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All copyrights are reserved by the Academy of Ambulatory Foot and Ankle Surgery. Pathway 2 STAGE 2 * HA Angle greater than or equal to 25 * IM Angle less than or equal to 16 * Joint Deviated, Congruent or Subluxed * +/- Hallux Deformity 1. CTB 2. EXOSTECTOMY 3. OSTEOTOMY 4. MC ARTHRODESIS STAGE 3 * HA Angle greater than 35 * IM Angle greater than 16 * Joint Deviated or Subluxed * +/- Hallux Deformity * Joint Arthrosis 1. CTB 2. EXOSTECTOMY 3. OSTEOTOMY 4. Resection Arthroplasty 5. MTP or MC ARTHRODESIS STAGE 1 * HA Angle less than 25 * IM Angle less than 12 * Joint Deviated or Congruent * +/- Hallux Deformity 1. CTB 2. EXOSTECTOMY 3. OSTEOTOMY ASSESS DEGREE & LOCATION OF DEFORMITY or ARTHROSIS Choose Surgical Procedure(s), all include Capsule Tendon Balance (CTB), Refer to Table 1 Continue Initial Therapy IMPROVED NO Improvement Proceed to Surgical Evaluation or if initial treatment performed by Primary Care Physician, Refer to Podiatric Foot & Ankle Surgeon CLINICAL RESPONSE Operative Tx * Proceed to Box #7 Non-Operative Tx * Orthoses * Shoe Modifications * Patient Education * Rx NSAIDs Patient Directed Tx * Wider, Lower Heeled Shoes * Bunion Pads * Ice * OTC NSAIDs INITIAL TREATMENT OPTIONS Radiographic Findings * Medial Prominence of 1st Metatarsal Head * +/- Joint Space Abnormality * +/- Lateral Adaptation of Metatarsal Articular Surface * Elevated HA Angle * Elevated IM Angle * Lateral Displacement of Sesamoids * Axial Rotation of Hallux * HAI Angle * +/- Presence of DJD Associated Findings * 2nd Digit Hammertoe * Plantar Callous * Central Metatarsalgia * Pronated Foot * Ankle Equinus * Ingrown Toenail Significant Findings * Medial Prominence - "Bunion" * Lateral Deviation of Great Toe * +/- Abnormal ROM 1st MTP Joint, 1st Ray * Painful Medial Bursitis * Neuritic Bunion Pain * Widening of Forefoot Significant History * Family History * Painful Bunion - Aggravated by shoewear - Progressive Deformity Hallus Valgus Source: Clinical Practice Guideline First Metatarsophalangeal Joint Disorders Panel. Diagnosis and treatment of first metatarsophalangeal joint disorders. J Foot Ankle Surg 2003 May-Jun;42(3):112-54.