Hallux Valgus

Pathway

Hallux Abducto Valgus (HAV) is a common condition affecting the forefoot in which the first metatarsophalangeal joint is progressively subluxed due to the lateral deviation of the hallux and medial deviation of the first metatarsal.

The resultant deformity often leads to the development of a soft tissue and osseous prominence on the medial aspect of the first metatarsal head, commonly referred to as a “bunion”.

HAV presents with a range of symptoms, from the purely cosmetic to major deformity, pain and disability. The following pathway produced on behalf of NHS Sheffield CCG aims to outline the appropriate management of the condition and define the threshold for surgical intervention.

Asymptomatic & Mild to Moderate Symptoms

• Asymptomatic HAV does not require treatment.
• Surgery for asymptomatic bunions, ie for cosmetic reasons alone, is regarded as a procedure of low clinical priority.
• All surgical providers are keen to stress that they would not perform surgery for cosmesis alone.
• If the bunion is not painful and mobility is not impaired then patients should be advised to wear suitable footwear to accommodate the bunion (wider fitting, lower heel, custom moulding/stretching shoe to accommodate deformity.)
• Analgesia and NSAIDs for mild to moderate pain
• The Sheffield Aches and Pains website has a section on foot and ankle pain which includes advice sheets for patients on managing HAV (Bunions) – view it here.
• If the bunion is significantly painful on a daily basis and or reducing mobility despite the above measures then referral to the Foot and Ankle Service for further assessment is indicated.

Moderate to severe symptoms

• Referral to Foot and Ankle Service for specialist assessment and triage, assessing degree and type of pain, the level and progression of deformity, the potential of non-surgical interventions and the patient’s suitability for and commitment to surgery.
• Additional Footwear modification/advice
• Offloading Orthotics
• Injection therapy

Severe symptoms

Consideration for surgery is appropriate where the above measures have failed and the
patient suffers from:

• Severe pain on most days.
• Significant deformity (clawing of 2nd toe, overriding of toes) that causes functional impairment.
• Impaired mobility due to either of the above

The factors listed in the table below should be considered by the triaging clinician to provide judgement on the suitability of an individual for surgical referral.

The table is divided into amber and green sections, results in the green section suggest (or determine) that surgery is the appropriate treatment option and results in the amber sections suggest (or determine) that non-surgical treatment is appropriate.

These results are considered in totality along with the patient’s health status, to conclude whether or not the patient should be referred for surgery.

Patients suitable for surgery are referred to one of two surgical providers depending on complexity and concomitant factors or co-morbidities. (Orthopaedic Foot and Ankle Surgery or Podiatric Surgery)