Hallux Valgus: Prevalence and Treatment Options

Background: Hallux valgus is a common deformity. Surgical treatment strategies have evolved markedly in recent years. We report on the administrative prevalence of this condition and the available treatments for it.

Methods: The administrative prevalence of hallux valgus and the treatments provided for it in Germany were determined from data supplied by BARMER, a statutory health insurance carrier. The classification and treatment of hallux valgus are outlined in a narrative overview, with particular attention to a meta-analysis.

Results: The administrative prevalence of hallux valgus in Germany is nearly 2%; 83% of the affected persons are women. Over a 6-year period, the number of operations declined, and there was a trend toward outpatient treatment. Hallux valgus should be classified as either mild/moderate or severe. The common surgical procedures achieved comparable correction of the bony deformity. The AOFAS score improved by an average of 33.8 points (95% CI: [30.5; 37.0]) across all surgical techniques, reaching average postoperative values that ranged from 81.4±7.7 and 90.1±4.8 points depending on the particular technique used. The choice of technique and the duration of follow-up had no significant effect on the subjective treatment outcome. The overall complication rate after surgical correction was 18.5%. The common complications were metatarsalgia, recurrent deformity, stiffness of the first metatarsal joint, wound-healing disorders, and hallux varus.

Conclusion: The primary treatment of hallux valgus should be conservative. The various surgical techniques correct the bony deformity with comparable efficacy and good postoperative AOFAS scores. Patients with more severe deformities and greater impairment seem to have a higher potential for improvement in the AOFAS score.

Cite this as: Ettinger S, Spindler FT, Marschall U,
Polzer H, Stukenborg-Colsman C, Baumbach SF: Hallux valgus: Prevalence and treatment options. Dtsch Arztebl Int 2025; 122: 308–14. DOI: 10.3238/arztebl.m2025.0068

Hallux valgus or bunion is a deformity of the big toe (hallux) characterized by an outward deviation of the big toe and an inward deviation of the first metatarsal bone (1). Patients with bunions present with pain, impaired mobility and discomfort when wearing shoes.

Even today, the pathogenesis of primary hallux valgus is not fully understood; the underlying mechanisms are most likely multifactorial. Possible factors include a genetic (familial) predisposition, muscular dysfunction and an inherited weakness of the capsule-ligament structures. Secondary causes discussed include posttraumatic and osteoarthritic changes as well as neuropathic conditions.

The work-up of symptomatic hallux valgus should comprise both clinical examination and imaging. Patients with clinically apparent but asymptomatic hallux valgus do not require routine diagnostic studies. The physical examination comprises inspection, where special attention should be paid to the condition of the skin/soft tissue overlying the hallux valgus pseudoexostosis, a concomitant misalignment of the small toes, and the extent of the valgus deformity of the big toe. In addition to palpation, the range of motion of the first metatarsophalangeal (MTP) joint and the adjacent joints should be assessed. Peripheral perfusion as well as motor function and sensitivity should also be assessed and the footwear should be examined for possible pressure points and signs of wear on the medial edge of the shoe. Imaging work-up should include standing weight-bearing radiographs of the foot in at least two views. In some cases, further radiographic work-up may be useful.

Learning objectives

This article should enable the readers to:

• know the administrative prevalence and surgical care situation in Germany (1),
• and to understand the current evidence with regard to the classification and surgical management of hallux valgus (2, 3).

In this CME article, the classification and treatment of hallux valgus and the available evidence are discussed, taking a systematic meta-analysis, focusing on patient-oriented endpoints, into account.

The prevalence and surgical care situation in Germany

The administrative prevalence of hallux valgus and the surgical treatment provided for it in Germany were determined based on longitudinal data on out- and in-patient medical services supplied by BARMER, a statutory health insurance carrier. This cohort, which has already been used in numerous other research projects (2, 3, 4), comprises nationwide data with a sex and age distribution comparable to other Western European countries. The data presented here was age- and gender-standardized and extrapolated to the German population. Details on the methods used are provided in the eMethods section.

Prevalence

Figure 1 shows the administrative prevalence of hallux valgus in the German population, overall and stratified by sex. The mean overall administrative prevalence across the entire period was 1 314 580 persons per year in Germany (approximately 1.9% of the total population; range: 1 219 900 [1.8%] to 1 385 700 [2.0%]). The sex distribution was constant, with female patients accounting for 83.3% (82.4%–84.5%). The analysis of prevalence rates by age group showed a significant increase over the study period, most notably in the over-80 age group (eFigure a).

Figure 1

Prevalence of hallux valgus in Germany

eFigure

Prevalence of hallux valgus in Germany

Surgical care

The number of hallux valgus operations are depicted in eFigure b. Overall, the number of surgical procedures declined, most notably in female patients. Whereas 44 490 surgical procedures were performed in 2014, this figure had declined to 30 480 procedures in 2023 (−31.5%; decline in female patients: −34.5%; decline in male patients: −2.1%). The percentage shares of the operation groups in relation to the total number of surgical procedures are shown in eFigure c. Primarily the joint-preserving surgical techniques were in decline, whereas an upward trend was noted for the proportion of TMT-I arthrodesis.

The decline in the number of surgical procedures starting in 2020 is thought to be due to the impact of the Corona pandemic. During the pandemic, a significant drop in the number of treatments provided was observed across the entire health sector. The interpretation of the decline in the number of operations in the years 2014–2019 can only be based on hypotheses. Possible explanations included a change in coding practice, incomplete documentation, changes in the OPS classification and their impact, as well as a change in the indication for and remuneration of the surgical correction of hallux valgus.

A multinomial logistic regression analysis found that age and sex influenced the chance of having hallux valgus surgery. Age had no appreciable impact on the chance of having surgery (odds ratio [OR] 0.966; p<0.001). Women had a higher chance of having surgery than men (OR 1.801; p<0.001). With regard to the choice of the surgical technique, age had no appreciable impact on the change of having either metatarsophalangeal (MTP) joint arthrodesis (OR 1.068; p<0.001) or tarsometatarsal (TMT) joint-I arthrodesis (OR 1.01; p<0.001). The role played by sex varied: Women were less likely to receive MTP joint arthrodesis (OR 0.573; p<0.001), while no significant difference between the sexes was found for TMT-I arthrodesis (OR 1.027; p = 0.541).

Finally, outpatient (either in a hospital or ambulatory surgery clinic setting) and inpatient surgery were compared over the course of the years (eFigure d). Here, a trend toward outpatient treatment was noted for all surgical procedures. The increasing number of surgical procedures performed on an outpatient basis is best explained by a combination of medical advances and structural changes. Thanks to new surgical techniques, modern perioperative pain and anesthesia management and more information for patients, hallux valgus correction surgery can now be performed safely on an outpatient basis. In addition, performing surgery on an outpatient basis is in line with an overriding health policy interest (resource efficiency, cost reduction, redistribution) seen in many areas of operative medicine.

Dataset for the classification and treatment of hallux valgus

We performed a systematic review and meta-analysis to obtain the dataset used to assess the classification and treatment of hallux valgus (5). Included were all prospective comparative studies (1 January 2012–31 January 2023) focusing on the surgical treatment of primary hallux valgus which reported data on at least one objective outcome parameter. 31 studies with a total of 53 study arms were included in the final meta-analysis. 23 studies with 38 study arms were prospective, randomized, controlled trials (RCTs). In the studies included, the following open or minimally invasive surgical techniques were used: Chevron distal (23 studies; 33 study arms), Scarf (16 studies; 23 study arms), Chevron proximal (3 studies; 3 study arms), TMT-I arthrodesis (4 studies; 5 study arms), second generation minimally invasive surgery (MIS) (6 studies; 6 study arms), third generation MIS (7 studies; 9 study arms). The mean patient age was 50 ± 9 years, 88 ± 19% of patients were female and the mean follow-up period was 34 ± 37 months.

Classification of hallux valgus

The severity of the hallux valgus deformity is usually classified based on a dorsoplantar weight-bearing standing radiograph of the foot. Traditionally, hallux valgus deformity has been classified as mild, moderate or severe, based on the intermetatarsal angle (IMA) and the hallux valgus angle (HVA) (1, 6, 7).

Normal findings are defined as an IMA<9° and an HVA<15° (1, 6, 7). This is where consensus usually ends. The eTable shows that the currently used classifications are rather heterogeneous. Ultimately, an IMA of 14° can be classified as mild, moderate or severe, depending on the study and the severity classification used (8).

eTable

Overview of the most commonly used classification, the results of this meta-analysis as well as the new classification

This heterogeneity casts doubt on the validity of the existing classifications. In addition, other factors, such as metatarsus adductus, rotation of the big toe and instability of the first tarsometatarsal joint, are not taken into account. For these reasons, the currently used classification was adapted. The adapted classification is based on the available literature (7, 8, 9) and the correction potential of the various osteotomy procedures. It recommends to use only a binary classification of severity into “moderate“ and “severe“ (eTable) (8).

Treatment of hallux valgus

In the following, the available treatment options will be discussed, with a focus on indication for surgery and patient-oriented endpoints.

Conservative treatment

It is recommended to initially provide conservative treatment over a period of about three months. In addition to counselling and pain pharmacotherapy (based on the WHO analgesic ladder), conservative management comprises fitting of footwear, physical therapy, and orthopedic technology. Orthopedic technology may involve the provision of insoles, positioning splints and/or shoe adjustments. While conservative treatment is not causal, it frequently alleviates symptoms.

Indication for surgery

In patients with symptomatic hallux valgus, surgical treatment is indicated if conservative treatment was unsuccessful. General criteria for an indication for surgery include significant distress/pain, reduced quality of life, functional limitations, and recurrent pressure sores /ulcers of the skin overlying the pseudoexostosis. Ultimately, the decision to perform surgery is made jointly by the surgeons and the patients after careful consideration of the risks and benefits.

Surgical techniques

More than 100 different surgical techniques for correction of hallux valgus deformity have been described (1). The currently prevailing surgical techniques can be divided into joint-preserving (osteotomy) and joint-stiffening (arthrodesis) procedures. Joint preservation procedures are further divided into open and minimally invasive procedures. Traditionally, the surgical technique is chosen based on the severity of the hallux valgus deformity. Up until now, the dogma has been that the different surgical techniques offer different corrective potential.

The meta-analysis helped to put this dogma into perspective (5). We showed that the osseous correction potential (difference before and after surgery) of the studied surgical techniques (Chevron distal, Scarf, Chevron proximal, tarsometatarsal (TMT)-I arthrodesis, second generation MIS, third generation MIS) was comparable. Across all techniques, IMA improved on average by 7.3° (95% confidence interval: [6.7°; 7.9°]) and HVA by 18.9° [17.3°; 20. 4°]. For IMA, no significant differences between the various surgical techniques were found. Only the use of third generation MIS seems to result in a significantly better HVA correction (21.2° [19.2°; 23.2°]) compared to the other assessed surgical techniques.

Based on these findings, an up-to-date treatment algorithm was developed (Figure 2). It has the new binary classification (moderate versus severe) at its core and attempts to cover the most commonly used surgical techniques. Two additional modulators were included: arthrosis of the metatarsophalangeal joint and instability of the first tarsometatarsal joint. However, other factors, such as the axis of the rear foot, torsion of the first metatarsal bone and the distal articular surface angle, can also influence the choice of surgical procedure.

Figure 2

Schematic representation of current treatment recommendations based on the new bilateral classification

Subjective surgical outcomes

As described above, the primary indication for surgical correction is a painful hallux valgus refractory to conservative treatment. Thus, the subjective treatment outcomes play a special role in the evaluation of the surgical outcome. As with the evaluation of osseous correction potential, the subjective treatment outcome of the patients was examined cumulatively (5). Subjective patient satisfaction could only be evaluated with regard to the American Orthopedic Foot and Ankle Society Score (AOFAS score). It is the most commonly used questionnaires, composed of a subjective (to be completed by the patients; maximum score of 60 points) and an objective (to completed by physicians; maximum score of 40 points) part. The score has attracted criticism for its investigator bias and a disproportionate representation of the pain domain (40 points) (10). AOFAS scores between 80 to 90 points are generally classified as good, scores higher than 90 points as very good (11). Figure 3 shows pre- and postoperative AOFAS scores at the last follow-up (34 ± 38 months) (12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30). The mean improvement in AOFAS score after surgery was 33.8 points [30.5; 37.0]. The cumulative, weighted mean AOFAS scores at the time of the last follow-up ranged between 81.4 ± 7.7 points and 90 ± 4.8 points. The available evidence did not allow for a more detailed evaluation, for example with regard to the proportion of patients with an AOFAS score above 80 points. Neither the choice of surgical technique used nor the duration of follow-up had a significant effect on the subjective treatment outcome. However, a positive correlation between subjective treatment outcome, as measured using the AOFAS score, and severity of the initial deformity was found. The preoperative IMA and HVA values account for 69% and 39%, respectively, of the postoperative improvement, while for ASOFAS scores this value was 82% (5). Consequently, patients with a higher degree of misalignment and severe functional impairment/pain appear to subjectively benefit more from surgery.

Figure 3

Presentation of the pre- and postoperative (final follow-up) values of the AOFAS score, by the various surgical techniques

Complications after surgical treatment

As with any surgical treatment, complications after surgical correction of hallux valgus are inevitable. The actual risk depends on multiple factors, including the choice of surgical procedure, individual risk factors, and postoperative follow-up care. Since the terminology used in the individual studies varies widely, it is not possible to make a definite valid statement on complications (31). Due to this heterogeneity, no quantitative but only a qualitative statement on the complication rate after hallux valgus correction can be made.

In the studies included in the meta-analysis (5), the complication rate across all surgical techniques was 18.5%. The most common complications were metatarsalgia, recurrent deformity, stiffness of the first metatarsal joint, wound-healing disorders, and hallux varus. There appeared to be no significant differences in complication rates between open and minimally invasive procedures (32, 33). Although rare, severe complications, such as avascular necrosis of the first metatarsal head, non-union, complex regional pain syndrome (CRPS), and revision surgery, did occur in up to 5% of cases (34, 35).

The patient perspective

Hallux valgus is a deformity of the big toe which progresses over time. In many cases, the misalignment does not cause pain. In some patients, however, the joint or the medial pseudoexostosis may be painful if irritated by pressure points caused by the chosen footwear. Other patients are more concerned with the externally visible deformity, which they perceived as unaesthetic or stigmatizing, than with the pain (36).

Initially, the patient should receive conservative treatment, focusing mainly on modifying the footwear. Shoes should be of adequate size, spacious in the toe box and made of soft material. While physiotherapy, insoles and positioning splints can alleviate discomfort in some patient, they do not change the progressive deformity (37).

After three months of unsuccessful conservative treatment, surgical treatment may be considered. The decision for surgical treatment must be made jointly with the patient and the patient‘s expectations must be brought into line with the expected healing process and treatment outcome (5).

The primary wound healing period after surgical hallux valgus correction is about 8 to 12 weeks, with high inter-individual variance (38). During the first two postoperative weeks, the foot should be kept elevated until wound healing is completed and, depending on the surgical procedure, weight bearing should be reduced with the help of crutches. A special shoe (e.g. a surgical shoe) should usually be worn for six weeks. Subsequently, the patient can wear ready-made shoes again; however, the choice of shoes can initially be limited due to a persistent swelling. Mobility of the metatarsophalangeal joint may be reduced for up to a year, depending on the surgical technique used.

After about four weeks, patients with primarily sedentary tasks can return to work. However, this is only possible, if the commute allows it. Patients with a longer commute to work, possibly relying on their own car, or with a standing profession may be unfit for work for around 12 weeks.

Patients often underestimate this protracted healing process (36). They may also experience “setbacks”, such as renewed pain with increased activity, a stubborn scar, swelling or impaired joint mobility. Therefore, a detailed informed consent discussion and a close doctor-patient relationship are crucial.

Conclusion

Hallux valgus is one of the most common foot deformities and has a multifactorial pathogenesis. In addition to the clinical examination, its work-up includes standing weight-bearing radiographs of the foot in at least two views. In some cases, an extended work-up may be useful. In Germany, on average almost 2% of the population suffers from hallux valgus (83% women; administrative prevalence). Between 2014 and 2019, a decline in the number of hallux valgus operations was noted (primarily among joint-preserving procedures). In addition, a trend toward outpatient treatment was observed in surgical care. The currently used classifications of hallux valgus show a high degree of heterogeneity. Based on the findings of a current systematic review (8), it is recommended to reduce the classification of hallux valgus to two degrees of severity: moderate and severe. Initially, patients should receive conservative treatment for about three months. The indication for surgical treatment of hallux valgus is usually established jointly with the patient after unsuccessful conservative treatment. The most common surgical procedures show a comparable osseous correction potential. Likewise, the subjective treatment results appear to be comparable for all surgical procedures. The AOFAS score improved by 33.8 points on average (95% CI: [30.5; 37.0]). However, patients with a higher degree of misalignment and severe functional impairment appear to subjectively benefit more from surgery. The overall complication rate after surgical hallux valgus correction is about 18.5%. The most common complications were metatarsalgia, recurrent deformity, stiffness of the first metatarsal joint, wound-healing disorders, and hallux varus. Whether surgery is performed using an open or minimally invasive approach does not appear to have an impact on the complication rate. Educating patients about the post-operative healing course is of particular importance. The primary healing period after surgery is about 8 to 12 weeks. This protracted healing process is frequently underestimated by patients.

Acknowledgement

The authors would like to thank the working group Science of the German Association for Foot and Ankle (D.A.F., Deutsche Assoziation für Fuß und Sprunggelenk) for its support of our systematic literature search and metaanalysis. Here, Prof. Dr. Natalia Gutteck, Prof. Dr. Sabine Ochman, PD Dr. Christian Plaaß, and Prof. Dr. Stefan Rammelt deserve special mention. We would also like to thank Laura Acar and Martial Mboulla Nzomo of the BARMER team for the great collaboration.

All authors, on behalf of the entire German Association for Foot and Ankle (D. A. F.), would like to thank Prof. Dr. Christina Stukenborg-Colsman for her outstanding achievements, humor, leadership, and visionary power. She was a pioneer in the field of foot and ankle surgery and a role model for an entire generation of orthopedic surgeons.

Conflict of interest statement
The authors declare that they have no conflicts of interest.

Manuscript received on 24 November 2024, revised version accepted on 3 April 2025.

Translated from the original German by Ralf Thoene, M.D.

Correspondence
Prof. Dr. med. Sebastian F. Baumbach

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