Hallux varus

What is Hallux Varus?

Hallux varus refers to a medial deviation of the first phalanx of the big toe, which moves away from the axis of the first metatarsal. This condition differs from the hallux valgus, where the toe is oriented towards the other toes, the first metatarsal is deviated medially, and the first phalanx is deviated laterally. Anatomically, there is an alteration in the balance between the soft tissues and the bony structures, particularly at the level of the metatarsophalangeal joint, which leads to functional discomfort that manifests as difficulty walking and painful adaptation to footwear. Hallux varus also corresponds to persistent instability of the metatarsophalangeal joint of the hallux, which can cause pain in the big toe and painful overload of the lateral metatarsals known as metatarsalgia.

Causes and Risk Factors

Hallux varus can have different origins; it is often related to a surgical procedure, but it can be congenital, post-traumatic, or part of Turf Toe. Hallux varus is not necessarily pathological, particularly when it is constitutional.

One of the most common causes is of iatrogenic origin, meaning it complicates a surgical intervention. In rare but classic cases, it can complicate a hallux valgus correction surgery. The risk factors for developing a hallux varus following a hallux valgus surgical correction are :

• Excessive correction of the first metatarsal or even the first phalanx.
• Inadequate correction of the first metatarsal with a residual abnormal position of the head of the first metatarsal.
• Excessive lateral joint release.
• Poor tissue quality.

Some people have one or two congenital hallux varus. In this case, it is not a structural abnormality of the foot from birth but rather an anatomical variation.

Hallux traumas, such as a fracture, dislocation, or tendon and capsuloligamentous injuries, can also disrupt the alignment of the big toe and cause hallux varus.

A thorough evaluation helps identify the main cause and adapt the management according to whether the hallux varus is symptomatic or not. An asymptomatic hallux varus does not require any treatment. In the case of symptomatic hallux varus, surgical treatment is recommended.

Symptoms and Clinical Signs

People suffering from hallux varus generally experience pain located at the big toe, specifically at the metatarsophalangeal joint, which is unstable. This discomfort can worsen while walking, making it difficult to wear shoes on a daily basis.

In addition to discomfort, the appearance of the foot is altered. The big toe takes on an abnormally inwardly deviated position, which can be accompanied by a progressive worsening and, in some cases, by a tendino-muscular retraction.

The joint instability of the metatarsophalangeal joint of the hallux causes overloading of the lateral metatarsals. This mechanical overload can cause pain in the plantar pad, joint pain of the metatarsophalangeal joints of the lateral rays, called metatarsalgia. The overload of the lateral rays can, in the short or medium term, cause osteoarthritis of the median Lisfranc.

The Diagnosis of Hallux Varus

The diagnosis of a foot pathology is based on a standardized and systematic clinical examination, combined with weight-bearing X-rays of the ankles and feet. During the consultation, the physical examination of the foot helps to identify any possible deviations of the big toe, assess the mobility and stability of the affected joint, and detail any associated injuries. The foot examination is performed dynamically while walking, and then statically on the examination table.

To clarify the diagnosis, weight-bearing X-rays are performed with various views, including anteroposterior, lateral, oblique and axial views of the sesamoids. These images allow for precise analysis of the angle of deviation, analysis of the relative lengths of the metatarsals, and assessment of the condition of the articular cartilage and remaining bone stock.

Treatment options for hallux varus

Surgical treatment

When the deformity is disabling, surgical intervention is recommended. The goal of surgery for hallux varus is to correct all the factors that led to this deformity. The main surgical procedures performed are :

• Tendon transfers, in particular the transfer of the abductor hallucis according to Leemrisje to correct the forces acting on the big toe. The abductor hallucis, which exerts a deforming force in hallux varus, becomes a valgus force after tendon transfer.
• Reconstruction of the lateral ligamentous complex can be performed using a double button system. This reconstruction is less invasive than the transfer of the abductor hallucis.
• Corrective osteotomies are performed to correct an excess or defect in correction at the level of the first metatarsal or even the first phalanx.
• Arthrodesis of the metatarsophalangeal joint of the hallux may be proposed in cases of non-preservable joint, insufficient bone stock, or failure of conservative surgical treatment of hallux varus.
• Lateral metatarsal osteotomies can also be performed at the same time in the case of associated metatarsalgia.

Non-surgical treatment

For the less disabling forms of hallux varus, some tips can be suggested :

• Shoe adaptation : Prefer models with a wide toe box to reduce pressure on the toe.
• Use of custom orthotics : Appropriate insoles stabilize the foot and help redistribute pressure at the forefoot. Silicone orthoplasties may be tried.
• Physical therapy and taping : Rehabilitation exercises and support techniques can alleviate discomfort and improve forefoot balance.

Rehabilitation and postoperative follow-up after correction of hallux varus

Rehabilitation after surgery for hallux varus is tailored to each patient and the surgical procedures performed in order to promote optimal functional recovery. Physical therapy plays a central role by strengthening the muscles of the foot and restoring good postural balance.

Over the weeks, the focus is on a controlled return to daily activities, with particular attention given to the choice of appropriate footwear, designed to maintain the corrections made during surgery. Careful support makes it possible to adjust these recommendations according to each patient’s progress.

The postoperative follow-up includes regular consultations, with clinical and radiographic examinations to monitor bone healing and prevent potential complications. This personalized approach allows for effective rehabilitation and a return to walking under the best possible conditions.

Personalized care at the Foot Clinic

At La Clinique du Pied, each patient requires a personalized assessment. Once the diagnosis is made, an individualized therapeutic protocol is proposed. Our team uses minimally invasive techniques such as arthroscopy and percutaneous surgery, although the correction of a hallux varus is most often performed through the traditional open minimally invasive surgery.