Managing Hallux Valgus in Athletes

Yulia Putinseva examines her foot during a changeover against Jasmine Paolini (not pictured) in a women’s singles match on day six of the 2024 U.S. Open tennis tournament. Mandatory Credit: Geoff Burke-USA TODAY Sport

Hallux valgus marked by a complex deformity of the first metatarsal phalangeal joint, and often leads to pain and dysfunction, potentially impacting an athlete’s ability to compete. When athletes are on the on the verge of opting for surgery, the question arises: is conservative management a viable alternative, or is surgical intervention inevitable?

Hallux valgus, commonly associated with a medial prominence or "bunion," is a multifaceted condition. Beyond the visible deformity, it involves intricate biomechanical alterations that can disrupt efficient movement, particularly during gait. While factors such as footwear, genetics, and joint hypermobility contribute to its development, managing the condition—especially in athletes—requires a nuanced approach.

The key lies in addressing the structural deformity and the compensatory patterns that develop, which can lead to further complications. Hallux valgus is a common condition that results from a complex positional deformity of the first ray. The bunion or medial prominence that results from the lateral deviation and pronation of the hallux is only one component of the three-dimensional deformity⁽¹⁾.

The precise biomechanical etiology remains unclear. A number of factors have been identified that create a predisposition for the development of hallux valgus. It is more common in females, which is likely related to differences in footwear, osseous anatomy, and generalized ligamentous laxity. The prevalence of hallux valgus increases with age because of the alterations in joint mechanics and plantar loading patterns. A strong genetic predisposition is also present⁽¹⁾. Furthermore, metatarsus adductus, equinus contracture, hammertoe deformity, and pes planus often coexist with hallux valgus.

Biomechanics

The first metatarsophalangeal joint (MTPJ) functions as a vital pivot for body weight transfer during the late stance phase of gait. It is plausible that progressive subluxation of the first MTPJ interferes with efficient toe-off and altered plantar pressures⁽²⁾. Deceased ankle dorsiflexion and rearfoot supination in the terminal gait phase may be present in athletes with hallux valgus. Moreover, they display increased intrinsic muscle activity on heel strike. A less stable gait with a shorter stride length also presents – which may be present as a compensatory mechanism⁽²⁾.
 
The foot and ankle complex achieves stability from active (dynamic) structures, including the muscles and tendons, and passive structures, including the osseous structure, cartilaginous linings, ligaments, and capsules.  The foot functions optimally in a neutral position. The stability is provided by the intrinsic and extrinsic muscle activity. The windlass mechanism is one of the mechanisms contributing to the foot’s stability (see figure 1). It is important during gait as it provides stability for shock absorption on heel strike and acts as a lever to propel forward in toe-off.