DefinitionHallux Valgus Severe



- medial prominence of head of 1st MT


Hallux Valgus

- medial deviation 1st MT

- lateral deviation of great toe




Metatarsal head

- has 2 grooves separating ridge (cristae)



- in each tendon of FHB

- sesamoids attach to P1

- no attachment to MT head

- sesamoid ligaments attach to sesamoids and plantar plate

- FHL passes plantar to the plate & between the sesamoids


Plantar plate

- formed by

- FHB / Abd. Hall / Add. Hall / Plantar aponeurosis /  capsule


Sesamoids and plantar plate stabilised

- abductor hallucis (medial)

- adductor hallucis & trans metatarsal ligament (lateral)

- insert into sesamoids & Base P1

- no muscles insert into head MT


Collateral ligaments

- from head of MT to base of P1

- insert into sesamoids




Great Toe provides stability to the medial aspect of the foot


Windlass mechanism of plantar aponeurosis

- plantar aponeurosis arises from tubercle of calcaneum

- medial slip inserts into base of proximal phalanx via sesamoids

- as body passes over foot, P1 forced into DF & slides over MT head

- plantar aponeurosis winds around MT head & plantarflexes the 1st MT

- creates arch


In hallux valgus, windlass is less effective

- results in transfer of weight to lateral aspect of foot

- especially second MT head


Blood Supply


3 main

- 1st dorsal and plantar metatarsal artery

- superficial branch of medial plantar artery




Medial plantar artery

- remains plantar to the MT until the level of the neck when it runs obliquely dorsally

- divides into the medial cervical branch, and the medial sesamoid branch




First plantar MT artery

- is formed by the deep plantar arch and a perforating branch from the DPA

- runs distally in the 1st MT space

- nutrient artery to neck (variable)

- cervico-sesamoid branch (constant)


Lateral Cervical branch

- enters plantar surface at base of neck

- supply major part of head

- care in not stripping under the neck to preserve the cervical branch



- small branch from DPA

- penetrates the dorso-lateral capsule near margin of  articular cartilage

- not big enough to provide sole supply

- can be sacrificed if needed




Great toe

- lateral deviation of the great toe  (HVA > 15o)

- medial deviation of the first metatarsal  (IMA > 9o)

- +/- subluxation of the first MTPJ

- hallux pronation

- prominent mediation eminence

- sesamoid rotation / uncovering


Lesser toes

- overriding of the second toe

- metatarsalgia

- lesser toe hammer & claw




Two ages of presentation


1.  Adolescent form

- usually bilateral


2.  Adult form ~ 50's

- strongly familial

- positive FHx in 2/3

- F > M

- F:M = 9:1 in those needing operations




Likely multifactorial


1.  Shoe Wearing



- more women are affected

- women's shoes are tight-toed

- unshod 2% vs 33% shod

- unshod toes separate on weight bearing

- in shoes, toes crowded & hallux abducted


2.  Hereditary

- usually strong FHx

- tend to present earlier

- AD with incomplete penetrance

- made worse by female's shoe wear


3.  Generalised Ligamentous Laxity

- splaying of forefoot

- excessive mobility of 1st TMT

- laxity of medial capsule of MTPJ


4.  Anatomical factors


Metatarsus Primus Varus

- associated with HV

- especially adolescent variety


Metatarsus Varus


1st MT

- long / short

- hyper pronated


2nd Toe amputation

- loss of lateral support for great toe



- rounded joint



- hypermobile

- medially slanted




Short achilles tendon


5.  Pathological Conditions


Rheumatoid arthritis

- leads to loss of capsular support

- RA best treated with fusion


Neurological conditions

- CP best treated with fusion




A.  Congruent MTP joint



- increased DMAA 

- Hallux valgus interphalangeus



- enlarged medial eminence (bunion)

- pressure against shoe

- painful bursa or cutaneous nerve



- MTP joint usually stable & won't sublux

- can’t do distal soft tissue release

- will sublux a congruent joint


B.  Incongruent MTPJ


Hallux Valgus Incongruent Joint, ex


Subluxed MTPJ

- usually progressive



- starts with lateral pressure on great toe

- tight high heels

- P1 moves laterally



- PI moves laterally & puts pressure on MT head

- moves it medially, thus increasing intermetatarsal angle

- attenuation of medial joint capsule

- sesamoid sling held in place by ADDH & transverse metatarsal ligament

- MT head moves further medially / varus deformity

- slides off sesamoids


Final deformity

- appearance of lateral migration of sesamoids

- however sesamoids maintain constant distance from second MT

- lateral sesamoid lies beside MT head in intermetatarsal space

- ADDH pronates the great toe

- medial extensor hood / capsule stretched

- EHL & FHL comes to lie lateral to MTPJ

- finally, lateral capsular structures become contracted & the deformity becomes fixed


C.  Medial Eminence

- MT head changes occur

- groove or medial sagittal sulcus develops at medial border of articular cartilage


D.  Bunion

- callosity of skin + bursa


E.  Lesser Toes

- MTP less stable & weight transferred to MT 2 & 3 -> callosities

- great toe may drift beneath 2nd toe

- alternatively, 2nd toe may subluxate laterally

- lateral toes become crowded

- often develop claw or hammer deformity

- increased weight bearing through middle MT heads may lead to metatarsalgia

- worse with clawing of lesser toes





- over medial eminence (75%)

- metatarsalgia under lesser toes

- degeneration of sesamoid joint

- dorsal aspect osteophytes / rigidus


Shoe problems

- wide foot

- difficulty fitting shoes


Secondary deformity of lesser toes

- especially hammer deformity of the second toe

- rubbing of the PIPJ on shoe


Cosmetic appearance




Hallux Valgus Clinical



- bunion

- HV

- clawing / hammer toes


Assess ROM ankle and STJ

- tight T Achilles


Look at wear patterns on foot

- callosities under 2/3 MT head



- tender bunion

- painful MTJP

- correctable / ROM correctable

- pain over sesamoids



- hypermobility

- > 9mm abnormal


Lesser toes

- deformity / correctable


Neurovascular examination


Weight Bearing AP X-ray


1.  Hallux Valgus Angle / MTPA

- metatarso-phalangeal angle

- normal < 15o


Hallux Valgus MTPA > 40


2.  Intermetatarsal angle/ IMA

- normal < 9o


Hallux Valgus Intermetatarsal Angle > 20 degrees


3.  Congruence

- place dots

- medial & lateral edges of the articular surfaces of the MT head & P1 base

- assess to see if line up / joint congruent


Hallux valgus Incongruent Joint


4. Interphalangeal angle

- normal is <10°

- identify hallux interphalangeus


5.  DMAA

- distal metatarsal articular angle

- normal < 6o


Hallux Valgus Increased DMAA


5.  Sesamoid subluxation

- amount of lateral sesamoid uncovered by MT

- medial sesamoid should not cross midline axis of MT


Hallux Valgus Lateral Sesamoid Uncovered




7.  Size of the medial eminence

- amount of MT head medial to the line along the medial border of the MT


8.  TMT Angle

- medial sloping


Hallux Valgus Medial Sloping TMTJ


Mann Classification  


1.  Congruent


2.  Incongruent


A.  Mild


MTPA < 30°

IMA < 15°

Lateral sesamoid < 50% uncovered


Hallux Valgus Mild


B. Moderate


MTPA 30 - 40°

IMTA 15 - 20o

Lateral sesamoid 50 - 75% uncovered


C. Severe


MTPA > 40°

IMTA > 20°

Lateral sesamoid > 75% uncovered


Hallux Valgus Severe Unilateral


3.  Degenerative


Hallux Valgus Severe Degenerative