FREQUENCY AND RELATED FACTORS OF HALLUX VALGUS AMONG FEMALE SCHOOL TEACHERS

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Amna Mazhar1*

1*Undergraduate, University Institute of Physical Therapy, The University of Lahore Gujrat campus, Pakistan

ABSTRACT

Background/Aim of Study: HV is a progressive, chronic deformity affecting the first metatarsophalangeal joint causing big toe lateral deviation and 1st metatarsal being medially deviated hence our objective is to calculate the frequency, factors associated with Hallux valgus and their rehabilitation.

Methodology: Non-probability A convenient sampling technique among 273 females aged 20-60 years from Jhelum District was done. Self-administrated questionnaires were filled out, and pain was measured using VAS. The goniometer and Manchester scale were used to evaluate HV deformity.

Results: The overall frequency of Hallux valgus was found to be 75.46%. 43.96% elder and 31.5% younger females. Mean age of participants was 42.95 ± 9.96. HV angle showed 24.9% were normal, 57.9% mild, 16.5% moderate, and 0.7% had severe deformity. The association of HV with BMI and shoe shape was statistically significant. No association was found between age, work experience, and heel height.

Conclusions: HV abnormality was high in elders when compared with youngers. The severity for HV grading showed mild deformity with bilateral HV more frequent among female. Foot wear i–e shoe shape and BMI plays a substantial role in the development of HV.

Key words: Hallux abductovalgus, bunion, metatarsophalangeal joint, associations, foot deformity, prevalence.

Introduction

Hallux valgus (HV) is a progressive, chronic deformity affecting the first metatarsophalangeal (MTP) joint causing big toe lateral deviation and 1st metatarsal being medially deviated, frequently found in females. Toe rotates in frontal plane, facing nail medially. According to estimate, prevalence in older adults over 65 was 35.7%, and 23% in adults between age 18 and 65. Prevalence of HV was found to be higher in females compared to male and increases with age 1.Enlargement of the MTP joint is considered a cause of HV. However, later, it was found that there was a higher prevalence in the group wearing shoes than in the group non-wearing when both were compared. Hallux valgus (HV) is a progressive disease depending on many factors, occurring in steps2. Early and important lesions are of the medial sesamoid and medial collateral ligament supporting medially at the 1st MTP joint; head moves medially, and the sesamoid bone out due to an uneven tarsometatarsal joint2 resulting in the valgus position when the proximal phalanx is in contact with sesamoids 3. The cause of HV is unknown, but usually women with lower limb deformities have difficulty wearing shoes, a big toe under pressure, a general appearance of the foot, and an abnormality of the lesser toe4. Pain in foot region can be caused by many factors; out of them, one is wearing high heels Nearly, 59% of females carry high-heel for 1-8 hours daily. The position of the foot in high heels puts strain which causes harmful effects on Foot structure5 causing hallux valgus, planter fasciitis, foot pain, cockup deformity. Heel pain is a general term used to describe pain and discomfort felt anywhere in or around the rear of the foot6.

In epidemiological studies, 21-70% of estimated prevalence of Hallux valgus in general population is seen and it usually varies7. Common findings and information upon physical, history or radiographic investigation and its association with hallux valgus shows MTP joint and medial eminence pain, skin irritation, infection, increased in intermetatarsal angle (IMA) up to 1-2 and subluxation of sesamoid8. Hallux valgus occurs in adolescent but affects adults more as compared to children. Studies shows ratio of HV as 15:1 in women than in men when diagnosed with deformity. Anatomically women have different bony structure and loose ligaments that play a major role causing pain in the MTP joint, degenerative deep agonizing pain, and discomfort along the bottom of the foot. HV is classified into three types based on severity of pain and radiographs as mild, moderate, and severe, the degree of HV angle and IMA angle when assessed were found to be higher than normal. Normally it is <15° for HVA and <9° for IMA9. Apart from age, other factors like fitted and high arch shoes, positive family and genetic history, Body Mass Index (BMI), fallen arches, limb length inequality and work-related hazards10 etc., also cause the abnormality. Deformity causes pain, increased chances of fall in older adults due to change in gait and proper functioning of foot11. However, pattern of foot structure from family in general indicates importance of genetic factors. Hallux valgus and its association with major factors such as metatarsal length, shape of head of metatarsal and hypermobility of first segment was also suggested in previous studies. Pes planus or flat foot, foot pain and increased BMI results into Hallux valgus12. During walking first MTP joint maintains upper body forward movement allowing body to moves in propulsive gait phase. In hallux lateral deviation alter bodyweight and unbalanced gait13. Muscle weakness, balance problem is present resulting into serious health conditions, chances of surgery increase and having negative effect of HV on public. Conservative treatment in early stage of skeleton growth with its lasting effect improves great toe position. Three of the most popular conservative therapy techniques are shoe modification, orthoses, and splints. Wearing broad, low-heeled, or specifically modified shoes with a larger medial pocket for the first metatarsophalangeal joint can reduce the forces that can distort the joint. Splint for medial move of great toe is prescribed for night. Inadequate correction and symptoms alleviation has been found after skeletal growth end. High heels of no more than 4 cm are usually not recommended for patients14. Commonly used exercises for treating HV are toe extension, abduction exercises with resistance training. Mobilization and manipulation are widely used as therapeutic or supportive therapy techniques at the same time. According to the results of two small preliminary trials, gradual mobilization and manipulation may short-term reduce pain and improve function, but further study is needed to assess their long-term effects15. It is reported that every year 2 million procedures are done to correct the deformity. In several researches strong association between public and issues of quality of life have been found16. Currently the patient undergoing correction of deformity is higher. Surgical choice to treat HV with its widespread pathology is done17. Treatment for severe Hallux valgus of first MTP joint by arthrodesis due to its safety and effectiveness has been suggested. Complication such as nonunion is common at site. Construction involves compression screws, staples and screws and dorsal plate. Incidence of 5.4% after arthrodesis as nonunion was found18. It is important to diagnose the deformity at early stage so that it can be easily cured.  For this purpose, present study was carried out to find out frequency and related factors of Hallux valgus among Female School Teachers with varying degree of HV.

Methodology

The descriptive cross-sectional study with non-probability convenient sampling was conducted in Jhelum, Punjab Pakistan with duration from August 2021 to Nov 2021. Sample of 273 Female teachers were collected from Government schools of Punjab after having written consents. Individuals were evaluated by self-made questionnaire, previous history, physical examination, and using equipment. The subjects who meet the inclusion and exclusion criteria were selected. Teachers with age 20-60, teaching for more than 1 year and working 7-8 hours or more per day were included. Exclusion criteria were foot congenital anomalies, pervious foot trauma or foot surgery (one year), Musculoskeletal disorders (Rheumatoid arthritis, Osteoarthritis, flatfoot, pes caves and gout). Anthropometric measurements i-e age, weight, height, BMI of participants were noted in the form with Underweight (<18.5), Normal BMI was 18.5-24.9, Overweight was 25-29.9, 30 or above was obese. For pain intensity VAS was used. To carry out varying degree of HV angle in female teachers Goniometer and Manchester Scale was used. According to American Academy of Orthopedic Surgeons (AAOS), Goniometer with 360° in standing weight-bear position was used. Participants were asked to place foot on ground with fulcrum positioned on foot medial aspect of MTP joint, stationary arm along the 1 metatarsal and moveable arm along proximal phalanx on medial aspect as shown in Figure 121. Goniometer was then moved in direction of big toe position and angle was measured. Normal (HV<15°), mild (HV <20°), moderate (HV 20-40°) and severe (HV >40°)9. Manchester Scale was used as self-assessment tool for HV grading (r =0.89). 4 graded pictures in MS were compared with participant’s big toe appearance. If big toe resembles with 1st picture, then it was grade 1 (normal). If big toe resembles with 2nd picture, then was said to grade 2, if big toe resembles with 3rd picture, then grade 3 and if big toe resembles with 4th picture it was said to be grade 4 as shown in Figure 2 respectively20.

Fig01: Measurement of HV angle 21

Figure 02: Grading of HV Using Manchester Scale.  A) grade 1 (no deformity), B) grade 2 (mild deformity), C) grade 3 (moderate deformity), D) grade 4 (severe deformity)20

Statistical Analysis

Data was analyzed by SPSS software version 24. Categorical data was display in frequencies and percentage. Numerical data was described in mean and standard deviation. Chi-square test was applied to assess the relationship between variables. For the significance appropriate statistical test was applied. P value ≤ 0.05 was considered as a significant value. All data was analyzed at a 95% confidential interval.

Results

Research included 273 female school teachers who underwent descriptive cross-sectional study. From results of current study, it was seen that frequency of HV among female participants was 75.46%, commonly having mild and bilateral HV. According to previous studies, estimated prevalence in older individual over 65 was 35.7%, and 23% in adults between age 18 and 65. Prevalence of HV was found to be higher in females then men and increases with age1.

Fig 03: Descriptive analysis for Frequency of HV

The percentage result for Hallux valgus showed 206 (75.46%) had HV and 67(24.54%) did not had HV. HV angle results showed 24.9% having no deformity, 57.9% having mild, 16.5% having moderate and 0.7% having severe deformity. The result for Manchester scale showed 32.2% with grade 1, 58.2% with grade 2, 9.25% with grade 3, and 0.4% with grade 4 deformity. When foot was evaluated most of them had bilateral HV i-e 44%, left was 17.9%, right 13.6% and 24.5% were not applicable as they have no deformity (normal). Pain intensity was measured and it showed most of them had no pain with 46.2%, mild pain 42.5%, with moderate pain 10.3% and severe pain was 1.1% respectively as illustrated in Table 1.

Table 01: Descriptive analysis for Hallux Valgus

Fig 04: Descriptive analysis for Age of participants

The histogram for Age of participants shows the Mean age was ±42.95, Std. deviation was ±9.69, with minimum age 20 and maximum age 60. Table 2 shows percentage results for HV and age group between 20-30 with 8.71% having deformity, 30-40, 40-50 and 50-60 showed 22.71%, 21.98% and 21.98% with deformity. BMI results showed 2.20% underweight, 21.98% normal, 28.57% overweight and 22.71% obese with HV deformity. Participants experience and deformity showed 1-5, 6-10. 11-15 and 15+ years as 11.72%, 16.12%, 15.38% and 32.23%. Results for shoe shape 30.77% round, 24.91% oval, 13.92% narrow box and 5.86% pointed showed deformity. Type of shoe with flat 31.87%, wedge 29.30%, cone 4.40% and ankle strap 9.89% had deformity. Participant’s heel height 1-2, 3-4 and none showed 50.92%, 18.68% and 5.86% deformity respectively.

Fig 05: Descriptive analysis for Goniometer HV Angle

The development of HV may be influenced by external elements like footwear as well as internal factors like anatomical traits linked to genetic predispositions. In our study, footwear i-e shoe shape and BMI showed association with HV.  The big toe, which is typically introverted by contraction of the abductor muscle, becomes erect when shoes with a tight toe box are worn. is compressed in the valgus position when bearing weight. Additionally, when wearing shoes with greater heels, the foot is fixed with a greater degree of dorsiflexion, and a more powerful force is put on the foot’s front. The transverse arch is thereby flattened. This increases the foot’s susceptibility to HV22.

Table 02: Descriptive analysis for Hallux valgus presence and Variables

Fig 06: Association b/w Participants Age group (years) and HV

Fig 07: Association b/w Body Mass Index and HV

Fig 08: Association b/w Type of shoe and Hallux valgus

Fig 09: Association b/w Shoe Shape and HV

Fig 10: Association b/w Heel height and HV

Fig 11: Association b/w duration of show wearing and HV

Table 03: Association between Hallux valgus and variables

Discussion

Hallux valgus (HV) is a progressive, chronic deformity affecting the first metatarsophalangeal (MTP) joint causing big toe lateral deviation and first metatarsal being medially deviated, frequently found in females1. This cross-sectional study was carried out to determine the development of Hallux valgus and related factors among female school teachers.  From current study it was seen that frequency of HV among participants was 75.46% with mild HV. Our findings are in accordance with study conducted by C Blandin et al., 2016 and N.H et al., 2009 when determined prevalence of HV to be 72% and 64.7% among gout patients and Korean individuals23,24. In previous studies carried out by Virinderpal et al., 2017 and Akinobu et al., 2014 among Kenya and Japanese population prevalence of HV was found to be 26.6% and 29.8%25,26. A study by Yangting Cai et al., 2023 provided estimates of HV incidence and prevalence worldwide. According to the results, the expected mutual prevalence and incidence of HV worldwide was 19%. In addition to rising trends in age, the incidence rate of HV was higher in older adults above the age of 60. The prevalence of HV was higher in females than in males. Globally, the prevalence of HV varied widely, with Asia and Oceania having the highest frequency27. According to present study, frequency of HV among females was 75.46% and higher in 30-40 years of age and does not progress further in later life. The study conducted by Hylton B et al., 2016 mentioned that at 20-39 age chances for Hallux valgus develops in future life while wearing constricted shoe wear28. Our study results showed HV was present at 20-30 age, more frequent 22.71% at 30-40 age with somewhat changes. Previous study by N.H Cho et al., 2009 supported our results as they recommended that Hallux valgus develops earlier age 40 and cannot progress significantly afterwards24. A study by Hylton B et al., 2011 discussed people in the 10 to 30 age range frequently wear shoes for longer than 8 to 9 hours a day owing to work and education, they are more likely to have hallux valgus than people in the 40 to 60 age range. Study by Jenna M et al., 2021 and Shannon E et al., 2017 reported with different shoe wear and pointed shoes HV prevalence to be increased among middle age individuals29,30. Flat shoe was more frequent in HV development, pointed shoe not very prevalent with only 5.86% female teachers reporting shoe shape. Whereas narrow toe box 13.92% was quite common among teachers. According to analysis by Naik N et al., 2019 out of 110 samples, hallux valgus affects women more frequently than men (67% vs. 44%), mostly because women are more prone than men to wear heels and tight, constrained shoes with a tiny toe box21. In current study it was seen that HV was develop in all categories of BMI. But was observed more prevalent in those who were overweight 28.57% and play substantial role in HV development. Chauhan et al., 2017 and his fellows carried out study and showed that co-relation between BMI and HV to be non-significant 26. Hallux valgus was linked to a lower BMI in women but a higher BMI in males, according to Hylton B. et al. 2011 they attributed this to the fact that overweight or obese women are more prone to wear less constrictive footwear21. A study conducted by Krishna B et al., 2021 left foot 84.76% both male (45.61%) and female (39.15%) was affected more when compared to right foot 70.05% both male (38.59%) and female (31.46%)31. Our results showed bilateral Hallux valgus 44% was present with mild deformity. Ki Won et al., 2013 supported our study with 97.3% bilateral HV development when seen on radiographs but had moderate abnormality and noteworthy alterations at time of age32. A study in Saudi Arabia by Almaqhawi A et al., 2023 showed the prevalence results, with 46.4% of subjects had some degree of HV, of which 41.4% had bilateral and 5.0% had unilateral HV. The literature has revealed a wide range of HV prevalence33. In previous studies HV severity and greater toe pain was reported to be co-related as done by Gregory et al., 2020 and his colleagues34. Our study results showed 126 female participants had no pain, 116 female participants had mild pain, 28 had moderate pain and 3 had severe pain. From the present study HV was seen present in all school teachers working for years. But more prevalence was seen in those working for 15+ years. Dewi S et al., 2019 discussed that > 4 years’ time duration chances for HV increases than with < 4 years’ work 35. Hylton B et al., 2016 in their study compared 20-29 and 30-39 aged female wearing heel height and toe-box shape. Very narrow toe-box and high heel was common in 20-29 age but was 10% less common in 40 years’ age28. In current study it was seen teacher wearing 3–4-inch heels had HV deformity but was more prevalent in 1-2 inch as they wore heel when they were between 20 to 30 years of age. In present study Hallux valgus angle when measured through goniometer showed severity of deformity. 24.9% showed no deformity, 57.9% mild deformity, 16.5% moderate deformity and 0.7% severe deformity. Mild deformity was more frequent among female teachers. A study by N.H Cho et al., 2009; Lewis et al., 2021 moderate HV was reported to be 13.2% with AP radiographs24,36. A previous study by Cristina et al., 2017 used Manchester Scale to determined HV degree 1. In our study Manchester scale showed 32.2% with grade 1, 58.2% grade 2, 9.2% grade 3 and 0.4% had grade 4 deformities. Grade 2 deformity was very much prevalent among female school teachers. Our study results showed 50.18% teachers work 7 hours most of day with shoes and had more prevalent HV than with 25.27 % more-time work. 47.99% reported they wear heel sometime and HV was present. HV was prevalent in teachers who wear heel for 3 days a week.

Limitations

This research had some limitations. Firstly, it was cross-sectional study, in command to assess onset and aggravation with other outside variables, continual monitoring of HV angle changes is essential. Secondly, goniometer and Manchester scale were used to evaluate HV chances of error can be there, radiographs and foot prints would have made it possible to measure the HV angle more precisely. Thirdly, genetically HV is really common, it’s significant to evaluate family members.  Only females with age 20-60 were reported and since our study limited to only small scale and not on other sectors so to generalized outcomes among both gender population was not feasible. HV impacts physical activity of an individual, quality of life was not discussed

Significance of Study and Clinical Implication

Few research has been done on HV in female school teachers, despite the fact that it is a prevalent foot deformity among women. In this research, we assessed HV in overall population and its association with other several factors and affirmed the connection of HV with shoe shape and BMI of population. In order to detect the illness at an early stage, shoe shape and BMI should be assessed. It is suggested further clinical implication studies should be conducted on large scale and with large sample size, radiographic assessment for HV, interventional studies, strengthening exercises, soft-tissue techniques as to enhance blood flow and protective measures regarding awareness in patients with foot wear and deformity must be done for reducing tension and imbalance of surrounding muscle, impact of HV and quality of life should be addresses.

Conclusion

It was concluded from the study that Hallux valgus abnormality was higher in elder aged female teachers when compared with younger. The severity for HV grading varies from person to person with most of them having mild and bilateral deformity. Teachers with working experience 15+ had HV. Foot wear i-e shoe shape and BMI plays a substantial role in HV development.

AUTHORS’ CONTRIBUTION: 

The following authors have made substantial contributions to the manuscript as under:

Conception or Design: Amna Mazhar

Acquisition, Analysis or Interpretation of Data: Amna Mazhar

Manuscript Writing & Approval: Amna Mazhar

All authors acknowledge their accountability for all facets of the research, ensuring that any concerns regarding the accuracy or integrity of the work are duly investigated and resolved.

ACKNOWLEDGEMENTS: We thank all the participants in this study.

INFORMED CONSENT: Written Informed Consent was taken from each patient.

CONFLICT OF INTEREST: The author (s) have no conflict of interest regarding any of the activity perform by PJR.

FUNDING STATEMENTS: None declared

ETHICS STATEMENTS: The approval number of the ethical committee was: REG/GRT/22/AHS-58. The rules and regulations set by the ethical committee of University of Lahore were followed while conducting the research.

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