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The Pathogenesis of Hallux Valgus

ARTICLE in THE JOURNAL OF BONE AND JOINT SURGERY SEPTEMBER 2011
Impact Factor: 5.28 DOI: 10.2106/JBJS.H.01630 Source: PubMed

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C OPYRIGHT ! 2011

BY

T HE J OURNAL

OF

B ONE

AND J OINT

S URGERY, I NCORPORATED

Current Concepts Review

The Pathogenesis of Hallux Valgus

A.M. Perera, FRCS(Orth), Lyndon Mason, MRCS(Eng), and M.M. Stephens, FRCSI
Investigation performed at the University Hospital of Wales, Cardiff, United Kingdom

The first ray is an inherently unstable axial array that relies on a fine balance between its static (capsule, ligaments,
and plantar fascia) and dynamic stabilizers (peroneus longus and small muscles of the foot) to maintain its
alignment.

In some feet, there is a genetic predisposition for a nonlinear osseous alignment or a laxity of the static stabilizers
that disrupts this muscle balance. Poor footwear plays an important role in accelerating the process, but occupation and excessive walking and weight-bearing are unlikely to be notable factors.

Many inherent or acquired biomechanical abnormalities are identified in feet with hallux valgus. However, these
associations are incomplete and nonlinear.

In any patient, a number of factors have come together to cause the hallux valgus. Once this complex pathogenesis
is unraveled, a more scientific approach to hallux valgus management will be possible, thereby enabling treatment
(conservative or surgical) to be tailored to the individual.

In the nineteenth century, hallux valgus was thought to be due

to an enlargement of the metatarsophalangeal joint of the great
toe1. It was not until Carl Hueter (1838-1882), a German-born
surgeon, coined the term hallux abducto valgus 2 that the deformity was more correctly described as a lateral deviation of
the great toe at the metatarsophalangeal joint. A century of
debate has failed to settle the importance of intrinsic versus
extrinsic causes in the etiology of hallux valgus. In the 1950s,
Sim-Fook and Hodgson compared shoe-wearing and nonshoe-wearing groups and showed a dramatic increase in the
prevalence of hallux valgus among the shoe-wearing group3.
Unfortunately, it did not explain the prevalence of hallux valgus
in the community of people who had never worn shoes, nor did
it account for the many individuals who wear high-fashion
footwear and never become affected. Clearly, the issue is more
complex than simply a problem of footwear. Although much
research has been done to define the multifactorial origin of

hallux valgus and the effect of those factors on surgical outcomes, the quality and strength of this evidence have been
variable.
Pathoanatomy of Hallux Valgus
Development of Hallux Valgus (Figs. 1 through 4)
It is generally accepted4,5 that hallux valgus occurs in steps,
frequently on a background of several predisposing factors
(Table I). These steps do not necessarily occur in series but may
transpire in parallel. These steps are as follows:
1. As the only medial supporting structures of the first
metatarsophalangeal joint are the medial sesamoid and medial
collateral ligaments, their failure is the early and essential
lesion.6
2. The metatarsal head can then drift medially, slipping
off the sesamoid apparatus. An oblique or an unstable tarsometatarsal joint may encourage this movement.

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of
any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of
this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No
author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what
is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the
article.

J Bone Joint Surg Am. 2011;93:1650-61

http://dx.doi.org/10.2106/JBJS.H.01630

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Fig. 1

Fig. 2

Fig. 1 Illustration of the medial view of the hallux, showing the medial structures whose failure is essential for hallux valgus deformity to occur. Fig. 2
Illustration of the metatarsal head of the hallux in the anteroposterior plane, showing the medial shift of the metatarsal head (step 2 in the development of
hallux valgus), with the valgus displacement of the proximal phalanx due to its attachment to the sesamoids, the deep transverse ligament (via the plantar
plate), and the adductor hallucis tendon (step 3). The extensor hallucis longus bowstrings laterally (step 6).

3. The proximal phalanx moves into a valgus position as

it is tethered at its base to the sesamoids, the deep transverse
ligament (via the plantar plate), and the adductor hallucis
tendon.

Fig. 3

4. The metatarsal head sits on the medial sesamoid and

can erode the cartilage and the crista. The lateral sesamoid can
appear to sit in the intermetatarsal space although it does not
actually move.

Fig. 4

Fig. 3 Illustration showing the medial shift of the metatarsal head in the axial plane (step 2 in the development of hallux valgus) and the pronation of the
metatarsal head that results from the muscle forces acting on it (step 7). The figure also illustrates the position of the sesamoids, abductor hallucis (AbH),
adductor hallucis (AdH), flexor hallucis longus (FHL), and extensor hallucis longus (EHL). Fig. 4 Illustration of the deformity of hallux valgus in the axial plane.
The metatarsal is pronated and shifted medially, resulting in the lateral shift of the abductor hallucis (AbH), adductor hallucis (AdH), flexor hallucis longus
(FHL), and extensor hallucis longus (EHL) (steps 6 and 8 in the development of hallux valgus). The bursa overlying the medial eminence thickens because of
the pressure effect of footwear on a prominent medial eminence (step 5). Because of the pressure of the medial sesamoid on the crista, the cartilage is
eroded and the crista flattened (step 4).

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TABLE I Potential Intrinsic and Extrinsic Factors

Extrinsic

Intrinsic

High-heeled narrow shoes

Genetics

Excessive weight-bearing

Ligamentous laxity
Metatarsus primus varus
Pes planus
Functional hallux limitus
Sexual dimorphism
Age
Metatarsal morphology
First-ray hypermobility
Tight Achilles tendon

5. The bursa overlying the medial eminence can thicken

because of the pressure effect of footwear on a prominent
medial eminence.
6. The extensor and flexor hallucis longus tendons appear
to bowstring laterally7, increasing the valgus displacement and
occasionally acting as dorsiflexors of the proximal phalanx.
7. As the metatarsal head drops off the sesamoid
apparatus, it pronates because of the muscle forces acting
across it.
8. Normally, the abductor hallucis strongly resists valgus
of the proximal phalanx, but it becomes dysfunctional as its
medial and plantar attachment rotates inferiorly8. The adductor hallucis is attached on the plantar surface laterally so it
tends to pull the phalanx into pronation as well as tethering
its base.
9. The weaker dorsal metatarsophalangeal joint capsule is
not reinforced by any tendons and rotates medially with
pronation and provides poor stability 9.
10. The metatarsal head elevation with medial motion
can transfer plantar pressure laterally. The relatively mobile
fifth metatarsal may also splay.
First Ray Biomechanics
The first ray plays a key role in maintaining the structure of the
medial arch9, and as the main load-bearing structure10, it is
subject to substantial forces during gait. Failure anywhere along
the first ray, from the distal phalanx to the talonavicular joint,
can result in hallux valgus. It is therefore worth considering the
first ray biomechanics as a common factor to many of the key
theories. There are no tendon attachments on the metatarsal
head, and maintenance of this inherently unstable axial array
requires (1) a congruent and stable metatarsophalangeal joint
during push-off, (2) a distal metatarsal articulation angle that
encourages stability, (3) balanced static and dynamic restraints,
and (4) a stable tarsometatarsal joint11.
Sesamoids

The functions of the sesamoid bones are, first, to absorb

weight-bearing forces and enhance the load-bearing capacity

of the first ray. The sesamoids increase the moment arm of

the flexor hallucis brevis, which powers plantar flexion of the
hallux, and, finally, they function to elevate the first metatarsal
head, which dissipates the forces on the metatarsal head12-16.
The first metatarsal head is elevated on the sesamoids during
stance, but the sesamoids move during hallux dorsiflexion,
coming to lie anterior to the metatarsal head rather than inferior. The sesamoid sling thus facilitates the first metatarsal
plantar flexion that is essential for hallux dorsiflexion.
The sesamoids can appear to subluxate with first metatarsal pronation alone17,18, but true subluxation requires a
number of events to occur first. The joint reaction force of
the metatarsosesamoid joint is normally sufficient to prevent
subluxation19. Thus, the metatarsosesamoid joint must become
unloaded either by elevation of the first metatarsal head or by
the transfer of plantar pressure laterally. Finally, the soft-tissue
restraints and the cristae need to fail.
First Ray Motion

Morton believed that dorsal hypermobility of the first metatarsal segment was responsible for the widest array of foot
deformity 20. However, several studies have questioned whether
motion at the tarsometatarsal joint even exists21-24. The studies
that described motion of the first tarsometatarsal joint had
no consensus with regard to either the axis of movement or
the magnitude. In so-called normal feet, the small amount of
movement permitted at the first tarsometatarsal joint is amplified by the long metatarsal shaft, resulting in an average
dorsoplantar motion of 6 mm25. However, the mean range of
motion of the entire first ray in the foot with hallux valgus is
significantly greater in both the sagittal and frontal planes.
First Metatarsophalangeal Joint Motion

The first metatarsophalangeal joint is a partial ball-and-socket

joint rather than a simple hinge. When the hallux is held stable
(as in push-off), the kinematic coupling of the first ray and the
ankle joint motion results in a frontal plane rotation, pronating
the great toe and causing a medial transverse plane motion. These
motions both increase the loading on the medial aspect of the
toe26, creating a valgus moment at the metatarsophalangeal
joint.
With the foot flat on the ground and loaded evenly (i.e.,
midstance), the dorsiflexion of the metatarsophalangeal joint is
limited to approximately 20" as further motion requires plantar
flexion of the first metatarsal27. The phalanx and metatarsal are
coupled such that 1" of phalangeal dorsiflexion requires 3" of
metatarsal plantar flexion28. The spiral-shaped nature of the
metatarsal head29 forces a translational sliding motion as the
proximal phalanx rotates30,31. Thus, the locus of the axis of
rotation has to move in an arc32 that necessitates metatarsal
motion proximally and plantarward in order to avoid compression at the metatarsophalangeal joint. Prevention of this
plantar flexion hinders dorsiflexion of the first metatarsophalangeal joint even when non-weight-bearing33. Plantar flexion
of the first ray also maintains ground contact during heel rise
when the obliquity of the metatarsophalangeal break, which is

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the axis of the four lateral metatarsophalangeal joints, is enhanced during late stance, causing lower-extremity external
rotation and inversion of the subtalar joint34.
Normal gait uses up to 65" of first metatarsophalangeal
dorsiflexion, and first ray elevation substantially compromises
this range of motion35. Furthermore, the normal hallux has a
tendency toward valgus (and any pronation further encourages
this tendency). This combination means that, when dorsiflexion
is restricted, the toe is forced to escape laterally in the direction
of least resistance. As the transverse sphericity of the first metatarsal head 29 permits multiplanar motion 36, the collaterals,
sesamoids, and the so-called rein effect of the first metatarsophalangeal joint rotator cuff are all required for stability.
Etiology of Hallux Valgus
The different factors can be divided into extrinsic and intrinsic
risks (Table I).
Extrinsic Factors
Footwear

Even prior to the understanding of hallux valgus pathology, the

use of footwear has been implicated as an etiology1,37,38. In 1909,
Porter39 advised against performing corrective surgery on patients unwilling to wear appropriate footwear because of a
greater risk of recurrence of the deformity. There is a low
prevalence of hallux valgus in unshod populations40,41, and the
prevalence increases with changes in shoe fashion42. However,
the association is not complete (Table II), and footwear is not at
all important in juvenile hallux valgus43.
High heels are commonly blamed for hallux valgus, and
there is a direct association between increased first metatarsal
loading and a valgus moment44. This forefoot loading is exacerbated by the forefoot sliding forward into the toe-box, pronating as it does so. A third of the population naturally favors
loading the lateral part of the forefoot and is at greatest risk of
this deformity. However, this forefoot loading is probably more
important in deformity progression than initiation45. There is
some limited evidence that altering the position of the heel
could counteract this tendency28.
TABLE II Prevalence of Deformity in Shod and Unshod Feet*
Shod
Feet (%)

Unshod
Feet (%)

Hallux valgus

33

Flatfoot

11

17

Deformity

Atavistic forefoot

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Metatarsus elevatus

39

Metatarsus primus varus

25

Hypermobility of the metatarsus

13
3

*The data are from the study by Sim-Fook and Hodgson . There
were 118 subjects in the group that wore shoes and 107 subjects in
the group that did not wear shoes.

The prevalence of hallux valgus in women who wear shoes

with a narrow toe-box or a high heel is certainly not 100%. This
may be due, in part, to the buttressing effect of the second toe, in
the association between hallux valgus and a hammer toe of the
second digit46 or between the length of the great toe and risk of
hallux valgus47. So even in women, footwear is probably more
important in progression than causation. It is intuitive to presume that this risk is greater in those with a wider foot.
Excessive Loading

Hallux valgus develops slowly, suggesting a process of repetitive

trauma; however, despite a perception that occupation48 or
excessive walking and weight-bearing49 is important, there is no
proven link50. The only exception is a weak association with
ballet dancing51,52. Mann and Coughlin53 reviewed the literature
on cumulative industrial trauma and dismissed any occupational link.
No clear link has been established between hallux valgus
and obesity 54 and other factors that affect loading such as foot
progression angle55 or foot dominance56. There are differences
in metatarsal loading in hallux valgus, but the relevance is
unknown56.
Intrinsic Factors
Genetic Factors

A genetic predisposition has long been suspected57. Among

the inheritable factors that may be relevant are metatarsal
formula, arch height, and hypermobility 58,59. The best evidence showed that 90% of 350 white patients had at least one
affected relative60, with the most common pattern of inheritance being autosomal dominant with incomplete penetrance.
The role of genetics in juvenile43 and young adult49 hallux valgus
is much more established, with maternal transmission found in
94% (twenty-nine) of thirty-one patients with a family history.
There is weak evidence of a racial difference. The prevalence of
hallux valgus in whites has been reported to be two times greater
than that in black Africans40,61.
Sexual Dimorphism

The true sex ratio is unknown, although the male-to-female

ratio of 1:1560,62,63 among those who have corrective surgery is
well established. The higher prevalence among women may be
due to footwear that is either poor (up to 90% of shoes in a
survey of 365 women were too small64) or less forgiving, resulting in earlier and more frequent presentation. Nevertheless,
the prevalence is still greater in women, but there is no quality
evidence to support the finding65. Even less is known of the
prevalence between the sexes with regard to juvenile hallux
valgus.
There are fundamental differences in osseous anatomy 66;
for instance, the metatarsal head articular surface in female
patients is more rounded and smaller, providing a less stable
joint67. Women also tend to have a more adducted first metatarsal68, which in turn may be due to differences in the tarsometatarsal articulation69. Other differences include metatarsal
dimension and distal and proximal articulation shape and

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angle68,70. Differences in foot pressures have been noted, but the

significance of these findings is unknown71.
Ligamentous laxity72 and first ray hypermobility73 are
more common in women, although several major series on the
outcomes of hallux valgus surgery have failed to provide maleto-female ratios9,74-77. No link has been made with pregnancy.
Systemic Conditions
Ligamentous Laxity

Mild ligamentous laxity is common in women with hallux

valgus78 and has been reported in 70% of twenty patients with
juvenile hallux valgus74. Therefore, in conditions with generalized
ligamentous laxity79, such as Marfan syndrome, Ehlers-Danlos
syndrome10, and rheumatoid arthritis80, hallux valgus is more
common and more difficult to treat. It is interesting, although
counterintuitive, that the only study assessing laxity with
use of the Beighton scoring system81 failed to find any association between generalized ligamentous laxity and hallux valgus 78. Despite the fact that patients with laxity have a
major risk for recurrence, little work has been done on this
condition82-84.
Age

A biomechanical study in elderly patients 85,86 showed that

changes in posture, joint kinematics, and plantar pressure are
associated with a greater risk of hallux valgus. However, age is a
poor predictor of hallux valgus angle87. Although the peak onset
is from thirty to sixty years of age, it is more likely that the
initial changes occur during adolescence43,88 or even earlier for
juvenile hallux valgus.
Metatarsus Primus Varus

The association between metatarsus primus varus and hallux

valgus is well known43,89-93, but it is not clear whether it is a
cause or an effect94. Humbert et al.95 argued that metatarsus
primus varus comes first, stating that, as the abductor hallucis
tendon subluxates inferiorly, it becomes dysfunctional, resulting in hallux valgus. Metatarsus primus varus is important
in juvenile hallux valgus92 and has been reported to be found
in up to 75% of such patients (forty-nine of sixty-five)96,97.
This rate is greater than the prevalence in patients with adult
hallux valgus (57% of 122 subjects)49 and in the general population (<1% of 635 subjects)98, but the appearance of metatarsus primus varus lags behind the development of the hallux
valgus49,91.
A weak association has been found between the magnitude of metatarsus primus varus and hallux valgus in women49,99,
but the evidence shows that it is related to the choice of footwear.
No direct association is found until the deformity becomes severe and self-propagating100,101; by that stage, muscle compression
forces push the metatarsal head medially with a force equal to the
posterior shear force of the hallux on the ground times the hallux
valgus angle102.
Snijders et al. concluded that the metatarsus primus
varus was secondary to the toe deformity, on the basis of biomechanical investigations38. This finding supports the obser-

vation that when hallux valgus is corrected, the metatarsus

primus varus can improve without an attempted correction of
the first metatarsal itself. This has been shown for basal osteotomy49, first metatarsal phalangeal joint fusion103,104, and even
Keller osteotomy 105, suggesting that metatarsus primus varus is
a secondary phenomenon. Cronin et al. believed that the adductor hallucis was a deforming force that could be used after
fusion to adduct the entire ray without a basal first metatarsal
osteotomy 103.
It appears that some people have an innate propensity
toward metatarsus primus varus and are at risk of juvenile hallux
valgus. If they wear high-heeled or small toe-box footwear, they
have an increased risk of developing adult hallux valgus. In severe hallux valgus, a self-propagating cycle of worsening hallux
valgus and metatarsus primus varus can develop.
Metatarsal Anatomy

Metatarsal dimension: Metatarsal formula refers to the relative lengths of the metatarsals. The normal order in terms of
decreasing length is second, first, third, fourth, and then
fifth, but the first and third are commonly equal in length.
Morton20 described the short first metatarsal of Morton foot
that he believed led to pronation and hypermobility of the
first ray and therefore hallux valgus. There is no clinical
evidence for this relationship, and more reliable measurement techniques have found the true association to be as low
as 4%49,106-108.
Mancuso et al. found that 80% of 110 patients with
hallux valgus had a so-called zero-plus first metatarsal (i.e., it
was equal to or greater in length than the second metatarsal),
whereas 80% of 100 control subjects had shorter first metatarsals109. According to Root et al., the long first metatarsal acts
as a functional metatarsus primus elevatus27 as it cannot
plantar flex below the transverse plane. This additional length
inhibits first metatarsophalangeal joint dorsiflexion and can
cause subluxation110.
A long first metatarsal creates a so-called buckle point111,112,
resulting in a hallux valgus with a high intermetatarsal angle,
and there is a strong association between protrusion distance
and intermetatarsal angle108. On this basis, Mancuso et al. advocated that the definition of so-called normal metatarsal
protrusion should be reduced to 2 to 0 mm from the accepted
standard of 2 to 12 mm109. It is important to remember that
pronation of the foot causes metatarsal dorsiflexion, making it
appear longer than it actually is113. However, the new definition
does not necessarily refute the theories regarding the long first
metatarsal, as the function of the foot when weight-bearing is
the important factor.
Metatarsal articular morphology: Heden and Sorto 112
observed that a round first metatarsal head is common in hallux
valgus (occurring in 90% of 100 affected subjects compared with
20% of 210 control subjects). A round first metatarsal head
creates a more unstable articulation than other shapes and is
associated with a higher rate of recurrence of hallux valgus114.
The round-shaped head is unlikely to be due to remodeling as it
is not associated with any degenerative change36. The flattened,

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so-called square or chevron-shaped head is more stable49,115.

Phillips116 noted that, as the vector of the extensor and flexor
tendons runs through the vertical axis of motion, the articulation
behaves somewhat like a hinge. However, the more rounded it is,
the closer the vertical axis lies to the surface. Thus, even small
displacements medially or laterally can produce greater angular
changes than in a flattened head36,49,53,82,91,117,118.
The biggest objection to this theory is that it is not clear
whether the described head shapes are truly discrete anatomical
entities, and magnetic resonance imaging studies support this
observation115. These appearances may be spurious, as apparent
shape varies with metatarsal pronation and inclination67,114.
Unfortunately, there is still no consistent or accurate method of
describing metatarsal head shape or of taking into account the
concept of traveling distance of the head119.
Measurement of the distal metatarsal articular angle is
notoriously unreliable120, and there is a very wide variation (14"
to 130") of normal. However, a congruent metatarsophalangeal
joint in hallux valgus requires an altered distal metatarsal articular angle, and the two are directly related38. This relationship is
strongest for juvenile hallux valgus43, suggesting a congenital
origin especially as degeneration of the joint is rare121. But there is
evidence of a 1" to 3" increase in the distal metatarsal articular
angle with every decade of life, suggesting that it may be acquired122. It is interesting that the congruent metatarsophalangeal joint appears to be more stable and less likely to progress87.
There is no association with metatarsal length, adduction, mobility, range of motion, or inheritance49.
The proximal metatarsal articulation shows individual
variation and an association between obliquity and hallux
valgus123,124. This association appears well established; however,
these studies are all based on radiographic appearances, and
apparent angulation varies considerably with foot posture7,125.
Intermetatarsal facets occur in approximately one-third of
humans126 and are associated with metatarsus primus varus and
increased obliquity of the first tarsometatarsal joint127 but not
with hallux valgus49,122.
Recent unpublished work presented at a British Orthopaedic Foot & Ankle Society meeting, held in Nottingham in
2010, indicated that the proximal articular morphology varies.
The authors found that an articular surface with a single facet
was associated with hallux valgus, and an articular surface with
three facets only occurred in subjects with normal feet. They
hypothesized that the increasing number of articular facets
evoked stability128.
Metatarsal bunion: The bunion is not an osteophyte7, new
bone formation129, or ossification of inflamed tissues. There is
actually no increase in the size of the medial eminence49,130. Instead, the metatarsal head is increasingly exposed by cartilage
loss because of the lack of contact from the phalanx131. The
sagittal groove, which is a thinning of the articular cartilage that
develops laterally on the metatarsal head, is thought to be caused
by pressure from the phalangeal margin131. It is an area of
minimal pressure (or fossa nudata)132, and robust histological
data have shown that it is due to a lack of stimulation rather than
erosion116. As the sagittal groove moves laterally with increasing

hallux valgus deformity, it is not considered an indication for

bunionectomy in severe hallux valgus7.
Metatarsal Biomechanics

Static stabilizers around the first metatarsophalangeal joint: No

musculotendinous structures attach to the metatarsal head.
The only structures on the medial side are the capsule, collateral ligament, and medial sesamoid ligament. These structures
are the most important joint stabilizers, and their insufficiency
is essential for the development of deformity. Sectioning them
alone results in a valgus angulation of >20"132. These structures
are mechanically abnormal in hallux valgus, with altered organization of the type-I and type-III collagen, leaving the first
metatarsophalangeal joint vulnerable to continuous and cyclical distraction during gait133. The insufficiency of these
structures is more likely effect than cause unless it is part of a
generalized ligamentous laxity.
McBride9 advocated transverse metatarsal ligament transection for correction, but there is no radiographic evidence to
support the use of this procedure86. This finding is not surprising
as the deep transverse ligament joins the five plantar pads together and not the metatarsal heads134. Sectioning the transverse
ligament hardly changes the valgus deformity and does not alter
the relationship between the first and second metatarsals135.The
lateral sesamoid is held by the transverse ligament and the adductor hallucis via the conjoined tendon and does not move. It is
the medial sesamoid ligament that fails6.
Dynamic stabilizers around the first metatarsophalangeal
joint: The abductor hallucis abducts, plantar flexes, and inverts
the great toe, while the adductor hallucis adducts, plantar
flexes, and everts the toe, providing a balanced so-called plantar
rotator cuff. When these moment arms are altered, the imbalance plays an important role in deformity progression.
Suggestions of a primary muscle imbalance based on histological and electromyographic studies136,137 probably reflect changes
secondary to the deformity 9,138.
Normal variations in the attachment of the abductor
hallucis have been described, but no association with hallux
valgus has been found139. The abductor hallucis also has a
secondary role as a medial arch support and, when the tendon
becomes dysfunctional in hallux valgus7, it may be responsible
for some of the tibialis posterior dysfunction140. There is no
evidence of shortening7 or overactivity of the adductor tendon,
although botulinum toxin injection into the muscle has successfully treated hallux valgus141.
Snijders et al.38 and Sanders et al.142,143 studied the role of
flexion forces in the etiology of hallux valgus. Downward pull
of the hallux onto the ground creates a force couple with a
valgus moment on the hallux and a varus moment on the first
metatarsal head, producing medial deviation and widening of
the foot. In the normal subjects studied, the foot narrowed. In
addition, the further the flexor hallucis longus is from the first
metatarsal head, the weaker the moment arm of the flexor and
the greater all three deformities become144. The moment arm of
the flexors moves from an inferior to a lateral direction as the
great toe pronates or moves into valgus145.

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Migration of the sesamoids over the crista is important in

deformity progression146,147. When the medial sesamoid ligament is attenuated15 and the loss of the restraint provided by the
crista148 occurs, deterioration can be rapid. The twofold increase in the prevalence of bipartite tibial sesamoids in feet with
hallux valgus149 is unexplained150.
Metatarsal Kinematics

The first-ray hypermobility theory states that the plane of

motion of the first ray described by Hicks151 is exaggerated26
because of tarsometatarsal joint instability. There are no ligamentous structures binding the distal first and second metatarsals so the first tarsometatarsal joint can be affected by a
number of factors, including pes planus, a long hallux, or a
functional equinus of the foot152. The elevation causes the pressures under the first metatarsal head to reduce. However, the
pronation and varus moments cause a relative increase in the
load on the medial side of the great toe, resulting in a valgus
moment on the hallux35.
The reported increased recurrence of hallux valgus after
surgical correction when the first tarsometatarsal joint is not
fused79 is disputed153. Furthermore, it has been shown that ray
realignment alone can stabilize sagittal motion without tarsometatarsal joint fusion73,78,153-155, probably because of a realignment
of the plantar fascia improving the windlass mechanism156,157.
This raises the question of whether the corollary is correct, i.e.,
is the instability due to a reduction in soft-tissue stability resulting from the malalignment158 or is the malalignment a result of reduction in soft-tissue stability?
Hypermobility is still not well understood159, and data on
the effect of first tarsometatarsal joint fusion are lacking. Interestingly, hypermobility usually refers to sagittal plane motion, but transverse plane motion (i.e., metatarsus primus
varus) may be in fact more important160,161.
Pes Planus

Much has been written18,162 about the role of pes planus in the
etiology of hallux valgus163. The mechanism appears obvious,
i.e., pronation increases loading on the plantar medial border
of the hallux during heel rise, but there are several other
changes116.
1. Pes planus produces an elevation and thus a functional
lengthening of the first metatarsal164, which can limit first
metatarsal phalangeal joint movement.
2. The peroneus longus is less able to stabilize the first
ray 165. If this insufficiency is prolonged, hypermobility of the
first ray can result166.
3. In the planovalgus foot, hindfoot and midfoot eversion
reduce the load on the first metatarsophalangeal joint, although
weight-bearing through the medial arch increases. This change
is due to the relative mobility of the first tarsometatarsal joint
compared with the second tarsometatarsal joint and the loss of
the pull of the peroneus longus116.
4. As the hindfoot everts, the foot becomes abducted to
the line of progression, increasing the abduction force in
dorsiflexion on heel rise.

5. There is early and excessive firing of the abductor and

adductor hallucis in the pronated foot167,168. Their line of pull
alters as the sesamoids rotate, resulting in an overall valgus
moment169.
Coughlin et al.17 showed that, as the foot pronates, the
first ray also rotates on its longitudinal axis. The first metatarsophalangeal joint collaterals are somewhat loose, allowing up to
2 mm of translation in the transverse plane on dorsiflexion30,
which can result in a repetitive injury to the medial restraints.
With pronation comes axial rotation of the so-called plantar
rotator cuff30 that further exacerbates the deformity131.
Despite the commonly held belief that pes planus plays an
important role in hallux valgus, there is cogent pedobarographic
and radiographic evidence to the contrary49,73,170,171, especially in
juvenile hallux valgus43,172. Coughlin and Jones49 assessed several
different measures of pes planus in hallux valgus and found none
to be significant. A link was detected between the prevalence of
plantar gapping of the first tarsometatarsal joint and severity of
hallux valgus, but this may be effect rather than cause. No study
has looked at the prevalence of hallux valgus in pes planus. The
association is likely to be far from 100%, given the difference
between the relative prevalence of the two (i.e., a 20% rate of pes
planus173 versus a 2% to 4% rate of hallux valgus174). It is important
to note that even studies implicating pes planus found rates close
to this background rate105. Mann and Coughlin53 believed pes
planus to be only clinically relevant in patients with a background
of neuromuscular deficit.
Given the proposed mechanism by which pes planus causes
hallux valgus, correction of the hallux valgus in isolation should be
associated with a higher recurrence rate. However, this has not
been the case43,53,77,172,175, although only one study 53 looked at older
patients in whom the biomechanical abnormalities had a longer
time to produce an acquired deformity.
Eustace et al. showed that first metatarsal pronation is
associated with hallux valgus and increases as the intermetatarsal
angle increases, such that pronation and varus are intimately
related176. Furthermore, they showed that medial longitudinal
arch collapse is also associated with first metatarsal pronation176 (a medial arch of <20" is associated with a first metatarsal
pronation of >10"). They were unable to demonstrate which
comes first, but it is logical when one considers the forces
involved that arch collapse drives the pronation rather than vice
versa177.
At present, the most that can be said is that any individual
with pes planus and hallux valgus is at risk for a more rapid
progression because of the forces that encourage further
deformity17.
Functional Hallux Limitus

Structural hallux limitus is a limitation of dorsiflexion on

both weight-bearing (<12") and non-weight-bearing (<50").
It can predispose to hallux rigidus, which is not relevant to
this review. Functional hallux limitus, on the other hand,
describes limitation of motion on weight-bearing only. This
poorly understood condition was first described, as far as we
know, in 1972178, but there continues to be little information

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Fig. 5

Proposed mechanism of hallux valgus development as a consequence of functional hallux limitus. MT = metatarsal and MTP = metatarsophalangeal.

on this subject in the orthopaedic literature to either confirm

or refute it. In essence, functional hallux limitus refers to the
restriction of hallux dorsiflexion that occurs when the first ray
is dorsiflexed. It can be observed to an extent even in normal
feet and is due to the axis of rotation of the joint shifting plantarward as the first ray elevates179. Functional hallux limitus is
purported to predispose to either hallux rigidus or hallux valgus180, depending on the coexisting biomechanics of the foot.
In hallux valgus, structural hallux limitus appears to be
exaggerated and the passive range of motion at the metatarsophalangeal joint commonly reduces on weight-bearing49.
The proposed link is that certain foot types (i.e., an everted
hindfoot, a flexible forefoot valgus, or a plantar-flexed first
ray)181 increase ground reaction force under the first metatarsal
head (Fig. 5). The predisposed foot types also increase the
ground reaction force earlier and for longer in the gait cycle182.
Feet with good midtarsal movement can accommodate this
first ray elevation. As the first ray dorsiflexes, the axis of the first
metatarsophalangeal joint inverts, so the greater the elevation
the greater the inversion. As the metatarsophalangeal joint
dorsiflexion is limited at heel rise, the hallux is forced in the
direction of least resistance. So feet with a great deal of mobility
in the first ray are at risk of hallux valgus. This theory seems to
fit in well with some of the other theories of the pathogenesis
of hallux valgus, and there is evidence that a dorsiflexed first
metatarsal is important180. This biomechanical theory still is
not proven. The actual prevalence of functional hallux limitus
and subsequent hallux valgus is low.

metatarsophalangeal joint has to dorsiflex to the same extent,

activating the windlass mechanism. This tension can prevent
the hallux from dorsiflexing. When the heel is lifted off the
ground, the metatarsophalangeal joint should dorsiflex to an
equal degree, but a tight plantar fascia causes a plantar flexion
moment on the hallux. This plantar flexion moment opposes
the dorsiflexion moment of the ground reaction forces on the
hallux, causing it to veer along the path of least resistance. If the
dorsiflexion forces are transmitted by a relatively rigid first
metatarsophalangeal joint through to the first metatarsal, then
this could explain the hypermobility often seen in the first
ray156.
Tight Achilles Tendon

Windlass Model

Mann and Coughlin53 and Hansen185 postulated that a tight

Achilles tendon can predispose to hallux valgus. This is because of early and increased forefoot loading186. The natural
tendency is to externally rotate the foot, rolling over the
medial border rather than going forward through the third
rocker (i.e., toe off, which is dorsiflexion at the metatarsophalangeal joint with concentric contraction of the gastrocnemius), increasing the valgus force. The evidence comes
mainly from work done with diabetic ulcers187, but there is
evidence of an association with hallux valgus if there is <5" of
dorsiflexion at the ankle188. Clinical studies of hallux valgus
have echoed this finding, but only if Achilles tendon tightness is
defined as being <10" of ankle dorsiflexion49. Others have
found no association35,189, and there is no evidence that failure
to address Achilles tendon tightness results in a higher recurrence of hallux valgus107.

The windlass model explains these findings more simply183. An

increase in hallux valgus deformity on weight-bearing184 is due
to tightening of the plantar fascia and the pronation effect of
weight-bearing157. When this motion is excessive, the plantar
aponeurosis is further tightened 157. On heel rise, the first

Overview
Hallux valgus is a complex condition with a range of deformities varying in severity, suggesting that several factors are
responsible. Inheritance and sex are important, but other

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anatomical and biomechanical factors, such as anatomical

metatarsal variants, including a long first metatarsal
(probably most important in men190), a rounded articulation,
and metatarsus primus varus, play an important role. These
variants increase the vulnerability to first-ray hypermobility,
pes planus, and ligamentous laxity.
The toe is at risk if loading is increased on the medial
side. If the forefoot is in a narrow toe-box or pronated because
of a hypermobile first ray or pes planus, the altered muscle pull
can combine with the ground reaction forces and be sufficient
to result in repetitive injury to the medial tissues. There is a lack
of evidence of a sufficient scientific level to support or disprove
the role of pes planus, first-ray instability 11, or functional hallux
limitus, although all have some intellectual appeal and possibly
some basis in terms of treatment response.
In the normal foot, there is a tendency for the great toe to
be pulled into valgus, but the static restraints (the ligaments
and the sesamoid apparatus) act like reins, preventing this
tendency 135. The muscles attached to the base of the phalanx
help to control the metatarsal head. Once the metatarsal head
starts to escape, this control diminishes and the muscles may
become deforming forces instead191. The deep transverse ligament (and to an extent the adductor) holds the phalanx in

place, while the incompetent medial sesamoid ligament and

medial collateral ligament allow the metatarsal head to drift
into varus.
We know that poor footwear is a risk, and yet few people
who wear high-fashion ladies shoes develop hallux valgus. The
same can be said of the other potential causes. The true answer
lies in the interplay of the various intrinsic and extrinsic factors
that come together in any one particular foot. Without largescale population studies or longitudinal studies, there will always be some unanswered questions on the true pathogenesis
and optimal treatment of hallux valgus. n

A.M. Perera, FRCS(Orth)

Lyndon Mason, MRCS(Eng)
University Hospital of Wales,
Cardiff, CF14 4XB, UK.
E-mail address for A.M. Perera: footandanklesurgery@gmail.com

M.M. Stephens, FRCSI

Cappagh National Orthopaedic Hospital,
Finglas, Dublin 11, Ireland

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