Hallux valgus and rigidus — Rapid

Synopsis

Distinguish symptomatic hallux valgus from first-metatarsophalangeal osteoarthritis, quantify deformity and function with weight-bearing assessment, protect skin and circulation, and match footwear, injections and reconstructive surgery to the actual pain generator.

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.

Key red flags

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.

Investigation priorities

First-line standing foot examinationFirst stepFirst line

Define deformity, flexibility, pain generator, callus, footwear conflict, sensation and circulation under load.

First-line weight-bearing foot radiographsFirst line

Measure alignment and arthritis and identify sesamoid, lesser-ray and midfoot disease for referral or planning.

Management branches

First-lineLocalise deformity-related pain

Great-toe deformity or stiffness causes shoe, joint or transfer symptoms without acute infection or ischaemia.

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

Key medicines

Topical diclofenac gelApply 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.

First-metatarsophalangeal corticosteroid injectionWhen 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.

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