My Foot and Ankle Hurt

My Foot and Ankle Hurt

Lauren E. Geaney, MD, FAAOS

Jonathan R. Kaplan, MD, FAAOS

MaCalus V. Hogan, MD, MBA, FAAOS, FAOA

Dr. Geaney or an immediate family member serves as a paid consultant to or is an employee of Paragon 28, Smith & Nephew, Novastep, and Vilex LLC; has received research or institutional support from Arthrex, Inc.; and serves as a board member, owner, officer, or committee member of American Orthopaedic Foot and Ankle Society and Connecticut Orthopaedic Society. Dr. Kaplan or an immediate family member has received royalties from Novastep; serves as a paid consultant to or is an employee of Medline, Novastep, and Vilex; has stock or stock options held in GLW Medical Innovation; and serves as a board member, owner, officer, or committee member of American Orthopaedic Foot and Ankle Society. Dr. Hogan or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf of Journal for Bone and Joint Surgery – Miller Review Course and Zimmer and serves as a board member, owner, officer, or committee member of AAOS Board of Special Societies, American Orthopaedic Foot and Ankle Society, International Society of Arthroscopy, Knee Surgery, and Orthopaedic Sports Medicine, J. Robert Gladden Society, and Nth Dimensions Education Solutions, Inc.




  • 23% of adults aged between 18 and 65 years

  • 35.7% of adults older than 65 years have hallux valgus1,2


  • Risk factors

    • Somewhat related to tight shoe wear in females3

    • Increased age2

    • Genetics (particularly in juveniles and young adults)4

    • Anatomy1,3,4

      • Longer first metatarsal

      • Round first metatarsal head

      • Lateral displacement of sesamoids

      • First ray/first tarsometatarsal instability

      • Pes planovalgus

Public Health Considerations

  • Hallux valgus has been associated with the choice of shoe wear. A study evaluating monozygotic and dizygotic female twin pairs concluded that hallux valgus was associated with a constrictive toe box during the fourth decade rather than share genetic factors.5

  • A recent systematic review similarly showed an association between high-heeled shoe wear and hallux valgus.6

Pertinent Anatomy/Pathoanatomy

Soft Tissue

  • The anatomy around the first metatarsophalangeal (MTP) joint is complex; an understanding of this anatomy is critical for successful surgical correction. The medial and lateral sesamoids are plantar to the first metatarsal head and separated by a crista. The flexor hallucis brevis has two insertions, one on each of the sesamoids.

  • There are four structures that are attached to the lateral sesamoid, including one head of the adductor hallucis, the lateral metatarsosesamoid ligament, the intermetatarsal ligament, and the lateral capsule. The only medial structures attached to the first metatarsal head are the medial collateral ligament and the medial sesamoid ligament4 (Figure 1).

  • As the medial capsule becomes attenuated, the first metatarsal begins to drift medially with respect to the sesamoids because there are no soft-tissue connections between the first and second metatarsals. As the first metatarsal head drifts medially, the two sesamoids with their respective heads of the flexor hallucis brevis become displaced laterally with respect to the metatarsal head and this causes a valgus moment on the proximal phalanx. Additionally, the abductor hallucis, which was a medial structure, translates plantarly, resulting in a pronation moment on the proximal phalanx. As the metatarsal head continues to displace, the extensor hallucis longus (EHL) and flexor hallucis longus (FHL)
    also displace medially and also act as a valgus force on the proximal phalanx further contributing to the deformity4 (Figure 2).

  • The dorsomedial cutaneous nerve (a branch of the superficial peroneal nerve) is the structure that is most commonly placed at risk during surgical correction. The nerve follows a medial
    plantar to dorsal course and commonly has a large medial branch that crosses approximately 2 cm proximal to the first MTP joint.7

Bony/Articular Structures

  • The first MTP joint includes not only the articulation between the first metatarsal and the proximal phalanx but also between the medial and lateral sesamoid and the metatarsal head. The first metatarsal may be rounded or chevron shaped and articulates with the concave surface of the proximal phalanx.

  • The range of motion of the first MTP joint is normally 35° of plantar flexion and 75° of dorsiflexion.8

  • With hallux valgus, it should be noted that the angle between the articular surface and the first metatarsal (the distal metatarsal articular angle [DMAA]) may be increased. This will differentiate a congruent deformity from an incongruent deformity (Figure 3). If the DMAA is increased, the articular surface will be facing laterally and will result in a congruent joint. Alternatively, if there
    is a normal DMAA and the articular surface is perpendicular to the shaft of the metatarsal, as the proximal phalanx shifts into valgus, this will result in an incongruent joint.

Pertinent History/Physical Examination Findings

  • History

    • Patients will most often present with complaints of pain over the medial eminence, particularly with shoe wear.

    • As the hallux valgus progresses, transfer metatarsalgia may develop, which may result in pain and/or calluses under the second metatarsal head.

    • Consideration for treatment should include assessment of comorbidities such as diabetes, particularly with neuropathy, history of neuromuscular disease, or inflammatory arthritis.

  • Physical examination

    • Patients will have a prominent medial eminence. The great toe will then shift into valgus and pronate.

    • It is important to evaluate the foot for any calluses. In particular, calluses will often develop under the medial great toe as the toe begins to pronate. Calluses under the second metatarsal head may develop as a result of transfer metatarsalgia.

    • The first MTP motion should be evaluated next to determine any stiffness or pain.

    • Any instability of the first tarsometatarsal (TMT) joint must be evaluated and compared with the opposite side. Although this is important to evaluate, there is some controversy about how to accurately quantify first TMT joint instability.9

    • Palpate the medial eminence and first MTP joint as well as the medial and lateral sesamoids. The lesser MTP joints should be inspected for any tenderness or deformity.

    • Numbness of the great toe may be a result of the dorsomedial cutaneous nerve being stretched over the medial eminence (and should be noted before surgery).

Relevant Imaging

  • AP, oblique, and lateral images are necessary for evaluation of hallux valgus. The diagnosis of hallux valgus is based on an increase in the hallux valgus angle (HVA) and the 1-2 intermetatarsal angle (1-2 IMA), which are calculated on the AP images.

  • Sesamoid views may sometimes be helpful to help evaluate the sesamoid position as well as to determine if there is any arthritis between the sesamoid and the first metatarsal head. This may also be a tool to help determine if there is rotation of the first metatarsal head.1

  • Radiographic angles are necessary for surgical planning.

    • The HVA is calculated by measuring the angle between the first metatarsal and the proximal phalanx.10

    • The 1-2 IMA is calculated as the angle between the shafts of the first and second metatarsal.

    • An HVA greater than 15° and a 1-2 IMA above 9° are considered evidence for a hallux valgus deformity10 (Figure 4).

    • The DMAA is obtained to determine whether a joint is congruent or incongruent. The angle is calculated as the angle between the distal articular surface and the longitudinal surface of the first metatarsal.1 An angle greater than 10° is considered
      abnormal and evidence of a congruent joint. An angle less than 10° is normal and suggests an incongruent deformity.

      • Congruency of the joint in this hallux valgus scenario indicates that the articular surface is abnormally tilted laterally (elevated DMAA).

      • Incongruency of the joint in hallux valgus indicates a soft-tissue imbalance, with contracture of lateral-sided soft-tissue structures around the great toe MTP joint (normal DMAA).

Classification of Deformity

  • Mild deformity: HVA between 15° and 20° and a 1-2 IMA between 9° and 11°

  • Moderate deformity: an HVA between 20° to 40° and a 1-2 IMA between 11° and 16°

  • Severe deformity: an HVA greater than 40° and an IMA greater than 16°1,10

Nonsurgical Measures

  • Nonsurgical management of hallux valgus is fairly limited considering nonsurgical management has not been shown to reduce the deformity or prevent the progression of hallux valgus.9

  • Nonsurgical management of hallux valgus is aimed at reducing the pain related to the prominence.

    • Patients should be advised to wear wider and deeper shoes.

    • Softer material such as mesh or soft leather tends to be more flexible to accommodate the prominence.

    • If the deformity is flexible, toe spacers may help reduce the prominence.1

    • Orthotics may be of limited benefit.11

Outcomes/Current Data Include the Following Studies

  • Nakagawa et al11 recruited 65 patients older than 20 years with an HVA over 20° and a symptomatic bunion who were interested in nonsurgical management. These patients were noted to have a significant decrease in their visual analog scale score at 6 months after wearing the orthotics. However, although the effect was still
    statistically significant, the effect of the orthotic diminished at the 12-month mark.

  • A 2-year follow-up study12 showed that 81% of patients continued to use the orthotics at the 24-month mark. This study confirmed no radiographic change in the HVA or IMA.

Surgical Intervention

Techniques—Top Three

Chevron Bunionectomy

Applied Anatomy/Approaches (Relevant Landmarks)

  • A distal soft tissue (a modified McBride procedure [soft-tissue release without sesamoidectomy]) may be performed with the chevron bunionectomy and is usually performed first.

    • An incision is initially made in the first web space and dissection is carried down to the lateral sesamoid.

    • A toothed laminar spreader may be placed between the metatarsals to allow better visualization.

    • The attachments to the lateral sesamoid are then released sequentially including:

      • The head of the adductor hallucis tendon is released off the lateral sesamoid.

      • Lateral suspensory sesamoid ligament is released from proximal to distal.

      • The lateral capsule is pie-crusted.

      • The intermetatarsal ligament is released from distal to proximal.

    • Alternatively, a release of the lateral suspensory sesamoid ligament may be completed through the first MTP joint after exposure.

  • The chevron osteotomy is next completed by making a medial incision over the medial eminence extending approximately halfway down the shaft of the first metatarsal.

  • Dissection is completed down to the medial capsule, being sure to carefully retract the dorsomedial cutaneous nerve that runs just dorsal to the incision.

  • An incision in the medial capsule is made and the capsule carefully elevated dorsally and plantarly being sure to preserve two robust cuffs of tissue to allow for a capsulorrhaphy at the end of the procedure.

  • The medial eminence is next shaved off before completing the bunionectomy.

  • The chevron bunionectomy is a V-shaped cut centered at the distal metatarsal head (Figure 5).

  • After this is complete, the metatarsal head is translated laterally.

  • This may be fixed with many different options but is often held in position with a single screw from dorsal to plantar being sure not to penetrate the plantar metatarsal head or the articular surface.

  • After the translation is complete, the overhanging medial bone is shaved down in line with the medial foot.

  • Some redundant capsule may be excised and a capsular imbrication performed.

Indications for Particular Technique

  • Mild deformity, usually with a 1-2 IMA less than approximately 13° and an HVA less than 20°.

Fixation Strategies

  • Typically a single compression screw is used across the chevron bunionectomy.

  • However, an absorbable screw may also be used9 as well as Kirschner wire (K-wire) fixation.13

  • More recently an intramedullary plate has been introduced as a fixation option for chevron bunionectomies.14

Postoperative Orders

  • Patients are generally allowed to bear weight on the heel directly after surgery.

  • Patients are advised to elevate the foot as often as possible to decrease swelling and possibly lower the rate of wound healing complications that can be related to excessive swelling.

  • Patients are allowed to bear weight as tolerated in the postoperative shoe for 6 weeks and then transition into a regular supportive shoe.

  • Some providers may recommend a toe spacer or strapping of the toe for up to 12 weeks following surgery.

Pearls and Pitfalls

  • It is very important to ensure that the osteotomy is translated directly lateral to avoid shortening or lengthening the first metatarsal when translated the metatarsal head. The surgeon similarly must avoid plantar flexion or dorsiflexion at the osteotomy site.

  • Osteonecrosis is a potential complication following chevron bunionectomies thought to occur as a result of stripping of the plantar and lateral periosteum;9 unnecessary stripping of the bone should be avoided.


  • Kaufmann et al13 sought to determine what factors were related to recurrence following chevron bunionectomies. They found that the radiographic factors that contributed to recurrence were an
    increased preoperative IMA and HVA and preoperative DMAA and sesamoid position.

  • Matsumoto et al14 published data on intramedullary fixation following chevron osteotomies. An average of 17.8° of correction of the HVA and 7.4° improvement in the IMA were found. Translation of the head of the metatarsal 6.5 mm was achieved and all patients had a successful union.

  • A technique with a longer plantar limb on the chevron bunionectomy has been introduced to correct more severe deformities. Song et al15 performed a retrospective analysis of 36 patients with moderate deformity and 36 patients with severe deformity using the extended distal chevron osteotomy technique. There was significant improvement in all radiographic angles within normal values for both the moderate and severe deformities. Eighty-two percent of patients in the moderate group and 81% of the patients in the severe group rated outcome as good to excellent.15

  • Quality of life may also be improved for patients with hallux valgus following chevron bunionectomy. Surgery improved the Short Form-36 (SF-36) scores for general health, emotional well-being, role limitations due to personal or emotional problems, physical functioning, and bodily pain. Age and duration of symptoms were related to lower postoperative scores for emotional well-being and bodily pain.16

Scarf Bunionectomy

Applied Anatomy/Approaches (Relevant Landmarks)

  • A modified McBride lateral soft-tissue release may be used before the scarf bunionectomy (see aforementioned description of chevron bunionectomy).

  • The medial first metatarsal and first MTP joint is exposed by making a medial incision over the medial eminence extending approximately from the proximal phalanx distally to the first TMT joint proximally.

  • A dissection is completed down to the medial capsule, being sure to carefully retract the dorsomedial cutaneous nerve that runs just dorsal to the incision.

  • An incision in the medial capsule is made and the capsule carefully elevated dorsally and plantarly, being sure to preserve two robust cuffs of tissue to allow for a capsulorrhaphy at the end of the procedure.

  • A complete dorsal release of the periosteum is important for fixation, but care must be taken to avoid overdissection dorsolaterally or plantarly and disruption of the vascular supply to the metatarsal head.

  • Before making the osteotomy incision, a K-wire may be passed to guide the cut from the medial metatarsal head, approximately 5 mm proximal to the articular cartilage and at the dorsal one-third to two-third junction of the width of the metatarsal head. The K-wire is aimed toward the fourth metatarsal head and in a slight plantarward direction to avoid lengthening or shortening the metatarsal head as it is translated.

  • The scarf bunionectomy is then completed with three separate cuts. The initial cut is a longitudinal cut that is sloping plantarward from distal to proximal. The proximal and distal cuts are then made at approximately 55° to 60°1,9 (Figure 6).

  • After ensuring that there are no periosteal connections between the shaft and the metatarsal head, the distal metatarsal is translated laterally and rotated medially. The reduction is then held with wires and two screws are generally placed to compress the osteotomy.

  • The overhanging bone is then resected in line with the medial foot and smoothed down to avoid prominences. Some redundant medial capsule may be excised and a capsular imbrication performed using 0 or 2-0 absorbable sutures in a pants-over-vest fashion.

Indications for Particular Technique

  • Moderate to severe bunion deformities

Fixation Strategies

  • In general, two compression screws are placed across the osteotomy.

Postoperative Orders

  • Patients are generally allowed to bear weight on the heel immediately after surgery.

  • Patients are advised to elevate the foot as often as possible to decrease swelling and possibly lower the rate of wound healing complications that can be related to excessive swelling.

  • Patients are allowed to bear weight as tolerated in the postoperative shoe for 6 weeks and then transition into a regular supportive shoe.

  • Some providers may recommend a toe spacer or strapping of the toe for up to 12 weeks following surgery.

Pearls and Pitfalls

  • It is important to avoid lengthening or shortening the first ray. To accomplish this, a K-wire may be placed under fluoroscopic guidance to ensure that the distal metatarsal is being translated directly lateral. If the metatarsal is shortened, this may result in transfer metatarsalgia where the load is placed on the second metatarsal head resulting in overload and pain. Lengthening of the metatarsal can result in stiffening of the first MTP joint. It is also important not to plantarflex or dorsiflex the metatarsal during translation.


  • A long-term study evaluated 75 patients (88 feet) in Hong Kong with an average 92-month follow-up. Mean overall American Orthopaedic Foot and Ankle Society (AOFAS) scores improved from 29.6 to 86.83 points and the visual analog scale score improved from 6.61 to 0.66. The average HVA correction was 25.42° and average IMA correction was 8.49°. However, the 8- to 10-year recurrence rate of the HVA over 20° was 31.8% with a higher preoperative HVA more likely to result in recurrence.17

  • Law et al18 found that scarf bunionectomy for severe deformity had excellent patient-reported outcomes and radiographic outcomes regardless of severity of deformity at 2-year follow-up.

  • A recent abstract described a retrospective study of 22 male patients (26 feet) who underwent scarf bunionectomy and in whom there was a significant improvement in both patient-reported outcomes and radiographic outcomes. There was improvement in visual analog scale score and SF-36 physical scores. IMA improved from 15.9° to 8.7° and HVA improved from 36.1° to 15.1°. These results were maintained over 7.6 years.19

  • A midterm retrospective cohort similarly showed improvement in radiographic parameters at an average of 13 months postoperatively. Patients had improvement of IMA from 14.3° to 7.9° and improvement of HVA from 32° to 11°. Only two patients reported complications—one with a symptomatic screw and the other with a fracture at the osteotomy site.20

  • A recent study measured postoperative foot width on radiographs following scarf bunionectomy. The change in the foot width was minimal and on average the width was reduced 2%. Those with larger deformities had a decrease in width, whereas those with smaller deformities had a paradoxical increase in foot width.21

Lapidus Bunionectomy

Applied Anatomy/Approaches (Relevant Landmarks)

  • A modified McBride procedure may be used for lateral soft-tissue release.

  • The approach to the Lapidus procedure begins with a dorsal incision over the first TMT joint. The EHL is identified, the tendon sheath is opened, and the tendon is retracted laterally (if the incision is dorsomedial, retract the tibialis anterior tendon medially).

  • In incision is then made directly over the capsule to expose the first TMT joint. An elevator is placed into the joint to free the capsule and allow full exposure down to the plantar aspect of the joint.

  • Using a combination of tools such as a chisels, curets, and microsagittal saws, the cartilage is removed from the joint. The joint is irrigated and evaluated until all of the cartilage has been sufficiently removed. The joint is then prepared either using a chisel in a fish-scaling manner or by using a small drill to penetrate the subchondral bone.

  • The joint is reduced and compressed with a pointed reduction clamp and held in place with a K-wire. When the first metatarsal and 1-2 IMA are sufficiently reduced, joint fixation is
    accomplished with either two crossing cannulated screws, a plate, or a combination of techniques.

  • After the first metatarsal is corrected, the medial eminence of the first metatarsal may be shaved down. This is performed through an incision directly over the medial eminence.

  • The medial capsule is split and the medial eminence shaved down with a saw. A capsular imbrication is completed following removal of the medial eminence.

Indications for Particular Technique

  • The Lapidus bunionectomy a fusion of the first TMT joint and is indicated for moderate to severe bunions or for cases with hypermobility of the first ray. This can also be considered in cases where the patient has a flatfoot for first TMT joint arthritis.1

Fixation Strategies

  • Options for fixation include crossing cannulated screws or plating. Newer techniques include intramedullary nailing.

Postoperative Orders

  • Postoperatively, patients typically do not bear weight for 6 to 12 weeks.

  • The patient’s foot is usually immobilized initially in a splint and after suture removal the transition is made into a boot or cast based on the surgeon’s preference.

Pearls and Pitfalls

  • Whenever performing a fusion, nonunion or malunion is a potential complication. In particular with this technique, a dorsiflexion malunion must be avoided. The first TMT joint is approximately 30 mm deep and approached dorsally. It is imperative that the plantar aspect of the joint be meticulously prepared to avoid this complication. Additionally, a clamp placed dorsally could accentuate a dorsiflexion force, so this should be monitored as well.


  • Studies have recently been evaluating the effect of early weight bearing on union rates for Lapidus bunionectomies.

    • One recent review of 8 clinical trials with 12-month minimal follow-up concluded that there was a 3.61% rate of nonunion with early weight bearing less than 2 weeks after surgery.22

    • Another recent study evaluated the addition of a crossing screw into the middle cuneiform with an average follow-up of 9.3 months. They reported a 96.7% union rate, a 6.8° improvement in the IMA, and 14.8° improvement in the HVA.23

    • Barp et al24 evaluated different constructs in their patient population in a retrospective review. A total of 147 patients were treated with an intraplate compression screw, a solid crossing screw, and a single screw with a locking plate all performed by a single surgeon. The overall nonunion rate was 6%, with 4% requiring hardware removal. There was no statistical significance between the different fixation constructs.




  • The first MTP joint is the most common location of arthritis in the foot.25

  • 10% of adults have symptomatic hallux rigidus, although it is predicted that many more have radiographic evidence of arthritis.25


  • Risk factors

    • Occurs more often in females than males

    • Family history: those with a family history are more likely to have bilateral disease versus unilateral disease in those with a history of trauma.26

    • Flatter or chevron-shaped metatarsal head27

    • Patients with trauma to the great toe, either a single event or repetitive microtrauma, are at risk for the development of hallux rigidus.25

    • There does not seem to be any relationship to Achilles tendon tightness, foot positioning, first metatarsal elevation, or first ray hypermobility.26

Pertinent Anatomy/Pathoanatomy

Oct 25, 2023 | Posted by in ORTHOPEDIC | Comments Off on My Foot and Ankle Hurt

Full access? Get Clinical Tree

Get Clinical Tree app for offline access