Clinicians › Foot

Hallux valgus

85 citationsUpdated Sep 2026

Overview

Surgical intervention for hallux valgus must be tailored to the specific type and severity of the deformity [2]. While reported success rates range from 80% to 95% [2], long-term outcomes are often less favorable than short- and mid-term results [10]. At a mean follow-up of 5.2 years, 25.9% of patients reported dissatisfaction with their surgical outcome [10]. Successful correction in young patients relies on proper case selection, precise surgical technique, and adequate postoperative management, including patient compliance [11]. Postoperative care must be meticulously executed to ensure optimal alignment of the hallux [16].

A variety of osteotomies and soft-tissue procedures address different severities of the deformity. The chevron osteotomy is a reliable option for mild and moderate cases, with outcomes that do not differ based on patient age [6]. Both modified minimally invasive and traditional incision chevron osteotomies effectively treat mild and moderate deformities [14]. The Austin osteotomy is also a safe and effective treatment for mild and moderate hallux valgus [38]. For moderate to severe symptomatic deformities accompanied by metatarsus primus varus, proximal first metatarsal osteotomy combined with a lateral soft-tissue procedure is effective [12]. Proximal osteotomy is a good method for treating severe hallux valgus, with 86% of patients stating the operation was worthwhile after 8 years of follow-up [31]. The Hohmann and Lapidus operations are good options for correction and have similar reliable long-term results [43].

Minimally invasive and arthroscopic techniques offer effective alternatives with specific considerations. MITA provides effective correction, achieving excellent radiographic alignment and favorable clinical outcomes [3]. Fourth-generation percutaneous transverse osteotomies demonstrate significant improvement in clinical and radiographic outcomes with a low rate of recurrence [15]. Arthroscopic correction can achieve good clinical and radiologic results provided that careful preoperative clinico–radiologic assessment excludes contraindicated patients [23]. In children, percutaneous surgery yields short-term outcomes comparable to adults, though under-correction remains a concern [1]. Minimally invasive surgery in juvenile patients allows for future procedures on minimally damaged tissues if needed [17]. During minimally invasive surgery, avoiding the potentially dangerous zone of the dorsomedial cutaneous nerve is recommended [22]. Obesity was not associated with unsatisfactory outcomes after ReveL for hallux valgus [18].

Anatomy & Pathophysiology

Definition and Etiology

Hallux valgus is the commonest of the foot deformities [71], also known as a bunion deformity [56]. It is defined as lateral deviation of the great toe with medial deviation of the first metatarsal [33], or specifically, lateral deviation of the proximal phalanx on the first metatarsal head [39]. This complex deformity includes lateral deviation of the proximal phalanx and the resultant medially directed pressure exerted against the metatarsal head [56]. In unshod populations, the big toe remains in line with the first metatarsal [71]; however, in shod populations, the hallux assumes a valgus position, which is termed hallux valgus only when angulation is excessive [71]. The incidence of hallux valgus is significantly higher in shod populations than unshod ones [56] and is 10 times greater in women than in men [56]. The condition is more common in women than in men [39], most frequently seen in female patients in their fourth or fifth decades of life [46].

The etiology of hallux valgus is multifactorial [35] [33] [56] [68], influenced by both intrinsic and extrinsic factors [48]. Intrinsic factors include genetic predisposition, ligamentous laxity, and predisposing anatomy such as a convex metatarsal head or pes planus [33]. A hypermobile first tarsometatarsal joint is also an intrinsic contributor [46]. Other predisposing intrinsic conditions include rheumatoid or inflammatory arthritis, generalized ligamentous laxity, and dysmorphism of the first metatarsal [46]. Connective tissue disorders and cerebral palsy are additional causes [39]. Extrinsic factors predominantly involve mechanical constriction from narrow footwear, which poses a greater risk than high heels [35]. Certain types of shoewear, including narrow toe boxes and high heels, play a role in pathophysiology [33] [46]. Splaying of the forefoot with varus angulation of the first metatarsal predisposes to lateral angulation of the big toe in people who wear shoes [71]. Metatarsus primus varus, which may be congenital or result from loss of muscle tone in the forefoot in elderly people, and pes planus have been implicated in the etiology [39] [71].

Approximately 70% of patients with hallux valgus have a family history of the condition, suggesting a hereditary component [39]. Hallux valgus is frequently associated with medial deviation of the first metatarsal [39] and is commonly related to wearing shoes with a narrow toe box [39]. The deformity is not associated with chronic tightness of the Achilles tendon or gastrocnemius, increased first ray mobility, bilaterality, or pes planus [56]. Hallux valgus is a dynamic condition where the deformity may be more correlated with motions during weightbearing than with plain static measurements [29]. It is a multiplanar deformity where the rotational component, specifically metatarsal pronation, has been recognized over the past 5 to 10 years and given considerable importance [13]. Metatarsal pronation is associated with hallux valgus, with the underlying mechanism generally being cuneometatarsal instability [101].

Hallux valgus negatively impacts self-reported foot pain, function, concerns about foot appearance, and footwear in otherwise healthy adults [58]. Deformity severity is positively associated with the magnitude of the anteroposterior postural sway [51]. Progressive Distance Mapping suggests subgroup-dependent, progressive associations between plantar fat-pad-anchored distance geometry and hallux valgus severity [80]. In Taiwanese female collegiate students with hallux valgus, arches were normal, plantar loads were predominantly concentrated on the medial aspects of both feet, and rearfoot valgus angles were positively correlated with ipsilateral hallux valgus angles [113]. Functional reach was predicted based on the hallux valgus angle in women aged 65 years and older [115]. More demanding weight-bearing tasks, such as standing short-foot, single-leg short-foot, calf raise, and stand swing, generally elicited greater activation than seated exercises in women with hallux valgus [116]. Hallux valgus could be an integral part of the causes of stress fractures of the proximal phalanx of the great toe [28].

Pathoanatomy

The pathoanatomy of hallux valgus involves gradual failure of the medial supportive structures, specifically the medial collateral ligament and tibial sesamoid, resulting in a varus position of the first metatarsal [46]. This first metatarsal varus results in a prominent first metatarsal head medially, which constitutes the "bunion" reported by the patient [46]. This prominent medial eminence is a common source of pain related to shoe wear [46]. As the deformity progresses, valgus deviation at the metatarsophalangeal joint of the proximal phalanx develops [46]. The alignment of the flexor and extensor hallucis longus tendons shifts laterally relative to the metatarsophalangeal joint, further exacerbating the deformity [46]. Secondary pathology and deformity can develop in the lesser toes, such as hammertoes and claw toes, which may be symptomatic [46].

Medial capsular attenuation is a component of the pathoanatomy [33]. The proximal phalanx drifts laterally [33]. Plantar-lateral migration of the abductor hallucis causes the proximal phalangeal unit to plantar flex and pronate the hallux [33]. The pronation of the hallux is amplified by the proximal phalangeal attachment of the adductor hallucis [33]. Stretching of the extensor hood of the extensor hallucis longus occurs [33]. Lateral deviation of the extensor hallucis longus and flexor hallucis longus causes a muscular imbalance and deforming force for valgus progression and pronation of the great toe [33]. The first metatarsal head moves medially off the sesamoids, increasing the intermetatarsal angle [33]. Pronation leads to rounding of the lateral metatarsal head, which should have a flat contour with no rotational deformity [33]. Rounding of the lateral metatarsal head can be hard to correct with distal first metatarsal osteotomy and requires rotational osteotomy or first tarsometatarsal arthrodesis [33]. Secondary contracture of the lateral capsule, adductor hallucis, and lateral metatarsal-sesamoid and intermetatarsal ligaments occurs [33].

With chronic deformity, the medial joint capsule becomes attenuated, and the lateral joint capsule becomes contracted [56]. As the metatarsal head is pushed medially, the sesamoids slowly erode the crista [56]. Erosion of the crista allows for lateral subluxation of the sesamoids from directly plantar to the first metatarsal [56]. With the lateral deviation of the hallux, the extensor hallucis longus and flexor hallucis longus assume a lateral position and contribute to the lateral forces on the hallux [56]. With a severe deformity, both the extrinsic and intrinsic muscles lie lateral to the longitudinal axis of the first metatarsophalangeal joint, thereby further enhancing the deformity [56]. Pronation of the hallux occurs because attenuation of the weakest portion of the capsule (the dorsomedial aspect) allows the abductor hallucis tendon to slide beneath the metatarsal head and rotate the proximal phalanx into a position of pronation [56]. More rapid progression of the deformity may occur in a small percentage of patients whose first metatarsocuneiform joint demonstrates a significant degree of instability [56].

Hallux valgus is not a single disorder but a complex deformity of the first ray that frequently is accompanied by deformity and symptoms in the lesser toes [68]. The angle between the first and second metatarsals is often more than the 8 to 9 degrees usually considered to be the upper limits of normal [68]. The valgus angle of the first metatarsophalangeal joint is often more than the 15 to 20 degrees considered to be the upper limits of normal [68]. If the valgus angle of the first metatarsophalangeal joint exceeds 30 to 35 degrees, pronation of the great toe usually results [68]. With pronation of the great toe, the flexion-extension axis of the first metatarsophalangeal joint moves farther plantarward [68]. In pronated hallux valgus, the only restraining medial structure is the medial capsular ligament with its capsulosesamoid portion and capsulophalangeal portion [68]. The adductor hallucis, which is unopposed by the abductor hallucis, pulls the great toe farther into valgus, stretching the medial capsular ligament [68]. Stretching of the medial capsular ligament attenuates this structure and allows the metatarsal head to drift medially from the sesamoids [68]. The flexor hallucis brevis, flexor hallucis longus, adductor hallucis, and extensor hallucis longus increase the valgus moment at the metatarsophalangeal joint, further deforming the first ray [68].

The deep transverse intermetatarsal ligament runs between the plantar plates at the metatarsophalangeal joints and does not insert into bone on the adjacent sides of the metatarsal heads [68]. The sesamoid ridge on the plantar surface of the first metatarsal head (the crista) flattens because of pressure from the tibial sesamoid [68]. With flattening of the crista, the fibular sesamoid displaces partially or completely into the first intermetatarsal space [68]. Displacement of the fibular sesamoid results in the patient bearing less weight on the first ray and more on the lesser metatarsal heads [68]. Increased weight on lesser metatarsal heads increases the likelihood of transfer metatarsalgia, calluses, and stress fracture of a lesser metatarsal [68]. An anatomic variant where the articular surface of the metatarsal head is offset, resembling a scoop of ice cream sitting at an angle on a cone, can lead to hallux valgus [68]. This offset articular surface has been described as the distal metatarsal articular angle [68]. An anatomic variant where the articular angle of the base of the proximal phalanx in relation to its longitudinal axis is offset can lead to hallux valgus [68]. This offset phalangeal articular angle has been described as the phalangeal articular angle [68]. The normal range of the phalangeal articular angle is generally considered to be 7 to 10 degrees [68]. The normal range of the distal metatarsal articular angle is generally considered to be 10 to 15 degrees [68]. Failure to correct the distal metatarsal articular angle can cause unsatisfactory results after surgery in some patients [68]. Forceful straightening of the hallux should be avoided if it sacrifices a congruent metatarsophalangeal articulation [68]. Phalangeal osteotomy or distal metatarsal osteotomy, rather than tightening of the medial capsular repair, should be used for further correction if a congruent articulation is sacrificed [68]. The valgus posture of the great toe frequently causes a hammer toe-like deformity of the second toe [68].

The elements of the deformity are lateral deviation and rotation of the hallux, together with a prominence of the medial side of the head of the first metatarsal [71]. There may also be an overlying bursa and thickened soft tissue in hallux valgus [71]. Lateral deviation of the hallux may lead to overcrowding of the lateral toes and sometimes over-riding [71]. Hallux valgus deformity in patients with cerebral palsy usually is associated with other deformities, such as equinovalgus foot, heel valgus, and external rotation of the tibia [72]. These conditions cause the foot to pronate, forcing the first metatarsophalangeal joint into abduction and creating a hallux valgus deformity [72]. The extensor hallucis tendon may sublux into the first web space and become an abductor of the hallux, leading to further deformity in patients with cerebral palsy [72].

Hallux valgus that occurs in the preteen or teenage years often is associated with a smaller medial eminence prominence than in the adult cohort [78]. Juvenile hallux valgus is often associated with increased magnitude of the first-second intermetatarsal angle [78], increased hypermobility of the first tarsometatarsal joint [78], and less pronation than in the adult cohort [78]. Juvenile hallux valgus has a higher recurrence rate with surgical intervention than in the adult cohort [78]. Juveniles are more likely to have bilateral deformities and a family history of hallux valgus [78]. Patients with juvenile hallux valgus may have difficulty with shoe wear, plantar callosities, and transfer metatarsalgia [78]. Typically, the angular deformity associated with hallux valgus is less severe in children than it is in adults [75]. Large medial prominences are rare in juvenile hallux valgus [75]. A congruent joint with an increased distal metatarsal articular angle is more common in juvenile hallux valgus than in the adult condition [75]. Juvenile hallux valgus is sometimes associated with other deformities, such as metatarsus adductus [75]. Generalized ligamentous laxity may be more common in children with hallux valgus than in the general population [75].

Varus of the first metatarsal with a large intermetatarsal angle is commonly present in juvenile and adolescent hallux valgus [76]. The distal metatarsal articular angle is typically increased in juvenile and adolescent hallux valgus [76]. Hallux valgus interphalangeus may be present in juvenile and adolescent hallux valgus [76]. Ligamentous laxity may be present in juvenile and adolescent hallux valgus, and a history of Ehlers–Danlos or Marfan syndrome should be elicited [76]. Family history is frequently positive for hallux valgus in juvenile and adolescent patients [76]. Hallux valgus interphalangeus is more common in juvenile-onset hallux valgus than in adult-onset hallux valgus [9]. The significant correlation between hallux valgus interphalangeus and forefoot abduction-related parameters in juveniles highlights the need for a comprehensive assessment and treatment of combined deformities in managing juvenile-onset hallux valgus [9]. Adolescent bunion is frequently hereditary and usually seen in early adolescence [42]. Adolescent bunion is almost always found in conjunction with a wide forefoot caused by varus of the first metatarsal shaft [42]. The wide forefoot allows severe lateral deviation of the great toe, causing the prominent base of the great toe to rub against the inside of the shoe and create a painful bunion [42]. The metatarsal articular surface may have a valgus orientation, as measured by the distal metatarsal articular angle [39]. This metatarsal dysmorphism may be present more often in patients with juvenile onset of hallux valgus and in males [46].

Classification

Hallux valgus is a multifactorial condition primarily associated with female sex, aging, and mechanical constriction from narrow footwear [35]. A decision tree model predicted the presence of hallux valgus on the basis of sex, age, and normalized arch height [97]. The deformity is multiplanar, with the rotational component, specifically metatarsal pronation, recognized over the past 5 to 10 years [13].

Other Considerations: There was a significant discrepancy between radiographically-assessed and self-recognized hallux valgus which narrowed with the progressing severity of hallux valgus [25]. The validity and reliability of the Manchester scale for self-assessment of hallux valgus was determined using weighted kappa statistics to assess agreement between examiners and participants [63]. The AOFAS-Hallux-MTP-IP scale can be recommended for the comprehensive assessment of the clinical conditions of patients with hallux valgus deformity in Mainland China [21]. Digital photographs provide a convenient and precise tool in the assessment of hallux valgus while avoiding the cost and radiation exposure associated with radiographs [26].

Clinically, congruency of the metatarsophalangeal joint should be considered when choosing surgical methods for different degrees of hallux valgus, and the MTPJA and CI can be used as quantitative evaluation indicators [92]. In a cohort of women with hallux valgus, 44.3% had an extension greater than 30 degrees in the relaxed position [128]. No significant association was found between hallux hyperextension and any stage of hallux valgus according to multinomial logistic regression models [128].

In a study of diabetic patients, a hallux valgus angle of 15 degrees, an intermetatarsal angle of 9 degrees, a distal metatarsal articular angle of ≥10 degrees, and a hallux valgus interphalangeus of ≥8 degrees were considered pathognomonic for hallux valgus [45].

Clinical Presentation

Definition and Etiology

Hallux valgus is defined as lateral deviation of the proximal phalanx on the first metatarsal head, frequently associated with medial deviation of the first metatarsal [39]. This condition represents a multiplanar deformity where the rotational component, specifically metatarsal pronation, has been recognized over the past 5 to 10 years and given considerable importance [13]. Intrinsic factors such as genetic predisposition, ligamentous laxity, and predisposing anatomy (convex metatarsal head, pes planus) are contributory to hallux valgus [33]. Conversely, hallux valgus is not associated with chronic tightness of the Achilles tendon or gastrocnemius, increased first ray mobility, bilaterality, or pes planus [56]. Eligibility for knee arthroplasty is associated with an increased risk of acquired hallux valgus [19].

Pathoanatomy

The pathoanatomy of hallux valgus involves medial capsular attenuation [33]. In hallux valgus, the proximal phalanx drifts laterally, leading to plantar-lateral migration of the abductor hallucis [33]. The change in position of the abductor hallucis causes the proximal phalangeal unit to plantar flex and pronate the hallux [33]. In hallux valgus, the extensor hood of the extensor hallucis longus is stretched [33]. In hallux valgus, the first metatarsal head moves medially off the sesamoids, increasing the intermetatarsal angle [33]. Pronation of the first metatarsal leads to rounding of the lateral head, which should have a flat contour with no rotational deformity [33]. Secondary contracture occurs in the lateral capsule, adductor hallucis, and lateral metatarsal-sesamoid and intermetatarsal ligaments in hallux valgus [33]. As hallux valgus deformity progresses, the alignment of the flexor and extensor hallucis longus tendons shifts laterally relative to the metatarsophalangeal joint, further exacerbating the deformity [46]. With chronic hallux valgus deformity, the medial joint capsule becomes attenuated, and the lateral joint capsule becomes contracted [56]. As the metatarsal head is pushed medially in hallux valgus, the sesamoids slowly erode the crista, allowing for lateral subluxation of the sesamoids from directly plantar to the first metatarsal [56]. With a severe hallux valgus deformity, both the extrinsic and intrinsic muscles lie lateral to the longitudinal axis of the first metatarsophalangeal joint, thereby further enhancing the deformity [56]. As hallux valgus deformity progresses, pronation of the hallux occurs because attenuation of the weakest portion of the capsule (the dorsomedial aspect) allows the abductor hallucis tendon to slide beneath the metatarsal head and rotate the proximal phalanx into a position of pronation [56]. More rapid progression of hallux valgus deformity may occur in a small percentage of patients whose first metatarsocuneiform joint demonstrates a significant degree of instability [56]. Childhood hallux valgus is mainly due to distal M1 joint surface orientation abnormality, unlike in adults where increased M1M2 angle is the main deformity [66].

Symptoms and Signs

The most common symptom of hallux valgus is pain over the medial eminence [56]. Patients with hallux valgus also complain of pain in the joint and pain under the second metatarsal head (transfer lesion or metatarsalgia) [56]. The hallux valgus deformity may prevent shoewear, and the activity limitation may be part of the constellation of symptoms [56]. The patient’s occupation, sports activities, and typical shoewear should be noted during evaluation for hallux valgus [56]. Preoperative patient-reported depression and anxiety may affect short-term surgical outcomes in women with hallux valgus [47]. This study is the first to demonstrate a relationship between hallux valgus and patellofemoral pain syndrome, revealing a significant difference in hallux valgus angles between the affected and asymptomatic limbs [65].

Clinical Examination

A complete evaluation for hallux valgus is performed on both lower extremities with the patient undressed from the knees to the toes [56]. The patient is instructed to stand and walk during the evaluation for hallux valgus [56]. The posture of the foot is noted as well as the position of the hallux and lesser toes during evaluation for hallux valgus [56]. The skin is evaluated for erythema, swelling, ulceration, or callosities during evaluation for hallux valgus [56]. The neurovascular status of the foot is carefully assessed, noting absent pulses and venous stasis changes during evaluation for hallux valgus [56]. If there is compromise of the vascularity, vascular studies may be obtained during evaluation for hallux valgus [56]. Doppler studies are obtained if there is any question regarding the circulatory status of the foot during evaluation for hallux valgus [56]. The severity of the hallux valgus deformity and any associated pes planus can be best assessed while the patient is standing [46]. While seated, the first metatarsophalangeal joint area is evaluated for signs of local irritation and bursal hypertrophy secondary to shoe wear during evaluation for hallux valgus [46]. Tenderness over the medial eminence is evaluated during the clinical examination for hallux valgus [46]. Numbness can occur in the dorsal medial cutaneous nerve distribution because of external pressure from a shoe during evaluation for hallux valgus [46].

Range of Motion and Stability

The range of motion is checked for the ankle, subtalar, transverse tarsal, and metatarsophalangeal joints during evaluation for hallux valgus [56]. It is important to note the range of motion of the first metatarsophalangeal joint in the deformed and corrected position during evaluation for hallux valgus [56]. The amount of motion limitation will give the surgeon insight into the degree of surgical correction that can be obtained at the joint without impairing motion of the joint [56]. Range of motion of the first metatarsophalangeal joint is evaluated during the clinical examination for hallux valgus [46]. Any pain with motion may suggest arthritis within the joint during evaluation for hallux valgus [46]. The first metatarsocuneiform joint is examined for hypermobility by stabilizing the medial cuneiform and ranging the first metatarsal dorsomedially and plantolaterally during evaluation for hallux valgus [56]. The first tarsometatarsal joint is evaluated for hypermobility, which remains a diagnostic challenge with poor reproducibility during evaluation for hallux valgus [46].

Imaging and Radiographic Assessment

Diagnostic confirmation of hallux valgus is made with the use of standard AP and lateral weight-bearing radiographs, as non–weight-bearing radiographs tend to underestimate the deformity [46]. Weight-bearing radiographs of the foot are important to evaluate the type and severity of the hallux valgus deformity [56]. Radiographs should be assessed for presence of arthritis at the first metatarsophalangeal joint, severity of the deformity as determined by the intermetatarsal angle between the first and second metatarsals (IMA), sesamoid subluxation, and the hallux valgus angle (HVA) [46]. Radiographs are also assessed for first tarsometatarsal hypermobility and congruency of the metatarsophalangeal joint, which is assessed by measuring the distal metatarsal articular angle (DMAA) of the first metatarsal head [46]. Arthrosis of the metatarsophalangeal joint is characterized by joint space narrowing, subchondral sclerosis, and osteophyte formation [56]. The characteristics of the medial eminence are evaluated, especially size, as measured from the sagittal groove [56]. Multiple measurements can be obtained from standard radiographs that guide treatment options for hallux valgus [33].

Hallux valgus angle: The hallux valgus angle is the angle created by the intersection of the lines that longitudinally bisect the proximal phalanx and first metatarsal [56]. The hallux valgus angle is the angle formed by line along first metatarsal shaft and line along shaft of proximal phalanx [33]. The hallux valgus angle identifies the degree of deformity at the metatarsophalangeal joint [39]. A normal hallux valgus angle is less than 15 degrees [56]. Normal hallux valgus angle is less than 15 degrees [33].

First–second intermetatarsal angle: The 1,2 intermetatarsal angle is the angle created by the intersection of the lines bisecting the first and second metatarsal shafts [56]. The first–second intermetatarsal angle is the angle formed by lines along first and second metatarsal shafts [33]. A normal 1,2 intermetatarsal angle is less than 9 degrees [56]. Normal first–second intermetatarsal angle is less than 9 degrees [33]. The intermetatarsal angle is not influenced by overresection of medial eminence and is not accurate for postoperative evaluation of distal osteotomies [39].

Distal metatarsal articular angle: The distal metatarsal articular angle is the angle of the distal articular surface of the first metatarsal to the long axis of the metatarsal [56]. The distal metatarsal articular angle is the angle formed by line along articular surface of first metatarsal and line perpendicular to axis of first metatarsal [33]. A normal distal metatarsal articular angle is less than 10 degrees of lateral deviation [56]. Normal distal metatarsal articular angle is less than 10 degrees [33]. Increased distal metatarsal articular angle is associated with a congruent deformity [33]. The distal metatarsal articular angle offset is a predisposing factor in development of hallux valgus [39].

Hallux valgus interphalangeus angle: The hallux valgus interphalangeus angle is the angle formed by lines along shafts of the proximal phalanx and distal phalanx [33]. Normal hallux valgus interphalangeus angle is less than 10 degrees [33]. Hallux valgus interphalangeus angle is associated with a congruent deformity [33].

Joint Congruency and Other Angles: A congruent first metatarsophalangeal joint has no lateral subluxation of the proximal phalanx in relation to the first metatarsal head [56]. An incongruent first metatarsophalangeal joint has lateral subluxation of the proximal phalanx on the metatarsal head [56]. The first metatarsocuneiform joint angle is based on the distal articular surface of the medial cuneiform and the longitudinal axis of the first metatarsal [56]. Excessive medial deviation of the first metatarsocuneiform joint may indicate that hypermobility may be present [56]. The proximal phalangeal articular angle offset is a predisposing factor in development of hallux valgus [39]. This method provides a convenient and precise tool in assessment of hallux valgus, while avoiding the cost and radiation exposure associated with radiographs [26]. It can be recommended for the comprehensive assessment of the clinical conditions of patients with hallux valgus deformity in Mainland China [21].

Investigations

Plain radiography: Standard anteroposterior and lateral weight-bearing radiographs are the primary diagnostic tools for confirming hallux valgus [46]. Non-weight-bearing radiographs tend to underestimate the severity of the deformity [46]. Radiographic assessment must evaluate the first metatarsophalangeal joint for arthritis, sesamoid subluxation, and first tarsometatarsal hypermobility [46]. Congruency of the metatarsophalangeal joint is determined by measuring the distal metatarsal articular angle of the first metatarsal head [46]. Metatarsal dysmorphism, as measured by this angle, may be more prevalent in patients with juvenile onset of hallux valgus and in males [46]. In cases of hallux rigidus, weight-bearing radiographs demonstrate arthritic changes including loss of joint space, subchondral sclerosis, and osteophytes [44].

Radiographic Angles and Measurements: The hallux valgus angle (HVA) is defined as the angle formed by the intersection of lines along the longitudinal axes of the first metatarsal shaft and the proximal phalanx shaft [33]. The first–second intermetatarsal angle (IMA) is defined by lines along the shafts of the first and second metatarsals, with a normal value less than 9 degrees [33]. The hallux valgus interphalangeus (HVI) angle is formed by lines along the shafts of the proximal and distal phalanges, with a normal value less than 10 degrees [33]. The distal metatarsal articular angle (DMAA) is the angle between a line along the articular surface of the first metatarsal and a line perpendicular to its axis; a normal DMAA is less than 10 degrees, and an increased angle is associated with a congruent deformity [33]. The proximal phalangeal articular angle (PPAA) is the articular angle of the base of the proximal phalanx relative to its longitudinal axis, with a normal value less than or equal to 10 degrees [39]. Offsets in both the DMAA and PPAA are predisposing factors for the development of hallux valgus [39].

Prognostic and Measurement Limitations: The preoperative hallux valgus angle is the main radiological predictor for correction outcomes [107]. Correction rates decline in patients with a preoperative HVA exceeding 37 degrees due to subluxation of the metatarsophalangeal joint [107]. The intermetatarsal angle is not influenced by overresection of the medial eminence and is not accurate for postoperative evaluation of distal osteotomies [39]. Hallux valgus angles based on margo medialis pedis measurements are slightly but statistically significantly smaller than metatarsophalangeal angles and should be considered conservative estimates [82]. There is a significant discrepancy between radiographically-assessed and self-recognized hallux valgus, which narrows as deformity severity progresses [25].

CT: Weightbearing CT scan assessment of foot alignment is used in patients with hallux rigidus [20].

Ultrasonography: Ultrasonography can evaluate first ray hypermobility in both symptomatic and asymptomatic hallux valgus patients [114]. Foot width and hallux valgus angle are associated with first ray hypermobility [114]. Increases in the hallux valgus angle and the first–second intermetatarsal angle are associated with symptoms among these patients [114].

Digital Photography: Digital photographs provide a convenient and precise tool for assessing the hallux valgus angle, avoiding the cost and radiation exposure associated with radiographs [26].

Other Considerations: Hallux valgus is a dynamic condition where deformity may correlate more with motions during weightbearing than with plain static measurements [29]. The American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal scale (AOFAS-Hallux-MTP-IP) is recommended for comprehensive clinical assessment in Mainland China [21]. Hallux valgus deformity and its severity are positively associated with the magnitude of anteroposterior postural sway [51]. A relationship exists between hallux valgus and patellofemoral pain syndrome, with significant differences in hallux valgus angles between affected and asymptomatic limbs [65]. In hallux valgus feet with postoperative metatarsalgia, the load function of the first metatarsal is obviously impaired, while central rays show indicative differences in instant load distribution rather than peak or cumulative load [124]. The dorsomedial cutaneous nerve has a potentially dangerous zone during minimally invasive surgery for hallux valgus, and avoiding this zone is recommended [22]. Augmented reality guided osteotomies can potentially improve accuracy during correction, particularly for less experienced surgeons [127].

Treatment

Non-Operative

Non-operative treatment cannot correct the hallux valgus deformity but can help control symptoms [96]. In children and adolescents, conservative management is usually adequate to relieve symptoms, though it does not correct the underlying deformity [103]. For juvenile hallux valgus, nonsurgical management should be considered first in all patients, especially those with ligamentous laxity or neuromuscular disorders, due to the higher recurrence rate associated with surgical intervention [78]. Shoe modifications, toe spacers, and night splints may be used for symptomatic management until physeal closure, although they are unlikely to correct the deformity [78]. For iatrogenic hallux varus, non-operative management is limited to accommodating the deformity with shoe modifications and shoe stretching [76].

Operative

Indications: Surgical treatment for hallux valgus must be adapted to the type and severity of the deformity, with success rates ranging from 80% to 95% [2]. Reducibility of the deformity must be taken into account when planning surgical treatment [40]. Obesity was not associated with unsatisfactory outcomes after ReveL for hallux valgus, challenging previous recommendations for preoperative weight loss [18].

Surgical Approach / Technique: Distal Metatarsal Osteotomies: The chevron osteotomy is a reliable procedure for correcting mild and moderate hallux valgus deformity, with outcomes that do not differ based on age [6]. Both modified minimally invasive and traditional incision chevron osteotomies effectively treat mild and moderate deformities with significantly improved clinical efficacy and imaging results [14]. The chevron-Akin double osteotomy is a safe and practicable procedure for mild-to-moderate hallux valgus [89]. Percutaneous distal metatarsal osteotomy is an effective and reliable method for correcting mild-to-moderate deformity [67]. The minimally invasive distal linear osteotomy achieves good clinical and radiographic outcomes comparable to open techniques in mild to severe deformity, with decreased recovery and rehabilitation times [69]. Distal linear metatarsal osteotomy (DLMO) is an acceptable procedure to correct reducible hallux valgus in most patients with moderate severity [55]. The SERI technique is effective in treating mild to moderate hallux valgus for symptom relief and functional improvement [64]. Distal metatarsal osteotomy is popular due to its simplicity, low invasiveness, lower complication rate, and shorter rehabilitation period [41]. It has mostly been used for mild to moderate hallux valgus because it can only correct lesser degrees of deformity [41]. Recent studies show that indications for distal chevron osteotomy with a distal soft-tissue procedure could be extended to include moderate to severe deformity [41]. Distal chevron osteotomy can achieve a greater degree of correction by the addition of a distal soft-tissue procedure [41]. The Akin closing wedge osteotomy of the proximal phalanx is indicated for hallux valgus interphalangeus and congruent deformity, and is performed when the proximal phalangeal articular angle is >10° [39]. The Akin closing wedge osteotomy has minimal ability to correct hallux valgus [39]. Distal soft-tissue release is indicated for incongruent deformity with an intermetatarsal angle < 11° and a hallux valgus angle < 35° [39]. In distal soft-tissue release, fibular sesamoid excision should be avoided to decrease the risk of hallux varus [39]. Distal soft-tissue release is rarely done as an isolated procedure and is combined with proximal procedures for larger deformities [39]. The distal metatarsal osteotomy (chevron) is indicated for congruent or incongruent deformity with an intermetatarsal angle < 13° and a hallux valgus angle < 30° [39]. For the distal metatarsal osteotomy (chevron), a biplanar (closing wedge) technique is used for a distal metatarsal articular angle > 15° [39]. In the distal metatarsal osteotomy (chevron), an extensive lateral capsular release should be avoided to minimize the risk of osteonecrosis [39]. The medial eminence resection (Silver procedure) is rarely indicated and reserved for elderly patients with minimal functional demands [39]. The medial eminence incision places the dorsomedial cutaneous nerve, a branch of the superficial peroneal nerve, at risk [39].

Proximal Metatarsal Osteotomies: Proximal osteotomy is a good method for treating severe hallux valgus deformity, with 86% of patients stating the operation was worthwhile after 8 years of follow-up [31]. The proximal metatarsal osteotomy is indicated when combined with a distal soft-tissue release for a hallux valgus angle > 25° and an intermetatarsal angle > 13° [39]. Multiple methods such as crescentic, proximal chevron, and oblique osteotomies can be used for proximal metatarsal osteotomy [39]. Overcorrection of the intermetatarsal angle during proximal metatarsal osteotomy can lead to hallux varus [39]. Dorsiflexion at the proximal metatarsal osteotomy site can result in transfer metatarsalgia [39]. Proximal metatarsal osteotomy is recommended for moderate to severe hallux valgus, but it is a technically more demanding procedure than distal metatarsal osteotomy with a longer incision, longer operation time, and higher rate of complications [41]. The combined proximal opening wedge and distal chevron osteotomy is a reliable technique for the correction of moderate to severe hallux valgus, providing strong angular correction with satisfactory clinical outcomes [90].

Arthrodesis and Resection Procedures: The metatarsal cuneiform fusion (Lapidus procedure) is indicated when combined with a distal soft-tissue release for hypermobility of the first ray [39]. A 10%-15% nonunion rate is noted for the Lapidus procedure, however many are asymptomatic [39]. In the Lapidus procedure, shortening and dorsiflexion at fusion must be avoided, which can result in metatarsalgia [39]. The Keller arthroplasty (resection of the base of the proximal phalanx) is indicated for elderly, low-demand patients with mild deformity and/or arthritic changes in the joint [39]. The Keller arthroplasty can lead to a cock-up toe deformity [39]. Transfer metatarsalgia can also be seen after Keller arthroplasty [39]. Metatarsophalangeal fusion is indicated for severe deformities (hallux valgus angle > 40°), arthritic changes in the joint, inflammatory conditions such as rheumatoid arthritis, and neurologic conditions such as cerebral palsy [39]. In metatarsophalangeal fusion, the joint should be fused in 10°-15° of valgus and 10°-15° of dorsiflexion relative to the first metatarsal [39]. First metatarsophalangeal joint fusion has been shown to provide the best overall outcome with functional gains and anatomic correction of the deformity being maintained in patients with cerebral palsy [72]. Isolated soft-tissue procedures for hallux valgus in patients with cerebral palsy rarely are successful and have a high recurrence rate [72]. Any other underlying deformities, such as heel valgus or external rotation of the tibia, should be corrected before surgical correction of the hallux valgus in patients with cerebral palsy [72]. If causative deformities are not corrected in patients with cerebral palsy, recurrence is almost certain, especially if fusion of the first metatarsophalangeal joint is not done [72].

Minimally Invasive and Percutaneous Techniques: Percutaneous hallux valgus surgery in children yields short-term clinical and radiographic outcomes that are comparable to those reported in adults, though under-correction remains a concern [1]. Third- and fourth-generation minimally invasive surgical techniques have proven effective in correcting radiographic parameters and improving pain and functional scores in patients undergoing revision for recurrent hallux valgus, with a low rate of complications [7]. The largest consecutive series of any percutaneous osteotomy technique used to correct hallux valgus deformity demonstrated significant improvement in clinical and radiographic outcomes with a low rate of recurrence [15]. The third-generation MICA provided significant improvement in clinical outcome measures at the 2-year follow-up and can be successfully used for correction of a range of hallux valgus deformities with a low rate of symptomatic recurrence [50]. The modified endoscopic distal soft tissue procedure with medial metatarsosesamoid ligament and intermetatarsal ligament augmentation is indicated for symptomatic hallux valgus recalcitrant to conservative treatment but is contraindicated in cases with bony deformity or where the intermetatarsal space cannot be closed manually [24].

Revision: Indications for soft-tissue repair for recurrent hallux valgus include a first-second intermetatarsal angle of ≤13 degrees, a hallux valgus angle of ≤30 degrees, a normal distal metatarsal articular angle (<10-15 degrees), minimal degenerative changes at the first metatarsophalangeal joint, 50 to 60 degrees of passive motion of the first metatarsophalangeal joint, subluxation but not complete dislocation of sesamoid bones, ability to displace the first metatarsal laterally at the metatarsocuneiform joint from its abnormal varus inclination, and some degree of longitudinal arch present when weight bearing [37]. If the arch is improved with passive dorsiflexion of the hallux while standing, the deformity is not fixed (structural pes planus) and a soft-tissue repair is likely to endure [37]. Hallux varus is a complication of hallux valgus surgery that was not widely recognized until McBride in 1935 reported its occurrence in 5% of patients treated with his procedure [52]. Incidences of hallux varus after almost all operations for hallux valgus range from 2% to 17% [52]. The main causes for hallux varus after hallux valgus surgery include complete release of the lateral structures of the metatarsophalangeal joint combined with excessive plication of the medial capsule, excessive resection of the medial eminence, excision of the fibular sesamoid, release of the lateral head of the flexor hallucis brevis at its insertion into the fibular sesamoid, and closure of the intermetatarsal angle to neutral or a negative value [52]. Hallux varus can be classified into two types: static (supple) and dynamic (fixed) [52]. Static hallux varus is asymptomatic and mainly a cosmetic complication, with all deformity occurring at the metatarsophalangeal joint in the transverse or frontal plane [52]. Dynamic hallux varus deformity is a multiplanar deformity that often is fixed, symptomatic, and difficult to correct surgically [52]. In dynamic hallux varus, the first metatarsophalangeal joint is hyperextended and the interphalangeal joint is acutely flexed [52]. Flexible iatrogenic hallux varus deformity can be corrected with a soft tissue procedure involving release of the abductor hallucis muscle and fascia and transfer of a portion of the extensor hallucis longus or extensor hallucis brevis tendon under the transverse intermetatarsal ligament to the distal metatarsal neck [76]. Suture button augmentation is commonly used with a tendon reconstruction for flexible hallux varus but should not be utilized in isolation [76]. Fixed iatrogenic hallux varus deformity, deformity with limited first metatarsophalangeal joint motion, joint pain, or presence of first metatarsophalangeal joint degenerative joint disease is treated with a first metatarsophalangeal joint arthrodesis [76].

Other Considerations: Pediatric and Adolescent Considerations: Although bunion is rare in children, this troublesome deformity often requires treatment and is frequently hereditary, usually seen in early adolescence, and almost always found in conjunction with a wide forefoot caused by varus of the first metatarsal shaft [42]. Surgery for adolescent bunions must address each aspect of the deformity by trimming the bunion, correcting the varus angulation of the first metatarsal by osteotomy, and centralizing and balancing the hallux valgus by lengthening the adductor hallucis muscle [42]. There is a fairly high incidence of recurrence of the deformity following surgery for adolescent bunions [42]. Juvenile hallux valgus occurs more commonly in girls than in boys [75]. The angular deformity associated with hallux valgus is typically less severe in children than it is in adults [75]. Open physes at the base of the proximal phalanx or first metatarsal may preclude the use of osteotomies or fusion in those areas to avoid growth arrest [75]. In the presence of open physes, an increased intermetatarsal angle is corrected with a medial opening wedge cuneiform osteotomy rather than a proximal metatarsal osteotomy or fusion [75]. Increased distal metatarsal articular angle in juvenile hallux valgus can be addressed with a distal biplanar chevron first metatarsal osteotomy [75]. Recurrence rates of up to 50% have been noted with surgical treatment of juvenile hallux valgus [75]. Proximal osteotomy is performed through the medial cuneiform in the patient with an open first metatarsal physis [76]. If arthrodesis of the first tarsometatarsal joint is required for laxity in juvenile hallux valgus, surgical intervention is delayed until physeal closure [76]. In cases of ligamentous laxity in juvenile hallux valgus, a first tarsometatarsal joint arthrodesis substitutes for a proximal osteotomy to correct the intermetatarsal angle [76]. Hallux valgus that occurs in the preteen or teenage years is often associated with a smaller medial eminence prominence, increased magnitude of the first-second intermetatarsal angle, increased hypermobility of the first tarsometatarsal joint, less pronation, and a higher recurrence rate with surgical intervention than in the adult cohort [78]. Arthrodesis of the metatarsophalangeal joint is appropriate in patients with ligamentous laxity (Ehlers-Danlos syndrome), cerebral palsy, Down syndrome, and rheumatoid arthritis [78].

Assessment and Imaging: The hallux valgus angle

Complications

Iatrogenic Deformity and Recurrence

Iatrogenic Hallux Varus: This deformity is usually acquired in adults as a complication of hallux valgus surgery [32]. Causes include overcorrection from bunion surgeries such as the McBride procedure, trauma, and systemic arthritis [32]. Successful treatment requires careful clinical and radiological work-up to identify the specific causes; each cause must then be corrected to achieve stable results over time [4].

Recurrence: Recurrence of hallux valgus can be predicted from immediate postoperative non-weight-bearing radiographs [59]. An endoscopic soft tissue procedure is indicated for symptomatic recurrence in high-risk patients to preserve the limb without extensive trauma [74]. The arthroscopic/percutaneous group showed a trend towards less correction of the Hallux valgus angle compared to the open group, potentially due to the initial experience with the technique [57].

Long-Term Outcomes and Dissatisfaction

Dissatisfaction: When using a validated outcome score for the assessment of outcome after surgery for hallux valgus, long-term results are worse than expected when compared with short- and mid-term outcomes, with 25.9% of patients dissatisfied at a mean follow-up of 5.2 years [10]. Late complications such as residual deformity and metatarsalgia are the primary causes of unsatisfactory outcomes [73].

Other Considerations

Adjacent Toe Complications: Ulcer occurrence on adjacent toes and hallux valgus deformity can develop after amputation of the second toe in diabetic patients [45].

Recovery

Light activity (weeks): The provided evidence does not specify a typical week range for desk work, driving, or light activities of daily living.

Full activity (months): The provided evidence does not specify a month range for manual work, sport, or full range-of-motion and strength return.

Complete recovery / outcome plateau (months): The provided evidence does not specify a month range for the stabilization of pain, strength, or final functional outcomes.

Rehabilitation protocol: Minimally invasive distal linear osteotomy is associated with decreased recovery and rehabilitation times compared to open surgical techniques [69].

Functional milestones: Third-generation minimally invasive chevron and Akin osteotomies (MICA) provide significant improvement in clinical outcome measures at the 2-year follow-up [50]. The syndesmosis procedure for hallux valgus yields good clinical and radiological results two years post-operatively [5]. Clinical and radiographic outcomes of male and female feet undergoing MITA are comparable at 1 year [79]. There is no statistically significant difference in clinical outcomes (AOFAS scores) between proximal and distal metatarsal osteotomies for moderate to severe hallux valgus deformity in the short and medium term [105]. There is no statistically significant difference in radiological outcomes (IMA, HVA) between proximal and distal metatarsal osteotomies for moderate to severe hallux valgus deformity in the short and medium term [105].

Other Considerations: Percutaneous hallux valgus surgery in children yields short-term clinical and radiographic outcomes comparable to those reported in adults [1]. Under-correction remains a concern following percutaneous hallux valgus surgery in children [1]. Minimally invasive distal transverse metatarsal osteotomy–Akin osteotomy (MITA) achieves excellent radiographic alignment and favorable clinical outcomes [3]. Appropriate treatment for iatrogenic hallux varus requires careful clinical and radiological work-up to identify the causes [4]. Each cause of iatrogenic hallux varus must be corrected to achieve stable results over time [4]. The short-term results of the syndesmosis procedure for the treatment of hallux valgus are satisfactory [5]. Outcome after chevron osteotomy for mild and moderate hallux valgus did not differ on the basis of age [6]. Third- and fourth-generation minimally invasive surgical techniques are effective in correcting radiographic parameters in patients undergoing revision for recurrent hallux valgus [7]. Third- and fourth-generation minimally invasive surgical techniques improve pain and functional scores in patients undergoing revision for recurrent hallux valgus [7]. Third- and fourth-generation minimally invasive surgical techniques for recurrent hallux valgus have a low rate of complications [7]. Successful treatment of recurrent hallux valgus requires understanding the underlying reason for the failure of initial treatment [8]. Successful treatment of recurrent hallux valgus requires correcting bony alignment, restoring joint congruity, and balancing soft tissues [8]. The correlation between hallux valgus interphalangeus and forefoot abduction-related parameters in juveniles highlights the need for a comprehensive assessment and treatment of combined deformities [9]. Metatarsal pronation in hallux valgus deformity has been given considerable importance over the past 5 to 10 years [13]. Modified minimally invasive chevron osteotomy effectively treats mild and moderate hallux valgus deformity with significantly improved clinical efficacy and imaging results [14]. Traditional incision chevron osteotomy effectively treats mild and moderate hallux valgus deformity with significantly improved clinical efficacy and imaging results [14]. Fourth-generation percutaneous transverse osteotomies for hallux valgus demonstrate significant improvement in clinical and radiographic outcomes [15]. Fourth-generation percutaneous transverse osteotomies for hallux valgus have a low rate of recurrence [15]. Obesity was not associated with unsatisfactory outcomes after reversed L-shaped osteotomy for hallux valgus [18]. The association between obesity and unsatisfactory outcomes after reversed L-shaped osteotomy challenges previous recommendations for preoperative weight loss [18]. Patients eligible for knee replacement have an increased risk of acquired hallux valgus [19]. There was a significant discrepancy between radiographically-assessed and self-recognized hallux valgus [25]. The discrepancy between radiographically-assessed and self-recognized hallux valgus narrowed with the progressing severity of hallux valgus [25]. Hallux valgus is a dynamic condition [29]. Hallux valgus deformity could be more correlated with motions during weightbearing than with plain static measurements [29]. Third-generation MICA can be successfully used for correction of a range of hallux valgus deformities [50]. Third-generation MICA has a low rate of symptomatic recurrence [50]. The arthroscopic/percutaneous group showed a trend towards less correction of the Hallux valgus angle compared to the open group [57]. The trend towards less correction in the arthroscopic/percutaneous group may be due to the initial experience with the technique [57]. Hallux valgus negatively impacts self-reported foot pain in otherwise healthy adults [58]. Hallux valgus negatively impacts function in otherwise healthy adults [58]. Hallux valgus negatively impacts concerns about foot appearance in otherwise healthy adults [58]. Hallux valgus negatively impacts footwear in otherwise healthy adults [58]. Minimally invasive distal linear osteotomy allows to achieve good clinical and radiographic outcomes comparable to those obtained with open surgical techniques in the management of mild to severe hallux valgus deformity [69]. Late complications such as residual deformity and metatarsalgia are the primary causes of unsatisfactory outcomes after distal first metatarsal displacement osteotomy [73]. Male feet undergoing MITA present with worse baseline functional impairment [79]. Male feet undergoing MITA show greater early functional recovery [79].

Key Evidence

• [L3] Percutaneous hallux valgus surgery in children yields short-term clinical and radiographic outcomes that are comparable to those reported in adults, though under-correction remains a concern. [1] (10.1016/j.otsr.2013.02.003)
• [L5] Surgical treatment for hallux valgus must be adapted to the type and severity of the deformity, with success rates ranging from 80% to 95%. [2] (10.1302/2058-5241.1.000015)
• [L4] MITA provides effective correction of hallux valgus, achieving excellent radiographic alignment and favorable clinical outcomes. [3] (10.1186/s13018-025-06361-3)
• [L5] Appropriate treatment for iatrogenic hallux varus requires careful clinical and radiological work-up to identify the causes, and each cause must then be corrected to achieve stable results over time. [4] (10.1016/j.otsr.2019.05.018)
• [L4] The short-term results of this surgical procedure for the treatment of hallux valgus are satisfactory, with good clinical and radiological results two years post-operatively. [5] (10.1302/0301-620x.96b4.32193)
• [L3] At these two follow-up periods, the chevron osteotomy was found to be a reliable procedure for the correction of mild and moderate hallux valgus deformity, and outcome did not differ on the basis of age. [6] (10.2106/00004623-200010000-00002)
• [L4] Third- and fourth-generation minimally invasive surgical techniques have proven effective in correcting radiographic parameters and improving pain and functional scores in patients undergoing revision for recurrent hallux valgus, with a low rate of complications. [7] (10.1186/s12891-026-09946-z)
• [L4] Successful treatment of recurrent hallux valgus requires understanding the underlying reason for the failure of initial treatment and correcting bony alignment, restoring joint congruity, and balancing soft tissues. [8] (10.1007/s00402-011-1447-6)
• [L3] The significant correlation between HIA and forefoot abduction-related parameters in juveniles highlights the need for a comprehensive assessment and treatment of combined deformities in managing juvenile-onset hallux valgus. [9] (10.1186/s13018-024-05408-1)
• [L3] When using a validated outcome score for the assessment of outcome after surgery for hallux valgus, the long-term results are worse than expected when compared with the short- and mid-term outcomes, with 25.9% of patients dissatisfied at a mean follow-up of 5.2 years. [10] (10.1302/0301-620x.97b2.34891)
• [L4] Successful hallux valgus correction in young patients depends on proper case selection, surgical technique, and adequate postoperative management including patient compliance. [11] (10.1007/bf00434002)
• [L4] Proximal first metatarsal osteotomy in combination with a lateral soft-tissue procedure is effective in correcting moderate to severe symptomatic hallux valgus deformity with metatarsus primus varus. [12] (10.1007/pl00013769)
• [L4] Hallux valgus deformity is a multiplanar deformity where rotational component, specifically metatarsal pronation, has been recognized over the past 5 to 10 years and given considerable importance. [13] (10.5435/jaaosglobal-d-20-00091)
• [L3] Both modified minimally invasive chevron osteotomy and traditional incision chevron osteotomy effectively treat mild and moderate hallux valgus deformity with significantly improved clinical efficacy and imaging results. [14] (10.1186/s12891-025-08355-y)
• [L5] This study, which was the largest consecutive series of any percutaneous osteotomy technique used to correct hallux valgus deformity, demonstrated significant improvement in clinical and radiographic outcomes with a low rate of recurrence. [15] (10.2106/jbjs.24.01326)
• [L5] The postoperative management must be meticulously carried out to ensure optimal alignment of the hallux. [16] (10.5435/00124635-199501000-00005)
• [L5] Minimally invasive surgery for juvenile hallux valgus allows another surgery to be done on minimally or undamaged tissues if needed later on. [17] (10.1016/j.otsr.2021.103168)
• [L3] Obesity was not associated with unsatisfactory outcomes after ReveL for hallux valgus, challenging previous recommendations for preoperative weight loss. [18] (10.1186/s12891-019-2823-6)
• [L2] Our study supports the increased risk of acquired hallux valgus in patients eligible for knee replacement. [19] (10.1186/s12891-024-07458-2)
• [L4] It can be recommended for the comprehensive assessment of the clinical conditions of patients with hallux valgus (HV) deformity in Mainland China. [21] (10.1186/s13018-025-06196-y)
• [L5] Avoiding this zone is recommended during minimally invasive surgery for hallux valgus. [22] (10.1186/s13018-023-04419-8)
• [L4] Arthroscopic correction of the hallux valgus deformity can achieve good clinical and radiologic results, provided that careful preoperative clinico–radiologic assessment is made to exclude patients contraindicated for the procedure. [23] (10.1016/j.arthro.2008.03.001)
• [L5] The procedure is indicated for symptomatic hallux valgus recalcitrant to conservative treatment but is contraindicated in cases with bony deformity or where the intermetatarsal space cannot be closed manually. [24] (10.1016/j.eats.2023.04.009)
• [L3] There was a significant discrepancy between radiographically-assessed and self-recognized hallux valgus which narrowed with the progressing severity of hallux valgus. [25] (10.1186/s12891-021-04978-z)
• [L3] This method provides a convenient and precise tool in assessment of hallux valgus, while avoiding the cost and radiation exposure associated with radiographs. [26] (10.2519/jospt.2012.3841)
• [L4] [28] (10.1177/0363546503258780)
• [L5] Hallux valgus is a dynamic condition, and the deformity could be more correlated with motions during weightbearing than with plain static measurements. [29] (10.1097/corr.0000000000002265)
• [L3] Proximal osteotomy is a good method for treating a severe hallux valgus deformity, with 86% of patients stating the operation was worthwhile after 8 years of follow-up. [31] (10.1007/bf00433994)
• [L2] HV is a multifactorial condition primarily associated with female sex, aging, and mechanical constriction from narrow footwear, which poses a greater risk than high heels. [35] (10.1186/s12891-026-10054-1)
• [L4] The Austin osteotomy is a safe and effective treatment for mild and moderate hallux valgus deformity. [38] (10.1007/bf00434548)
• [L3] Reducibility of hallux valgus deformities must be taken into account in the surgical treatment of this entity. [40] (10.1016/j.otsr.2013.01.009)
• [L1] [41] (10.1302/0301-620x.97b2.34449)
• [L1] The Hohmann and Lapidus operations are good options for correction of a hallux valgus deformity, with similar reliable long-term results. [43] (10.1302/0301-620x.95b9.31560)
• [L3] [45] (10.1186/s13018-023-03577-z)
• [L3] The study suggests that preoperative patient-reported depression and anxiety may affect short-term surgical outcomes in women with hallux valgus. [47] (10.1186/s13018-026-06968-0)
• [L5] Hallux valgus is a complex deformity influenced by both extrinsic factors, such as constricting footwear, and intrinsic factors, including heredity and foot mechanics. [48] (10.2106/00004623-199606000-00018)
• [L4] The third-generation MICA provided significant improvement in clinical outcome measures at the 2-year follow-up and can be successfully used for correction of a range of hallux valgus deformities with a low rate of symptomatic recurrence. [50] (10.2106/jbjs.20.01178)
• [L4] Hallux valgus deformity and its severity were positively associated with the magnitude of the anteroposterior postural sway. [51] (10.1186/s12891-021-04385-4)
• [L4] DLMO is an acceptable procedure to correct reducible hallux valgus in most patients with moderate level of severity. [55] (10.1007/s00402-012-1665-6)
• [L3] The Arthroscopic/percutaneous group showed a trend towards less correction of the Hallux valgus angle compared to the open group, potentially due to the initial experience with the technique. [57] (10.1016/j.arthro.2023.01.053)
• [L4] Hallux valgus negatively impacts self-reported foot pain, function, concerns about foot appearance, and footwear in otherwise healthy adults. [58] (10.1186/1471-2474-13-197)
• [L1] [59] (10.1530/eor-23-0093)
• [L2] [63] (10.1186/1471-2474-11-215)
• [Paper] The SERI technique is effective in treating mild to moderate hallux valgus in terms of relief from symptoms and functional improvement. [64] (10.1007/s00264-013-1980-8)
• [L3] This study is the first to demonstrate a relationship between hallux valgus and patellofemoral pain syndrome, revealing a significant difference in hallux valgus angles between the affected and asymptomatic limbs. [65] (10.1007/s00167-009-0775-3)
• [L3] Childhood hallux valgus is mainly due to distal M1 joint surface orientation abnormality, unlike in adults where increased M1M2 angle is the main deformity. [66] (10.1016/j.otsr.2021.102938)
• [L2] The study shows that percutaneous distal metatarsal osteotomy is an effective and reliable method for correction of a mild-to-moderate hallux valgus deformity. [67] (10.1007/s00402-012-1585-5)
• [L5] The minimally invasive distal linear osteotomy allows to achieve good clinical and radiographic outcomes comparable to those obtained with open surgical techniques in the management of mild to severe hallux valgus deformity, with decreased recovery and rehabilitation times. [69] (10.1007/s00402-013-1778-6)
• [Paper] This technical note describes an endoscopic soft tissue procedure for correcting recurred hallux valgus deformity, which is indicated for symptomatic recurrence in high-risk patients to preserve the limb without extensive trauma. [74] (10.1016/j.eats.2016.10.022)
• [L3] Male feet undergoing MITA present with worse baseline functional impairment but show greater early functional recovery, with clinical and radiographic outcomes comparable to those of female feet at 1 year. [79] (10.1186/s12891-026-10023-8)
• [L4] Progressive Distance Mapping (PDM) suggests subgroup-dependent, progressive associations between plantar fat-pad-anchored distance geometry and hallux valgus severity. [80] (10.1186/s13018-025-06587-1)
• [L4] Because the hallux valgus angles based on margo medialis pedis measurements were slightly but statistically significantly smaller, these measurements should be considered conservative estimates of the metatarsophalangeal angle. [82] (10.1186/1471-2474-15-133)
• [L2] Chevron-Akin double osteotomy is a safe and practicable procedure for the treatment of mild-to-moderate hallux valgus. [89] (10.1007/s00402-011-1385-3)
• [L4] The combined proximal opening wedge and distal chevron osteotomy is a reliable technique for the correction of moderate to severe hallux valgus, providing strong angular correction with satisfactory clinical outcomes. [90] (10.1302/0301-620x.98b9.35984)
• [L3] Clinically, congruency of the MTP joint should be considered when choosing surgical methods for different degrees of hallux valgus, and the MTPJA and CI can be used as quantitative evaluation indicators. [92] (10.1186/s13018-022-03028-1)
• [L5] Non-operative treatment cannot correct the deformity but can help control symptoms. [96] (10.1302/2058-5241.1.000005)
• [L4] The decision tree model predicted the presence of hallux valgus on the basis of sex, age, and normalized arch height. [97] (10.1186/s12891-023-06389-8)
• [L4] The study found metatarsal pronation to be associated with hallux valgus, with the underlying mechanism generally being cuneometatarsal instability. [101] (10.1016/j.otsr.2012.05.005)
• [L5] Non-operative treatment is usually adequate to relieve symptoms but not to correct the deformity. [103] (10.2106/00004623-199512000-00020)
• [L1] The meta-analysis found no statistically significant difference in clinical outcomes (AOFAS scores) or radiological outcomes (IMA, HVA) between proximal and distal metatarsal osteotomies for moderate to severe hallux valgus deformity in the short and medium term. [105] (10.1007/s00264-018-3782-5)
• [L1] The preoperative HVA is the main radiological predictor for correction of hallux valgus, with correction rates declining in patients with HVA exceeding 37 degrees due to subluxation of the MTPJ. [107] (10.1186/1471-2474-9-70)
• [L4] Taiwanese female collegiate students with hallux valgus exhibited normal arches, with plantar loads predominantly concentrated on the medial aspects of both feet, and their rearfoot valgus angles were positively correlated with the ipsilateral hallux valgus angles. [113] (10.1186/s12891-025-09372-7)
• [L3] Width of the feet and hallux valgus angle were associated with hypermobility of the first ray while an increase in the hallux valgus angle and the first–second intermetatarsal angle were associated with symptoms among hallux valgus patients. [114] (10.1186/s13018-025-05856-3)
• [L4] Functional reach was predicted based on the hallux valgus angle, whereas the five-repetition sit-to-stand, maximal step length, and walking time were predicted based on toe flexor strength. [115] (10.1186/s12891-022-05962-x)
• [L4] More demanding weight-bearing tasks, such as standing short-foot, single-leg short-foot, calf raise, and stand swing, generally elicited greater activation than seated exercises. [116] (10.1186/s12891-026-09949-w)
• [L3] For hallux valgus feet with postoperative metatarsalgia, the load function of the first metatarsal is obviously impaired, while central rays show indicative differences in instant load distribution rather than peak or cumulative load. [124] (10.1186/s13018-017-0622-z)
• [L5] This pilot-study suggests that AR guided osteotomies can potentially improve accuracy during hallux valgus correction, particularly for less experienced surgeons. [127] (10.1186/s12891-020-03373-4)
• [L4] [128] (10.1186/s12891-024-07219-1)

See Also

• Hallux rigidus

References

[1] Percutaneous hallux valgus surgery in children: Short-term outcomes of 33 cases. Orthopaedics & Traumatology: Surgery & Research. 2013. DOI: 10.1016/j.otsr.2013.02.003

[2] Hallux valgus, ankle osteoarthrosis and adult acquired flatfoot deformity: a review of three common foot and ankle pathologies and their treatments. EFORT Open Reviews. 2016. DOI: 10.1302/2058-5241.1.000015

[3] Outcomes and Complications for Minimally Invasive Distal Transverse Metatarsal Osteotomy–Akin Osteotomy (MITA) for Hallux Valgus: 493 Cases. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-06361-3

[4] Surgical treatment of iatrogenic hallux varus. Orthopaedics & Traumatology: Surgery & Research. 2020. DOI: 10.1016/j.otsr.2019.05.018

[5] The use of a syndesmosis procedure for the treatment of hallux valgus. The Bone & Joint Journal. 2014. DOI: 10.1302/0301-620x.96b4.32193

[6] The Chevron Osteotomy for Correction of Hallux Valgus. The Journal of Bone and Joint Surgery-American Volume. 2000. DOI: 10.2106/00004623-200010000-00002

[7] Minimally invasive surgery in the correction of recurrent hallux valgus: a case series with 2‑year follow‑up. BMC Musculoskeletal Disorders. 2026. DOI: 10.1186/s12891-026-09946-z

[8] Salvage of recurrence after failed surgical treatment of hallux valgus. Archives of Orthopaedic and Trauma Surgery. 2011. DOI: 10.1007/s00402-011-1447-6

[9] Hallux valgus interphalangeus is more common in juvenile-onset hallux valgus than in adult-onset hallux valgus. Journal of Orthopaedic Surgery and Research. 2024. DOI: 10.1186/s13018-024-05408-1

[10] Surgery for the correction of hallux valgus. The Bone & Joint Journal. 2015. DOI: 10.1302/0301-620x.97b2.34891

[11] Hallux valgus in young patients: long-term results after McBride operation. Archives of Orthopaedic and Trauma Surgery. 1997. DOI: 10.1007/bf00434002

[12] Moderate to severe hallux valgus deformity: correction with proximal crescentic osteotomy and distal soft-tissue release. Archives of Orthopaedic and Trauma Surgery. 2000. DOI: 10.1007/pl00013769

[13] Metatarsal Pronation in Hallux Valgus Deformity: A Review. JAAOS: Global Research and Reviews. 2020. DOI: 10.5435/jaaosglobal-d-20-00091

[14] Modified minimally invasive chevron osteotomy versus traditional incision chevron osteotomy. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-08355-y

[15] Fourth-Generation Percutaneous Transverse Osteotomies for Hallux Valgus. Journal of Bone and Joint Surgery. 2025. DOI: 10.2106/jbjs.24.01326

[16] Disorders of the First Metatarsophalangeal Joint. Journal of the American Academy of Orthopaedic Surgeons. 1995. DOI: 10.5435/00124635-199501000-00005

[17] Treatment of hallux valgus in children and adolescents. Orthopaedics & Traumatology: Surgery & Research. 2022. DOI: 10.1016/j.otsr.2021.103168

[18] The influence of obesity and gender on outcome after reversed L-shaped osteotomy for hallux valgus. BMC Musculoskeletal Disorders. 2019. DOI: 10.1186/s12891-019-2823-6

[19] Eligibility for knee arthroplasty is associated with increased risk of acquired hallux valgus - a Mendelian randomized study. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07458-2

[20] Campbell S Operative Orthopaedics 4 Volume Set. MULTIPLE Z-PLASTY RELEASE OF A CONGENITAL RING > HALLUX RIGIDUS.

[21] A cross-cultural adaptation and validation of the Chinese version of American orthopaedic foot and ankle society hallux metatarsophalangeal-interphalangeal scale (AOFAS-Hallux-MTP-IP) in patients with hallux valgus. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-06196-y

[22] The potentially dangerous zone of the dorsomedial cutaneous nerve in minimally invasive surgery for hallux valgus: a cadaveric study. Journal of Orthopaedic Surgery and Research. 2023. DOI: 10.1186/s13018-023-04419-8

[23] Arthroscopy‐Assisted Correction of Hallux Valgus Deformity. Arthroscopy. 2008. DOI: 10.1016/j.arthro.2008.03.001

[24] Modified Endoscopic Distal Soft Tissue Procedure With Medial Metatarsosesamoid Ligament and Intermetatarsal Ligament Augmentation. Arthroscopy Techniques. 2023. DOI: 10.1016/j.eats.2023.04.009

[25] The discrepancy between radiographically-assessed and self-recognized hallux valgus in a large population-based cohort. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-021-04978-z

[26] Validity and Reliability of Hallux Valgus Angle Measured on Digital Photographs. Journal of Orthopaedic & Sports Physical Therapy. 2012. DOI: 10.2519/jospt.2012.3841

[28] Relationship between Stress Fractures of the Proximal Phalanx of the Great Toe and Hallux Valgus. The American Journal of Sports Medicine. 2004. DOI: 10.1177/0363546503258780

[29] Impact of First Metatarsal Hyperpronation on First Ray Alignment: A Study in Cadavers. Clinical Orthopaedics & Related Research. 2022. DOI: 10.1097/corr.0000000000002265

[31] Proximal osteotomy in hallux valgus, long-term results of 167 operated feet. Archives of Orthopaedic and Trauma Surgery. 1997. DOI: 10.1007/bf00433994

[32] Tachdjian S Pediatric Orthopaedics From The Texas Scottish Rite Hospital For Children E Book. Plate 15.3 Kramer/Barmada Osteotomy of the Base of the Femoral Neck for Slipped Capital Femoral Epiphysis > Distal Metatarsal Osteotomy > Hallux Varus.

[33] Miller S Review Of Orthopaedics. SECTION 16 PATELLAR TRACKING IN TOTAL KNEE ARTHROPLASTY > ADULT HALLUX VALGUS.

[35] Determinants and associated factors for hallux valgus: a systematic review and meta-analysis. BMC Musculoskeletal Disorders. 2026. DOI: 10.1186/s12891-026-10054-1

[37] Campbell S Operative Orthopaedics 4 Volume Set. MULTIPLE Z-PLASTY RELEASE OF A CONGENITAL RING > RECURRENT HALLUX VALGUS WITH NORMAL DISTAL METATARSAL ANGLE AFTER BUNIONECTOMY > BOX 82.6.

[38] Clinical and radiological results after Austin bunionectomy for treatment of hallux valgus. Archives of Orthopaedic and Trauma Surgery. 1996. DOI: 10.1007/bf00434548

[39] Aaos Comprehensive Orthopaedic Review 3. Disorders of the First Ray > I. Hallux Valgus.

[40] Efficacy of first metatarsophalangeal joint lateral release in hallux valgus surgery. Orthopaedics & Traumatology: Surgery & Research. 2013. DOI: 10.1016/j.otsr.2013.01.009

[41] A comparison of proximal and distal Chevron osteotomy, both with lateral soft-tissue release, for moderate to severe hallux valgus in patients undergoing simultaneous bilateral correction. The Bone & Joint Journal. 2015. DOI: 10.1302/0301-620x.97b2.34449

[42] A Lange Medical Book Current Diagnosis Treatment In Orthopedics Fifth Edition. 10Pediatric Orthopedic Surgery > 9. Adolescent Bunions (Hallux Valgus).

[43] Long-term results of the Hohmann and Lapidus procedure for the correction of hallux valgus. The Bone & Joint Journal. 2013. DOI: 10.1302/0301-620x.95b9.31560

[44] A Lange Medical Book Current Diagnosis Treatment In Orthopedics Fifth Edition. 8Foot and Ankle Surgery > 2. Hallux Rigidus.

[45] Ulcer occurrence on adjacent toes and hallux valgus deformity after amputation of the second toe in diabetic patients. Journal of Orthopaedic Surgery and Research. 2023. DOI: 10.1186/s13018-023-03577-z

[46] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Foot and Ankle Reconstruction > Hallux Valgus.

[47] Preoperative patient-reported depression and anxiety may affect short-term surgical outcomes in women with hallux valgus. Journal of Orthopaedic Surgery and Research. 2026. DOI: 10.1186/s13018-026-06968-0

[48] Instructional Course Lectures, The American Academy of Orthopaedic Surgeons - Hallux Valgus†. The Journal of Bone & Joint Surgery*. 1996. DOI: 10.2106/00004623-199606000-00018

[50] Third-Generation Minimally Invasive Chevron and Akin Osteotomies (MICA) in Hallux Valgus Surgery. Journal of Bone and Joint Surgery. 2021. DOI: 10.2106/jbjs.20.01178

[51] Hallux valgus deformity and postural sway: a cross-sectional study. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-04385-4

[52] Campbell S Operative Orthopaedics 4 Volume Set. MULTIPLE Z-PLASTY RELEASE OF A CONGENITAL RING > ACQUIRED HALLUX VARUS AND INTRINSIC MINUS HALLUX.

[55] Minimally invasive distal linear metatarsal osteotomy for correction of hallux valgus: a preliminary study of clinical outcome and analytical radiographic results via a mapping system. Archives of Orthopaedic and Trauma Surgery. 2012. DOI: 10.1007/s00402-012-1665-6

[56] A Lange Medical Book Current Diagnosis Treatment In Orthopedics Fifth Edition. 8Foot and Ankle Surgery > 1. Hallux Valgus.

[57] Podium Presentation Title: A Cohort Comparison of Arthroscopic and Open Lapidus Correction and Complications for Hallux Valgus. Arthroscopy. 2023. DOI: 10.1016/j.arthro.2023.01.053

[58] Foot pain and functional limitation in healthy adults with hallux valgus: a cross-sectional study. BMC Musculoskeletal Disorders. 2012. DOI: 10.1186/1471-2474-13-197

[59] Recurrence rates with long-term follow-up after hallux valgus surgical treatment using shaft metatarsal osteotomies: a systematic review and meta-analysis. EFORT Open Reviews. 2024. DOI: 10.1530/eor-23-0093

[63] Validity of self-assessment of hallux valgus using the Manchester scale. BMC Musculoskeletal Disorders. 2010. DOI: 10.1186/1471-2474-11-215

[64] A minimally invasive technique for surgical treatment of hallux valgus: simple, effective, rapid, inexpensive (SERI). International Orthopaedics. 2013. DOI: 10.1007/s00264-013-1980-8

[65] Hallux valgus in patients with patellofemoral pain syndrome. Knee Surgery, Sports Traumatology, Arthroscopy. 2009. DOI: 10.1007/s00167-009-0775-3

[66] Abnormalities in distal first metatarsal joint surface orientation: Distal Metatarsal Articular Angle and Distal Metatarsal-2 Articular Angle. Orthopaedics & Traumatology: Surgery & Research. 2021. DOI: 10.1016/j.otsr.2021.102938

[67] Percutaneous distal metatarsal osteotomy versus distal chevron osteotomy for correction of mild-to-moderate hallux valgus deformity. Archives of Orthopaedic and Trauma Surgery. 2012. DOI: 10.1007/s00402-012-1585-5

[68] Campbell S Operative Orthopaedics 4 Volume Set. MULTIPLE Z-PLASTY RELEASE OF A CONGENITAL RING > HALLUX VALGUS (BUNION).

[69] Role of percutaneous distal metatarsal osteotomy for the management of hallux valgus deformity. Archives of Orthopaedic and Trauma Surgery. 2013. DOI: 10.1007/s00402-013-1778-6

[71] Apley And Solomon S Concise System Of Orthopaedics And Trauma. HALLUX VALGUS.

[72] Campbell S Operative Orthopaedics 4 Volume Set. COMBINED ONE-STAGE CORRECTION OF SPASTIC DISLOCATED HIP > HALLUX VALGUS DEFORMITY.

[73] Distal First Metatarsal Displacement Osteotomy: ITS PLACE IN THE SCHEMA OF BUNION SURGERY.. The Journal of Bone and Joint Surgery. American Volume. 1974.

[74] Correction of Recurred Hallux Valgus Deformity by Endoscopic Distal Soft Tissue Procedure. Arthroscopy Techniques. 2017. DOI: 10.1016/j.eats.2016.10.022

[75] Aaos Comprehensive Orthopaedic Review 3. Disorders of the First Ray > II. Juvenile Hallux Valgus.

[76] Miller S Review Of Orthopaedics. JUVENILE AND ADOLESCENT HALLUX VALGUS.

[78] Orthopaedic Knowledge Update. Congenital Disorders of the Foot* > Juvenile Hallux Valgus.

[79] Gender differences in early functional recovery after minimally invasive distal transverse metatarsal osteotomy - Akin Osteotomy (MITA) for hallux valgus: a propensity-matched study of 300 cases. BMC Musculoskeletal Disorders. 2026. DOI: 10.1186/s12891-026-10023-8

[80] Progressive distance mapping of the plantar fat pad in hallux valgus reveals subgroup-specific morphologic subtypes. Journal of Orthopaedic Surgery and Research. 2026. DOI: 10.1186/s13018-025-06587-1

[82] The hallux valgus angle of the margo medialis pedis as an alternative to the measurement of the metatarsophalangeal hallux valgus angle. BMC Musculoskeletal Disorders. 2014. DOI: 10.1186/1471-2474-15-133

[89] Clinical outcome after Chevron–Akin double osteotomy versus isolated Chevron procedure: a prospective matched group analysis. Archives of Orthopaedic and Trauma Surgery. 2011. DOI: 10.1007/s00402-011-1385-3

[90] Correction of moderate to severe hallux valgus with combined proximal opening wedge and distal chevron osteotomies. The Bone & Joint Journal. 2016. DOI: 10.1302/0301-620x.98b9.35984

[92] Radiographic evaluation of congruency of the first metatarsophalangeal joint in hallux valgus. Journal of Orthopaedic Surgery and Research. 2022. DOI: 10.1186/s13018-022-03028-1

[96] Treatment of hallux valgus deformity. EFORT Open Reviews. 2016. DOI: 10.1302/2058-5241.1.000005

[97] Contributions of age, gender, body mass index, and normalized arch height to hallux valgus: a decision tree approach. BMC Musculoskeletal Disorders. 2023. DOI: 10.1186/s12891-023-06389-8

[101] Axial rotation of the first metatarsal head in a normal population and hallux valgus patients. Orthopaedics & Traumatology: Surgery & Research. 2012. DOI: 10.1016/j.otsr.2012.05.005

[103] Bunions and Deformities of the Toes in Children and Adolescents. The Journal of Bone & Joint Surgery. 1995. DOI: 10.2106/00004623-199512000-00020

[105] Proximal versus distal metatarsal osteotomies for moderate to severe hallux valgus deformity: a systematic review and meta-analysis of clinical and radiological outcomes. International Orthopaedics. 2018. DOI: 10.1007/s00264-018-3782-5

[107] Hallux valgus angle as main predictor for correction of hallux valgus. BMC Musculoskeletal Disorders. 2008. DOI: 10.1186/1471-2474-9-70

[113] Biomechanical characteristics of medial plantar load and rearfoot valgus in young female adults with hallux valgus: a cross-sectional study. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-09372-7

[114] Accuracy of diagnosis and evaluation of first ray hypermobility in symptomatic and asymptomatic hallux valgus patients using ultrasonography. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-05856-3

[115] Relationship between foot morphology, muscle strength, and physical performance test in women aged 65 years and older: a cross-sectional study. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05962-x

[116] Electromyographic activation of extrinsic and intrinsic foot muscles during nine different foot exercises in women with hallux valgus: a cross-sectional comparative study. BMC Musculoskeletal Disorders. 2026. DOI: 10.1186/s12891-026-09949-w

[124] Loading pattern of postoperative hallux valgus feet with and without transfer metatarsalgia: a case control study. Journal of Orthopaedic Surgery and Research. 2017. DOI: 10.1186/s13018-017-0622-z

[127] Augmented reality guided osteotomy in hallux Valgus correction. BMC Musculoskeletal Disorders. 2020. DOI: 10.1186/s12891-020-03373-4

[128] Cross-sectional study of the prevalence of hyperextension of the first metatarsophalangeal joint and its relationship to onycholysis in women with hallux valgus. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07219-1