Hallux Valgus Postoperative Rehabilitation Protocol

Disclaimer: This protocol is a general evidence-based guideline for rehabilitation following Hallux Valgus correction (Bunionectomy). Surgical techniques vary significantly (e.g., Chevron osteotomy, Lapidus arthrodesis, Akin osteotomy). Adherence to the operating surgeon’s specific weight-bearing restrictions and tissue healing timelines supercedes this protocol.

1. Clinical Overview and Pathophysiology

Hallux Valgus (HV) is a complex progressive deformity of the first metatarsophalangeal (MTP) joint. While often visually characterized by a "bunion" on the medial aspect of the foot, the pathophysiology involves a three-dimensional malalignment. The first metatarsal deviates medially (varus), while the hallux deviates laterally (valgus) and often rotates into pronation. This deviation compromises the static stabilizers of the joint, specifically the medial collateral ligament, and alters the dynamic vector of the Flexor Hallucis Longus (FHL) and Extensor Hallucis Longus (EHL), causing them to act as deforming forces that exacerbate the valgus drift.

From a biomechanical standpoint, the primary functional loss in HV is the disruption of the "Windlass Mechanism." In a healthy foot, dorsiflexion of the hallux during the propulsive phase of gait tightens the plantar aponeurosis, raising the medial longitudinal arch and creating a rigid lever for push-off. Post-operative rehabilitation focuses not merely on bone healing, but on restoring this critical first ray mechanic to prevent transfer metatarsalgia, lesser toe deformities, and proximal kinetic chain compensations.

2. Phase-Based Rehabilitation Timeline

Phase I: Protection and Acute Management (Weeks 0–6)

Clinical Goals: The primary objective during the initial phase is the protection of the osteotomy site or fusion to ensure bony union. Secondary goals include edema management, pain control, and prevention of proximal joint stiffness (knee and hip).

Weight Bearing Status: Typically heel-weight bearing (HWB) in a stiff-soled postoperative shoe or cam boot. Forefoot loading is strictly contraindicated to prevent displacement of fixation hardware.

Interventions and Exercises:

• Edema Control: Elevation of the limb above heart level for 45 minutes of every hour. Cryotherapy applied behind the knee or at the ankle (avoiding direct contact with the surgical site initially).
• Proximal Conditioning: Open kinetic chain exercises for the hip and knee to prevent atrophy. Examples include straight leg raises (4-way), seated knee extension, and hamstring curls.
• Intrinsic Activation: "Toe waving" of the lesser toes (2-5) to maintain tendon gliding, provided this does not pull on the surgical site.
• Manual Therapy: Soft tissue mobilization to the calf and posterior tibialis to prevent secondary tightness from altered gait mechanics.

Phase II: Progressive Loading and Motion Restoration (Weeks 6–12)

Clinical Goals: This phase marks the transition from protection to function. The focus shifts to restoring range of motion (ROM) at the first MTP joint, normalizing gait mechanics, and desensitizing the surgical scar.

Weight Bearing Status: Progression from postoperative shoe to a wide-box athletic shoe (often minimal drop/stiff sole) as tolerated. Full weight bearing (FWB) is generally permitted once radiographic evidence of union is confirmed.

Interventions and Exercises:

• First MTP Mobilization: This is the critical window to prevent permanent stiffness. Passive and active-assisted dorsiflexion and plantarflexion of the first MTP joint. Goal: Achieve 45–60 degrees of extension necessary for normal gait.
• Scar Mobilization: Cross-friction massage over the incision site (once fully closed) to prevent adhesions between the skin and extensor tendons.
• Gait Retraining: Cueing the patient to roll through the foot rather than abducting the hip to clear the limb. Emphasis on appropriate heel strike and mid-foot loading.
• Intrinsic Strengthening: "Short Foot" exercises (doming) to re-engage the plantar intrinsic muscles without curling the toes (hammer toe compensation).
• Proprioception: Double-leg stance on foam surfaces; progression to tandem stance.

Phase III: Functional Restoration and Return to Activity (Weeks 12+)

Clinical Goals: Restoration of full plyometric capacity, normalization of the Windlass mechanism during high-velocity movements, and return to sport/occupation.

Weight Bearing Status: Full, unrestricted weight bearing in standard footwear.

Interventions and Exercises:

• Dynamic Loading: Bilateral heel raises progressing to unilateral heel raises. Emphasis is placed on engaging the hallux during the peak of the raise to load the first ray.
• Eccentric Control: Step-downs and lunge variations to demand stability from the foot while controlling tibial advancement.
• Plyometrics: Double-leg hopping progressing to single-leg hopping. Box jumps with a focus on silent landing mechanics.
• Agility Drills: Ladder drills and cutting maneuvers to test the lateral stability of the foot and the patient's confidence in the surgical repair.

3. Specific Exercise Examples

The following exercises represent key milestones in the recovery process:

• Grade I-IV Joint Mobilizations (Phase II): The physical therapist applies dorsal and plantar glides to the first metatarsal and proximal phalanx. This mitigates arthrofibrosis, a common complication post-bunionectomy.
• Marble Pick-ups (Phase II/III): Used to improve dexterity and strength of the flexor hallucis longus and brevis. The patient attempts to pick up marbles or a towel using only their toes.
• Retro-Walking (Phase III): Walking backward on a treadmill. This forces the patient to extend the hip and plantarflex the ankle/toes effectively, recruiting the posterior chain without the high impact of forward running.

4. Return to Play (RTP) Criteria

Clearance for return to high-impact sports or demanding occupational tasks is performance-based, not merely time-based. The patient must meet the following criteria:

• Radiographic Healing: Surgeon confirmation of solid bony union without hardware complication.
• Range of Motion: First MTP extension greater than 60 degrees (necessary for running) and plantarflexion capable of gripping the ground. Ankle dorsiflexion must be symmetrical to the contralateral side.
• Pain Levels: Pain rating of ≤ 2/10 during functional activities and no post-activity effusion lasting longer than 12 hours.
• Strength Symmetry: Limb Symmetry Index (LSI) of >90% for calf strength (single-leg heel raise capacity) compared to the uninvolved side.
• Functional Testing: Ability to perform 10 single-leg hops with stable landing mechanics and no compensatory hip strategies.