Orthotic management of common forefoot deformities: a clinical practice guideline for hallux valgus.

Results

Torkki et al. (4) compared custom-made foot orthoses with surgery and no intervention for painful hallux valgus at 6 and 12 months. At 6 months, pain intensity decreased more in the surgical group than in the control group and more in the orthosis than in the control group. At one year follow-up, pain decreased more in the surgical group than in the control and the orthosis groups. However, all groups improved when compared with baseline.

Tehraninasr et al. (11) compared the effects of insoles with a toe separator and night splint on patients with painful hallux valgus at 3 months. Pain reduction was statistically significant in the insole group (p<0.05). No significant difference was found in the night splint group. Hallux valgus and intermetatarsal angles decreased however differences found were not significant.

Table 1. Summary of studies conducted on hallux valgus.

Only a few randomised trials were identified evaluating orthotic management of Morton’s neuroma (Table 2). Saygi et al. (12) compared footwear modifications with steroid injections and found steroid injections to be better in relieving pain at 6 month follow-up however at one year follow-up no statistically significant outcomes were found. Kilmartin & Wallace (13) used supination and pronation orthoses and reported 50% pain reduction in supination group and 45% pain reduction in pronation group however the results were not statistically significant.

Table 2. Summary of studies conducted on Morton’s neuroma. (Derived from Bondi et al. (7)

Table 3. Summary of study conducted on metatarsalgia.

Clinical Practice Guideline

Hallux valgus

This clinical practice guideline on hallux valgus is based upon consensus of current clinical practice and review of the clinical literature. The guideline was developed by the Clinical Practice Guideline First Metatarsophalangeal (MTP) Joint Disorders Panel of the American College of Foot and Ankle Surgeons. (6) The pathways are illustrated in the diagram below followed by written description for each step (1-8).

Fig 1. Clinical practice guideline pathways for hallux valgus. Derived from Vanore et al. (6) 2003

 

                                                                               

       

     

                                                      INITIAL TREATMENT OPTIONS                                          5

PATIENT DIRECTED Tx                NON-OPERATIVE Tx                      SURGERY

Wider, lower heeled shoes                        Orthoses

Bunion pad                                Shoe modifications

Ice                                        Patient Education

NSAIDs                                        Rx NSAIDs

        6

               IMPROVED                                                        NOT IMPROVED

1. Significant history

Patients presenting with this deformity often have a significant family history of bunion deformity. (6) The deformity may be noted in adolescence, although it is more prevalent in women older than 30 years. (6) Pain is generally associated with irritation at the bunion and may be aggravated by tight footwear, particularly in women's footwear. (14) Hallux valgus is considered to be a progressive condition and patients can present from mild enlargement of the metatarsal head to severe dislocation of the first MTP joint (1,5,15).

2. Significant Findings

Significant findings include a medial prominence with abduction of the great toe. There is notable widening of the forefoot and difficulty finding shoes. First ray hypermobility secondary to rear-foot pronation is generally present. (6)

3. Associated Findings

Hallux valgus can present with numerous associated findings such as hammertoe deformity of the second toe, plantar callous usually under the 2nd metatarsal head, and central metatarsalgia. Generally, bunion formation is associated with first ray insufficiency leading to lateral weight transfer and symptoms that may include metatarsalgia. (6)

4. Radiographic Findings

Radiographic evaluation includes assessment of general radiographic parameters and angular relationships of the osseous segments involved in this deformity. These angles (described in fig 1.) are also used to base decisions on surgical procedure selection. (6)

Fig 2. The hallux abductus (HA) angle is formed by the angle between the longitudinal axis of the hallux and first metatarsal. The intermetatarsal (IM) angle is formed by the longitudinal axis of the first and second metatarsals, respectively. Vanour et al. (6)

5. Conservative treatment options

When symptoms begin to interfere with a patient's lifestyle, initial treatment such as wider, lower-heeled shoes, bunion pads, ice, and over-the-counter analgesics is often self-directed. Patients who are unresponsive to the initial treatment or unable to fulfil the self-directed regimen should be directed to a podiatric foot and ankle surgeon for evaluation. (6)

Initial care involves patient education, including a discussion of the natural history of the disorder, evaluation of footwear, and prior treatment. Nonsurgical alternatives include shoe modifications with pocketing of the medial shoe contour or wider shoes. Although there is no scientific evidence to support the efficacy of orthotic devices in the treatment of hallux valgus, symptomatic relief may be realized by some patients. (13)

Surgical recommendations might be considered on the initial evaluation of hallux valgus deformity. Because hallux valgus is a progressive disorder and is often evaluated in the second or third stage, surgical consideration can be undertaken early in the course of treatment. (6)

6. Clinical response

When nonsurgical care is given, the clinical response is assessed. If the patient is doing well, initial treatment may be continued. If there has been little or no improvement or if initial improvement deteriorates, surgical treatment is appropriate. If a primary care physician performed the initial evaluation and treatment, referral to a podiatric foot and ankle surgeon is indicated. (6)

Hereafter, the appropriate surgical procedure is decided by the surgeon depending on the stage of the deformity. Hallux valgus is classified into stages 1, 2 and 3 which are based on the HA and the IM angles (Fig 1). These will not be included in the guideline as surgical options are not being discussed in this review.

Discussion

In clinical practice it is routine to explore orthotic therapy for the management of forefoot conditions with very little evidence to continue their use. There are only a handful of randomised controlled trials which are summarised in the results section. The studies conducted on hallux valgus (Table 1) have different age groups and interventions thus it is difficult to make any comparisons. Torkki et al. (4), a large well conducted randomised trial found that foot orthosis use for hallux valgus is beneficial as it was better than no treatment. Most studies do not provide sufficient information on the materials or manufacturing technique used to construct the orthoses used in the trails. Tehraninasr et al. (11) and Postema et al. (14) are the few that do. In Tehraninasr et al.’s study a 3 month follow-up period was not long enough to note any structural changes in the angulations as well as long-term pain reduction so a longer study period would have given the ability to make stronger assumptions in the effect of the orthosis and night splint.

Saygi et al. (12), a comparison study looking at steroid injections and shoe modifications have such a short follow-up making the results only preliminary. Once again a longer follow-up would have provided more valuable results. The Kilmartin & Wallace (13) study in their comparative study of supination and pronation orthosis could not provide any evidence to support the usefulness of one orthosis over the other.

All studies covered different therapeutic approaches to the conditions. An overall conclusion regarding the effectiveness of foot orthoses cannot be drawn and the studies cannot be compared with one another.

Conclusion

The review was conducted to evaluate the effectiveness of orthotic management of forefoot deformities. There appears to be a distinct lack of quality research for these common conditions. The research is scarce and there are only a handful randomised controlled trials. The studies also examine different areas and no comparison of data is possible. In hallux valgus, conservative measures may be used initially to reduce the symptomatology associated with this deformity however, surgical repair is often used more commonly to correct the deformity. Large well designed clinical trials are required to confirm the validity of existing smaller trials. Until then, orthotic management of forefoot deformities can only be base on clinical experience.

Total word count (excluding information boxes and reference list): 1,969 words

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References

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