hallux valgus ( hv ) is a common deformity characterized by angulation of the hallux starting 
 at the first metatarsophalangeal ( mtp ) joint towards the second toe .
following the 
 angulation of the first metatarsal bone towards the medial side , lateral deviation and 
 internal rotation through the longitudinal axis occur in the hallux .
the incidence of hv has been increasing and , if not 
 treated , it may severely impair a patient s functional status .
it is a painful , progressive 
 condition and also negatively affects the appearance of the foot3 .
intrinsic and extrinsic factors affect the development of hv pathology . extended or extreme 
 pronation of the rearfoot , acquired pes planus , achilles contracture , increased joint 
 laxity , metatarsocuneiform joint hypermobility , low transverse arch , familial factors , 
 increase in body weight , gender , cerebral palsy , and stroke are among the main intrinsic 
 factors4 , 5 .
it has been reported that long term activities carried out in a 
 standing position also increase the intensity of pain1 , 3 .
wearing high heels and shoes 
 constricting the forefoot are among the extrinsic factors that accelerate the development of 
 hv deformity and increase its intensity .
therefore , hv has been reported to be more frequent 
 among women and also among individuals living in shoe - wearing societies6 , 7 .
although the underlying mechanisms of hv development have not been not fully elucidated , 
 because it is also seen in non - shoe - wearing societies , it is possible that deformity caused 
 by an underlying mechanism is aggravated by wearing wrong types of shoe , and symptoms may 
 also increase with misuse of shoes7 . individuals daily standing times and daily walking distances as well as the types of 
 platforms on which they stand or walk are important factors affecting the intensity of their 
 complaints as well as determining their physical limitations .
pain is the most important and 
 the most commonly reported hv - related complaint .
pathologies and deformities occurring in 
 the foot , which has an important function in terms of lower - extremity kinematics , cause pain 
 and mobility problems , and may eventually result in insufficiency in physical activity8 .
furthermore , it was reported 
 that the quality of life of hv patients complaining of both deformity and pain is more 
 negatively affected than that of hv patients with no symptoms .
studied 
 osteoarthritis patients over the age of 55 and reported that increasing intensity of 
 comorbid hv deformity has a negative effect on both general and foot - related quality of 
 life9 .
it was also reported that along 
 with increase in the angulation of the first mtp towards hallux valgus , increase in the 
 intermetatarsal angle also has negative effects on the quality of life10 .
the aim of the present study was to clinically determine bilateral hv deformity , to present 
 its relationship with changes in the position of the rear foot joints , and to determine its 
 effects on the quality of life , pain , and related functional status of women with hv 
 deformity .
the study initially included 32 women with clinically diagnosed hv ( age range : 2054 
 years ) .
inclusion criteria were as follows : age range of 1855 years , bilateral deformity with 
 right - dominance , first mtp angle of > 15 as radiologically determined by the referring 
 physician , deformity intensity > 2 based on the manchester scale , muscle forces on ankle 
 and foot > 4 , no history of surgery , and no systemic disease , neurological , cognitive , 
 mental , or psychological problems .
informed consents were obtained from each participant and also permission from the local 
 ethics committee was obtained ( lut 09/37 - 26 ) . demographic data ( age , height , and body weight ) , symptoms accompanying deformity ( hallux 
 bunion and flatfoot ) , and familial hv history were recorded .
the reason for this was because right - dominant people form the 
 majority ( 90% ) of the general population11 and the preferred cerebral lateralization status is related to foot 
 and hand dominancy . in order to confirm the lower extremity dominancy of the participants , 
 they were asked to stand still before stairs .
then , they were commanded to climb and the 
 first foot they used was recorded .
the patients who used their right foot four or more times 
 out of five trials were classified as right - dominant12 .
the mancester scale , developed by garrow , was used to determine the severity of the hv 
 deformity of the participants . on the manchester scale , which is a valid and reliable 
 clinical tool ,
the severity of deformity is determined by comparing the patient s foot with 
 standardized images of feet with four grades of hv and the deformities are classified into 
 four groups , as follows : none ( 1 ) , mild ( 2 ) , moderate ( 3 ) , and severe ( 4)13 . after evaluation the scale ,
lovett , was conducted for muscle groups ( m. 
 tibialis anterior , m. extensor digitorum communis , m. extensor hallucis longus and brevis , 
 m. triceps surae ) that may have an impact on the lower extremity , and thus walking and that 
 cause secondary pathological changes in the foot and ankle . those participants with a muscle 
 strength lower than 4 were excluded from the study14 .
hv angles were determined by measuring the angle between the axes of the first metatarsal 
 and proximal phalanx at the dorsum of the foot and were recorded as in degrees15 , 16 .
the results of goniometric measurement , which is a simple , low - cost , 
 and risk - free measurement method , were found correlate with pain and the inter - metatarsal 
 and inter - phalangeal angle , which are indicators of the level of deformity .
it was also 
 presented that this is a valid and reliable measurement method for measuring joint 
 movement17 .
navicular height ( nh ) is the elevation of the navicular tuberosity from the ground in the 
 full weight - bearing position18 , 19 .
sagittal displacement of the navicular tuberosity may 
 reflect extreme subtalar joint pronation , and thus insufficient support of the ligaments and 
 muscle tendons in the medial longitudinal arch20 .
furthermore , it may show the degree of plantar flexion of the 
 talus , which provides stabilization through subtalar joint pronation , on the calcaneus21 . in the literature
, nh has been reported 
 to range between 6  3.4 and 9  4.2  mm . in a sitting position , in the sagittal plane
, the 
 difference of the height of the navicular bone between the subtalar neutral 
 non - weight - bearing - position and the 50% weight - bearing position is called the  navicular 
 drop ( nd ) . in the literature ,
an nh value of 15  mm or more is accepted as abnormal , and the 
 normal value of nd is about 10  mm22 . for 
 the nh measurements ,
the height of the navicular tuberosity from the ground was measured 
 using a caliper and recorded in millimeters .
nh values were measured for both the left and 
 right feet in both the weight - bearing and non - weight - bearing positions . the subtalar angle ( sta ) used to determine rearfoot rotation ( valgus / varus ) , and is defined 
 as the angle between the longitudinal line dividing the calcaneus midline and the line that 
 bisects the distal third of the leg20 . 
 furthermore , sta , which is also defined as the angle between the upper achilles tendon and 
 the distal extension of the rearfoot in a weight - bearing position to diagnose a normal foot 
 when it is 04 , physiological flatfoot when it is 520 , and pathological flatfoot when it 
 is over 2023 . in the present study , sta 
 values of the patients of left and right foot
were measured using a goniometer in both 
 weight - bearing and non - weight - bearing positions .
the angular deviations towards varus were 
 recorded as and those towards valgus were positive values recorded as .
visual analog scale 
 ( vas ) was used to determine the maximum pain level that individuals felt during walking due 
 to hv deformity .
the patients were asked to mark the level of pain they felt on 100  mm 
 horizontal line for each foot and the point they marked was recorded in millimeters24 . to evaluate the function affected by pain and deformity , scales developed by the american 
 orthopaedic foot and ankle society ( aofas ) with established validity and reliability
were 
 used the aofas - hallux metatarsophalangeal - interphalangeal ( mtp - ip ) scale and the mid - foot 
 scale ( mf ) . using the aofas hallux mtp - ip scale ,
the pain around the mtp joint and its 
 related functional impact as well as the alignment of the mtp joint were determined .
using 
 the aofas mf scale , pain , functional status and alignment in the mid - foot region were 
 determined .
the score range was from 0 to 100 with lower scores indicating greater 
 deformity25 . using the foot function index ( ffi ) ,
information regarding the level of pain individuals 
 felt during various activities ( 9 questions ) , difficulties individuals experience ( 9 
 questions ) , and related activity limitations ( 3 questions ) was obtained .
the index has 21 
 questions in 3 sections and patients are asked to state their condition on a scale of 0 to 
 10 .
section scores are calculated by dividing the total score of each section with the total 
 number of questions included in the section and multiplying the result by 100 .
total scores 
 are similarly calculated by adding up all the scores and dividing the total by the number of 
 questions and multiplying the result by 100 , and higher scores indicate greater 
 pain / symptom26 .
the sf-36 survey was used to evaluate the participants health - related quality of life . 

sf-36 is a self - reported questionnaire which is composed of 36 items classified into 8 
 domains , namely , vitality , physical functioning , bodily pain , general health perceptions , 
 physical role functioning , emotional role functioning , social role functioning , and mental 
 health .
the most distinctive feature of sf-36 is that it measures physical functioning and 
 related abilities .
the sub - scales evaluate health on a range from 0 to 100 ; 0 indicates 
  poor health  and 100 indicates 
the mean and range 
 were used for variables obtained by direct measurement and frequency values were 
 calculated for distributions of the categorical data .
correlation analysis was used to 
 investigate the relationships of hv deformity angle with pain , measurements regarding the 
 position of the rearfoot , function , and the quality of life .
since the data were not 
 normally distributed , spearman s correlation coefficient was used .
correlation values  
 0.4 were considered satisfactory ( r  0.811.0 excellent , 0.610.80 very good , 0.410.60 
 good , 0.210.40 fair , and 0.000.20 poor ) .
the mean age , height and weight of the participants were 40.5  10.3  years , 165.7  4.8  cm , 
 and 69.7  11.1  kg , respectively .
family histories of the patients showed that 16 patients 
 ( 59.3% ) had a family history of hv and 18 patients ( 66.7% ) had a family history of 
 bunions .
patients hv angles , levels of pain , nh ( weight - bearing and non - weight - bearing ) and sta are 
 presented in table 1table 1.mean and standard deviation ( sd ) values of the measures ( n=27)mean  sdhallux valgus angle ( )non - weight - bearingright29.6  7.1left34.1  6.2*navicular height ( mm)weight - bearingright3.4  0.5left3.4  0.6non - weight - bearingright4.0  0.6left4.1  0.5subtalar angle ( )weight - bearingright8.0  2.9left9.1  2.9*non - weight - bearingright3.6  2.4left3.4  2.3pain ( vas ) mmduring walkingright4.5  2.8left6.2  2.8**significant difference , p<0.05 .
* significant difference , p<0.05 hv angles , weight - bearing sta values , and the maximum level of pain felt during walking for 
 the left feet of the women with hv were found to be higher .
the ffi scores or the 
 participants were the highest for the pain parameter , and the lowest for the activity 
 restriction section .
regarding the aofas hallux mtp - ip and mf results , it was observed that 
 subjects scores were lower for the hallux mtp - ip ( table 2table 2.results of pain - related functional status and quality of life scale 
 ( n=27)mean  sdfoot function indexpain45.6  18.5function 39.8  18.2activity restriction23.0  9.9aofas hallux mtf - ip scalepain21.5  8.2function29.3  5.3alignment4.8  4.0total55.5  14.4aofas mf scale pain24.1  5.7function28.9  4.8alignment8.2  1.3total61.7  8.9sf-36physical function36.1  9.6physical role37.9  9.2pain37.9  8.5general health37.9  10.9vitality36.8  9.8social function37.6  10.7emotional role33.8  11.9mental health 35.9  8.4physical component summary38.8  8.5mental component summary35.8  8.9 ) . in the sf-36 survey filled out by the participants
, they scored 38.8  8.5 and 35.8  8.9 
 on the physical and mental component summary measures , respectively ( table 2 ) .
when the correlation of hv angle with pain felt on both left and right feet was calculated , 
 a low positive correlation was observed between the right hv angle and the right vas value 
 ( p < 0.05 ) .
no correlations observed between the right and left hv angles and navicular drop , which is 
 the difference between weight - bearing nh and non - weight - bearing nh ; however , there was a low 
 negative correlation between the non - weight - bearing right subtalar angle and right hv angle 
 ( p < 0.05 ) ( table 3table 3.relationship of hv angle with pain , nd , and stahallux valgus anglerightleftrrpain non - weight bearingright0.408*0.012left0.2480.101navicular dropright0.2000.047left0.0490.054subtalar angleweight - bearingright0.3620.049left0.0010.199non - weight - bearingright0.425*0.218left0.3490.025*p < 0.05 ) . when the hv angle was compared with functional scales , such as pain , pain - related 
 functional restrictions , social isolation and alignment ,
a positive correlation was observed 
 between the left hv angle and 3 subscales of ffi ( p < 0.05 ) .
in addition , there was a 
 positive correlation between the pain parameters of ffi and the right hv angle ( p < 0.05 ) 
 ( table 4table 4.correlation between hv angle and function scaleshallux valgus anglerightleft rrffipain0.515 * 0.632*function0.3290.542*activity restriction0.2380.424*aofas hallux - mtp - ippain0.1800.580*function0.2260.167alignment0.0230.047total0.1840.261aofas - mfpain0.2880.595*function0.0580.202alignment0.3020.240total0.1360.429**p < 0.05 ) . based on the results of the aofas hallux - mtp - ip and aofas - mf scales ,
there was a negative 
 correlation between the pain - related measurements of the scales and the left hv angle ( p 
 < 0.05 ) .
moreover , there was a negative correlation between the left hv angle and the 
 total score of aofas - mf ( p < 0.05 ) ( table 
 4 ) .
there was no correlation between the physical and mental component summaries of sf-36 and 
 hv angle ( p > 0.05 ) ; however , there was a mild negative correlation between sub - domains 
 of sf-36 , namely physical role ( r=0.433 , p= 0.024 ) , pain(r = 0.534 , p= 0.004 ) and social 
 function(r = 0.499 , p= 0.008 ) , and hv angle ( p < 0.05 ) .
hv deformity is the most common painful condition affecting the foot and causes functional 
 restrictions .
most studies of hv patients have reported the results of interventions to 
 decrease deformities and surgical treatments . however ,
therefore , our focus was on the effects of hv 
 deformity on pain , rearfoot mechanics , functional status and quality of life .
we included only female hv patients because it is known that hv is more prevalent among 
 females than among males .
this difference in prevalence may be due to tight shoes being 
 preferred by females as well as structural differences1 , 3 .
roddy et al . investigated 
 the relation between age and hv in women and found that , compared to the below-40 age group , 
 hv prevalence was 1.76 times higher in the 4049 age groups and 3.5 times higher in the 
 5059 age groups6 .
the mean age of the participants in the present study was 40.5  
 10.3  years . although hv is more prevalent in older age groups , the high prevalence that we 
 observed in this young adult group , although the number of subjects in this study was not 
 large enough to draw a conclusion , was surprising .
the reason for this finding may be that 
 the incidence and onset of deformities have been shifting towards younger ages in 
 industrializing societies . it may also be related to increasing body weight and decreasing 
 functional activity . in the present study , based on the determination of the position of the navicular bone with 
 respect to the feiss line ,
all of the participants were found to have flatfoot with varying 
 degrees from mild to severe .
furthermore , based on the results of sta and nh , which are used 
 to investigate the rearfoot mechanics , we found rearfoot over - pronation in the 
 weight - bearing position in most of the participants .
wong reported that flatfoot , which is 
 caused by posterior tibial tendon dysfunction , causes abductor hallucis muscle dysfunction 
 and thus prolonged and excessive pronation occurring in the subtalar joint results in 
 structural flexibility in the foot , which results in the vulnerability of the foot to 
 mechanical forces and shocks29 .
although our hypothesis was that angular values of the left and right feet and related 
 parameters would not differ from each other , interestingly , the hv angle and sta / vas results 
 show that the pathology of the left foot was more severe in the participants of the present 
 study .
the severity of deformity of the left foot may be associated with the fact that all 
 participants were right - dominant .
this result may mean that , in right - dominant patients the 
 left foot is subjected to different load patterns and thus its load - handling capability is 
 lower , and because of that it is prone to deformity .
although the number of patients in this 
 study was not sufficient enough to draw conclusions , the results highlight the importance of 
 not ignoring the left foot in right - dominant patients .
however , the result that angular 
 values obtained for the left foot were higher than those of the right foot and that the 
 increase in these values negatively affects the rear foot position , functional status , and 
 quality of life , supports our hypothesis . in other words ,
the increase in the hv angle 
 differentiates the left foot with regard to three sub - scales of ffi , total scores of aofas 
 hallux mtp - ip and aofas - mf , and the physical role , pain , emotional role sub - domains of sf-36 
 indicating a decrease in functional status and the quality of life . in the present study ,
the results for the dominant foot demonstrate that the level of 
 deformity in the foot that is dominant in functional activities and related functions and 
 quality of life are affected less than expected . on the other hand
, the results for the 
 non - dominant foot show increase in hv deformity angle yields increased pain , and 
 foot - specific functional status and general quality of life deteriorate due to pain and 
 progressive deterioration in foot biomechanics . when healthcare professionals who are 
 specialized in foot health , pathologies , deformities and treatment are making a treatment 
 plan for hv , they should approach the patient holistically , and remember that the pathology 
 may affect the patient s physical , emotional and social functions as well as the symptoms 
 they perceive . we think that the results of the present study will guide future studies .
this study had a limited scope as the entire group of participants comprised female cases . 
 among the limitations of the present study
are the low number of patients included in the 
 study and lack of radiological data , which is considered the golden standard in the 
 literature , for determining the level of deformity .
 [ purpose ] to investigate the relationship between hallux valgus ( hv ) deformity and the 
 position of rearfoot joints , and its effects on the quality of life , pain , and related 
 functional status of women with bilateral hallux valgus ( hv ) . 
 [ subjects and methods ] the 
 subjects were 27 right - dominant women . 
 demographic data , hv angle , weight - bearing and 
 non - weight - bearing subtalar pronation ( sp ) , and navicular height were recorded . 
 visual 
 analog pain scale , foot function index ( ffi ) , and the american orthopaedic foot and ankle 
 society ( aofas ) first metatarsophalangeal- interphalangeal ( mtp - ip ) and aofas mid foot 
 ( mf ) scales , and sf-36 were also used . 
 [ results ] hv angle , weight - bearing sp , and pain 
 intensity of the left foot were higher . 
 hv angle of left foot was correlated with all 
 sub - scales of ffi , the pain parameter of aofas mtp - ip , and pain and total scores of 
 aofas - mf scale . 
 hv angle of the left foot correlated with physical role , pain , and social 
 function sub - domains of sf-36 . 
 right hv angles were correlated with right foot pain and 
 non - weight - bearing sp . 
 [ conclusion ] increasing hv angle and pathomechanical changes in the 
 rear foot are correlated , resulting in increasing pain and thus decreasing functional 
 status as well as decreasing quality of life . 
 although all the participants were 
 right - dominant , their left foot problems were more prominent . 
INTRODUCTION
SUBJECTS AND METHODS
RESULTS
DISCUSSION