congr.

Congr./

congr.

16 11 F 18/19 21/23 8/6 9/7 3 -1 -2 +2 +2 Dev./

dev.

Dev./

dev.

17

18

12

13

F

F

Mother

Mother

20/15

28/26

30/11

20/11

8/12

12/15

8/8

9/13

3

5

+5

+2

+19

+9

-4

-3

0

-4

Dev./

congr.

Sublux./

sublux.

Sublux./

congr.

Sublux./

dev.

19 13 F Mother 22/23 22/31 9/4 10/10 2 -1 -9 +5 0 Sublux./

sublux.

Sublux./

sublux.

20 13 M 27/25 18/13 10/10 9/8 2 +2 +5 0 +1 Sublux./

sublux.

Dev./

congr.

21 14 F 24/24 31/30 13/9 16/16 3 0 +1 +4 0 Sublux./

sublux.

Sublux./

sublux.

22 14 F 27/27 28/24 11/9 14/12 4 0 +4 +2 +2 Sublux./

sublux.

Sublux./

dev.

23 14 F Grand-mother

18/14 22/17 7/10 10/10 2 +4 +5 -3 0 Dev./

dev.

Dev./

dev.

24 14 F 20/19 30/28 10/10 11/10 2 1 +2 0 +1 Dev./

dev.

Sublux./

sublux.

25 16 F 17/13 15/16 8/8 6/7 3 +4 -1 0 -1 Dev./

congr.

Dcv.!

dcv.


*Before treatment I at the time of follow-up.

had discontinued use of the brace had no recurrence prominent metatarsal head in both feet. The angles werefour years after treatment was stopped on the right and within the normal range. There was an improvement ineighteen months after treatment was stopped on the the appearance of eight feet. Radiographic measure-left. The other patient (Case 5) had no recurrence more ments did not improve for five of the feet, even thoughthan four years after treatment was stopped. the patients felt that the foot had improved.

Group B Group C

This group included five patients (three girls and two There was no way to measure changes in these feet,boys), between seven and sixteen years old, who had a as radiographs had not been made, but the over-all din-



ical impression, and a comparison of photographs madebefore and after treatment, suggested that there had

been an improvement in more than half of the feet.

Recurrence

The deformity recurred during the course of treat-

ment in three patients (Cases 4, 20, and 25), and it re-

curred during an interruption in treatment in a patient

(Case 6) who did not use the splint for six months at the

age of ten and one-half years. The deformity did not

recur in any patient after the treatment was stopped.

Discussion

Some authors’7 have reported a low frequency ofhallux valgus in children, but others have found a valgus

deformity in 22 per cent’ and 39 per cent” of school-age

girls. In another report, 57 per cent of adults who had

the deviation recalled having had it since adolescence2.

Scranton and Zuckerman stated that bunions are rare

before the age of ten. However, I have seen bunions invery young children, even in the first months of life.

The structural factors in the development of halluxvalgus include metatarsus varus, pes planus, ligamentouslaxity, and a tight heel-cord’7. There is a strong heredi-

tany factor’6, as was confirmed in this series: eleven pa-tients (40 pen cent) had a close relative who had the

deformity. Ill fitting footwear has been cited as a cause

of the deformity7’424, but it was not the cause among our

patients. One patient (Case 1) had always been bare-

foot, and most had worn only sport shoes or sneakers.The natural history of this deviation, according

to Piggott, is that the congruous type of deformity re-mains stable. As deviated and subluxated joints areprone to deteriorate, these patients should be candi-

dates for prophylactic operations. However, I found nomention of spontaneous regression of the angulation in

the literature.

Juvenile hallux valgus is different from the bunionseen in the adult. The deviation of the toe is less pro-

nounced, the medial eminence is smaller with excep-

tional bursal thickening, and a rotation deformity is

present only in patients who have a more pronounced

lesion. There are no degenerative changes at the meta-

tarsophalangeal joint, and the physes are still open7.Treatment of juvenile hallux valgus is controversial.

The patient or the family asks for improvement of an

unsightly deformity, and the prescription, ugly shoes, is

as unpleasant as the deviation. Other patients are told

to watch passively how the deviation worsens while they

wait for the optimum age to have an operation. Nor is

there general consensus as to the final result of either

therapy.

Operative treatment of hallux valgus is not an easy

proposition to a youngster. The indications for opera-

tion are not precise: some authors have included cos-

metic appearance as an indication9”�, while others havenot mentioned it”.

There is disagreement about the ideal procedure

or the optimum age for the operation. Some authors

have advised against an operation before bone matuna-

tion3�, and others have found no difference in the re-

sults of operative treatment of severe bunion deformity

whether or not bone maturation has taken place’5.

The results of operative treatment have not been

uniform, and the rate of recurrence has been high: 61

per cent in the study of Ball and Sullivan and 47 per cent

in that of Geissele and Stanton. Helal reported a 45.7per cent rate of failure in his operatively treated pa-tients. Studies of patients who were operated on before

the age of fifteen years old revealed a 25 per cent�’ anda 12 per cent’ prevalence of unsatisfactory results.

Other complications of operative treatment include

the need for revision procedures, hypentrophic scars,

cramps, narrowing of the metatarsal head”, metatarsal-gia, stiffness of the metatarsophalangeal joint2, overcor-

rection, and shortening of the first metatarsal5’2.

Non-operative therapy for juvenile hallux valgususually includes the prescription of a commercial splint25

and the use of roomy footwear or an arch support7, butit is unlikely that fashion-conscious patients in this age-

group would wear shoes that are markedly different

from those of their peers1’.

There are numerous splints on the market, but these

are poorly tolerated by youngsters. As the orthotics are

mass-manufactured, there is little possibility of adaption

to the different sizes and anatomical variations of the

children.

In the present study, a non-operative approach was

attempted for patients who were too young for an op-

eration or in whom the deviation of the toe was not

severe enough to justify an operation. An office-made

splint modeled directly onto the patient’s foot was cho-

sen for this study because it allows accommodation for

the anatomical and pathological characteristics of the

individual. The splint can also be reset periodically,

which allows intermittent positioning. It exerts an in-

elastic traction on the soft tissues that surround the

joint. The structures are held near the end of their elastic

limit until they relax or grow into this position. Then the

splint is reset and a new elastic limit is reached”.

The program of treatment includes passive and ac-tive medial mobilization of the metatarsophalangeal

joint. Piggott stated that active side-to-side movements

do not normally occur, but when our patients were prop-

erly trained most could perform such movements.

It is also advisable to prescribe onthotics for cx-

tremely pronated feet, with the only aim being reliefof the pressure on the medial side of the toe26. It wasfound that patients who had been managed with an

operation for flexible flat feet, and were not managed

with arch supports postoperatively, had a recurrence of

the deviation”1’.Some authors have dismissed non-operative treat-

ment as futile5, and others have stated that the long-term

I 374 J. A. GROISO


results are unknown3 or that the effects of such treat-

ment are only symptomatic27. These less satisfactory re-

suits could have been due to the use of improper splints

- that is, those that had been mass-manufactured or

that were elastic or poorly contoured - or perhaps they

were due to a lack of compliance. which is difficult at

this young age.

However. the results in the group of patients in the

present analysis were very satisfactory. Fifty per cent of

the feet in Group A had an improvement of the meta-

tansophalangeal angle. but only 32 per cent had an im-

provement of the intermetatarsal angle. Geissele and

Stanton also found that insufficient diminution of the

width of the forefoot was the most common complaint

among youngsters who had had an operation.

As the response to treatment was not reflected sim-

ilarly by both measurements in the same patient (one

parameter can improve as the other remains stable or

deteriorates), the conclusion was that, of twenty-five

patients in Group A. three (12 per cent) did not have an

improvement in either of the measured angles.I believe that the described approach deserves to be

tried, as many youngsters were helped by a benign treat-

ment that delayed or stopped the progression of the

deviation in some and improved or even totally cor-

rected the deformity in others.

Noii The author thanks Nora (‘ampora. M.D.. for assistance with thc analysis of the

records.

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3. Bonney, George, and Macnab, Ian: Hallux valgus and hallux rigidus. A critical survey of operative results. J. Bone and Joint Surg..

34-13(3): 366-385. 1952.

4. Carr, C. R., and Boyd, B. M.: Correctional osteotomy for metatarsus primus varus and hallux valgus. J. Bone and Joint Surg., 50-A:

1353-1367, Oct. 1968.

5. Chomeley.J. A.: Hallux valgus in adolescents. President’s address. Proc. Roy. Soc. Med., 51: 903-906, 1958.

6. Cole, A. E.: Foot inspection ofthe school child. J. Am. Podiat. Ass,i.. 49: 446-454. 1959.

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8. Craigmile, D. A.: Incidence, origin, and prevention of certain foot defects. British Med. J., 2: 749-752. 1953.

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10. Fess, E. E., and Philips, C. A.: Stand Splititing, Principles and Methods. Ed. 2. St. Louis. C. V. Mosby. 1987.

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Hallux Valgus Conservative Treatement