Hallux valgus — first metatarsal osteotomy

Adults after first metatarsal osteotomy with stable fixation, such as chevron/Austin, scarf or minimally invasive chevron and Akin osteotomies (MICA). Before starting, review the operative report, every osteotomy site, fixation stability and the orthopaedic surgeon’s written instructions. Akin osteotomy, lesser metatarsal osteotomies and surgery on toes II–V may require additional restrictions. Proximal osteotomies and extensive reconstructions need an individual plan. First tarsometatarsal fusion (Lapidus), first MTP fusion, revision surgery, infection and impaired union require a separate protocol.

FIRST 6 WEEKS: wear the postoperative forefoot offloading shoe when walking. Load the heel and the limb only as permitted by the surgeon. After 6 weeks, increase weight bearing only after clinical and radiographic review. Absence of pain and elapsed time alone do not confirm union.

Forefoot offloading does not automatically mean the entire limb must remain non-weight-bearing. The surgeon specifies permitted loading; crutches assist protection, balance and gait. If non-weight-bearing is prescribed, that instruction takes priority.

During the first 6 weeks, do not walk barefoot or in an ordinary shoe on the operated foot. Avoid heel raises, jumping, running, resistance under the forefoot and forceful foot rollover. Do not lengthen walks merely because the shoe reduces pain.

Begin hallux motion with the surgeon’s clearance when wound condition and correction stability allow; a routine 6-week delay is not required. Start with gentle unloaded active motion. Do not manually straighten the hallux alignment or pull it sideways. Therapist-applied joint mobilisation is not automatically an exercise to repeat independently.

Exercise without sharp pain, painful catching or a mechanical block. Any mild discomfort should settle promptly. If pain, swelling or limping are worse the next day, reduce the dose and return to the previous level. Persistent worsening requires review.

The doses below are cautious starting suggestions to individualise, rather than a regimen validated for every technique. Increase one element at a time: walking duration, repetitions or difficulty. Do not exercise through increasing pain.

Akin osteotomy

An additional union site in the proximal hallux phalanx. Avoid pulling the hallux tip, twisting and forced correction. Assisted movement and the grip require specific clearance; stable fixation does not remove the need for protection.

Weil osteotomy and surgery on toes II–V

Check the number of osteotomies, any plantar plate repair, fusions and wires. Do not move a joint crossed by a fixation wire or press on an exposed wire. Exercise the operated lesser toes and load the forefoot only according to the surgeon’s plan.

Procedures requiring a separate programme

Lapidus, first MTP fusion, proximal osteotomy with stricter loading, extensive reconstruction or revision: do not apply these timeframes automatically. Do not mobilise a fused joint. With multiple procedures, follow the most restrictive requirement.

Footwear and everyday walking

Until 6 weeks: use the prescribed postoperative shoe. After review: use wide, stable, comfortable footwear; later use ordinary shoes without pressure or pain. Swelling may persist for several months. High heels and narrow toe boxes need particular caution and are not a rehabilitation goal.

Stairs and household tasks

Use the handrail, the shoe and the taught stair pattern; initially take one step at a time. Avoid prolonged standing, carrying loads while using crutches and tasks requiring tiptoe standing. Increase household tasks alongside walking tolerance.

Work

Sedentary work may be possible earlier if leg elevation, breaks and safe transport are available. Standing or manual work and work requiring protective footwear depend on healing, swelling and walking capacity. Do not set one return date for everyone.

Driving

Do not drive in the postoperative shoe or with loading restrictions that prevent rapid braking. After right foot surgery, do not plan to resume before 6 weeks; reaching this date alone is insufficient. Comfortable ordinary footwear, safe emergency braking, no medication impairing reactions and surgeon clearance are required. The left foot also needs assessment when using a manual transmission. [4]

Cycling and swimming

Use a stationary bike after clearance for pedal pressure, usually after the week 6 review; start with low resistance. Swim after complete wound healing and clearance, without forceful wall push-off. Adapt activity to concomitant procedures. [1]

Running and sport

Establish comfortable walking, exercise tolerance and confirmed union first. Impact, jumping or direction-change sports are commonly considered after 4–6 months, according to the technique and surgeon assessment. Stiffness, pain or swelling require a step back in progression. [1]

Goal: protect the osteotomy and manage swelling.

• Wear the forefoot offloading shoe for all walking; make short trips on level ground, using crutches when needed. Follow the surgeon’s loading instructions.
• Rest with the leg elevated and the calf and heel supported; avoid prolonged standing. Change position and move the knee and hip without pressure through the forefoot.
• Perform ankle movements without resistance or forced end range. Exercise the hallux only if the surgeon has already allowed it.

Progress when: the first review is completed, the wound has no complications, pain is controlled and walking in the shoe is safe. Forefoot protection continues.

Goal: restore first MTP motion while maintaining protection.

• Continue using the forefoot offloading shoe until the end of 6 weeks unless the surgeon changes the instruction. Do not switch to ordinary footwear independently.
• After wound assessment and surgeon clearance, gently lift and lower the hallux actively. Movement should occur at the first MTP joint without twisting or pressure on the osteotomy.
• Physiotherapist instruction: foot positioning, permitted range, symptom monitoring and gait technique. Then use short independent home sessions. Marked stiffness requires reassessment.

Before increasing loading: review at around week 6, radiographs showing acceptable healing progress and maintained correction, and explicit surgeon clearance. Prolong protection if healing is delayed.

Goal: comfortable everyday walking and further motion recovery.

• Once cleared, gradually transition to stable, roomy footwear with space for swelling and the toes. Roomy does not mean unstable slippers. Wean crutches according to gait rather than the date alone.
• Start with short walks on level ground. Increase distance if pain, swelling and limping do not worsen by the next day. Do not force push-off through the hallux.
• Continue active motion. Add hand-assisted movement only after instruction and clearance for that mobilisation, particularly after Akin osteotomy. Gently activate the arch in sitting without curling the toes.

Progress when: the surgeon accepts healing stability, walking is comfortable without a significant limp and symptoms do not worsen the next day. Residual swelling may delay ordinary footwear.

Goal: natural gait and gradual strengthening after union.

• Use ordinary footwear only when it accommodates the foot without pressure and allows pain-free walking. Continue wider footwear if swelling persists; do not force the change.
• After confirmed union and clearance for full forefoot loading, restore natural foot rollover. Start heel raises with both feet and hand support, without shifting weight onto the outer edge of the foot.
• Running, jumping and rapid direction-change sports require union, functional recovery and surgeon clearance; they are commonly considered after 4–6 months. This timeframe does not provide automatic clearance.

Further progression requires: full permitted loading, stable gait, controlled pain-free heel raises and no reactive swelling. If symptoms worsen, return to easier activity and have the foot reviewed.