Hallux valgus and rigidus

01OverviewDefinition, clinical context and the essential points that orientate the chapter.

Ask what hurts and why. In hallux valgus, pain may arise from medial shoe pressure, the joint, a second-toe collision or transfer callus rather than the angle itself. In rigidus, dorsal pain during toe-off, hills, squatting or shoe contact dominates early, while advanced arthritis hurts throughout movement. Establish progression, footwear, work, sport, previous trauma, gout or inflammatory arthritis, diabetes, neuropathy, smoking and vascular symptoms. Treatment should solve function and pain, not satisfy an X-ray threshold.

Examine standing and walking. Observe toe rotation, medial eminence, arch, hindfoot, lesser-toe crowding and callus, then see whether hallux valgus corrects gently without force. Palpate the joint, sesamoids and lesser metatarsal heads. Measure dorsiflexion and plantar flexion, noting end-range dorsal impingement versus pain throughout the arc and grind. Check first-ray mobility, calf tightness, skin, protective sensation, capillary refill and pulses. Examine shoes for toe-box width and pressure marks.

Weight-bearing anteroposterior, lateral and oblique foot radiographs are the first structural tests when symptoms are atypical, surgery is considered or arthritis needs grading. They demonstrate hallux valgus and intermetatarsal alignment, sesamoid position, joint congruity, osteophytes, joint-space loss and lesser-ray disease. Special sesamoid views or CT are reserved for selected questions. MRI is not routine; it may help occult cartilage, osteonecrosis, stress injury or tumour questions.

Conservative treatment begins with a wide and deep toe box, soft upper, low heel and enough length to prevent end pressure. A bunion pad, toe spacer or sleeve can reduce rubbing when it fits without creating new pressure. Callus should be managed by podiatry rather than cut at home in diabetes or vascular disease. Orthoses can help flexible flatfoot or transfer pain but do not straighten a fixed bunion. Strength and calf flexibility support gait without reversing bone alignment.

For hallux rigidus, a stiff sole, rocker-bottom shoe or carbon-fibre insert reduces painful first-joint dorsiflexion. Modify repeated deep toe extension and preserve movement only within a comfortable arc. Topical NSAID or a brief compatible systemic course can support walking. A carefully placed intra-articular corticosteroid injection may provide temporary diagnostic and symptomatic benefit, generally less durable in advanced arthritis; exclude infection and counsel about glucose, skin, bleeding and rare septic joint.

Hallux-valgus surgery is offered for persistent pain or functional footwear difficulty after suitable non-operative care, not to prevent all progression or improve appearance alone. Distal or proximal metatarsal osteotomy, scarf or chevron techniques, and first tarsometatarsal fusion are selected from deformity, joint congruity and first-ray instability. Soft-tissue correction alone has high recurrence. Explain swelling for months, restricted footwear, nerve irritation, recurrence, overcorrection, non-union and transfer pain.

For rigidus, dorsal cheilectomy removes impinging osteophyte and preserves movement when pain is mainly at terminal dorsiflexion and joint surfaces remain sufficiently preserved. Osteotomy may alter motion in selected disease. First-metatarsophalangeal fusion is the dependable reference procedure for advanced arthritis, severe deformity or failed joint-preserving surgery. It relieves arthritic motion pain but fixes toe position, affecting heel height, kneeling and some sports. Implant arthroplasty has selected indications and revision considerations.

Diabetes, neuropathy and peripheral arterial disease require explicit risk assessment, skin protection and sometimes vascular or multidisciplinary foot input before elective surgery. Smoking increases wound and non-union risk. Anticoagulation needs a perioperative plan from responsible teams. Pregnancy usually favours footwear and activity measures, with analgesia matched to gestation. Older age alone does not exclude surgery; functional goals, bone quality, circulation and rehabilitation support matter.

Key points

Hallux valgus is lateral deviation and rotation of the great toe with a medial first-metatarsal prominence; symptoms come from shoe pressure, joint pain, crowding and transfer metatarsalgia, not appearance alone.
Hallux rigidus is first-metatarsophalangeal osteoarthritis causing painful loss of dorsiflexion, dorsal osteophyte and impaired push-off; advanced disease hurts through mid-range.
First-line investigation for symptomatic deformity being considered for referral is weight-bearing foot radiography, because non-weight-bearing images underestimate alignment and load relationships.
Examine the deformity standing, test whether valgus and hindfoot are flexible, assess first-joint motion and grind, lesser toes, plantar callus, footwear, sensation and pulses.
First-line hallux-valgus management is a wide deep toe box, low heel, pressure padding, activity and callus care; splints and spacers may ease rubbing but do not permanently correct the bony deformity.
First-line rigidus care adds a stiff or rocker sole, carbon insert or shoe modification that limits painful dorsiflexion, with exercise to preserve comfortable movement and general capacity.
Refer symptomatic valgus only after footwear and conservative care fail, not for cosmetic appearance; procedure choice depends on deformity, arthritis, first-ray stability and patient goals.
Cheilectomy can suit earlier dorsal rigidus, whereas first-metatarsophalangeal arthrodesis is the reference operation for advanced painful arthritis; discuss loss of joint movement, footwear and non-union risk.

02AetiologyUnderlying causes, associations and risk factors, with why each one matters.

Inherited foot morphology

Hallux valgus clusters in families and is influenced by first-ray alignment, ligament laxity, metatarsal shape and pes planus rather than footwear alone.

Footwear pressure

A narrow toe box and high heel crowd the forefoot, aggravate medial-eminent pain and accelerate symptoms in a susceptible foot without being the sole cause.

First-joint osteoarthritis

Hallux rigidus follows cartilage degeneration from age, previous trauma, joint shape, repetitive loading or inflammatory disease, sometimes without an identifiable trigger.

Inflammatory and neuromuscular disease

Rheumatoid arthritis, gout, connective-tissue laxity and neurological imbalance can produce deformity, altered joint destruction and different operative requirements.

03PathophysiologyThe causal sequence from the underlying abnormality to symptoms and harm.

1
Valgus and metatarsal drift
The proximal phalanx deviates laterally while the first metatarsal drifts medially, unbalancing tendons and sesamoids and making deformity progressively self-reinforcing.
2
Medial pressure and transfer load
The prominent metatarsal head rubs footwear and inefficient first-ray loading shifts pressure to lesser metatarsal heads, producing callus and metatarsalgia.
3
Dorsal cartilage loss
Hallux rigidus often begins dorsally, where osteophytes and reduced joint clearance make dorsiflexion painful during terminal stance and shoe contact.
4
Global rigid arthritis
As cartilage loss advances, pain occurs through mid-range as well as at end range, the joint stiffens and gait rolls laterally to avoid toe-off.

04Clinical features and red flagsSymptoms, examination findings, patterns of presentation and time-critical warnings.

Symptomatic hallux valgus

Lateral great-toe drift with medial-eminent rubbing, shoe restriction, joint pain or second-toe crowding defines clinically relevant deformity.

Transfer callosity

Tender callus beneath lesser metatarsal heads indicates first-ray load transfer and may be the main disability rather than the bunion itself.

Early hallux rigidus

Dorsal osteophyte and pain at terminal dorsiflexion during toe-off occur while mid-range movement remains relatively comfortable.

Advanced hallux rigidus

Marked range loss, crepitus and pain through the middle of movement indicate diffuse joint-surface disease less suitable for cheilectomy alone.

Neuropathic skin threat

Callus, ulceration or pressure marks with sensory loss require protective footwear and diabetic-foot assessment before elective correction.

Vascular threat

Rest pain, tissue loss, coolness and absent pulses require vascular assessment before attributing symptoms to deformity or planning surgery.

Red flags requiring action

A hot exquisitely painful first metatarsophalangeal joint with fever, skin breach or immune compromise requires urgent septic-joint assessment even when gout is plausible.
Ulceration over the medial eminence, under the metatarsal heads or between toes in diabetes or neuropathy activates an urgent diabetic-foot and pressure-offloading pathway.
A cool pale or blue toe, rest pain, non-healing skin or absent pulses requires urgent vascular assessment before any elective foot procedure.
Rapid deformity, unilateral heat and swelling with neuropathy suggests Charcot arthropathy rather than ordinary progressive bunion or osteoarthritis.
Night pain, destructive change or an atypical enlarging mass requires tumour or infection investigation.

05InvestigationsWhat to request, why it matters and how to interpret it.

Investigation order

Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.

01
First-line standing foot examinationFirst stepFirst line
Why
Define deformity, flexibility, pain generator, callus, footwear conflict, sensation and circulation under load.
Interpretation and limitations
Treat symptoms and functional compromise; an asymptomatic angle alone is not an operative indication.
02
First-line weight-bearing foot radiographsFirst line
Why
Measure alignment and arthritis and identify sesamoid, lesser-ray and midfoot disease for referral or planning.
Interpretation and limitations
Use weight-bearing AP, lateral and oblique views; relate angles and joint-space loss to clinical pain and flexibility.
03
Dedicated sesamoid or axial view
Why
Assess sesamoid position, plantar first-ray pain or selected operative anatomy.
Interpretation and limitations
Sesamoid displacement accompanies valgus but should not be interpreted without weight-bearing alignment and symptoms.
04
CT for complex fusion or bone anatomy
Why
Map non-union, severe deformity or adjacent-joint disease when cross-sectional detail changes reconstruction.
Interpretation and limitations
CT is not routine first-line imaging and should answer a defined specialist question.
05
Targeted infection, crystal or vascular assessment
Why
Investigate an acutely hot joint, ulcer, tissue threat or absent perfusion before elective treatment.
Interpretation and limitations
Aspiration distinguishes crystal from septic arthritis when needed; Doppler and vascular imaging follow clinical arterial concern.

06Differential diagnosisRealistic alternatives and the features that help distinguish them.

Gout or septic arthritis

Abrupt intense warmth and swelling differs from chronic shoe pressure, but aspiration is required when bacterial infection remains possible because crystals do not exclude sepsis.

Sesamoid disorder

Plantar first-metatarsal-head pain and focal sesamoid tenderness, sometimes after impact loading, localises below rather than dorsomedial to the joint.

Inflammatory forefoot disease

Several swollen metatarsophalangeal joints, prolonged morning stiffness and systemic features suggest rheumatoid or another inflammatory arthritis.

Turf-toe injury

Acute forced hyperextension with plantar capsular tenderness and bruising indicates traumatic plantar-plate injury rather than chronic hallux rigidus.

Neuropathic deformity

Loss of protective sensation, marked warmth, swelling and rapid bony change raises Charcot disease and requires immediate offloading.

07ManagementImmediate care, first-line treatment, alternatives and escalation.

01First-lineLocalise deformity-related painFirst stepFirst lineGreat-toe deformity or stiffness causes shoe, joint or transfer symptoms without acute infection or ischaemia.

1Examine standing alignment, flexibility, joint motion, lesser toes, plantar pressure, skin, sensation and pulses.
2Identify whether medial rubbing, joint arthritis, transfer metatarsalgia or second-toe conflict is the principal target.
3Trial a wide deep toe box, low heel, pressure padding and condition-specific sole or insert modification.
4Review walking, footwear and activity goals before obtaining weight-bearing radiographs for referral or planning.

02Valgus escalationCorrect pain, not appearanceEscalationHallux-valgus pain or footwear disability persists despite adequate shoe and pressure measures.

1Obtain weight-bearing radiographs and document joint congruity, first-ray stability, arthritis and associated lesser-toe disease.
2Refer for procedure selection based on deformity pattern, bone and joint health, goals and tolerance of postoperative restrictions.
3Explain that splints do not permanently realign bone and surgery is not offered solely for cosmetic preference.
4Optimise smoking, diabetes, skin, circulation and anticoagulation and plan protected weight-bearing and work absence.

03Rigidus stepwiseReduce painful dorsiflexionFirst-joint osteoarthritis produces dorsal impingement or painful loss of motion.

1Use a stiff or rocker sole or carbon insert, activity modification and suitable short analgesia.
2Consider one image-guided intra-articular injection when temporary relief or diagnostic localisation will change decisions.
3Offer cheilectomy discussion when pain is predominantly dorsal and end-range with preserved mid-range cartilage.
4Offer fusion discussion for advanced mid-range pain, major stiffness or failed preservation, explaining fixed position and non-union risk.

04Urgent alternativeProtect tissue before deformity treatmentAlternativeHeat, ulcer, drainage, acute severe swelling, neuropathic collapse or vascular insufficiency is present.

1Use urgent joint aspiration and infection treatment when septic arthritis remains possible.
2Route an ulcerated or infected diabetic foot to multidisciplinary services and offload the pressure area.
3Make a hot neuropathic foot non-weight-bearing and assess for active Charcot disease.
4Seek vascular review for rest pain, tissue loss or impaired perfusion before any elective correction.

Key medicines and prescribing safety2 treatments · regimens, roles and cautions

Provides local relief for arthritic or pressure-related pain while footwear and sole modifications are introduced.

Topical diclofenac gel

Apply 2–4 g of diclofenac 1.16% gel over intact painful first-joint skin per use, up to three or four uses daily for a short course within the licensed maximum.

Avoid ulcers, broken skin and NSAID hypersensitivity, consider total NSAID exposure and pregnancy, and inspect skin carefully in neuropathy.

Can provide temporary relief in hallux rigidus and clarify how much pain originates from the arthritic joint.

First-metatarsophalangeal corticosteroid injection

When selected after infection exclusion, give one accurately placed intra-articular corticosteroid dose under the trained local small-joint protocol, using image guidance where needed and reviewing benefit before any repeat.

Warn about flare, skin depigmentation, fat atrophy, transient glucose rise, bleeding and rare septic arthritis; assess diabetes and anticoagulation and never inject through compromised skin.

08ComplicationsImportant consequences, why they occur and why they matter clinically.

Transfer metatarsalgia

Reduced first-ray load acceptance shifts pressure beneath lesser metatarsal heads, leading to pain, callus and plantar-plate overload.

Second-toe deformity

A drifting great toe crowds or underrides the second toe, promoting hammering, crossover, corn and metatarsophalangeal instability.

Skin breakdown

Medial-eminent friction and interdigital pressure can ulcerate, especially when neuropathy, ischaemia or poorly fitting footwear removes warning pain.

Progressive stiffness and gait change

Advanced rigidus reduces push-off, shortens stride and transfers load laterally, causing forefoot and compensatory proximal-limb symptoms.

Postoperative recurrence or non-union

Valgus can recur after under-correction, while osteotomy or fusion risks infection, nerve symptoms, hardware irritation, non-union and adjacent transfer pain.

09Monitoring and follow-upTreatment response, safety checks and longer-term review.

Record footwear tolerance, walking distance, first-joint pain, transfer callus and second-toe conflict rather than angle alone.
Inspect skin and pressure areas after spacers, pads, orthoses or new shoes, particularly with diabetes or neuropathy.
Follow great-toe movement and whether pain occurs only at end range or throughout the arc because this changes surgical options.
After injection, document duration of functional gain and monitor glucose, skin and infection signs where relevant.
After osteotomy or fusion, follow wound, alignment, neurological symptoms and radiographic union before advancing weight-bearing.
Reassess pulses, tissue viability and ulcer risk whenever pain pattern or skin changes, not only before surgery.

10Special situationsVariants, exceptions and circumstances that change the usual approach.

A bunion is more than a bump

The whole first-ray and sesamoid alignment changes, so shaving the prominence alone does not correct the deforming mechanics.

Standing films tell the truth

Loading reveals metatarsal separation, sesamoid relationship and arch contribution that may disappear on a non-weight-bearing image.

Pain arc guides rigidus surgery

Terminal dorsal pain with comfortable mid-range suits joint preservation better than pain throughout motion from diffuse cartilage loss.

Spacers relieve but do not remodel

A toe spacer can reduce pressure in a flexible deformity but cannot permanently reverse established metatarsal and phalangeal alignment.

Fusion position is functional

Toe dorsiflexion and rotation at fusion determine shoe choice, gait and kneeling, so intraoperative positioning matters as much as union.

Callus maps load transfer

Plantar callosity beneath lesser metatarsals reveals where the first ray has stopped accepting load and should shape the treatment plan.

11Common pitfallsFrequent interpretation and management errors.

01
Offering hallux-valgus surgery for appearance without persistent pain or functional footwear difficulty.
02
Using non-weight-bearing films to plan a deformity that appears mainly under load.
03
Treating the medial prominence alone and ignoring first-ray, sesamoid and lesser-toe alignment.
04
Calling every painful stiff great toe hallux rigidus without excluding gout, infection and sesamoid disease.
05
Performing cheilectomy for diffuse mid-range arthritic pain where dorsal spur removal cannot solve cartilage loss.
06
Planning elective correction before assessing ulceration, neuropathy, diabetes and arterial supply.