Does hallux valgus impair physical function?

Does hallux valgus impair physical function? Background: The relationships between radiographic hallux valgus (HV) and various physical functions independent of knee osteoarthritis (KOA) were examined among residents of a mountain village in Japan. Methods: Study participants were recruited from mountain village residents aged ≥50 years. Participants’ height, weight, and body mass index (BMI) were measured, and baseline data, including age, sex, and foot pain, were obtained using interviews and questionnaires. Radiography of the feet and knees was performed to assess the presence of HV (HV angle ≥20°) and KOA (Kellgren-Lawrence grade ≥ II). Grip strength, 6-m walk at usual and maximum speeds, single-leg stance time, and stand up from a chair time were evaluated as physical function performance tests. Plantar pressure patterns were also examined. Results: Moderate-severe HV (HV angle ≥30 degrees), impaired grip strength and maximum walking speed, and painful HV reduced usual and maximum walking speeds independent of KOA. Hallux plantar pressure decreased according to the HV angle. Hallux plantar pressure was significantly lower in painful HV than in the no HV feet or painless HV. Conclusions: Moderate-severe HV deformity and HV-related pain impaired physical function independent of KOA. By controlling the pain and severe deformity of HV by treatments such as surgery, the physical function of HV patients might be improved. Keywords: Hallux valgus, Physical function, Knee osteoarthritis, Epidemiology elderly Background found no association between HV and disability, such as Hallux valgus (HV) is one of the most common foot the Timed Up & Go test [6], walking speed [6–8], and bal- deformities in adults; it is characterized by abnormal an- ance tests [8]. On the other hand, increasing HV severity gulation, rotation, and lateral deviation of the hallux at has been shown to negatively impact health-related quality the first metatarsophalangeal joint [1]. The prevalence of of life and self-reported function [4, 9, 10], and HV has HV has been reported as 58% in adult women and 25% been linked to balance function [11] and increased fall risk in adult men (HV angle ≥15°) in the USA [2], 28.4% in in older adults [12, 13]. adults (self-reported hallux valgus) in the UK [3], 64.7% Our cohort study started in 1997 to investigate the (HV angle ≥15°) in a Korean population aged between epidemiology of knee osteoarthritis (KOA) [14, 15] and 40 and 69 years [4], and 29.8% (HV angle > 20°) in a osteoporosis [16]. The study of HV started from 2009, Japanese population aged over 65 years [5]. While HV is and we reported the prevalence and risk factors for HV basically regarded as a structural deformity, there is [5]. In our study [5], HV showed a significant relation- debate surrounding the association between abnormal ship with KOA. In general, KOA is associated with lower foot structure and related disability. Several studies have physical extremity function [17]. However, no report has shown a relationship between HV and physical function after taking into account the existence of KOA. * Correspondence: meiten@clin.medic.mie-u.ac.jp Departments of Orthopaedic Surgery, Mie University Graduate School of The purpose of this cross-sectional study was to inves- Medicine, 2-174 Edobashi, Tsu City, Mie 514-8507, Japan tigate whether HV affects physical function after taking Departments of Orthopaedic and Sports Medicine, Mie University Graduate into account KOA among elderly persons. School of Medicine, Tsu City 514-8507, Mie, Japan Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Nishimura et al. BMC Musculoskeletal Disorders (2018) 19:174 Page 2 of 9 Methods single-leg stance time with eyes open, and stand up from Individuals aged ≥50 years were recruited from among a chair time. Grip strength was measured using a Takei the inhabitants of a mountain village in Japan. The main 5401 handgrip dynamometer (Takei Scientific Instru- industry is the forest industry. The study was started in ments Co., Niigata, Japan). The participants stood and 1997, with follow-up every two years. All studies were held the dynamometer with the arm at right angles and held at the local hospital. This present study analyzed the elbow by the side of the body. Two measurements data from the seventh to tenth biennial examinations in were done for each hand. We used the average of the 2009, 2011, 2013, and 2015, respectively. The number of highest measurement of each hand. Participants were participants in 2009, 2011, 2013, and 2015 was 314, instructed to walk at their usual and maximum speeds. 221, 223, and 204, respectively. For individuals who We measured the time was with a stopwatch. The data participated in two or more iterations of these four ex- for plantar pressure patterns were taken using a gait aminations, only the data from the earliest examination analyzer (Walk Way MW 1000; Anima, Tokyo, Japan). were included. For example, if an individual partici- This analyzer has a sheet length of 2.4 m, and this sheet pated in 2009, 2011 and 2015, the data in 2009 were in- was set in the middle of the 6-m walkway. In order to cluded in this study. Exclusion criteria were rheumatoid investigate how strongly participants pushed the ground arthritis and past history of surgery for hallux valgus. A with the great toe, the percentage of the hallux footprint total of 562 participants (194 male, 368 female) were in the whole footprint was examined. Each footprint was part of this study. picked up using the gait analyzer (Fig. 1), and the hallux Before direct examination, a baseline questionnaire in- cluding name, age, sex, medical history, and pain was sent to the participants. Direct examination consisted of phys- ical measurement, medical interview, physical examin- ation, X-rays, blood tests, and physical function tests. We measured participants’ height and body weight, and the body mass index (BMI) was calculated as weight (kg) di- vided by height squared (m ). Medical interviews and physical examinations were performed one-on-one by orthopedic surgeons. Bunions were detected by inspection and palpation. Painful bunions were determined by apply- ing pressure to the bunion. Knee X-rays were taken with the knee in a fully extended standing position. KOA was scored according to the Kellgren-Lawrence grading sys- tem [18]. Radiographic KOA was defined as grade ≥ 2. We took foot X-rays with participants standing upright with both feet on the cassette, as described by Saltzman [19]. The HV angle, which is formed by the bone axes of the first metatarsal and the first proximal phalanx, was consistently measured by the same examiner [20]. These imaging data were analyzed using Image J version 1.37 software (National Institutes of Health, Bethesda, MD, USA). Hallux valgus was deemed to be present if the HV angle was ≥20°, according to the Japanese Orthopaedic Society criteria. HV severity was classified as mild (≥20° and < 30°), moderate (≥30° and < 40°), or severe (≥40°). Participants reporting pain in the right or left hal- lux on most days of a month for at least 1 month in the previous year were classified as having right or left hallux pain. Participants with radiographic HV and self-reported hallux pain or a painful bunion checked by orthopedic surgeons were defined as having painful HV. If a partici- Fig. 1 Representative footprint. Blue dotted line shows the region of pant had left hallux pain and right radiographic HV, that interest (ROI) of a whole footprint, and the black dotted line shows the ROI of a hallux footprint for pressure analysis. The percentage of the participant was not included in the painful HV group. hallux footprint is calculated as the hallux footprint pressure divided by The physical function tests consisted of grip strength, the whole footprint 6-meter (m) walk at usual and maximum speeds, Nishimura et al. BMC Musculoskeletal Disorders (2018) 19:174 Page 3 of 9 footprint and the whole footprint were enclosed, and the 160 participants (26 male, 134 female), whereas the no pressure was analyzed with analysis software (PREDAS HV group had 402 participants (168 male, 234 female). MD-1000; Anima, Tokyo, Japan). The percentage of the Participants in the HV group were significantly shorter hallux footprint was defined as [hallux footprint]/[whole and older than those in the no HV group, and the footprint]. Examining the foot pressure patterns, the percentages of female and KOA were significantly higher percentage of hallux footprint was checked, from in the HV group than in the no HV group. When which was calculated hallux pressure/whole foot pres- participants were classified into a no HV-mild HV sure. We measured single-leg stance time with eyes group and a moderate-severe HV group, participants in open for both legs, and we calculated the average time. the moderate-severe HV group were significantly shorter Participants were instructed to stand on one leg while ele- and lighter than those in the no HV-mild HV group, and vating the contralateral limb. The time until the raised leg the percentages of female and KOA were significantly was touched on the floor was measured. The maximum higher in the moderate-severe HV group than in the no time was 60 seconds (s). The stand up from a chair time HV-mild HV group. When participants were classified was the time taken to stand from a chair five times with into a no HV or painless HV group and a painful HV hands folded in front of the chest and feet flat on the group, the participants in the painful HV group were sig- floor. nificantly shorter than those in the no HV or painless HV Based on the worse HV angle in their feet, the partici- group, and the percentages of female and KOA were sig- pants were classified into a no HV group (HV angle < 20°) nificantly higher in the painful HV group than in the no and an HV group (HV angle ≥20°). They were then classi- HV or painless HV group. fied into a no HV-mild HV group (HV angle < 30°) and a The relationships between HV and physical functions moderate-severe HV group (HV angle ≥30°). Finally, they are shown in Tables 2 and 3. Table 2 shows the results were classified into a painful HV group and a no HV or after adjustment for age, sex, and BMI, and Table 3 painless HV group. shows the results after adjustment for age, sex, BMI, and KOA. There was no significant difference between the Statistical analysis HV group and the no HV group in physical functions. Means ± standard deviations were calculated for vari- On the other hand, grip strength and maximal 6-m ables unless otherwise noted. Associations among the walking time were significantly stronger and faster in the physical characteristics between the groups were deter- no HV-mild HV group than in the moderate-severe HV mined by the unpaired t-test or Fisher’s exact test. The group, respectively. In terms of HV-related pain, both relationships between physical functions (grip strength, usual and maximum walking speeds were significantly single-leg stance time, standing up from a chair, and 6-m slower in the painful HV group than in the no HV or walking times at usual and maximum speeds) and HV painless HV group. During 6-m walking, a significant (HV angle ≥20°), moderate-severe HV (HV angle ≥30°), or negative correlation was observed between the HV angle painful HV (HV angle ≥20° with pain) were evaluated by and the percentage of hallux footprint (Fig. 2). Pearson’s multiple linear regression analysis both after adjusting for correlation coefficient (r) and the corresponding p value age, sex, and BMI, and for age, sex, BMI, and KOA. The were r = − 0.44 and p < 0.01. The percentage of hallux correlation between the HV angle and the percentage of footprint was significantly higher in no HV feet than in the hallux footprint was analyzed by Pearson’scorrelation HV feet (Fig. 3a). The percentage of hallux footprint was coefficient. Percentages of the hallux footprint be- significantly higher in no HV or mild HV feet than in tween no HV foot and HV, between no HV-mild HV and moderate-severe HV feet (Fig. 3b). Moreover, the per- moderate-severe HV, and between no HV foot or painless centage of hallux footprint was significantly higher in no HV and painful HV were analyzed by the Mann-Whitney HV or painless HV feet than in painful HV feet (Fig. 3c). test. The significance level was set at 5% in a two-tailed test. All data were analyzed using PASW Statistics for Discussion Windows version 22 (IBM, Armonk, NY, USA). The results of this cross-sectional study indicated that participants with moderate-severe HV or painful HV Results had impaired physical functions compared to partici- The overall prevalence of definite radiographic HV was pants with no HV-mild HV or painless HV after taking 28.4% (160/562); it was 13.4% (26/194) in males and into account age, sex, BMI, and radiographic KOA. 36.4% (134/368) in females. The rates of mild, moderate, Hallux loading was reduced with increasing HV severity and severe HV in the 562 participants were 16.5% (93/562), or HV-related pain. 9.3% (52/562), and 2.7% (15/562), respectively. With regard to standing balance, Menz et al. [21], Table 1 shows the physical characteristics of the par- Spink et al. [22], and Nix et al. [11] reported that poorer lat- ticipants who fulfilled the criteria. The HV group had eral stability, poorer coordinate stability, and increased Nishimura et al. BMC Musculoskeletal Disorders (2018) 19:174 Page 4 of 9 Table 1 Comparison of participants’ basic data between the no HV group and the HV group, between the no HV -mild HV group and the moderate-severe HV group, and between the no HV or painless HV group and the painful HV group No HV group HV group No HV-mild HV group Moderate-severe HV group No HV or painless HV group Painful HV group (n = 402) (n = 160) (n = 495) (n = 67) (n = 529) (n = 33) Age (years) **71.1 ± 8.8 73.3 ± 8.7 71.5 ± 8.9 73.4 ± 8.3 71.6 ± 8.8 74.0 ± 9.1 Sex (% female) **58.2 83.8 **62.2 89.6 *64.1 87.9 Height (cm) **154.6 ± 8.9 151.1 ± 7.8 **154.2 ± 8.7 149.7 ± 7.5 *153.9 ± 8.6 148.9 ± 9.0 Weight (kg) **55.8 ± 10.3 53.5 ± 9.4 *55.5 ± 10.2 52.4 ± 9.5 55.4 ± 10.1 51.9 ± 10.0 BMI (kg/m ) 23.3 ± 3.2 23.4 ± 3.6 23.3 ± 3.3 23.4 ± 3.5 23.3 ± 3.3 23.4 ± 3.7 KOA (%) **33.8 55.0 **37.2 59.7 *40.0 42.4 HV hallux valgus, BMI body mass index, KOA knee osteoarthritis **p < 0.01, *p < 0.05 postural sway were associated with HV in elderly popula- but maximum walking requires a higher level of physical tions. On the other hand, Mickle et al. [23] and Menz and function than usual walking. Thus, moderate-severe HV ap- Lord [24] showed no relationship between HV and standing peared to be associated with maximum walking speed in balance. These previous reports included much finer ana- the present study. lyses, with evaluation of the center of pressure (COP) using Previous studies reported that foot pain was associated a force plate, and/or more severe conditions, such as eyes with poor physical function. Some studies [24–26] re- closed, than the present study. The data of the present ported that participants with foot pain had more diffi- study were only for standing time with eyes open to exam- culty walking than participants without foot pain. In ine standing balance, but there was no relationship between addition, some reports [1, 4] showed that HV was asso- HV and standing balance. If finer evaluations, such as ciated with more self-reported foot pain and poorer analyzing COP, and/or more severe conditions, such as self-reported physical function. Abhishek et al. [10]further eyes closed, were performed, some differences might be highlighted the importance of hallux pain with HV, detected. reporting that health-related quality of life was progres- To thebestofour knowledge, therehavebeennoreports sively impaired in participants with HV alone, hallux pain of the relationship between HV and hand grip strength. alone, and HV with hallux pain. In the present study, The present study showed that moderate-severe HV de- walking speeds of participants with painful HV were formity (HV angle ≥30°) was associated with impaired hand slower than those of participants with no HV or mild HV. grip strength. It is easy to imagine that patients with Previous reports [27–29] showed an inverse relation- moderate-severeHVhavesmaller grip strength of thefoot ship between HV severity and reduced hallux loading. because of poor alignment of the 1st MTP joint. Grip Nix et al. [11] and Mickle et al. [13] showed that partici- strength of the hallux might be correlated with hand grip pants with HV had decreased hallux plantar flexion strength. Thus, patients with poor grip strength in the strength. Sanders et al. [30] reported an inverse relation- moderate-severe HV group may show poor grip strength of ship between HV angle and hallux plantar flexion the hallux. However, this is just a hypothesis, and further strength, as well as lower mean hallux plantar flexion studies are needed. strength in those with painful HV than in those with HV No significant between-group differences were found without complaints. Moreover, Mickle et al. [23] re- in walking performance in some studies [11, 22]. The ported less hallux loading in HV patients than controls. present data for the no HV group and the HV group are Hurn et al. [29] reported that participants with moderate consistent with these previous studies. However, the (average HV angle = 30.8°) and severe HV (average HV definitions used in the various studies differed, since the angle = 39.9°) showed significantly reduced hallux plan- data were self-reported (such as the Manchester scale) tar pressure-time compared to controls. These reports or HV < 20° was used, so that the HV groups had many are consistent with the results of the present study. mild HV participants. In the present study, maximum These reduced hallux plantar pressures might reflect im- walking speed was faster in the no HV-mild HV group paired physical function, such as slower walking speed. than in the moderate-severe HV group. Cho et al. [4] Caution must be applied when comparing reports showed that participants with moderate or greater HV from different studies [1]. Some studies have used (HV angle > 25°) had significantly worse functional status, self-report information, such as the Manchester scale foot health function status, and self-assessment of their foot [21–23, 31], and others have used X-ray definitions. In condition. These data support the present data. There were terms of X-ray examinations, studies have used a range no data about maximum walking speed in previous studies, of definitions, such as HV angle > 15° or 20° and so Nishimura et al. BMC Musculoskeletal Disorders (2018) 19:174 Page 5 of 9 Table 2 Comparison of physical functions between the no HV group and the HV group, between the no HV-mild HV group and the moderate-severe HV group, and between the no HV or painless HV group and the painful HV group after adjusted for age, sex, and body mass index No HV HV Standard partial p No HV-mild Moderate- Standard partial p No HV or Painful HV Standard partial p regression coefficient Value HV severe HV regression coefficient Value painless HV regression coefficient Value (n =402) (n = 160) (n =495) (n = 67) (n = 529) (n = 33) Grip strength, kg Crude 28.6 ± 8.5 25.1 ± 6.2 28.2 ± 8.2 23.1 ± 6.0 27.9 ± 8.1 23.2 ± 7.0 Adjusted 27.6 ± 5.2 27.6 ± 5.2 0.007 0.910 27.8 ± 5.1 26.3 ± 5.2 −0.140 *0.034 27.7 ± 5.1 26.4 ± 5.1 −0.088 0.189 Single-leg stance Crude 31.2 ± 22.8 24.8 ± 22.1 30.0 ± 22.7 24.3 ± 22.7 29.8 ± 22.7 22.5 ± 22.9 time, s Adjusted 30.1 ± 18.3 27.4 ± 18.6 −0.079 0.125 29.6 ± 18.2 27.3 ± 18.5 − 0.051 0.332 29.5 ± 18.2 26.3 ± 18.3 − 0.052 0.323 Stand up from a Crude 10.1 ± 3.6 11.1 ± 4.5 10.2 ± 3.6 11.5 ± 5.5 10.3 ± 3.8 11.8 ± 4.3 chair time, s Adjusted 10.3 ± 3.4 10.7 ± 3.5 0.063 0.175 10.3 ± 3.4 11.2 ± 3.5 0.089 0.056 10.3 ± 3.4 11.3 ± 3.4 0.077 0.106 Usual gait Crude 1.01 ± 0.21 1.01 ± 0.24 1.02 ± 0.21 1.00 ± 0.26 1.02 ± 0.22 0.92 ± 0.25 speed, m/s Adjusted 1.01 ± 0.20 1.03 ± 0.20 0.039 0.376 1.02 ± 0.20 1.01 ± 0.20 −0.003 0.949 1.02 ± 0.21 0.93 ± 0.20 − 0.108 *0.017 Maximum gait Crude 1.33 ± 0.27 1.28 ± 0.31 1.33 ± 0.27 1.22 ± 0.33 1.33 ± 0.27 1.17 ± 0.37 speed, m/s Adjusted 1.32 ± 0.24 1.32 ± 0.24 0.002 0.968 1.33 ± 0.24 1.26 ± 0.24 −0.103 *0.037 1.33 ± 0.23 1.22 ± 0.24 −0.120 *0.016 HV hallux valgus, M male, F female, s second, m/s meters per second *p < 0.05 Nishimura et al. BMC Musculoskeletal Disorders (2018) 19:174 Page 6 of 9 Table 3 Comparison of physical functions between the no HV group and the HV group, between the no HV-mild HV group and the moderate-severe HV group, and between the no HV or painless HV group and the painful HV group after adjustment for age, sex, body mass index, and knee osteoarthritis No HV HV Standard partial p No HV-mild Moderate- Standard partial p No HV or Painful HV Standard partial p regression coefficient Value HV severe HV regression coefficient Value painless HV regression coefficient Value (n = 402) (n = 160) (n = 495) (n = 67) (n = 529) (n = 33) Grip strength, kg Crude 28.6 ± 8.5 25.1 ± 6.2 28.2 ± 8.2 23.1 ± 6.0 27.9 ± 8.1 23.2 ± 7.0 Adjusted 27.6 ± 5.2 27.7 ± 5.3 0.007 0.813 27.7 ± 5.1 26.4 ± 5.2 −0.055 *0.043 27.7 ± 5.1 26.5 ± 5.1 −0.035 0.206 Single-leg stance Crude 31.2 ± 22.8 24.8 ± 22.1 30.0 ± 22.7 24.3 ± 22.7 29.8 ± 22.7 22.5 ± 22.9 time, s Adjusted 30.1 ± 18.4 27.6 ± 18.7 −0.049 0.162 29.6 ± 18.2 27.5 ± 18.6 − 0.03 0.391 29.5 ± 18.2 26.5 ± 18.3 −0.032 0.351 Stand up from a Crude 10.1 ± 3.6 11.1 ± 4.5 10.2 ± 3.6 11.5 ± 5.5 10.3 ± 3.8 11.3 ± 4.3 chair time, s Adjusted 10.3 ± 3.5 10.7 ± 3.5 0.048 0.222 10.3 ± 3.4 11.1 ± 3.5 0.069 0.072 10.3 ± 3.4 11.8 ± 3.4 0.059 0.118 Usual gait Crude 1.01 ± 0.21 1.01 ± 0.24 1.02 ± 0.21 1.00 ± 0.26 1.02 ± 0.22 0.92 ± 0.25 speed, m/s Adjusted 1.01 ± 0.20 1.03 ± 0.21 0.044 0.279 1.01 ± 0.20 1.02 ± 0.20 0.003 0.931 1.02 ± 0.20 0.94 ± 0.20 −0.091 *0.021 Maximum gait Crude 1.33 ± 0.27 1.28 ± 0.31 1.33 ± 0.27 1.22 ± 0.33 1.33 ± 0.27 1.17 ± 0.37 speed, m/s Adjusted 1.32 ± 0.24 1.32 ± 0.24 0.007 0.849 1.33 ± 0.24 1.27 ± 0.24 −0.072 *0.048 1.33 ± 0.23 1.23 ± 0.24 −0.084 *0.018 HV hallux valgus, M male, F female, s second, m/s meters per second *p < 0.05 Nishimura et al. BMC Musculoskeletal Disorders (2018) 19:174 Page 7 of 9 Fig. 2 Relationship between the percentage of hallux footprint and the hallux valgus angle on. The present study used standardized weight-bearing survey site and could understand and sign an informed radiographs, and the definition of HV was an HV angle > 20° consent form. Thus, elderly participants in this study according to the definition of the Japanese Foot and were relatively healthier and had no dementia. Further- Ankle Society. more, since workers in Japan usually retire between 63 The present study has several limitations. First, since it and 65 years old, male participants in their 50s usually was a cross-sectional study, causal relationships cannot have health examinations at their work place. Thus, male be determined. Second, participants could walk to the participants in their 50s who worried about their health Fig. 3 Comparison of the percentage of the hallux footprint between the no HV group and the HV group (a), between the no HV-mild HV group and the moderate-severe HV group (b), and between the no HV or painless HV group and the painful HV group (c). HV hallux valgus. *p < 0.01. Mann-Whitney test Nishimura et al. BMC Musculoskeletal Disorders (2018) 19:174 Page 8 of 9 tended to attend our exam. Due to this healthy user bias, Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in published the participants in this study do not truly represent the maps and institutional affiliations. general population. The percentage of men in this study was 34.5%, but the percentage of men over 65 years old Author details Departments of Orthopaedic Surgery, Mie University Graduate School of in this village was 39.2% in 2009. Further, the percentage Medicine, 2-174 Edobashi, Tsu City, Mie 514-8507, Japan. Departments of of men over 65 years old in Japan was 42.8% in 2009. Orthopaedic and Sports Medicine, Mie University Graduate School of This sex mismatch is also one of the limitations. Third, Medicine, Tsu City 514-8507, Mie, Japan. Department of Orthopaedic Surgery, Suzuka Kaisei Hospital, Suzuka City 513-8505, Mie, Japan. Clinical the examinations were held in a specific mountain village, Research Support Center, Mie University Hospital, 2-174 Edobashi, Tsu City, so that this study is not necessarily representative of all of Mie 514-8507, Japan. Japan. Fourth, the balance test was simply single-leg Received: 16 January 2018 Accepted: 17 May 2018 standing time with eyes open. If a standing test with eyes closed and/or postural sway using a force plate were used, significant differences might be detected in the balance References tests. Fifth, hallux pain is not always due to HV. Thus, 1. Nix S, Smith M, Vicenzino B. Prevalence of hallux valgus in the general painful HV does not necessarily mean pain related to HV. population: a systematic review and meta-analysis. J Foot Ankle Res. 2010;3:21. 2. Nguyen US, Hillstrom HJ, Li W, Dufour AB, Kiel DP, Procter-Gray E, Gagnon MM, Hannan MT. Factors associated with hallux valgus in a population- Conclusions based study of older women and men: the MOBILIZE Boston study. This cross-sectional epidemiological study showed that Osteoarthr Cartil. 2010;18(1):41–6. moderate-severe HV impaired some physical functions 3. Roddy E, Zhang W, Doherty M. Prevalence and associations of hallux valgus in a primary care population. Arthritis Rheum. 2008;59(6):857–62. (grip strength and maximum walking speed), and painful 4. Cho NH, Kim S, Kwon DJ, Kim HA. The prevalence of hallux valgus and its HV slowed walking speed regardless of radiographic KOA. association with foot pain and function in a rural Korean community. J Hallux plantar pressure decreased according to HV angle Bone Joint Surg Br. 2009;91(4):494–8. 5. Nishimura A, Kato K, Fukuda A, Nakazora S, Yamada T, Uchida A, Sudo A. and pain. We suspect this reduced hallux pressure is one Prevalence of hallux valgus and risk factors among Japanese community of the reasons for the functional impairments in partici- dwellers. J Orthop Sci. 2014;19(2):257–62. pants with moderate-severe HV or painful HV. By con- 6. Chaiwanichsiri D, Janchai S, Tantisiriwat N. Foot disorders and falls in older persons. Gerontology. 2009;55(3):296–302. trolling pain and treating severe HV deformity with 7. Badlissi F, Dunn JE, Link CL, Keysor JJ, McKinlay JB, Felson DT. Foot treatments such as surgery, the physical functions of HV musculoskeletal disorders, pain, and foot-related functional limitation in patients might be improved. older persons. J Am Geriatr Soc. 2005;53(6):1029–33. 8. Keysor JJ, Dunn JE, Link CL, Badlissi F, Felson DT. Are foot disorders associated with functional limitation and disability among community- Abbreviations dwelling older adults? J Aging Health. 2005;17(6):734–52. BMI: body mass index; HV: hallux valgus; KOA: knee osteoarthritis 9. Menz HB, Roddy E, Thomas E, Croft PR. Impact of hallux valgus severity on general and foot-specific health-related quality of life. Arthritis Care Acknowledgements Res (Hoboken). 2011;63(3):396–404. The authors would like to thank the staff of Houtoku Hospital for their 10. Abhishek A, Roddy E, Zhang W, Doherty M. Are hallux valgus and big toe invaluable assistance. pain associated with impaired quality of life? A cross-sectional study. Osteoarthr Cartil. 2010;18(7):923–6. Funding 11. Nix SE, Vicenzino BT, Smith MD. Foot pain and functional limitation in This study was supported by JSPS KAKENHI Grant Number JP15K08732 and healthy adults with hallux valgus: a cross-sectional study. BMC Grants-in-Aid for H25-Choujyu-007 (Director, Noriko Yoshimura) from the Musculoskelet Disord. 2012;13:197. Ministry of Health, Labour and Welfare of Japan. 12. Menz HB, Morris ME, Lord SR. Foot and ankle risk factors for falls in older people: a prospective study. J Gerontol A Biol Sci Med Sci. 2006; 61(8):866–70. Availability of data and materials 13. Mickle KJ, Munro BJ, Lord SR, Menz HB, Steele JR. ISB clinical biomechanics The datasets analyzed during the current study are available from the award 2009: toe weakness and deformity increase the risk of falls in older corresponding author on reasonable request. people. Clin Biomech (Bristol, Avon). 2009;24(10):787–91. 14. Nishimura A, Hasegawa M, Kato K, Yamada T, Uchida A, Sudo A. Risk factors Authors’ contributions for the incidence and progression of radiographic osteoarthritis of the knee AN conceived of this study and participated in the study design, and performed among Japanese. Int Orthop. 2011;35(6):839–43. data acquisition, analysis and interpretation, and drafted the manuscript. NI and 15. Nishimura A, Hasegawa M, Wakabayashi H, Yoshida K, Kato K, Yamada T, SN participated in the interpretation of data and performed statistical analyses. KK Uchida A, Sudo A. Prevalence and characteristics of unilateral knee and AS contributed to the study design and coordination, and helped to draft the osteoarthritis in a community sample of elderly Japanese: do fractures manuscript. TO helped to perform statistical analysis and interpretation of data. All around the knee affect the pathogenesis of unilateral knee osteoarthritis? J authors read and approved the final manuscript. Orthop Sci. 2012;17(5):556–61. 16. Nishimura A, Akeda K, Kato K, Asanuma K, Yamada T, Uchida A, Sudo A. Ethics approval and consent to participate Osteoporosis, vertebral fractures and mortality in a Japanese rural This study was approved by the institutional review board of Mie University community. Mod Rheumatol. 2014;24(5):840–3. Graduate School of Medicine. All of the participants provided written, informed 17. Iversen MD, Price LL, von Heideken J, Harvey WF, Wang C. Physical consent. examination findings and their relationship with performance-based function in adults with knee osteoarthritis. BMC Musculoskelet Disord. 2016;17:273. Competing interests 18. Kellgren JH, Lawrence JS. Radiological assessment of osteo-arthrosis. Ann The authors declare that they have no competing interests. Rheum Dis. 1957;16(4):494–502. Nishimura et al. BMC Musculoskeletal Disorders (2018) 19:174 Page 9 of 9 19. Saltzman CL, Brandser EA, Berbaum KS, DeGnore L, Holmes JR, Katcherian DA, Teasdall RD, Alexander IJ. Reliability of standard foot radiographic measurements. 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Foot pain and disability in older women. Am J Epidemiol. 1998;148(7):657–65. 26. Benvenuti F, Ferrucci L, Guralnik JM, Gangemi S, Baroni A. Foot pain and disability in older persons: an epidemiologic survey. J Am Geriatr Soc. 1995;43(5):479–84. 27. Menz HB, Morris ME. Clinical determinants of plantar forces and pressures during walking in older people. Gait Posture. 2006;24(2):229–36. 28. Mueller MJ, Hastings M, Commean PK, Smith KE, Pilgram TK, Robertson D, Johnson J. Forefoot structural predictors of plantar pressures during walking in people with diabetes and peripheral neuropathy. J Biomech. 2003;36(7):1009–17. 29. Hurn SE, Vicenzino B, Smith MD. Functional impairments characterizing mild, moderate, and severe hallux valgus. Arthritis Care Res (Hoboken). 2015;67(1):80–8. 30. Sanders AP, Snijders CJ, van Linge B. Medial deviation of the first metatarsal head as a result of flexion forces in hallux valgus. Foot & ankle. 1992;13(9):515–22. 31. Menz HB, Morris ME. Determinants of disabling foot pain in retirement village residents. J Am Podiatr Med Assoc. 2005;95(6):573–9. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png BMC Musculoskeletal Disorders Springer Journals

Does hallux valgus impair physical function?

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Medicine & Public Health; Orthopedics; Rehabilitation; Rheumatology; Sports Medicine; Internal Medicine; Epidemiology
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Abstract

Background: The relationships between radiographic hallux valgus (HV) and various physical functions independent of knee osteoarthritis (KOA) were examined among residents of a mountain village in Japan. Methods: Study participants were recruited from mountain village residents aged ≥50 years. Participants’ height, weight, and body mass index (BMI) were measured, and baseline data, including age, sex, and foot pain, were obtained using interviews and questionnaires. Radiography of the feet and knees was performed to assess the presence of HV (HV angle ≥20°) and KOA (Kellgren-Lawrence grade ≥ II). Grip strength, 6-m walk at usual and maximum speeds, single-leg stance time, and stand up from a chair time were evaluated as physical function performance tests. Plantar pressure patterns were also examined. Results: Moderate-severe HV (HV angle ≥30 degrees), impaired grip strength and maximum walking speed, and painful HV reduced usual and maximum walking speeds independent of KOA. Hallux plantar pressure decreased according to the HV angle. Hallux plantar pressure was significantly lower in painful HV than in the no HV feet or painless HV. Conclusions: Moderate-severe HV deformity and HV-related pain impaired physical function independent of KOA. By controlling the pain and severe deformity of HV by treatments such as surgery, the physical function of HV patients might be improved. Keywords: Hallux valgus, Physical function, Knee osteoarthritis, Epidemiology elderly Background found no association between HV and disability, such as Hallux valgus (HV) is one of the most common foot the Timed Up & Go test [6], walking speed [6–8], and bal- deformities in adults; it is characterized by abnormal an- ance tests [8]. On the other hand, increasing HV severity gulation, rotation, and lateral deviation of the hallux at has been shown to negatively impact health-related quality the first metatarsophalangeal joint [1]. The prevalence of of life and self-reported function [4, 9, 10], and HV has HV has been reported as 58% in adult women and 25% been linked to balance function [11] and increased fall risk in adult men (HV angle ≥15°) in the USA [2], 28.4% in in older adults [12, 13]. adults (self-reported hallux valgus) in the UK [3], 64.7% Our cohort study started in 1997 to investigate the (HV angle ≥15°) in a Korean population aged between epidemiology of knee osteoarthritis (KOA) [14, 15] and 40 and 69 years [4], and 29.8% (HV angle > 20°) in a osteoporosis [16]. The study of HV started from 2009, Japanese population aged over 65 years [5]. While HV is and we reported the prevalence and risk factors for HV basically regarded as a structural deformity, there is [5]. In our study [5], HV showed a significant relation- debate surrounding the association between abnormal ship with KOA. In general, KOA is associated with lower foot structure and related disability. Several studies have physical extremity function [17]. However, no report has shown a relationship between HV and physical function after taking into account the existence of KOA. * Correspondence: meiten@clin.medic.mie-u.ac.jp Departments of Orthopaedic Surgery, Mie University Graduate School of The purpose of this cross-sectional study was to inves- Medicine, 2-174 Edobashi, Tsu City, Mie 514-8507, Japan tigate whether HV affects physical function after taking Departments of Orthopaedic and Sports Medicine, Mie University Graduate into account KOA among elderly persons. School of Medicine, Tsu City 514-8507, Mie, Japan Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Nishimura et al. BMC Musculoskeletal Disorders (2018) 19:174 Page 2 of 9 Methods single-leg stance time with eyes open, and stand up from Individuals aged ≥50 years were recruited from among a chair time. Grip strength was measured using a Takei the inhabitants of a mountain village in Japan. The main 5401 handgrip dynamometer (Takei Scientific Instru- industry is the forest industry. The study was started in ments Co., Niigata, Japan). The participants stood and 1997, with follow-up every two years. All studies were held the dynamometer with the arm at right angles and held at the local hospital. This present study analyzed the elbow by the side of the body. Two measurements data from the seventh to tenth biennial examinations in were done for each hand. We used the average of the 2009, 2011, 2013, and 2015, respectively. The number of highest measurement of each hand. Participants were participants in 2009, 2011, 2013, and 2015 was 314, instructed to walk at their usual and maximum speeds. 221, 223, and 204, respectively. For individuals who We measured the time was with a stopwatch. The data participated in two or more iterations of these four ex- for plantar pressure patterns were taken using a gait aminations, only the data from the earliest examination analyzer (Walk Way MW 1000; Anima, Tokyo, Japan). were included. For example, if an individual partici- This analyzer has a sheet length of 2.4 m, and this sheet pated in 2009, 2011 and 2015, the data in 2009 were in- was set in the middle of the 6-m walkway. In order to cluded in this study. Exclusion criteria were rheumatoid investigate how strongly participants pushed the ground arthritis and past history of surgery for hallux valgus. A with the great toe, the percentage of the hallux footprint total of 562 participants (194 male, 368 female) were in the whole footprint was examined. Each footprint was part of this study. picked up using the gait analyzer (Fig. 1), and the hallux Before direct examination, a baseline questionnaire in- cluding name, age, sex, medical history, and pain was sent to the participants. Direct examination consisted of phys- ical measurement, medical interview, physical examin- ation, X-rays, blood tests, and physical function tests. We measured participants’ height and body weight, and the body mass index (BMI) was calculated as weight (kg) di- vided by height squared (m ). Medical interviews and physical examinations were performed one-on-one by orthopedic surgeons. Bunions were detected by inspection and palpation. Painful bunions were determined by apply- ing pressure to the bunion. Knee X-rays were taken with the knee in a fully extended standing position. KOA was scored according to the Kellgren-Lawrence grading sys- tem [18]. Radiographic KOA was defined as grade ≥ 2. We took foot X-rays with participants standing upright with both feet on the cassette, as described by Saltzman [19]. The HV angle, which is formed by the bone axes of the first metatarsal and the first proximal phalanx, was consistently measured by the same examiner [20]. These imaging data were analyzed using Image J version 1.37 software (National Institutes of Health, Bethesda, MD, USA). Hallux valgus was deemed to be present if the HV angle was ≥20°, according to the Japanese Orthopaedic Society criteria. HV severity was classified as mild (≥20° and < 30°), moderate (≥30° and < 40°), or severe (≥40°). Participants reporting pain in the right or left hal- lux on most days of a month for at least 1 month in the previous year were classified as having right or left hallux pain. Participants with radiographic HV and self-reported hallux pain or a painful bunion checked by orthopedic surgeons were defined as having painful HV. If a partici- Fig. 1 Representative footprint. Blue dotted line shows the region of pant had left hallux pain and right radiographic HV, that interest (ROI) of a whole footprint, and the black dotted line shows the ROI of a hallux footprint for pressure analysis. The percentage of the participant was not included in the painful HV group. hallux footprint is calculated as the hallux footprint pressure divided by The physical function tests consisted of grip strength, the whole footprint 6-meter (m) walk at usual and maximum speeds, Nishimura et al. BMC Musculoskeletal Disorders (2018) 19:174 Page 3 of 9 footprint and the whole footprint were enclosed, and the 160 participants (26 male, 134 female), whereas the no pressure was analyzed with analysis software (PREDAS HV group had 402 participants (168 male, 234 female). MD-1000; Anima, Tokyo, Japan). The percentage of the Participants in the HV group were significantly shorter hallux footprint was defined as [hallux footprint]/[whole and older than those in the no HV group, and the footprint]. Examining the foot pressure patterns, the percentages of female and KOA were significantly higher percentage of hallux footprint was checked, from in the HV group than in the no HV group. When which was calculated hallux pressure/whole foot pres- participants were classified into a no HV-mild HV sure. We measured single-leg stance time with eyes group and a moderate-severe HV group, participants in open for both legs, and we calculated the average time. the moderate-severe HV group were significantly shorter Participants were instructed to stand on one leg while ele- and lighter than those in the no HV-mild HV group, and vating the contralateral limb. The time until the raised leg the percentages of female and KOA were significantly was touched on the floor was measured. The maximum higher in the moderate-severe HV group than in the no time was 60 seconds (s). The stand up from a chair time HV-mild HV group. When participants were classified was the time taken to stand from a chair five times with into a no HV or painless HV group and a painful HV hands folded in front of the chest and feet flat on the group, the participants in the painful HV group were sig- floor. nificantly shorter than those in the no HV or painless HV Based on the worse HV angle in their feet, the partici- group, and the percentages of female and KOA were sig- pants were classified into a no HV group (HV angle < 20°) nificantly higher in the painful HV group than in the no and an HV group (HV angle ≥20°). They were then classi- HV or painless HV group. fied into a no HV-mild HV group (HV angle < 30°) and a The relationships between HV and physical functions moderate-severe HV group (HV angle ≥30°). Finally, they are shown in Tables 2 and 3. Table 2 shows the results were classified into a painful HV group and a no HV or after adjustment for age, sex, and BMI, and Table 3 painless HV group. shows the results after adjustment for age, sex, BMI, and KOA. There was no significant difference between the Statistical analysis HV group and the no HV group in physical functions. Means ± standard deviations were calculated for vari- On the other hand, grip strength and maximal 6-m ables unless otherwise noted. Associations among the walking time were significantly stronger and faster in the physical characteristics between the groups were deter- no HV-mild HV group than in the moderate-severe HV mined by the unpaired t-test or Fisher’s exact test. The group, respectively. In terms of HV-related pain, both relationships between physical functions (grip strength, usual and maximum walking speeds were significantly single-leg stance time, standing up from a chair, and 6-m slower in the painful HV group than in the no HV or walking times at usual and maximum speeds) and HV painless HV group. During 6-m walking, a significant (HV angle ≥20°), moderate-severe HV (HV angle ≥30°), or negative correlation was observed between the HV angle painful HV (HV angle ≥20° with pain) were evaluated by and the percentage of hallux footprint (Fig. 2). Pearson’s multiple linear regression analysis both after adjusting for correlation coefficient (r) and the corresponding p value age, sex, and BMI, and for age, sex, BMI, and KOA. The were r = − 0.44 and p < 0.01. The percentage of hallux correlation between the HV angle and the percentage of footprint was significantly higher in no HV feet than in the hallux footprint was analyzed by Pearson’scorrelation HV feet (Fig. 3a). The percentage of hallux footprint was coefficient. Percentages of the hallux footprint be- significantly higher in no HV or mild HV feet than in tween no HV foot and HV, between no HV-mild HV and moderate-severe HV feet (Fig. 3b). Moreover, the per- moderate-severe HV, and between no HV foot or painless centage of hallux footprint was significantly higher in no HV and painful HV were analyzed by the Mann-Whitney HV or painless HV feet than in painful HV feet (Fig. 3c). test. The significance level was set at 5% in a two-tailed test. All data were analyzed using PASW Statistics for Discussion Windows version 22 (IBM, Armonk, NY, USA). The results of this cross-sectional study indicated that participants with moderate-severe HV or painful HV Results had impaired physical functions compared to partici- The overall prevalence of definite radiographic HV was pants with no HV-mild HV or painless HV after taking 28.4% (160/562); it was 13.4% (26/194) in males and into account age, sex, BMI, and radiographic KOA. 36.4% (134/368) in females. The rates of mild, moderate, Hallux loading was reduced with increasing HV severity and severe HV in the 562 participants were 16.5% (93/562), or HV-related pain. 9.3% (52/562), and 2.7% (15/562), respectively. With regard to standing balance, Menz et al. [21], Table 1 shows the physical characteristics of the par- Spink et al. [22], and Nix et al. [11] reported that poorer lat- ticipants who fulfilled the criteria. The HV group had eral stability, poorer coordinate stability, and increased Nishimura et al. BMC Musculoskeletal Disorders (2018) 19:174 Page 4 of 9 Table 1 Comparison of participants’ basic data between the no HV group and the HV group, between the no HV -mild HV group and the moderate-severe HV group, and between the no HV or painless HV group and the painful HV group No HV group HV group No HV-mild HV group Moderate-severe HV group No HV or painless HV group Painful HV group (n = 402) (n = 160) (n = 495) (n = 67) (n = 529) (n = 33) Age (years) **71.1 ± 8.8 73.3 ± 8.7 71.5 ± 8.9 73.4 ± 8.3 71.6 ± 8.8 74.0 ± 9.1 Sex (% female) **58.2 83.8 **62.2 89.6 *64.1 87.9 Height (cm) **154.6 ± 8.9 151.1 ± 7.8 **154.2 ± 8.7 149.7 ± 7.5 *153.9 ± 8.6 148.9 ± 9.0 Weight (kg) **55.8 ± 10.3 53.5 ± 9.4 *55.5 ± 10.2 52.4 ± 9.5 55.4 ± 10.1 51.9 ± 10.0 BMI (kg/m ) 23.3 ± 3.2 23.4 ± 3.6 23.3 ± 3.3 23.4 ± 3.5 23.3 ± 3.3 23.4 ± 3.7 KOA (%) **33.8 55.0 **37.2 59.7 *40.0 42.4 HV hallux valgus, BMI body mass index, KOA knee osteoarthritis **p < 0.01, *p < 0.05 postural sway were associated with HV in elderly popula- but maximum walking requires a higher level of physical tions. On the other hand, Mickle et al. [23] and Menz and function than usual walking. Thus, moderate-severe HV ap- Lord [24] showed no relationship between HV and standing peared to be associated with maximum walking speed in balance. These previous reports included much finer ana- the present study. lyses, with evaluation of the center of pressure (COP) using Previous studies reported that foot pain was associated a force plate, and/or more severe conditions, such as eyes with poor physical function. Some studies [24–26] re- closed, than the present study. The data of the present ported that participants with foot pain had more diffi- study were only for standing time with eyes open to exam- culty walking than participants without foot pain. In ine standing balance, but there was no relationship between addition, some reports [1, 4] showed that HV was asso- HV and standing balance. If finer evaluations, such as ciated with more self-reported foot pain and poorer analyzing COP, and/or more severe conditions, such as self-reported physical function. Abhishek et al. [10]further eyes closed, were performed, some differences might be highlighted the importance of hallux pain with HV, detected. reporting that health-related quality of life was progres- To thebestofour knowledge, therehavebeennoreports sively impaired in participants with HV alone, hallux pain of the relationship between HV and hand grip strength. alone, and HV with hallux pain. In the present study, The present study showed that moderate-severe HV de- walking speeds of participants with painful HV were formity (HV angle ≥30°) was associated with impaired hand slower than those of participants with no HV or mild HV. grip strength. It is easy to imagine that patients with Previous reports [27–29] showed an inverse relation- moderate-severeHVhavesmaller grip strength of thefoot ship between HV severity and reduced hallux loading. because of poor alignment of the 1st MTP joint. Grip Nix et al. [11] and Mickle et al. [13] showed that partici- strength of the hallux might be correlated with hand grip pants with HV had decreased hallux plantar flexion strength. Thus, patients with poor grip strength in the strength. Sanders et al. [30] reported an inverse relation- moderate-severe HV group may show poor grip strength of ship between HV angle and hallux plantar flexion the hallux. However, this is just a hypothesis, and further strength, as well as lower mean hallux plantar flexion studies are needed. strength in those with painful HV than in those with HV No significant between-group differences were found without complaints. Moreover, Mickle et al. [23] re- in walking performance in some studies [11, 22]. The ported less hallux loading in HV patients than controls. present data for the no HV group and the HV group are Hurn et al. [29] reported that participants with moderate consistent with these previous studies. However, the (average HV angle = 30.8°) and severe HV (average HV definitions used in the various studies differed, since the angle = 39.9°) showed significantly reduced hallux plan- data were self-reported (such as the Manchester scale) tar pressure-time compared to controls. These reports or HV < 20° was used, so that the HV groups had many are consistent with the results of the present study. mild HV participants. In the present study, maximum These reduced hallux plantar pressures might reflect im- walking speed was faster in the no HV-mild HV group paired physical function, such as slower walking speed. than in the moderate-severe HV group. Cho et al. [4] Caution must be applied when comparing reports showed that participants with moderate or greater HV from different studies [1]. Some studies have used (HV angle > 25°) had significantly worse functional status, self-report information, such as the Manchester scale foot health function status, and self-assessment of their foot [21–23, 31], and others have used X-ray definitions. In condition. These data support the present data. There were terms of X-ray examinations, studies have used a range no data about maximum walking speed in previous studies, of definitions, such as HV angle > 15° or 20° and so Nishimura et al. BMC Musculoskeletal Disorders (2018) 19:174 Page 5 of 9 Table 2 Comparison of physical functions between the no HV group and the HV group, between the no HV-mild HV group and the moderate-severe HV group, and between the no HV or painless HV group and the painful HV group after adjusted for age, sex, and body mass index No HV HV Standard partial p No HV-mild Moderate- Standard partial p No HV or Painful HV Standard partial p regression coefficient Value HV severe HV regression coefficient Value painless HV regression coefficient Value (n =402) (n = 160) (n =495) (n = 67) (n = 529) (n = 33) Grip strength, kg Crude 28.6 ± 8.5 25.1 ± 6.2 28.2 ± 8.2 23.1 ± 6.0 27.9 ± 8.1 23.2 ± 7.0 Adjusted 27.6 ± 5.2 27.6 ± 5.2 0.007 0.910 27.8 ± 5.1 26.3 ± 5.2 −0.140 *0.034 27.7 ± 5.1 26.4 ± 5.1 −0.088 0.189 Single-leg stance Crude 31.2 ± 22.8 24.8 ± 22.1 30.0 ± 22.7 24.3 ± 22.7 29.8 ± 22.7 22.5 ± 22.9 time, s Adjusted 30.1 ± 18.3 27.4 ± 18.6 −0.079 0.125 29.6 ± 18.2 27.3 ± 18.5 − 0.051 0.332 29.5 ± 18.2 26.3 ± 18.3 − 0.052 0.323 Stand up from a Crude 10.1 ± 3.6 11.1 ± 4.5 10.2 ± 3.6 11.5 ± 5.5 10.3 ± 3.8 11.8 ± 4.3 chair time, s Adjusted 10.3 ± 3.4 10.7 ± 3.5 0.063 0.175 10.3 ± 3.4 11.2 ± 3.5 0.089 0.056 10.3 ± 3.4 11.3 ± 3.4 0.077 0.106 Usual gait Crude 1.01 ± 0.21 1.01 ± 0.24 1.02 ± 0.21 1.00 ± 0.26 1.02 ± 0.22 0.92 ± 0.25 speed, m/s Adjusted 1.01 ± 0.20 1.03 ± 0.20 0.039 0.376 1.02 ± 0.20 1.01 ± 0.20 −0.003 0.949 1.02 ± 0.21 0.93 ± 0.20 − 0.108 *0.017 Maximum gait Crude 1.33 ± 0.27 1.28 ± 0.31 1.33 ± 0.27 1.22 ± 0.33 1.33 ± 0.27 1.17 ± 0.37 speed, m/s Adjusted 1.32 ± 0.24 1.32 ± 0.24 0.002 0.968 1.33 ± 0.24 1.26 ± 0.24 −0.103 *0.037 1.33 ± 0.23 1.22 ± 0.24 −0.120 *0.016 HV hallux valgus, M male, F female, s second, m/s meters per second *p < 0.05 Nishimura et al. BMC Musculoskeletal Disorders (2018) 19:174 Page 6 of 9 Table 3 Comparison of physical functions between the no HV group and the HV group, between the no HV-mild HV group and the moderate-severe HV group, and between the no HV or painless HV group and the painful HV group after adjustment for age, sex, body mass index, and knee osteoarthritis No HV HV Standard partial p No HV-mild Moderate- Standard partial p No HV or Painful HV Standard partial p regression coefficient Value HV severe HV regression coefficient Value painless HV regression coefficient Value (n = 402) (n = 160) (n = 495) (n = 67) (n = 529) (n = 33) Grip strength, kg Crude 28.6 ± 8.5 25.1 ± 6.2 28.2 ± 8.2 23.1 ± 6.0 27.9 ± 8.1 23.2 ± 7.0 Adjusted 27.6 ± 5.2 27.7 ± 5.3 0.007 0.813 27.7 ± 5.1 26.4 ± 5.2 −0.055 *0.043 27.7 ± 5.1 26.5 ± 5.1 −0.035 0.206 Single-leg stance Crude 31.2 ± 22.8 24.8 ± 22.1 30.0 ± 22.7 24.3 ± 22.7 29.8 ± 22.7 22.5 ± 22.9 time, s Adjusted 30.1 ± 18.4 27.6 ± 18.7 −0.049 0.162 29.6 ± 18.2 27.5 ± 18.6 − 0.03 0.391 29.5 ± 18.2 26.5 ± 18.3 −0.032 0.351 Stand up from a Crude 10.1 ± 3.6 11.1 ± 4.5 10.2 ± 3.6 11.5 ± 5.5 10.3 ± 3.8 11.3 ± 4.3 chair time, s Adjusted 10.3 ± 3.5 10.7 ± 3.5 0.048 0.222 10.3 ± 3.4 11.1 ± 3.5 0.069 0.072 10.3 ± 3.4 11.8 ± 3.4 0.059 0.118 Usual gait Crude 1.01 ± 0.21 1.01 ± 0.24 1.02 ± 0.21 1.00 ± 0.26 1.02 ± 0.22 0.92 ± 0.25 speed, m/s Adjusted 1.01 ± 0.20 1.03 ± 0.21 0.044 0.279 1.01 ± 0.20 1.02 ± 0.20 0.003 0.931 1.02 ± 0.20 0.94 ± 0.20 −0.091 *0.021 Maximum gait Crude 1.33 ± 0.27 1.28 ± 0.31 1.33 ± 0.27 1.22 ± 0.33 1.33 ± 0.27 1.17 ± 0.37 speed, m/s Adjusted 1.32 ± 0.24 1.32 ± 0.24 0.007 0.849 1.33 ± 0.24 1.27 ± 0.24 −0.072 *0.048 1.33 ± 0.23 1.23 ± 0.24 −0.084 *0.018 HV hallux valgus, M male, F female, s second, m/s meters per second *p < 0.05 Nishimura et al. BMC Musculoskeletal Disorders (2018) 19:174 Page 7 of 9 Fig. 2 Relationship between the percentage of hallux footprint and the hallux valgus angle on. The present study used standardized weight-bearing survey site and could understand and sign an informed radiographs, and the definition of HV was an HV angle > 20° consent form. Thus, elderly participants in this study according to the definition of the Japanese Foot and were relatively healthier and had no dementia. Further- Ankle Society. more, since workers in Japan usually retire between 63 The present study has several limitations. First, since it and 65 years old, male participants in their 50s usually was a cross-sectional study, causal relationships cannot have health examinations at their work place. Thus, male be determined. Second, participants could walk to the participants in their 50s who worried about their health Fig. 3 Comparison of the percentage of the hallux footprint between the no HV group and the HV group (a), between the no HV-mild HV group and the moderate-severe HV group (b), and between the no HV or painless HV group and the painful HV group (c). HV hallux valgus. *p < 0.01. Mann-Whitney test Nishimura et al. BMC Musculoskeletal Disorders (2018) 19:174 Page 8 of 9 tended to attend our exam. Due to this healthy user bias, Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in published the participants in this study do not truly represent the maps and institutional affiliations. general population. The percentage of men in this study was 34.5%, but the percentage of men over 65 years old Author details Departments of Orthopaedic Surgery, Mie University Graduate School of in this village was 39.2% in 2009. Further, the percentage Medicine, 2-174 Edobashi, Tsu City, Mie 514-8507, Japan. Departments of of men over 65 years old in Japan was 42.8% in 2009. Orthopaedic and Sports Medicine, Mie University Graduate School of This sex mismatch is also one of the limitations. Third, Medicine, Tsu City 514-8507, Mie, Japan. Department of Orthopaedic Surgery, Suzuka Kaisei Hospital, Suzuka City 513-8505, Mie, Japan. Clinical the examinations were held in a specific mountain village, Research Support Center, Mie University Hospital, 2-174 Edobashi, Tsu City, so that this study is not necessarily representative of all of Mie 514-8507, Japan. Japan. Fourth, the balance test was simply single-leg Received: 16 January 2018 Accepted: 17 May 2018 standing time with eyes open. If a standing test with eyes closed and/or postural sway using a force plate were used, significant differences might be detected in the balance References tests. Fifth, hallux pain is not always due to HV. Thus, 1. Nix S, Smith M, Vicenzino B. Prevalence of hallux valgus in the general painful HV does not necessarily mean pain related to HV. population: a systematic review and meta-analysis. J Foot Ankle Res. 2010;3:21. 2. Nguyen US, Hillstrom HJ, Li W, Dufour AB, Kiel DP, Procter-Gray E, Gagnon MM, Hannan MT. Factors associated with hallux valgus in a population- Conclusions based study of older women and men: the MOBILIZE Boston study. This cross-sectional epidemiological study showed that Osteoarthr Cartil. 2010;18(1):41–6. moderate-severe HV impaired some physical functions 3. Roddy E, Zhang W, Doherty M. Prevalence and associations of hallux valgus in a primary care population. Arthritis Rheum. 2008;59(6):857–62. (grip strength and maximum walking speed), and painful 4. Cho NH, Kim S, Kwon DJ, Kim HA. The prevalence of hallux valgus and its HV slowed walking speed regardless of radiographic KOA. association with foot pain and function in a rural Korean community. J Hallux plantar pressure decreased according to HV angle Bone Joint Surg Br. 2009;91(4):494–8. 5. Nishimura A, Kato K, Fukuda A, Nakazora S, Yamada T, Uchida A, Sudo A. and pain. We suspect this reduced hallux pressure is one Prevalence of hallux valgus and risk factors among Japanese community of the reasons for the functional impairments in partici- dwellers. J Orthop Sci. 2014;19(2):257–62. pants with moderate-severe HV or painful HV. By con- 6. Chaiwanichsiri D, Janchai S, Tantisiriwat N. Foot disorders and falls in older persons. Gerontology. 2009;55(3):296–302. trolling pain and treating severe HV deformity with 7. Badlissi F, Dunn JE, Link CL, Keysor JJ, McKinlay JB, Felson DT. Foot treatments such as surgery, the physical functions of HV musculoskeletal disorders, pain, and foot-related functional limitation in patients might be improved. older persons. J Am Geriatr Soc. 2005;53(6):1029–33. 8. Keysor JJ, Dunn JE, Link CL, Badlissi F, Felson DT. Are foot disorders associated with functional limitation and disability among community- Abbreviations dwelling older adults? J Aging Health. 2005;17(6):734–52. BMI: body mass index; HV: hallux valgus; KOA: knee osteoarthritis 9. Menz HB, Roddy E, Thomas E, Croft PR. Impact of hallux valgus severity on general and foot-specific health-related quality of life. Arthritis Care Acknowledgements Res (Hoboken). 2011;63(3):396–404. The authors would like to thank the staff of Houtoku Hospital for their 10. Abhishek A, Roddy E, Zhang W, Doherty M. Are hallux valgus and big toe invaluable assistance. pain associated with impaired quality of life? A cross-sectional study. Osteoarthr Cartil. 2010;18(7):923–6. Funding 11. Nix SE, Vicenzino BT, Smith MD. Foot pain and functional limitation in This study was supported by JSPS KAKENHI Grant Number JP15K08732 and healthy adults with hallux valgus: a cross-sectional study. BMC Grants-in-Aid for H25-Choujyu-007 (Director, Noriko Yoshimura) from the Musculoskelet Disord. 2012;13:197. Ministry of Health, Labour and Welfare of Japan. 12. Menz HB, Morris ME, Lord SR. Foot and ankle risk factors for falls in older people: a prospective study. J Gerontol A Biol Sci Med Sci. 2006; 61(8):866–70. Availability of data and materials 13. Mickle KJ, Munro BJ, Lord SR, Menz HB, Steele JR. ISB clinical biomechanics The datasets analyzed during the current study are available from the award 2009: toe weakness and deformity increase the risk of falls in older corresponding author on reasonable request. people. Clin Biomech (Bristol, Avon). 2009;24(10):787–91. 14. Nishimura A, Hasegawa M, Kato K, Yamada T, Uchida A, Sudo A. Risk factors Authors’ contributions for the incidence and progression of radiographic osteoarthritis of the knee AN conceived of this study and participated in the study design, and performed among Japanese. 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Foot Ankle Int. 1994;15(12):661–5. 20. Helal B, Gupta SK, Gojaseni P. Surgery for adolescent hallux valgus. Acta Orthop Scand. 1974;45(2):271–95. 21. Menz HB, Morris ME, Lord SR. Foot and ankle characteristics associated with impaired balance and functional ability in older people. J Gerontol A Biol Sci Med Sci. 2005;60(12):1546–52. 22. Spink MJ, Fotoohabadi MR, Wee E, Hill KD, Lord SR, Menz HB. Foot and ankle strength, range of motion, posture, and deformity are associated with balance and functional ability in older adults. Arch Phys Med Rehabil. 2011;92(1):68–75. 23. Mickle KJ, Munro BJ, Lord SR, Menz HB, Steele JR. Gait, balance and plantar pressures in older people with toe deformities. Gait Posture. 2011;34(3):347–51. 24. Menz HB, Lord SR. Foot pain impairs balance and functional ability in community-dwelling older people. J Am Podiatr Med Assoc. 2001;91(5):222–9. 25. Leveille SG, Guralnik JM, Ferrucci L, Hirsch R, Simonsick E, Hochberg MC. Foot pain and disability in older women. Am J Epidemiol. 1998;148(7):657–65. 26. Benvenuti F, Ferrucci L, Guralnik JM, Gangemi S, Baroni A. Foot pain and disability in older persons: an epidemiologic survey. J Am Geriatr Soc. 1995;43(5):479–84. 27. Menz HB, Morris ME. Clinical determinants of plantar forces and pressures during walking in older people. Gait Posture. 2006;24(2):229–36. 28. Mueller MJ, Hastings M, Commean PK, Smith KE, Pilgram TK, Robertson D, Johnson J. Forefoot structural predictors of plantar pressures during walking in people with diabetes and peripheral neuropathy. J Biomech. 2003;36(7):1009–17. 29. Hurn SE, Vicenzino B, Smith MD. Functional impairments characterizing mild, moderate, and severe hallux valgus. Arthritis Care Res (Hoboken). 2015;67(1):80–8. 30. Sanders AP, Snijders CJ, van Linge B. Medial deviation of the first metatarsal head as a result of flexion forces in hallux valgus. Foot & ankle. 1992;13(9):515–22. 31. Menz HB, Morris ME. Determinants of disabling foot pain in retirement village residents. J Am Podiatr Med Assoc. 2005;95(6):573–9.

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BMC Musculoskeletal DisordersSpringer Journals

Published: May 29, 2018

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