655433

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FAIXXX10.1177/1071100716655433Foot & Ankle InternationalYamamoto et al

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Quality of Life in Patients With

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DOI: 10.1177/1071100716655433

Hallux Valgus fai.sagepub.com

Yohei Yamamoto, MD1, Satoshi Yamaguchi, MD, PhD1, Yuta Muramatsu, MD, PhD1,
Atsushi Terakado, MD, PhD2, Takahisa Sasho, MD, PhD1, Ryuichiro Akagi, MD, PhD1,
Jun Endo, MD, PhD1, Yasunori Sato, PhD3, and Kazuhisa Takahashi, MD, PhD1

Abstract
Background: The purposes of this study were to compare the quality of life (QOL) of subjects who had untreated
symptomatic hallux valgus with the QOL of the general population and to investigate factors associated with the QOL of
the subjects.
Methods: One hundred sixteen subjects with previously untreated and symptomatic hallux valgus were surveyed. QOL
was assessed using the 36-item Short Form Health Survey (SF-36). Additionally, clinical evaluations (the visual analog
scale for pain, Japanese Society for Surgery of the Foot Scale, lesser toe pain, and pain in other parts of the body) and
radiographic evaluations (hallux valgus angle, intermetatarsal angle between the first and second metatarsals, and dislocation
of the second metatarsophalangeal joint) were performed. Differences in the SF-36 between the subjects and the general
population were tested using independent t tests. Correlations between the QOL measurements, clinical evaluations, and
radiographic evaluations were assessed using Spearman rank correlation coefficient.
Results: All SF-36 subscales and physical component summary scores for the subjects were significantly lower than
those of the general population. Notably, the standardized physical function subscale (38.2 ± 15.8, P < .001) and
physical component summary scores (38.9 ± 14.5, P < .001) were more than 10 points lower than those of the general
population. Most QOL and clinical evaluation parameters were not correlated or were negligibly correlated with
radiographic evaluations. Similarly, lesser toe pain or pain in other parts of the body was not correlated with QOL or
clinical evaluations.
Conclusion: The QOL of untreated and symptomatic hallux valgus subjects was lower than that of the general population.
All QOL and clinical evaluation parameters were not significantly or negligibly correlated with the severity of toe deformities.
Surgical decision making should not be based on the severity of the deformity alone, but rather patient QOL should also
be carefully assessed.
Level of Evidence: Level III, comparative series.

Keywords: hallux valgus, quality of life, Short Form 36

Introduction issues.1,20,27 Studies have compared the QOL of people

with HV with that of the general population using the
Hallux valgus (HV) is one of the most common foot dis- 36-item Short Form Health Survey (SF-36) and other
eases that needs treatment in general practice and orthope- measurements.8,9,14,22,31-33 They also assessed
dic clinics.7 The prevalence of HV in the general population
ranges from 21% to 70%, and the condition is more often
1
diagnosed in older adults.2,11,35 Consequently, 2 million Department of Orthopaedic Surgery, Graduate School of Medical and
Pharmaceutical Sciences, Chiba University, Japan
operations to correct HV deformities are performed in the 2
Kitachiba Spine & Sports Clinic, Inage-ku, Japan
United States every year.7 HV has a significant impact on 3
Clinical Research Center, Chiba University Hospital, Chuo-ku, Japan
daily activities. For example, HV is associated with an
Corresponding Author:
altered gait pattern5 and linked to an increased risk of falls
Satoshi Yamaguchi, MD, PhD, Department of Orthopaedic Surgery,
in older adults.21 Graduate School of Medical and Pharmaceutical Sciences, Chiba
Recently, several studies have shown that HV is University, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan.
strongly associated with social and quality of life (QOL) Email: y-satoshi@mvb.biglobe.ne.jp

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2 Foot & Ankle International 
the correlation between QOL and the severity of the
deformity. However, the results may vary depending on
the subjects’ backgrounds and nationalities. For exam-
ple, a cohort study by Menz et al followed an older gen-
eral population of more than 50 years old.22 People with
HV had significantly lower scores on all SF-36 subscales
than those without HV. Moreover, there was a progres-
sive reduction in all SF-36 component scores as the
severity of HV increased. Conversely, Thordarson et al
reported that HV patients undergoing corrective surgery
had equal or higher scores on the mental subscales.32 HV
angles in preoperative patients were not correlated with
outcome scores on the American Academy of Orthopedic
Surgeons (AAOS) questionnaire or SF-36. The discrep-
ancy between the studies suggests that QOL for people
with HV should be estimated for specific backgrounds,
including the presence or absence of symptoms and his-
tory of treatment. However, no studies have reported the
QOL of patients with previously untreated and symptom-
atic HV who visit outpatient clinics. This patient popula-
tion is a target of initial treatment for HV; therefore,
clarifying the QOL of untreated and symptomatic HV
patients is clinically important for orthopedic surgeons
and general practitioners who are responsible for the ini-
tial treatment.
In addition to the severity of hallux deformity, other
factors can affect the QOL of HV patients. Treatment of
HV primarily aims to correct the hallux deformity and
reduce pain in the hallux. However, 26% to 30% of HV
patients were dissatisfied even after the hallux deformity
was surgically corrected.4,19 Thus, understanding other
associated factors may provide insight into treatment tar-
gets in addition to correcting the hallux deformity. Several
factors have been reported to be correlated with the QOL
of HV patients, including age and body mass index.3,25
The presence of lesser toe pain with callosity under the
metatarsophalangeal joints can also be a factor.14
Furthermore, pain in other parts of the body can be asso-
ciated with QOL for HV patients. Nishimura et al found
that the prevalence of knee osteoarthritis was 61% in
Japanese community dwellers with HV.24 Menz et al
showed that the prevalence rates of hip pain and low back
pain were 48.2% and 39.5%, respectively, in individuals
with HV in a large cohort study.22 However, these associ-
ated factors have not been thoroughly investigated.
The purposes of this study were to compare the QOL
of symptomatic HV patients who did not receive treat-
ment with that of the general population and investigate
factors associated with the QOL of HV patients. We
hypothesized that the QOL of symptomatic HV patients
would be lower than that of the general population. We
also hypothesized that the severity of the HV deformity as
well as severity of the lesser toe deformity would not be
correlated with the QOL measures.
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Methods
Subjects
The institutional review board of our hospitals approved
this study, and written informed consent was obtained from
all subjects. Subjects were prospectively recruited at the
outpatient foot and ankle clinics of our hospital and 2 affili-
ated hospitals in Japan from March 2011 to November
2014. Patients who reported hallux or forefoot pain caused
by HV for more than 1 month and had an HV angle greater
than 20 degrees in the weight-bearing anteroposterior (AP)
radiographs of the foot were included.1 Patients less than 20
years old, with a history of HV treatments (eg, insoles,
braces) in the last 6 months, a history of HV surgery, mid-
foot or hindfoot pain due to flatfoot, osteoarthritis of the
first metatarsophalangeal joint, systemic inflammatory dis-
orders (eg, rheumatoid arthritis, spondyloarthropathy), or
central nervous system disorders (eg, Parkinson disease)
were excluded. Furthermore, patients who did not consent
to participate in this study or patients with asymptomatic
feet were also excluded.
A total of 181 subjects were recruited. Sixty-four subjects
were excluded, because of their age being under 20 years old
(n = 6), treatment history (n = 8), symptomatic flatfoot (n =
10), osteoarthritis of the first metatarsophalangeal joint (n =
6), systemic inflammatory disorders (n = 15), central ner-
vous system disorders (n = 5), refusal to participate (n = 12),
asymptomatic feet (n = 2), and an HV angle less than 20
degrees (n = 1). Finally, 116 symptomatic and untreated HV
subjects, with 103 women and 13 men, were enrolled in the
study. Seventy-six subjects had bilateral pain, 18 subjects
had pain in the right foot, and the remaining 22 had pain in
the left foot. The mean age of the subjects was 63 ± 11 years,
and the mean body mass index was 22 ± 4.
Subject Backgrounds
Age25 and body mass index3 were surveyed, since these fac-
tors can affect the QOL of HV patients. Body mass index
was calculated from self-reported body weight and height.
Quality of Life and Clinical Evaluations
QOL assessments and clinical evaluations were performed
at the first visit to the outpatient clinic. The QOL assess-
ments were performed using the Japanese version of the
SF-36,12,13 AAOS Foot and Ankle Core Scale, and Shoe
Comfort Scale.17 For the SF-36, the raw values of the 8 sub-
scale scores (physical function, role-physical, bodily pain,
general health, vitality, social function, role-emotional, and
mental health) and 2 summary scores (physical component
and mental component) were standardized relative to nor-
mative data of the general population. Accordingly, the
mean scores ± standard deviations were 50 ± 10 for all
Yamamoto et al 3
SF-36 scores for the general population. This normative
data set of the SF-36 provides mean scores of different age
groups, from the 20s to 70s, as well as the overall mean
scores.12,13 The AAOS Foot and Ankle Core Scale and Shoe
Comfort Scale are validated subjective scales scored from 0
to 100 points, which consist of 20 and 5 questions, respec-
tively.17 Clinical evaluations were performed using a visual
analog scale (VAS) for pain15 and the Japanese Society for
Surgery of the Foot (JSSF) hallux scale.23 The VAS for pain
is a 10-cm horizontal scale, ranging from 0 (no pain) to 10
(the worst pain imaginable).15 The JSSF scale is a validated
objective scale scored from 0 to 100 points, and it consists
of 40 points for pain, 45 points for function, and 15 points
for alignment.23 Higher scores on the JSSF scale indicate a
better clinical outcome. Moreover, laterality of the symp-
toms and the presence of lesser toe pain with callosity under
the second and/or third metatarsophalangeal joint was
assessed.14 The presence of back, hip, knee, and ankle pain
was also assessed.26 Six certified orthopedic surgeons, who
were independent of the examiner of the radiographic eval-
uations, performed the clinical evaluations. In subjects with
bilateral HV, the clinical evaluations were performed on the
more painful side.
Radiographic Evaluations
Subjects underwent weight-bearing AP and lateral radio-
graphs of the foot. The HV angle and intermetatarsal angle
between the first and second metatarsals were determined
by the weight-bearing AP radiograph.29,31 Dislocation or
subluxation of the second metatarsophalangeal joint often
accompanies HV and may produce pain and a callosity
underneath the second metatarsal head.10 Therefore, dislo-
cation of the second metatarsophalangeal joint was deter-
mined by the weight-bearing lateral radiograph. The degree
of dislocation was classified into 4 grades: grade 0 (nor-
mal), grade 1 (subluxation with equal or more than 50% of
the phalangeal joint surface covering the metatarsal joint
surface), grade 2 (subluxation with less than 50% of the
joint), and grade 3 (complete dislocation).34 One orthopedic
surgeon, who was independent of the examiners of the clini-
cal evaluations, measured all radiographs. In subjects with
bilateral HV, the radiographic measurements were per-
formed on the more painful side.
Statistical Analyses
To compare the QOL of HV subjects with the QOL of the
general population, differences in the subscale scores and
summary scores of the SF-36 were assessed between the
HV subjects and the general population using independent t
tests. Additionally, the SF-36 scores of the HV subjects
were compared with those of the general population in their
60s using independent t tests, because the mean age of the
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HV subjects was 63 years as mentioned in the results. To
clarify factors associated with QOL for HV subjects, corre-
lations between each QOL evaluation (the SF-36 subscale
score and summary score, AAOS Foot and Ankle Core
Scale, and Shoe Comfort Scale), clinical evaluation (VAS
for pain and JSSF scale), and age, body mass index, and
radiographic evaluation (HV angle and intermetatarsal
angle) were assessed using Spearman rank correlation coef-
ficient. Each QOL evaluation item and clinical evaluation
score was compared between patients with bilateral versus
unilateral symptoms, with versus without a painful lesser
toe, and with versus without pain in other parts of the body
using the Wilcoxon signed-rank test. Each QOL evaluation
item and clinical evaluation score was also compared
among the patient groups with different grades of second
metatarsophalangeal joint dislocation using the Kruskal-
Wallis test and Steel-Dwass post hoc test. Patients with
grade 2 and 3 dislocations were combined into one group
for the statistical analyses because only 3 subjects had a
grade 2 dislocation. Statistical significance was set at P <.05
for all statistical tests.
Results
The mean pain VAS was 44 ± 28, and the mean JSSF scale
was 60 ± 16. Forty subjects (34%) had lesser toe pain. Fifty-
five subjects (47%) had pain in other parts of the body,
including back pain (n = 28), hip pain (n = 6), knee pain (n =
34), and ankle pain (n = 3). Twenty-five patients had pain in
2 or more parts of the body. The mean HV angle and the
intermetatarsal angle were 40 ± 11 degrees and 17 ± 4
degrees, respectively. Twenty-four patients had an HV angle
between 20 and 29 degrees, 35 had an HV angle between 30
and 39 degrees, and 57 had a severe deformity, with an HV
angle equal to or more than 40 degrees. There were 43 sub-
jects (37%) with second metatarsophalangeal joint disloca-
tions. The number of subjects with dislocations of grades 0,
1, 2, and 3 were 73, 30, 3, and 10, respectively.
Standardized values of all SF-36 subscales and physical
component summary scores for symptomatic HV subjects
were significantly lower than those of the general popula-
tion (P = .015 for general health, P = .009 for mental health,
and P < .001 for others) (Figure 1). Notably, the physical
function subscale (38.4 ± 15.7, P < .001) and physical com-
ponent summary scores (39.0 ± 14.5, P < .001) were more
than 10 points lower than those of the general population.
Furthermore, all SF-36 subscales, except for the general
health subscale score, for symptomatic HV subjects were
lower than those of the general population in their 60s
(Table 1).
The HV angle and intermetatarsal angle were not cor-
related with most of the QOL or clinical evaluations
(Table 2). The correlation between the HV angle and the
JSSF scale was statistically significant, as were the
4 Foot & Ankle International 

Figure 1.  Standardized SF-36 values for symptomatic HV subjects. All SF-36 subscales and physical component summary scores for
symptomatic HV subjects were significantly lower than those of the general population. Error bars represent standard deviations.
The mean scores for the general population are 50.
*P < .001, **P = .015, ***P = .009.
SF-36, 36-item Short Form Health Survey; HV, hallux valgus; PCS, physical component summary score; MCS, mental component summary score.

Table 1.  Standardized SF-36 values for symptomatic HV subject groups with grade 0, 1, and 2/3 second metatarso-
subjects and the general population in their 60s.11,12 phalangeal dislocations. The mental component summary
Mean ± SDa   score for the subjects with a grade 0 dislocation (median,
47.3; range, 32.1-63.3) was significantly lower than that
Present Study 60s of the subjects with a grade 1 dislocation (median, 51.5;
  (n = 116) (n = 438) P range, 31.1-73.3) (P = .02). Additionally, the JSSF scale
Physical function 38.2 ± 15.8 46.9 ± 12.3 <.001 scores of the subjects with a grade 0 dislocation (median,
Role-physical 41.7 ± 13.2 49.0 ± 11.5 <.001 62; range, 39-93) were significantly higher than those of
Bodily pain 42.4 ± 8.3 49.7 ± 10.3 <.001 the subjects with a grade 2/3 dislocation (median, 52;
General health 47.7 ± 10.0 48.8 ± 10.3 .30 range, 34-80) (P = .006).
Vitality 45.8 ± 9.6 52.1 ± 10.3 <.001 Similar to the radiographic measurements, age was not
Social function 44.4 ± 12.5 50.3 ± 10.7 <.001 correlated with most of the QOL or clinical evaluations.
Role-emotional 44.2 ± 13.7 50.1 ± 11.2 <.001 There were significant correlations between age and the
Mental health 47.5 ± 10.0 51.8 ± 10.1 <.001 physical function (P = .02), role-physical (P = .04), and
PCS 38.9 ± 14.5 47.6 ± 9.9 <.001 physical component summary scores (P = .004) of the
MCS 49.1 ± 8.4 52.4 ± 9.8 <.001 SF-36. However, the correlations were weak, with the cor-
Abbreviations: MCS, mental component summary score; PCS, physical relation coefficients ranging from −0.19 to −0.26 (Table 2).
component summary score; SD, standard deviation; SF-36, 36-item Body mass index was not correlated with most of the QOL
Short Form Health Survey.
a
and clinical evaluations, except for the mental component
All values for HV subjects were significantly lower than those of the summary score and the AAOS Shoe Comfort Scale. The
general population in their 60s.
correlations were weak, and the correlation coefficients
were 0.19 for the mental component summary score and
correlations between the intermetatarsal angle and both -0.22 for the AAOS Shoe Comfort Scale (Table 2). The
the physical function subscale and mental component QOL and clinical evaluations did not differ between bilat-
summary score of the SF-36. However, the correlations eral versus unilateral symptoms, the presence versus
were weak, with the correlation coefficients ranging from absence of lesser toe pain, or the presence versus absence of
−0.30 to 0.19. There were no significant differences in pain in other parts of the body, except that the general health
most of the QOL and clinical evaluations among the 3 subscale of the SF-36 in patients with bilateral symptoms

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Yamamoto et al 5

Table 2.  Correlation Between the QOL and Clinical Evaluation Score and Age, Body Mass Index, and Radiographic Evaluations.a

Correlation Coefficient P Value

Body Mass HV IM Bilateral/Unilateral Lesser Pain in

SF-36 Age Index Angle Angle Symptom Toe Pain Other Parts
  Physical function −0.22* −0.14 −0.13 −0.27** .14 .65 .27
 Role-physical −0.19* 0.04 −0.04 −0.12 .08 .66 .05
  Bodily pain −0.05 0.00 −0.13 −0.18 .16 .62 .57
  General health −0.08 0.03 0.01 −0.10 .03 .46 .22
 Vitality 0.10 0.06 −0.02 −0.12 .21 .81 .23
  Social function −0.11 0.04 −0.02 −0.02 .55 .47 .12
 Role-emotional −0.14 0.09 −0.01 −0.12 .12 .35 .14
  Mental health −0.13 0.14 −0.01 −0.02 .43 .26 .99
 PCS −0.26** −0.08 −0.07 −0.17 .08 .49 .07
 MCS 0.11 0.19* 0.05 0.01 .59 .07 .49
AAOS
  Foot and Ankle Core Scale −0.03 −0.09 −0.19 −0.23* .48 .65 .34
  Shoe Comfort Scale 0.15 0.22* −0.09 −0.22 .79 .82 .73
VAS −0.05 −0.02 0.11 0.16 .58 .44 .79
JSSF −0.17 0.00 −0.32** −0.21* .52 .71 .66

Abbreviations: AAOS, American Academy of Orthopaedic Surgeons; HV, hallux valgus; IM, intermetatarsal; JSSF, Japanese Society for Surgery of the
Foot Hallux Scale; MCS, mental component summary score; PCS, physical component summary score; QOL, quality of life; SF-36, 36-item Short Form
Health Survey; VAS, visual analog scale for pain.
a
Correlations were assessed using Spearman rank correlation coefficient. The QOL evaluation item and clinical evaluation scores were compared
between patients with bilateral versus unilateral symptoms, and patients with versus without lesser toe pain or pain in other parts of the body using
the Wilcoxon signed-rank test. Values indicate the correlation coefficient and P value.
*P < .05, **P < .01.

was significantly worse than that of patients with unilateral
symptoms (Table 2).
Discussion
We assessed the QOL of subjects with untreated and symp-
tomatic HV who visited outpatient clinics. Most of the SF-36
values, in particular physical functions for HV subjects, were
significantly lower than those of the general population as
well as the population in the 60s. Furthermore, we showed
that all QOL evaluation items and clinical evaluations were
not significantly or negligibly correlated with age, body mass
index, or radiographic measurements, and were not influ-
enced by pain in the lesser toes or other parts of the body.
In this study, standardized values of all SF-36 subscales
and physical component summary scores for untreated and
symptomatic HV subjects were significantly lower than those
of the general population. Thordarson et al investigated the
QOL of HV patients undergoing corrective surgery using the
SF-36.32 The authors showed that the mental subscale scores,
such as vitality, social function, role-emotional, mental
health, and general health, were equal to or higher than those
of the general American population. They suggested that the
results reflected the higher functional demands of patients
who hope to undergo corrective surgery and concluded that
bodily pain appears to be a sensitive measure of problems
experienced by patients undergoing hallux valgus surgery.
Saro et al also investigated the QOL for preoperative women
with HV using the SF-36.28 They found that only the bodily
pain SF-36 subscale was significantly lower than that of the
general Swedish population. Conversely, Menz et al sur-
veyed the 2831 participants of the North Staffordshire
Osteoarthritis Project.22 Although their study population
included both symptomatic and asymptomatic subjects, they
found that all SF-36 values for people with HV were signifi-
cantly lower than those for people without HV. The results of
our study mirrored those of Menz et al,22 but differed from
the results of Thordarson et al32 and Saro et al.28 The discrep-
ancy may result from the difference in subject backgrounds.
Specifically, patients with painful and untreated HV had
impaired QOL, as presented in this study, whereas the
selected patients who hope to undergo HV surgery may have
high functional demands, as Thordarson et al showed.32
We showed that the severity of the hallux deformity, includ-
ing the HV angle and intermetatarsal angle, was not correlated
or was negligibly correlated with any of the QOL scores or
VAS for pain. The HV angle was significantly correlated with
the JSSF score; however, this finding was because the JSSF
includes an item of 15 points to assess the deformity of the hal-
lux. Similarly, Thordarson et al found no significant differ-
ences in any QOL measurement item among 3 patient groups
with mild, moderate, and severe deformities.32 Nishimura et al

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6 Foot & Ankle International 
performed a cohort study of Miyagawa village in Japan.24
They also reported that the EQ-5D scores in people with severe
HV deformity were not significantly lower than the scores of
people with moderate deformity. In contrast, Menz et al
showed a significant negative correlation between the HV
angle and all SF-36 subscales in a large population-based
study.22 However, the correlations in their studies were weak,
and may not be clinically significant. Additionally, their cohort
included subjects without HV and subjects with asymptomatic
HV, thus the results may not be applicable to clinical practice,
where patients have symptomatic HV. The reason for the lack
of correlation between the QOL measures and the severity of
hallux deformity in our study is unclear. One possible explana-
tion is that the severity of deformity has no impact on the
symptoms. Nevertheless, once it is symptomatic, it affects the
QOL regardless of the severity.
In this study, the degree of dislocation of the second
metatarsophalangeal joint did not affect the QOL of patients
with symptomatic HV. Except for the mental component
summary score, none of the SF-36 subscales or physical
component summary scores of the subjects with a disloca-
tion of grade 0 (HV alone) were significantly different from
the subjects with dislocations of grade 1 or 2/3. Lesser toe
pain also did not affect the QOL of the HV subjects. In con-
trast, Gines-Cespedosa et al found that preoperative HV
patients with metatarsalgia and a deformity of the lesser toe
had significantly worse physical function, role-physical,
bodily pain, role-emotional, mental health, and mental
component summary scores of the SF-36 compared to HV
patients without these conditions.14 The discrepancy
between our study and Gines-Cespedosa et al may be,
again, due to differences in the patient backgrounds.
This study has several limitations. First, the sample size
of the subjects was relatively small compared with previous
population-based studies.3,22,24 In this study, our focus was
on subjects who have painful feet and require treatment in
orthopedic clinics. Additionally, we carefully excluded sub-
jects who had received prior treatment, because previous
treatments might have affected the QOL measures.
Consequently, 116 subjects were enrolled in this study,
which is comparable to other studies in which symptomatic
HV subjects were evaluated.1,16 Post hoc power analysis
showed that the statistical power was 1.0 for the comparison
of the physical function subscale and physical component
summary score of the SF-36 between the subjects and gen-
eral population. Second, the occupational physical activity
of the patients, which might be correlated with QOL,16 was
not assessed. In Japan, most women work as homemakers
after marriage and having children.30 In fact, 75 of 116 sub-
jects (65%) were homemakers in this study, and their occu-
pational activity levels were uniformly low. This made it
difficult to assess if the activity level was correlated with
their QOL. Third, the patient cohort in this study was
Japanese. Differences in lifestyle and footwear can cause
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different symptoms in HV patients18; thus the results of this
study may not be extrapolated to HV subjects in other coun-
tries. However, Western-style shoes have been standard
footwear in Japan for several decades, and the number of
HV cases has markedly increased in the late 20th century.
Fourth, we examined the factors associated with the QOL of
HV patients within the symptomatic HV patient group. A
comparison with asymptomatic HV patients as a control
would have provided additional information on the associ-
ated factors. Fifth, we used the JSSF scale for our clinical
evaluation. Although the JSSF scale is a validated outcome
measure, it is mainly used in Japan and is not widely used in
other countries. However, we performed comprehensive
QOL evaluations, including the SF-36, AAOS score, and
VAS for pain. Therefore, the results of this study could be
widely applicable for comparison with other studies. Finally,
the body mass indexes of the patients were calculated from
the self-reported weight and height. Patients tend to underes-
timate their weight,6 and thus the calculated body mass
index might have been lower than the actual value.
Conclusion
All subscales and physical component summary scores of
the SF-36 for untreated HV patients were significantly
lower than those of the general population. The QOL and
clinical evaluations were not significantly or negligibly cor-
related with age, body mass index, deformity of the hallux
and second toe, lesser toe pain, or pain in other parts of the
body. Surgical decision making should not be based on the
severity of the deformity alone, but rather the patient’s QOL
should also be carefully assessed.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, author-
ship, and/or publication of this article.
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