Introduction

The hallux valgus deformity in the athlete is no different from the deformity in the nonathlete, but it becomes almost a philosophical question because a foot is to an athlete what a hand is to a musician. Its function must be respected because without it, the athlete, whether a ballerina or lineman, may not be able to perform at an acceptable level. In most cases, unless the athlete’s career is jeopardized by his or her hallux valgus deformity, surgical correction probably should not be undertaken for fear that a less than perfect result may jeopardize the athlete’s career.

Biomechanics of the First Metatarsophalangeal Joint

The main function of the first metatarsophalangeal joint is to stabilize the longitudinal arch through the windlass mechanism. Anatomically the windlass mechanism consists of the plantar fascia inserting into the base of the proximal phalanx via the plantar plate (Fig. 19-1). As the windlass mechanism becomes functional in the last half of stance by the dorsiflexion of the proximal phalanx on the metatarsal head, the metatarsals are depressed as weight is transferred to the toes. The effect of the windlass mechanism is greatest for the hallux and least for the small toe. Secondarily the windlass mechanism elevates the longitudinal arch and aids in inversion of the calcaneus (Fig. 19-2). When a hallux valgus deformity develops and lateral subluxation of the proximal phalanx on the metatarsal head occurs, the sesamoid sling is no longer beneath the first metatarsal head; therefore the windlass mechanism becomes less functional (Fig. 19-3). This is because when dorsiflexion of the phalanx occurs, plantarflexion of the metatarsal and weight transfer to the hallux are diminished resulting in progressive loss of the stability of the longitudinal arch. As it progresses, this loss of stability weakens the medial longitudinal arch, resulting in weight transfer from the first metatarsal to the second. This subsequently can result in excessive fatigue of the foot and possibly callus formation beneath the second metatarsal. This combination of effects results in diminished performance in the athlete, although it could be tolerated by the nonathlete.

Figure 19-1 Plantar aponeurosis. (A) Cross section. (B) Division of plantar aponeurosis around flexor tendons. (C) Components of plantar pad and its insertion into the base of the phalanx. (D) Extension of toes draws plantar pad over metatarsal head, pushing them into plantarflexion.

From Mann RA: In Coughlin MJ, Mann RA, editors: Surgery of the foot and ankle, ed 7, St Louis, 1999, Mosby.

Figure 19-3 Severe hallux valgus deformity with subluxed metatarsophalangeal joint. A deformity of this severity significantly alters the function of the plantar aponeurosis, giving rise to progressive instability of the longitudinal arch. Although this is tolerated by the nonathlete, it may present a significant disability for the athletic individual.

Types of Hallux Valgus Deformity

The hallux valgus deformity can be divided into two basic groups—persons with a congruent joint and those with a noncongruent or subluxed joint. In those with the congruent deformity, the windlass mechanism is not disrupted, and therefore the stability of the foot is not a problem (Fig. 19-4, A). In these individuals, the main disability is a large medial eminence, which results in chafing against their shoe. In the noncongruent deformity, there is progressive subluxation of the metatarsophalangeal joint that leads to instability and weight transfer (Fig. 19-4, B). In these individuals, the problem is more than an enlarged medial eminence because of the instability that occurs. If the enlarged medial eminence results in sufficient disability for the athlete and he or she can no longer function at the level needed to participate in his or her sport, a hallux valgus repair can be considered.

Conservative Management

Conservative management of the athlete with a hallux valgus deformity begins with specifically pinpointing the area of maximal pain because our conservative management must be directed toward relieving that problem. Generally, pain is over the medial eminence and not infrequently where the dorsal medial cutaneous nerve crosses over the bony medial eminence. First, the size of the shoe must be evaluated carefully in relation to the foot. Next, the pattern of the seams that cross over the medial eminence must be evaluated, because, although leather will give way to pressure from the medial eminence, the stitching will not. Sometimes just altering the seams that cross over the bony prominence will result in a great deal of relief. If it appears that the shoe is of adequate size, then the area over the painful spot can be relieved by having the shoe enlarged over this area. This is particularly useful in the athlete who requires a rigid boot, such as a skier, hockey player, rollerblader, and so forth. Even the ballet slipper can be expanded to a certain extent to relieve the pressure over the medial eminence.

The shoe itself could be stiffened to decrease stress across the first metatarsophalangeal joint if the patient’s athletic performance would not be diminished. Obviously a lineman can tolerate a stiffer shoe than a ballerina or gymnast.

As a general rule, an orthotic device per se will not do anything to relieve the problems associated with a hallux valgus deformity unless there is sesamoid pain or a transfer lesion beneath the second metatarsophalangeal joint. One must be careful when using an orthotic device because it will take up a certain amount of volume in the shoe and as a result may aggravate the patient’s problem rather than relieve it. An orthotic device will not prevent a bunion from occurring.

If the hallux valgus deformity has progressed to the point at which a transfer lesion is occurring beneath the second metatarsal head, then some type of an orthotic device to relieve the pressure will be useful. One must keep in mind, however, that whenever something is added to a shoe it takes up volume; if the shoe is already small, this can aggravate the problem. A change in shoewear may be necessary if an orthotic device is to be used.

Sometimes when an individual has a large medial eminence that is painful, there is tendency to place a pad over the involved area, with the thought that this will relieve pressure, but in actuality doing this increases the pressure. The person should be advised to cut out an area in the pad so that pressure is taken off of the medial eminence rather than applied to it.