Background
Hallux valgus (HV) is a highly prevalent and progressive musculoskeletal foot deformity, affecting one in three adults over 65 years of age, nearly one in four adults aged 18 to 65 years and 8 % of children (under 18 years old) [
1]. Corrective surgery is one form of management, with 6273 orthopaedic procedures performed in 2014 at a direct Medicare Australia cost of $2.5 million [
2]. Surgery is often done in conjunction with non-surgical treatments, which may be offered as an alternative to surgery for those with unfavourable medical comorbidities, age [
3] or lifestyle factors [
4]. Experts agree that non-surgical interventions should be the primary form of treatment offered in juvenile HV, and should always precede operative management, to attempt to reduce symptoms [
3‐
5]. Consequently, patients with HV often present to podiatrists or other health care practitioners for management [
6].
In managing HV non-surgically, practitioners and patients are confronted with a wide range of available options [
7], and limited research based evidence exists to inform such treatment decisions. The American College of Foot and Ankle Surgeons 2003 [
5] consensus statement for initial HV treatment (recommended prior to operative management), includes information on patient education, footwear modifications, orthoses, bunion pads, ice and anti-inflammatory medications. A 2004 systematic review [
8] of all interventions for HV (surgical and non-surgical), reported there were only three randomized controlled trials investigating non-surgical interventions for HV (total
n = 233), concluding at that time there was insufficient evidence supporting the efficacy of treatments studied (foot orthoses or night splints). No recent clinical guidelines or systematic reviews are available surrounding HV treatment, but two small clinical studies have reported equivocal effects of foot orthoses on structural alignment of the hallux (
n = 54) [
9], and for manual therapies versus night splints on pain in HV (
n = 30) [
10]. Compounding the situation of a wide range of available options and limited research based evidence is a lack of understanding of what current podiatric practice offers patients with HV.
Experts advise that treatment should be guided by the patient’s presenting problem [
7,
11], however the list of specific concerns reported in those presenting with HV varies widely [
12]. Studies have shown that HV may be associated with big toe pain [
13], concerns regarding foot appearance, difficulty fitting footwear [
14], poor foot function [
14,
15] and poor health-related quality of life [
16,
17]. It could be assumed that these are the reasons people seek treatment for HV, but research to determine this has not been undertaken [
7]. Furthermore, it is unknown whether podiatrists note particular physical examination findings that may also guide their treatment decisions.
An improved understanding of the current practice of podiatrists, along with further information on what brings patients with HV to clinics, will inform planning of clinical trials and practice guidelines. This survey of current practice among Australian podiatrists treating HV was conducted to determine whether there exists a non-surgical treatment consensus, and also whether the current state of practice is aligned with available clinical guidelines. A secondary aim was to explore the most common presenting problems and physical examination findings associated with HV in those seeking treatment from Australian podiatrists.
Discussion
The results of this survey have demonstrated that a consensus exists among Australian podiatrists regarding non-surgical management of HV, although typically management recommendations differ between adults, older adults and juveniles with HV. The most common recommendation for all patient types was advice regarding different footwear, recommended by 92 % of podiatrists for adults, 91 % for older adults, and 77 % for juvenile HV. Despite the lack of empirical evidence for the efficacy of orthoses for HV, custom and prefabricated devices are commonly prescribed by podiatrists for HV management. Padding techniques were more likely to be utilised in older adults with HV, while survey respondents were more likely to recommend stretching or strengthening exercises and night splints in juvenile HV.
Current practice of Australian podiatrists managing HV largely aligns with ‘initial treatment options’ outlined by the American College of Foot and Ankle Surgeons in their 2003 clinical consensus document [
5], although this organisation acknowledges that their ‘clinical practice guideline’ is no longer up-to-date. Their recommended non-surgical treatment options include footwear advice (wider, lower heeled shoes) or modification, bunion pads, orthoses, ice and non-steroidal anti-inflammatory medications. One notable difference in our study was that use of anti-inflammatory medications was quite low (17 % would recommend for adults, 4 % for juvenile HV and 23 % for older adults), although podiatrists with surgical specialty training were significantly more likely to recommend anti-inflammatory medications for adults and juveniles (
p <0.01). This could potentially be explained by the fact that at the time of the survey, the vast majority of podiatrists in Australia did not have endorsement to prescribe or supply scheduled medicines. Furthermore, since publication of the American College of Foot and Ankle Surgeons guidelines in 2003, more caution is generally advised regarding the use of non-steroidal anti-inflammatory medications, particularly in older adults [
19]. Another difference was in the use of ice for pain relief, as it was not captured by the focus group discussion and therefore was not listed as one of the possible treatment options in the fixed response question format.
This study further investigated whether demographic factors may affect the way podiatrists manage HV. Management recommendations did not differ according to geographical location (state or territory) or years of clinical experience. If these measures are considered to be a proxy for location and year of clinical training, these results suggest that there is a level of consistency in podiatry clinical education across Australia. Interestingly, there were some significant differences between male and female podiatrists in their typical treatment recommendations. Female podiatrists were more likely to offer conservative approaches such as padding and strapping. This may be due to a more sympathetic perspective regarding footwear worn by patients. In contrast, male podiatrists were more likely to offer custom orthoses to older adults.
There was a relatively high level of consensus among podiatrists’ responses for common presenting concerns in HV, but again these differed between adult and juvenile HV. Trouble fitting shoes, pain, and corns or calluses were reported to be most common in adults and older adults, while juveniles appear to present more often with concern about appearance or family history of bunions, in addition to pain and difficulty with footwear. While these presenting concerns clearly stood out as most commonly reported, all concerns listed in our survey were selected by at least 35 % of podiatrists in at least one age group (see Table
3), indicating that the range of presenting problems in patients with HV varies widely.
A more complete picture emerges by examining the physical examination findings reported by podiatrists to be commonly associated with HV (see Table
4). For example, excessive pronation was reported by podiatrists to be commonly found in juvenile HV (75 %) and adult HV (50 %). There is a proposed link between pes planus and HV [
20,
21] and so it is unsurprising that orthoses are commonly prescribed for HV, despite limited evidence of their efficacy [
9,
22,
23]. Interestingly, different findings appear to be more notable in older adults with HV, with degenerative change or osteoarthritis, lesser toe deformities, and corns or callus becoming more pronounced. It is quite conceivable that as problems secondary to HV develop, such as toe deformities, the treatment plan should be tailored to account for these secondary but associated problems.
This study leads to a number of important outcomes for clinical practice and research. Given the high prevalence and disability associated with HV, up-to-date clinical guidelines are clearly needed for non-surgical management of HV. Such guidelines should differentiate between management of adult HV versus juvenile HV, as the presenting concerns and recommended management of juvenile HV have been shown to differ substantially. It has been recommended previously that a patient’s presenting complaint associated with HV should influence treatment decisions [
7]. Based on the widely varying presenting problems associated with HV, as well as different findings on physical examination, caution should be exercised by podiatrists not to apply a ‘blanket approach’ to all patients with this condition. Perhaps treatments to directly relieve symptoms, such as padding and anti-inflammatories, could be more widely utilised by Australian podiatrists to complement other therapeutic strategies such as foot orthoses. While stretching and strengthening exercises appeared to feature in the management of juvenile HV, they were not commonly recommended for adults with HV. Research is needed to determine whether exercise therapy may be beneficial in individuals with HV of all ages. Further research is clearly warranted to form an evidence base for non-surgical management of HV, and the results of this survey could inform the design of such clinical trials, having established what is usual podiatric practice in Australia. Another recommendation for further research is that common problems associated with HV such as pain, callus formation and difficulty with footwear should be considered essential outcome measures in assessing the efficacy of HV management strategies. Previous studies have often used hallux alignment as the primary (and sometimes only) outcome measure [
9,
22].
A number of study strengths and limitations should be considered in the interpretation of our results. A strength of this study is that survey responses were returned from a range of podiatrists across Australia, including those of different ages and years of experience. There are a number of limitations that should be considered in making inferences from this data. First, there was a low response rate (11 %), and this could lead to non-response bias. Characteristics of non-responders were not able to be directly investigated; however, podiatrists who completed the survey were compared to podiatry workforce data with regard to geographical location and proportion of males to females. The proportion of females (65 %) was quite similar to podiatry workforce data published by the Podiatry Board of Australia in October 2013 (61 %) [
24]. With regard to geographical location, there was a higher response from Queensland (31 %) compared to workforce data (17 %), and a lower response from New South Wales (13 %) compared to workforce data (26 %), while proportions from other states and territories were similar to workforce data [
24]. Second, there were a number of incomplete surveys returned, potentially due to the complexity of the survey question format, which required multiple responses for each question. Third, the responses from podiatrists may have been influenced by recall bias, and this study being a cross-sectional survey was not an audit of actual practice, but rather captured podiatrists’ views of their ‘typical’ approach to HV management and ‘typical’ presenting concerns and physical examination findings associated with HV. Even so, the majority of participants reported seeing greater than five cases of HV per month, so this condition was regularly encountered by survey respondents. Fourth, due to the fixed response nature of our question format, our lists of treatments, presenting concerns and physical examination findings were not exhaustive and some treatment options were omitted (e.g. mobilisation/manipulation and ice, as previously discussed). Finally, our survey categorised HV by patient age group, but it should be acknowledged that treatment recommendations may also differ according to whether a patient presents with mild deformity or moderate to severe HV. Similarly, recommendations may differ if a patient has an underlying systemic pathology such as inflammatory arthritis. It may be useful to categorise treatment recommendations in this way; however, this approach was not considered feasible in our survey due to the length and complexity of the survey instrument.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
SH conducted the focus group, designed and distributed the survey, conducted statistical analysis and drafted the manuscript. BV and MS were involved with study conception and design, interpretation of data and critical revision of the manuscript. All authors read and approved the final manuscript.