Abstract
Aims
Hallux valgus (also known as a bunion) is a common forefoot deformity impacting pain, function, quality of life, and mobility, with higher prevalence in females and increasing incidence with age. The high prevalence and rates of surgical treatment potentially have a major impact on the healthcare system. The aim of this stakeholder consultation was to identify current issues with provision of hallux valgus treatment, as well as identify achievable goals to improve understanding of hallux valgus and guide future assessment, treatment pathways, and research directions with the aim of improving clinical outcomes for patients.
Methods
Scoping searches were undertaken to inform and identify relevant outcome sets and existing evidence relating to hallux valgus. A one-day think tank conference was held on 21 June 2024, involving stakeholders from various sectors, including patients, primary and secondary care professionals, researchers, and representatives of national societies. Key themes and issues related to hallux valgus were identified and used to develop structured action development plans.
Results
Major issues identified include the absence of national policy recommendations, variability in treatment pathways, and gaps in research and patient education. Patient experiences highlighted the significant impact on quality of life and the need for standardized information and care pathways. Key priorities for research include developing a core outcome set and understanding the patient’s lived experience, while policy priorities focus on creating national guidelines and raising awareness of the condition’s socioeconomic and functional impacts.
Conclusion
The inaugural UK National Hallux Valgus Think Tank identified critical issues in the management of hallux valgus and developed strategies to improve clinical outcomes through research and policy development. Establishing a working group and prioritizing both research and policy initiatives will be essential to advancing the understanding and treatment of hallux valgus.
Cite this article: Bone Jt Open 2025;6(4):432–439.
Keywords: Hallux valgus, Forefoot deformity, Bunion, Metatarsal osteotomy, Outcomes assessment, Percutaneous surgery, Soft tissue release, Non-operative management
Keywords: hallux valgus deformity, bunions, clinical outcomes, surgical treatment, valgus deformity, forefoot deformity, hallux, healthcare professionals, nonoperative treatment, hallux valgus surgeries
Introduction
Hallux valgus, otherwise known as bunion, is a common foot issue leading to problems with pain, function, and difficulty mobilizing and wearing shoes. It represents a complex 3D deformity, with inward migration (medialization) of the first metatarsal, outward pointing (valgus deformity) of the first metatarsophalangeal joint, and outward rotation (pronation) of the metatarsal, as shown in Figure 1.
Fig. 1.
A clinical photograph and radiograph demonstrating a hallux valgus deformity.
Disease burden
Approximately 23% of adults aged between 18 and 65 years have hallux valgus, rising to 36% in people aged over 65 years.1 In addition, females are over twice as likely to develop hallux valgus compared to males (30% females, 13% males).2 Multiple studies have shown that people with hallux valgus have worse scores on health-related quality of life (HRQoL).3,4 In addition, hallux valgus can affect balance and gait.5 In the elderly, this is particularly relevant as it leads to an increased risk of falls and sustaining other fall-related injuries.6,7 Furthermore, research has shown that there is an increase in pain and agreater reduction in physical function, general health, social function, and mental health as severity of hallux valgus increases, with an unknown socioeconomic impact.3,4,8-10 Although the severity of hallux valgus generally increases with time, this does not necessarily correspond with a decrease in function.4,11
Treatment pathway
Patients with hallux valgus are treated by a large number of healthcare professionals via various pathways spanning primary and secondary care. Patients with hallux valgus may seek advice from general practitioners, physiotherapists, podiatrists, and other foot health professionals (who may have a large variation in foot knowledge and specialist skills). There is variability in local referral pathways and funding from clinical commissioning groups across the UK.12,13 Referral to secondary care (either in the public or independent sector) typically involves foot and ankle specialist orthopaedic surgeons; however, in some cases, podiatric surgeons may be involved in delivery of surgical treatment.
Impact on the NHS
A recent study based on Hospital Episodes Statistics (HES) in England over a ten-year period from 1999 to 2019 showed that an average of 10,157 hallux valgus surgeries are carried out every year.14,15 In addition, patients aged between 60 and 64 years were the largest group to undergo the procedure, with females eight times more likely to undergo the procedure. There has been an upward trend in procedure numbers since 2000, with numbers plateauing between 14,000 to 16,000 per year between 2011 to 2019. Conservative estimates of cost (based on these figures) to perform hallux valgus surgery (£700 to £1,700 per foot) suggest the financial impact of surgery alone to the NHS is upwards of £15 million per year.13,16 The average cost in the independent sector is £3,000 to £7,000 per foot.17,18
Hallux valgus is a common condition that has a substantial impact on a large proportion of the UK population, as well as the NHS. The variability in referral pathway, treatment, and relatively limited evidence base for various treatment options precipitated a UK National Hallux Valgus Think Tank.
The aim was to convene a UK National Hallux Valgus Think Tank with relevant stakeholders to identify current issues with provision of hallux valgus treatment, as well as to identify achievable goals to improve understanding of hallux valgus and guide future assessment, research, and treatment pathways with the aim of improving clinical outcomes for patients.
Methods
To inform the content and focus of the think tank, scoping searches were undertaken to identify existing evidence relating to hallux valgus in the existing literature. A scoping review of the literature on hallux valgus was conducted by a clinical librarian. The results of this scoping review were reviewed by the lead study team, who discussed the findings and identified key points and areas of interest. These key areas and discussion points were then agreed upon during the planning phase ahead of the think tank. Following approval from the study team, a guidance document (which included the key discussion points as well as a summary of the literature) were circulated to delegates ahead of the think tank. This evidence summary was used to formulate a guidance document that was circulated in advance along with points to facilitate discussion. Key discussion topics identified included:
Primary care/secondary care interface
Outcome assessment
Nonoperative management
Surgical management
Post-surgery care
Economic considerations
A one-day think tank involving a cross-section of both medical and allied professionals, with patients with lived experience of hallux valgus and relevant stakeholders, was convened on 21 June 2024. We identified 40 people (including eight patients), of whom 22 agreed to participate, with two patients agreeing to participate in video interviews and share their experiences prior to the meeting. We had difficulty identifying existing Patient and Public Involvement and Engagement (PPIE) groups for hallux valgus and, as a result, well-supported patients who were able to be involved were not available (unlike other foot and ankle pathology, e.g. diabetic foot). Table I shows the stakeholders present.
Table I.
Stakeholders involved in the inaugural UK National Hallux Valgus Think Tank.
| Domain | Stakeholder |
|---|---|
| Patients | Patients |
| Primary care | General practitioner |
| Foot health specialist | |
| Podiatrist | |
| Secondary care | Physiotherapy |
| Foot and ankle orthopaedic surgeons | |
| Surgical podiatry | |
| Research and funding bodies | Foot and ankle charity |
| Research physiotherapy | |
| Orthopaedic Research UK | |
| Clinical trials unit | |
| National societies | British Orthopaedic Foot and Ankle Society |
| Royal College of Podiatry | |
| Higher education institutions | Higher education institutes (as research institutes and trainers of medical and allied health professionals) |
Format
The think tank was developed and held following a standardized approach.19 Delegates were distributed equally between four round tables with consideration given to having a mix of stakeholders on each discussion group. Round table discussions took place between relevant stakeholders, addressing four main discussion point considerations with guided prompts (Figure 2). Discussion topics included:
Fig. 2.
Discussion prompts for the UK Hallux Valgus Think Tank workshop sessions.
Current provision of care for hallux valgus
Identification of key issues affecting stakeholders with regard to hallux valgus
Priorities for improving hallux valgus service and research
Identification of future workstreams, packages of work, and desirable outputs
During this meeting, feedback was sought among delegates regarding each of these discussion points and shared among all present. Outcomes from each round table were recorded for analysis. Each video was reviewed to identify keywords, concepts, and points raised, which were collated and combined to identify draft key themes and issues regarding the management of hallux valgus in the UK. This was done by one author (MT), and subsequently verified and approved by the steering study group. It was not possible to perform a formal ranking/prioritization exercise during the think tank.
Results
In total, 20 delegates representing key stakeholders were involved in the think tank. During the round table discussions it became clear that many of the issues identified spanned multiple topics. The key themes, settings, and issues identified by stakeholders during the UK Hallux Valgus Think Tank can be seen in Table II.
Table II.
Key issues identified by stakeholders during UK National Hallux Valgus Think Tank.
| Setting | Theme | Knowledge gap |
|---|---|---|
| National | Policy development | No national policy recommendations regarding the management of hallux valgus |
| Public awareness | Limited public awareness of hallux valgus and impact on NHS/socioeconomic considerations | |
| Primary/secondary care | Pathway development | Variability in pathways and interface between primary/secondary care |
| Patient education Clinician education |
Limited understanding of disease aetiology, progression, prevention, management options, time frames, and effectiveness. Similar limited knowledge regarding suitable home management strategies, exercises, orthosis, and appropriate referral pathways Development of trusted resources |
|
| Research | ‘The lived experience’ of people living with bunions | The impact of hallux valgus on people’s emotional and physical lives, quality of life, including employment, social activities, functional limitations, and mental health. Experience of people seeking treatment in and out of NHS care, including self-management. Experiences and experience of people across the diagnostic and management pathway |
| Clinical outcomes | Lack of core outcome set | |
| Research priorities | Lack of clear direction for research priorities | |
| Treatment variability | Limited methodologically robust randomized controlled trials evaluating surgical and non-surgical treatments | |
| Current care | Understanding what pathways are available and used, and by whom |
Discussion
Pathway variability
There was consensus that there is considerable national variability in terms of access to primary and secondary healthcare, as well as the role of healthcare professionals, nonoperative treatment, and the primary/secondary care interface.6,12,13 Stakeholders felt that having a recognized national standardized pathway and standard of care similar to other conditions, such as knee osteoarthritis20 and hip/knee arthroplasties,21 would be useful for planning and provision of care. Ideally, a national standardized pathway would need to consider:
Triage
Minimum criteria for referrals/surgery
Timeframes for treatment
Help to streamline/reduction in unnecessary appointments along the pathways
Nonoperative treatment options
Surgical techniques
Outcome measures
Patient experience
There were substantial concerns raised regarding the patient experience and the limited evidence exploring the impact of hallux valgus on people’s quality of life, including employment, social activities, and mental health. It was also noted that there is a large group of patients who have hallux valgus who do not undergo surgical treatment, relying on self-care and other private sector provision; however, little is known about this group in terms of their experience or outcomes, which is reflected in the limited literature exploring this.22 Here perhaps lies the greatest opportunity to improve outcomes, by understanding the scope and efficacy of current self-care, preferences for conservative management, and ways in which people would like to access professional health services.
Input from patients highlighted the variability in advice and knowledge received from healthcare professionals at all stages of the treatment pathway including the role of operative and nonoperative treatment options. This led to confusion regarding expected outcomes, rate of recovery, indications, risks and benefits of treatment. Patients felt that the language, quality, and detail of information provided to them by clinicians needed to improve to match the quality and depth of material/advice provided to patients undergoing hip and knee surgery (which was felt to be much clearer and consistent at all stages of the treatment pathway). It was felt that education of healthcare professionals regarding the latest evidence for operative and nonoperative treatment of hallux valgus would be beneficial, as well as development of a patient-friendly source of online ‘trusted’ advice and information. This could be in addition to existing resources from professional bodies, national societies to better inform patients, managed expectations (especially post-surgical recovery and pain), and direct counter-scare stories (e.g. via social media) with accessibility built in for the diverse groups of patients served. Accessibility, such as different languages, media formats, and sources, was considered important.
Research
There was considerable debate regarding the research needed to help improve the quality of care for patients with hallux valgus. Alongside the need for research into the lived experiences of patients with bunions, there was agreement that a core outcome set is critical, as is identification and validation of appropriate outcome measures that matter to patients and healthcare professionals. This would assist the assessment and implementation of new evidence as it emerges, for example the new National Institute for Health and Care Excellence (NICE) guidance regarding minimally invasive hallux valgus surgery.23
There was discussion regarding surgical and non-surgical management of hallux valgus, and the need to evaluate different treatments in terms of clinical effectiveness, recurrence rate, and complication rate. There was also discussion regarding the role of minimally invasive surgery, first metatarsal pronation in the aetiology and treatment of hallux valgus, management of severe complex deformity, and the need to identify research priorities specifically in hallux valgus akin to the recently published research priority setting partnership for foot and ankle conditions.24-28
Next steps
Following the first UK National Hallux Valgus Think Tank, a number of next steps and action plans have been identified, as shown in Figure 3.
Fig. 3.
Key outcomes following inaugural UK National Hallux Valgus Think Tank.
There was consensus that a working group should be established to manage and inform the direction of future activities regarding hallux valgus with input from all relevant stakeholders. Priorities identified by consensus for future activities included a dual integrated approach with simultaneos focus on both a research and policy pathway, as shown in Figure 3.
Research pathway
The key priorities identified as part of the research focus were:
Understanding the patient’s lived experience
Develop a core outcome set for hallux valgus
Understand research priorities for the treatment, management, and care pathway for hallux valgus
Policy pathway
The key priorities identified as part of the policy focus were:
Development of a national policy document for hallux valgus
Identify national pathway variation across the UK for assessment and management of hallux valgus
Develop a standardized evidence-based national referral and treatment pathway for hallux valgus
A focused campaign to raise awareness and provide a trusted online resource for patients and the public regarding the socioeconomic and functional impact of hallux valgus on the population
These goals were chosen on the basis of their impact and potential to increase understanding of hallux valgus, and guide future assessment and treatment pathways with the aim of improving clinical outcomes for patients.
In conclusion, the inaugural UK National Hallux Valgus Think Tank brought together relevant stakeholders and identified relevant themes relating to hallux valgus care. Two broad strategies focusing on research and policy outcomes were developed with the aim of improving clinical outcomes for patients.
Take home message
- Hallux valgus (also known as a bunion) lacks standardized national care pathways despite affecting 23% to 36% of adults, and is estimated to cost the NHS £15 million annually for surgeries.
- The inaugural UK National Hallux Valgus Think Tank identified significant variability in treatment approaches and patient information, recommending parallel research and policy initiatives to address these gaps.
- A working group will be established to implement priorities including developing core outcome measures, creating standardized evidence-based pathways, and improving patient education resources.
Author contributions
T. L. Lewis: Data curation, Formal analysis, Investigation, Methodology, Project administration, Validation, Visualization, Writing – original draft, Writing – review & editing
A. See: Data curation, Formal analysis, Investigation, Methodology, Project administration, Validation, Visualization, Writing – original draft, Writing – review & editing
M. Thomas: Conceptualization, Investigation, Methodology, Validation, Writing – review & editing
L. Houchen-Wolloff: Conceptualization, Data curation, Investigation, Methodology, Project administration, Resources, Validation, Writing – review & editing
A. Angadji: Conceptualization, Data curation, Funding acquisition, Project administration, Resources, Supervision, Writing – review & editing
C. McDaid: Investigation, Methodology, Supervision, Validation, Writing – review & editing
S. O'Neill: Investigation, Methodology, Project administration, Supervision, Writing – review & editing
C. Nester: Investigation, Methodology, Project administration, Supervision, Writing – review & editing
J. Mangwani: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Supervision, Validation, Writing – review & editing
Funding statement
The author(s) disclose receipt of the following financial or material support for the research, authorship, and/or publication of this article: this think tank was facilitated and supported financially by Orthopaedic Research UK.
ICMJE COI statement
M. Thomas and A. Angadji are employees of Orthopaedic Research UK. T. Lewis reports royalties or licenses and consulting fees from Vilex, which are unrelated. J. Mangwani declares royalties or licenses from Meshworks, and consulting fees from MeshWorks and Orthosolutions; and is Caldicott Guardian for British Orthopaedic Foot and Ankle Society, all of which are also unrelated to this work. A. See reports a AOUK&I major research grant, which is also unrelated. S. O’Neill discloses unrelated grants or contracts from Expanding Excellence in England, Private Physiotherapy Education Fund, British Association of Sports and Exercise Medicine, and ERC (UK Research and Innovation) funding for IAA.
Data sharing
All data generated or analyzed during this study are included in the published article.
Acknowledgements
UK Hallux Valgus Think Tank collaborative:
Ali Abbasian, Arash Angadji, Ann Berger, Jodie Breach, Robert Clayton, Kartik Hariharan, Natasha Hossain, Thomas Lewis, Jitendra Mangwani, Catriona McDaid, Chris Nester, Seth O'Neill,Arul Ramasamy, Robbie Ray, Carrie Sandford, Abbas See, Andrea Sott, Martin Thomas, Madhu Tiruveedhula, and Christopher Withey.
We would like to thank Pip Divall for her help with the scoping literature search.
Ethical review statement
This study reports findings from a voluntarily attended stakeholder think tank event focused on hallux valgus care. All participants consented for their contributions to be included in subsequent publications, and all authors had the opportunity to review and contribute to the manuscript prior to submission. No patient-identifiable data was collected during this process. As this work represents a consensus-building exercise rather than a clinical study, formal ethical approval was not sought as per UK Health Research Authority guidance.
Open access funding
Funding for the open access fee was provided by Orthopaedic Research UK.
Social media
Follow J. Mangwani on X @jitmangwani
© 2025 Lewis et al. Open Access This article is distributed under the terms of the Creative Commons Attribution No Derivatives (CC BY-ND 4.0) licence (https://creativecommons.org/licenses/by-nd/4.0/), which permits the reuse of the work for any purpose, including commercially, provided the original author and source are credited; however, it cannot be distributed to others in any adapted form.
Contributor Information
Thomas L. Lewis, Email: t.lewis2@nhs.net.
Abbas See, Email: Abbas.See@nottingham.ac.uk.
Martin Thomas, Email: m.thomas@oruk.org.
Linzy Houchen-Wolloff, Email: Linzy.Houchen@uhl-tr.nhs.uk.
Arash Angadji, Email: a.angadji@oruk.org.
Catriona McDaid, Email: catriona.mcdaid@york.ac.uk.
Seth O'Neill, Email: seth.oneill@leicester.ac.uk.
Chris Nester, Email: c.nester@keele.ac.uk.
Jitendra Mangwani, Email: jm753@leicester.ac.uk.
Collaborators: Hallux Valgus Think Tank collaborative, Ali Abbasian, Arash Angadji, Ann Berger, Jodie Breach, Robert Clayton, Kartik Hariharan, Natasha Hossain, Thomas Lewis, Jitendra Mangwani, Catriona McDaid, Chris Nester, Seth O'Neill, Arul Ramasamy, Robbie Ray, Carrie Sandford, Abbas See, Andrea Sott, Martin Thomas, Madhu Tiruveedhula, and Christopher Withey
Data Availability
All data generated or analyzed during this study are included in the published article.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
All data generated or analyzed during this study are included in the published article.