Background
The prevalence of hallux valgus, a foot deformity, is higher in women than in men [
1]. Based on measurements using a foot printer, hallux valgus was found in 29.7–41.5% of Japanese female university students [
2,
3]. Regarding hallux valgus and motor function in young women, feet with hallux valgus were shown to have significantly reduced toe flexor strength, and a correlation was found between toe flexor strength and maximum step length [
3]. Although a causal relationship has not been established, it is important to prevent hallux valgus from an early stage because feet with hallux valgus show decreased motor function.
It has been reported that the pronation of the metatarsals is characteristic of feet with hallux valgus [
4,
5]. Regarding the morphology of the hallux valgus and midfoot, the foot pressure distribution during walking on the hallux valgus showed that the foot pressure on the lateral side of the midfoot significantly decreased [
3], which is associated with midfoot pronation and decreased modified arch index [
6,
7]. With regard to the hindfoot of hallux valgus, a correlation has been observed between the hallux valgus angle and inward inclination angle of the calcaneus in older women [
8]. In medial knee osteoarthritis, a relationship between the hallux valgus angle and medial tilt of the calcaneus has been reported [
9‐
11]. Conversely, it has also been reported that the Q and tibiofemoral angles increase with hallux valgus [
12]. However, these previous studies were conducted on older people, and it is possible that the alignment of the lower leg due to knee joint disease has an effect on hallux valgus. Furthermore, the relationship between hallux valgus and varus/valgus of the hindfoot is unclear.
Hypermobility of the tarsometatarsal (TMT) joint has been reported to be a pathological condition of hallux valgus [
13,
14]. However, it is unclear whether hallux valgus causes hypermobility of the TMT joint or vice versa. The foot consists of many joints, including the TMT joint, and performs three-dimensional (3D) motion (dorsiflexion-plantarflexion, abduction-adduction, and eversion-inversion) and compound motion (pronation-supination). Feet with hallux valgus may differ, not only in TMT joint mobility, but also in the midfoot and hindfoot morphology compared to those without.
This study aimed to clarify the relationship between the morphology and mobility of the hindfoot with hallux valgus and explore the characteristics of the entire foot in young women with no injuries to the lower extremities.
Results
A total of 147 participants agreed to participate in this study. Of these, seven women with a history of knee and ankle surgery were excluded. Thirty-two women had bilateral or unilateral hallux valgus, and 108 had no hallux valgus. Table
1 presents the characteristics of the participants.
Table 1
Characteristics of participants
Age (years) | 19 | (18–19) | 19 | (18–19) | 0.144 |
Height (cm) | 158.0 | (154.0–161.0) | 157.8 | (152.9–161.2) | 0.584 |
Body weight (kg) | 51.2 | (47.0–56.0) | 48.8 | (46.4–52.0) | 0.027 |
BMI (kg/m2) | 20.5 | (18.9–22.5) | 19.9 | (18.7–21.1) | 0.546 |
Table
2 shows the foot morphology and ankle joint ROM depending on the presence of hallux valgus. The HFA was 3.44 ± 3.15° in participants without hallux valgus and 5.14 ± 3.48° in those with hallux valgus. The amount of change in arch-height ratio was 2.35 ± 1.02 mm/mm*100 in participants without hallux valgus and 2.86 ± 1.25 mm/mm*100 in those with hallux valgus. The degree of change in the arch-height ratio due to posture was significantly greater in participants with hallux valgus (
p = 0.021). There was no significant difference in the ROM of the ankle joint between participants with or without hallux valgus.
Table 2
Comparison of foot morphology and ankle range of motion on the presence of hallux valgus
Foot morphology |
HV angle | 10.3 (7.9–13.3) | 17.6 (16.8–19.9) | < 0.001 |
Arch-height ratio | 17.61 ± 2.20 | 16.76 ± 2.63 | 0.069 |
HFA | 3.44 ± 3.15 | 5.14 ± 3.48 | 0.010 |
Change in arch-height ratio | 2.35 ± 1.02 | 2.86 ± 1.25 | 0.021 |
Change in HFA | -2.15 ± 3.14 | -3.35 ± 2.87 | 0.055 |
Ankle joint ROM |
Dorsiflexion | 14.3(13.0–16.2) | 15.3(13.4–18.1) | 0.199 |
Plantarflexion | 7.7(6.7–8.5) | 7.5(6.8–8.5) | 0.546 |
Inversion | 42.5(38.0–53.5) | 50.0(42.0–55.0) | 0.133 |
Eversion | 24.0(20.0–30.0) | 23.5(20.0–32.0) | 0.913 |
Table
3 shows the correlation between foot morphology and ankle joint ROM depending on the presence of hallux valgus. In the group without hallux valgus, no relationship was observed between foot morphology and ankle ROM. In the hallux valgus group, the change in arch-height ratio and HFA was correlated with the ROM of eversion (
r = 0.391,
p = 0.027;
r = -0.362,
p = 0.042).
Table 3
Relationship between foot morphology and ankle joint range of motion depending on the presence of hallux valgus
No-HV n = 108 | | | | |
| Dorsiflexion | Plantarflexion | Inversion | Eversion |
HV angle | 0.089 | 0.022 | -0.191* | 0.135 |
Arch-height ratio | 0.010 | 0.118 | -0.124 | -0.009 |
HFA | 0.115 | -0.065 | 0.055 | -0.096 |
Change in arch-height ratio | -0.112 | -0.126 | 0.138 | 0.108 |
Change in HFA | -0.172 | 0.221* | -0.174 | -0.006 |
HV n = 32 | | | | |
| Dorsiflexion | Plantarflexion | Inversion | Eversion |
HV angle | 0.195 | -0.009 | 0.031 | -0.013 |
Arch-height ratio | -0.126 | -0.250 | -0.156 | -0.089 |
HFA | 0.026 | 0.210 | 0.210 | 0.082 |
Change in arch-height ratio | -0.032 | -0.002 | 0.308 | 0.391* |
Change in HFA | 0.027 | 0.275 | -0.112 | -0.362* |
Discussion
We compared the hindfoot morphology and ankle joint of ROM of young women with and without hallux valgus. The HFA in participants with hallux valgus was tilted inward, and the arch-height ratio decreased significantly when the sitting position was changed to the standing position. There was no difference in the ROM of the ankle joint with or without hallux valgus; however, with hallux valgus, there was a relationship between the angle of eversion on the frontal plane and the amount of change in arch-height ratio and HFA.
Regarding the fact that the calcaneus tilts inwards in participants with hallux valgus, radiographic observation of the hindfoot alignment of hallux valgus reveals valgus deviation of the subtalar joint [
22]. Furthermore, as observed using 3D computed tomography, large hallux valgus angles result in hindfoot bones that easily rotate in the everting direction. As a result, it has been reported that the talus may induce greater internal rotation of the first metatarsal [
23]. Hindfoot valgus is associated with pronation of the first metatarsal, and conversely, hindfoot varus is associated with supination of the first metatarsal, assessed using weight-bearing computed tomography [
24]. The morphology of the hindfoot is considered to be affected by the knee joint and middle foot. The participants in this study were young women who were not outpatients for lower extremity orthopedic disease at the time of the study and had not received knee or ankle surgery in the past. Among those with no knee joint problems, the findings confirmed that the foot with hallux valgus had a larger HFA, that is, the calcaneus tilted inward.
In addition, those with hallux valgus had a significantly greater amount of change due to posture with arch-high ratio than those without hallux valgus. In a study of healthy young people, it was reported that the arch-height index and flexibility changed depending on the weight-bearing load [
25], and it was confirmed that the arch changes with the weight-bearing load. Hypermobility of the first ray, which consists of the medial cuneiform bone, first metatarsal bone, and hallux – forming the arch – has been reported as a related factor in hallux valgus, although the causal relationship is unclear [
13]. According to computed tomography imaging of hallux valgus in a standing position, pronation of the first metatarsal bone is more affected than that of the first TMT joint [
5]. Therefore, in the present study, since the height of the navicular bone was measured as the arch height, the part of the bone that constitutes the medial arch was measured. Considering the chain reaction of the bones that form the arch, the large change in arch-height ratio in the hallux valgus group suggests that the bones that form the arch are highly mobile, as in other reports.
There was no difference in the ROM of the ankle joints with or without hallux valgus. A correlation has been reported between significantly increased ROM of the hip joint internal rotation, ankle dorsiflexion/plantarflexion, and first metacarpophalangeal joint dorsiflexion, together with significantly increased Q, tibiofemoral, and rearfoot angles, and the presence of hallux valgus [
12]. However, the above studies were limited by their small sample size, wide age range of the participants, and use of clinic attendees as the control group. In comparison, the participants of the current study were of a young age, and there seems to be no effect of age-related osteoarthritis. In addition, in this study, the ROM of the ankle dorsiflexion [
16] and plantarflexion [
17] was measured using a method that has been confirmed to be more reliable than or equal to angle measurement using a goniometer. Therefore, the current results may have differed from those of previous reports because of the use of different measurement tools. On the other hand, at a hallux valgus angle of ≥ 16°, the amount of change in arch-height ratio and HFA correlated with the ROM of eversion. It is presumed that hypermobility of the navicular and calcaneus bones that make up the medial arch increases ROM of eversion of the foot.
This study has several limitations. First, the footprint measurement was not based on radiographs because it was performed in healthy women. Therefore, it may be difficult to compare all results with radiographs because an index that can be perceived from the body surface was used. Second, the ROM of the ankle joint was measured using a non-invasive method. The ankle is a complex composed of the ankle joint and the subtalar joint [
26], and the movement of the ankle joint consists of multi-joint compound movements. In the assessment of ROM of the ankle joint, it is impossible to separate the movements of each joint, including the subtalar joint. Third, inversion and eversion ankle range of motion are movements of the frontal plane. However, the highly reliable measurement method with the goniometer is where the ankle was relaxed in comfortable plantarflexion. Therefore, it may be slightly different from the motion of the frontal plane. Fourth, the amount of weight-bearing load on the sole was not specified in the measurement of the arch-height ratio and HFA in the sitting position. It is not possible to compare the change in weight-bearing load from sitting to standing with the changes in arch height and HFA. Fifth, because arch height is a measure of navicular tubercle height, it may be difficult to compare with studies that directly assessed first-ray mobility. Sixth, 140 women were available for analysis, and while the sample size varied according to incidence, it was slightly under-represented in this study.
Conclusions
The results of this study indicated that, in feet with hallux valgus, HFA tilts inward, and the amount of change in the arch-height ratio increases depending on the posture. The amount of change in arch-height ratio and HFA correlate with the eversion angle, suggesting hypermobility of the bone joints that form the medial arch. To prevent hallux valgus from a young age, it is considered desirable to appropriately utilize footwear and insoles that support the arch and simultaneously suppress the inclination of the calcaneus.
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