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Hallux varus and hallux valgus (commonly referred to as bunions) are deformities of the big toe that can cause pain, difficulty walking, and problems with footwear. These conditions are often linked, with hallux varus sometimes occurring as a complication of bunion surgery. While surgery is a treatment option, strengthening specific muscles in the foot and lower leg may help reduce symptoms and improve function.

Signs & Symptoms

Hallux Varus

  • Medial deviation (inward angling) of the big toe
  • Difficulty wearing shoes due to the misalignment
  • Instability and weakness during walking and push-off
  • Pain, particularly when the toe rubs against footwear
  • Limited movement at the metatarsophalangeal (MTP) joint
  • Possible development of claw toe deformity

Hallux Valgus (Bunions)

  • Lateral deviation (outward angling) of the big toe
  • A bony lump forming at the base of the big toe
  • Redness, swelling, or tenderness around the MTP joint
  • Pain, which may worsen with prolonged standing or walking
  • Restricted toe movement
  • Difficulty finding well-fitting shoes

Causes and Contributing Factors

Hallux Varus

  • Overcorrection following hallux valgus (bunion) surgery
  • Muscular imbalances, particularly affecting the abductor hallucis, adductor hallucis, flexor hallucis brevis, and extensor hallucis muscles
  • Congenital abnormalities
  • Rheumatoid arthritis or other inflammatory joint conditions
  • Trauma or excessive stretching of the ligaments

Hallux Valgus (Bunions)

  • Genetic predisposition
  • Footwear that is too tight, narrow, or high-heeled
  • Ligamentous laxity, often seen in people with flat feet
  • Increased weight-bearing pressure on the forefoot
  • Hypermobile first ray (increased movement at the base of the first metatarsal)
  • Structural abnormalities in the foot, such as metatarsus primus varus (a medial angling of the first metatarsal)

Grading of Deformity

Hallux varus deformities are classified into three types:

  • Type 1: Bone deformity
  • Type 2: Myoligamentous (muscle and ligament) imbalance
  • Type 3: Combined deformity

For hallux valgus, the severity is measured using the hallux valgus angle (HVA) and intermetatarsal angle (IMA):

  • Mild: HVA < 20° and IMA < 11°
  • Moderate: HVA 20°–40° and IMA 11°–16°
  • Severe: HVA > 40° and IMA > 16°

Prognosis

The progression of both conditions depends on several factors, including footwear choices, activity levels, and muscle strength.

  • Hallux varus may remain stable or worsen over time, especially if left untreated. In severe cases, surgery may be needed to realign the toe.
  • Hallux valgus tends to worsen gradually. While surgery can correct the deformity, there is a 15% recurrence rate due to ongoing biomechanical issues and weak foot muscles.

Treatment

Physiotherapy and Rehabilitation

Physiotherapy plays a key role in managing both conditions, either as a primary treatment for mild cases or as post-operative rehabilitation.

Muscle Strengthening

Weakness in key foot and calf muscles can contribute to deformities and pain. Strengthening exercises target the following muscles:

  • Foot muscles: Abductor hallucis, adductor hallucis, flexor hallucis brevis
  • Calf muscles: Tibialis posterior, peroneus longus

Manual Therapy

Hands-on techniques may help improve joint mobility and reduce pain. This includes:

  • Mobilisation of the first MTP joint to restore flexibility
  • Soft tissue release for tight muscles and fascia
  • Gait retraining to improve walking mechanics

Functional Training

Restoring normal foot function is essential. Physiotherapists may guide patients through:

  • Balance exercises to improve foot control
  • Walking drills to ensure correct weight-bearing through the first metatarsal
  • Toe-strengthening exercises to enhance push-off power

Pain Management

  • Ice therapy to reduce inflammation
  • Taping or splinting to support the big toe and relieve pressure
  • Custom orthotics to correct foot alignment and reduce strain

Post-Surgical Rehabilitation

For patients recovering from hallux valgus surgery, a structured physiotherapy program can:

  • Reduce swelling through lymphatic drainage and elevation
  • Restore normal gait patterns through targeted exercises
  • Strengthen the peroneus longus muscle to prevent complications
  • Improve mobility through joint mobilisations

Studies suggest that rehabilitation can enhance weight-bearing function of the first day after bunion surgery, leading to better long-term outcomes.

Non-Surgical Options

  • Footwear modifications: Wide toe box, cushioned soles, and low heels
  • Splints or toe spacers: Help maintain toe alignment, particularly in early-stage hallux valgus
  • Taping techniques: Can support the toe and reduce pain, particularly when combined with exercise

Surgical Treatment

Surgery is considered when conservative treatments fail. The aim is to:

  • Correct deformity
  • Restore normal gait patterns
  • Maintain joint function

Procedures for hallux varus include:

  • Tendon transfers: To rebalance muscular forces
  • Soft tissue releases: To correct overcorrection from previous bunion surgery
  • Bone realignment (osteotomy): If the deformity is severe

Procedures for hallux valgus include:

  • Chevron or Scarf osteotomy: To realign the first metatarsal
  • Lapidus procedure: For hypermobile first rays
  • Keller resection arthroplasty: For severe cases with arthritis

Surgical success rates are high, but recurrence is possible without proper rehabilitation.

Physiotherapy provides a valuable non-surgical approach for managing hallux varus and hallux valgus. Strengthening exercises, manual therapy, and functional retraining can improve foot function and reduce pain. For post-surgical patients, rehabilitation enhances recovery and helps prevent recurrence.