Hypermobility of the First Ray: the Cinderella of the measurements conventionally assessed for correction of Hallux Valgus

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Carlo Biz
Giacomo Maso
Enrico Malgarini
Jacopo Tagliapietra
Pietro Ruggieri


hypermobility, hypermobility of first ray, first ray mobility, hallux valgus, Lapidus procedure, foot biomechanics


Background and aim of the work: hypermobility of the first ray (FRH) began to be considered as a pathological entity from Morton’s studies and was associated as a primary cause of hallux valgus (HV ). Currently, this relationship is in discussion, and various authors consider FRH as a consequence of the deformity. The purpose of this narrative review is to summarise the most influential publications relating to First Ray Mobility (FRM) to increase knowledge and promote its conventional assessment during clinical practice. Methods: papers of the last century were selected to obtain a homogeneous and up-to-date overview of I-MTCJ mobility and HV, as well as their relationship and management. Results: in recent years, FRH was studied from a biomechanical and pathophysiologic point of view. There is still not enough data regarding the aetiology of FRM. The higher rate of instability found in HV lacks an explanation of which is the cause and which is the effect. However, the Lapidus arthrodesis is still a valid method in cases of FRH and HV, even if is not rigorously indicated to treat both. When approaching FRH, radiographic or clinical findings are mandatory for the right diagnosis. Conclusions: FRM is an important factor that must be considered in routine clinical practice and prior and post HV surgery, as much as the conventional parameters assessed. Surgeons should consider performing I-MTCJ arthrodesis only if strictly necessary, also paying attention to soft tissue balancing. Improving the measurement of FRH could be useful to determine if it is a cause or effect of the HV deformity.


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1. Voellmicke K V, Deland JT. Manual examination technique to assess dorsal instability of the first ray. Foot ankle Int. 2002 Nov 17;23(11):1040–1.
2. Glasoe WM, Allen MK, Saltzman CL, Ludewig PM, Sublett SH. Comparison of Two Methods Used to Assess First-Ray Mobility. Foot Ankle Int. 2002 Mar 28;23(3):248–52.
3. DJ Morton -. Hypermobility of the first metatarsal bone: the interlinking factor between metatarsalgia and longitudinal arch strains. JBJS. 1928;Volume 10(Issue 2):p 187-196.
4. P.W. Lapidus. The operative correction of the metatarsus primus varus in hallux valgus. Surg Gynecol Obs. 1934;183–91.
5. LAPIDUS PW. A quarter of a century of experience with the operative correction of the metatarsus varus primus in hallux valgus. Bull Hosp Joint Dis. 1956 Oct;17(2):404–21.
6. Lapidus PW. The author’s bunion operation from 1931 to 1959. Clin Orthop Relat Res. 1960;16:119–35.
7. Courriades H. L’ hypermobilite du premier rayon. Podologie. 1971;6:146–53.
8. Rodgers MM PC. A device for the measurement of first ray mobility. Proc North Am Congr Biomech. 1986;
9. Romash MM, Fugate D, Yanklowit B. Passive Motion of the First Metatarsal Cuneiform Joint: Preoperative Assessment. Foot Ankle. 1990 Jun 30;10(6):293–8.
10. Klaue K, Hansen ST, Masquelet AC. Clinical, Quantitative Assessment of First Tarsometatarsal Mobility in the Sagittal Plane and Its Relation to Hallux Valgus Deformity. Foot Ankle Int. 1994 Jan 17;15(1):9–13.
11. Faber FWM, Kleinrensink G-J, Mulder PGH, Verhaar JAN. Mobility of the First Tarsometatarsal Joint in Hallux Valgus Patients: A Radiographic Analysis. Foot Ankle Int. 2001 Dec 28;22(12):965–9.
12. Faber FWM, Mulder PGH, Verhaar JAN. Role of First Ray Hypermobility in the Outcome of the Hohmann and the Lapidus Procedure. J Bone Jt Surg. 2004 Mar;86(3):486–95.
13. Fraser JJ, Koldenhoven RM, Saliba SA, Hertel J. Reliability of ankle-foot morphology, mobility, strength and motor performance measures. Int J Sports Phys Ther. 2017 Dec;12(7):1134–49.
14. Geng X, Wang C, Ma X, Wang X, Huang J, Zhang C, et al. Mobility of the first metatarsal-cuneiform joint in patients with and without hallux valgus: in vivo three-dimensional analysis using computerized tomography scan. J Orthop Surg Res. 2015 Dec 15;10(1):140.
15. Fraser JJ, Koldenhoven RM, Jaffri AH, Park JS, Saliba SF, Hart JM, et al. Foot impairments contribute to functional limitation in individuals with ankle sprain and chronic ankle instability. Knee Surgery, Sport Traumatol Arthrosc. 2020 May 6;28(5):1600–10.
16. Glasoe WM, Yack J, Saltzman CL. The Reliability and Validity of a First Ray Measurement Device. Foot Ankle Int. 2000 Mar 28;21(3):240–6.
17. Singh D, Biz C, Corradin M, Favero L. Comparison of dorsal and dorsomedial displacement in evaluation of first ray hypermobility in feet with and without hallux valgus. Foot Ankle Surg. 2016 Jun;22(2):120–4.
18. Faber FWM, Kleinrensink G-J, Verhoog MW, Vijn AH, Snijders CJ, Mulder PGH, et al. Mobility of the First Tarsometatarsal Joint in Relation to Hallux Valgus Deformity: Anatomical and Biomechanical Aspects. Foot Ankle Int. 1999 Oct 28;20(10):651–6.
19. Glasoe WM, Coughlin MJ. A Critical Analysis of Dudley Morton’s Concept of Disordered Foot Function. J Foot Ankle Surg. 2006 May;45(3):147–55.
20. Roukis TS, Landsman AS. Hypermobility of the first ray: a critical review of the literature. J Foot Ankle Surg. 2003 Nov;42(6):377–90.
21. Glasoe WM, Yack HJ, Saltzman CL. Anatomy and biomechanics of the first ray. Phys Ther. 1999 Sep;79(9):854–9.
22. Michaud TC. Human locomotion : the conservative management of gait-related disorders. Newton Biomechanics; 2011. 412 p.
23. Michaud TC, Nawoczenski DA. The Influence of Two Different Types of Foot Orthoses on First Metatarsophalangeal Joint Kinematics During Gait in a Single Subject. J Manipulative Physiol Ther. 2006 Jan;29(1):60–5.
24. Michaud TC. Foot orthoses and other forms of conservative foot care. Baltimore: Williams & Wilkins; 1993. 249 p.
25. Glasoe WM, Michaud TC. Measurement of Dorsal First Ray Mobility: A Topical Historical Review and Commentary. Foot Ankle Int. 2019 May 22;40(5):603–10.
26. Greisberg J, Sperber L, Prince DE. Mobility of the First Ray in Various Foot Disorders. Foot ankle Int. 2012;33(1).
27. Seng C, Chunyin Ho D, Chong KW. Restoring Sesamoid Position in Scarf Osteotomy: A Learning Curve. J Foot Ankle Surg. 2015 Nov;54(6):1089–92.
28. Chen JY, Rikhraj K, Gatot C, Lee JYY, Singh Rikhraj I. Tibial Sesamoid Position Influence on Functional Outcome and Satisfaction After Hallux Valgus Surgery. Foot Ankle Int. 2016 Nov 20;37(11):1178–82.
29. de Cesar Netto C, Richter M. Use of Advanced Weightbearing Imaging in Evaluation of Hallux Valgus. Foot Ankle Clin. 2020 Mar;25(1):31–45.
30. Kelso S, Richie D, Cohen I, Weed J, Root M. Direction and range of motion of the first ray. J Am Podiatr Med Assoc. 1982 Dec;72(12):600–5.
31. D’Amico JC, Schuster RO. Motion of the first ray: clarification through investigation. J Am Podiatry Assoc. 1979 Jan 1;69(1):17–23.
32. HICKS JH. The mechanics of the foot. I. The joints. J Anat. 1953 Oct;87(4):345–57.
33. Mizel MS. The role of the plantar first metatarsal first cuneiform ligament in weightbearing on the first metatarsal. Foot Ankle. 1993 Feb 17;14(2):82–4.
34. Doty JF, Harris WT. Hallux Valgus Deformity and Treatment. Foot Ankle Clin. 2018 Jun;23(2):271–80.
35. Sarrafian SK. Functional Characteristics of the Foot and Plantar Aponeurosis under Tibiotalar Loading. Foot Ankle. 1987 Aug 30;8(1):4–18.
36. Sarrafian SK. Functional Characteristics of the Foot and Plantar Aponeurosis under Tibiotalar Loading. Foot Ankle. 1987 Aug 30;8(1):4–18.
37. Grebing BR, Coughlin MJ. The Effect of Ankle Position on the Exam for First Ray Mobility. Foot Ankle Int. 2004 Jul 28;25(7):467–75.
38. Doty JF, Coughlin MJ. Hallux valgus and hypermobility of the first ray: facts and fiction. Int Orthop. 2013 Sep;37(9):1655–60.
39. Umberto AM, Valentina C, Laura M, Maria P. Is it still current to talk about first ray hypermobility? Acta Bio Medica Atenei Parm. 2019;90(Suppl 1):32.
40. DiGiovanni CW, Greisberg J. Foot and ankle : core knowledge in orthopaedics. Elsevier Mosby; 2007. 394 p.
41. Rolian C, Lieberman DE, Hallgrímsson B. TThe Coevolution of Human Hands and Feet. Evolution (N Y). 2010 Jun 1;64(6):1558–68.
42. Van Beek C, Greisberg J. Mobility of the First Ray: Review Article. Foot Ankle Int. 2011 Sep;32(9):917–22.
43. Dullaert K, Hagen J, Klos K, Gueorguiev B, Lenz M, Richards RG, et al. The influence of the Peroneus Longus muscle on the foot under axial loading: A CT evaluated dynamic cadaveric model study. Clin Biomech (Bristol, Avon). 2016 May;34:7–11.
44. Wanivenhaus A, Pretterklieber M. First Tarsometatarsal Joint: Anatomical Biomechanical Study. Foot Ankle. 1989 Feb;9(4):153–7.
45. Merton L. Root, John H. Weed WPO. Normal and Abnormal Function of the Foot - Clinical Biomechanics Volume II -. Clinical Biomechanics Corp:Los Angeles, CA U, editor. 1977.
46. Tavara-Vidalón SP, Monge-Vera MÁ, Lafuente-Sotillos G, Domínguez-Maldonado G, Munuera-Martínez P V. Static Range of Motion of the First Metatarsal in the Sagittal and Frontal Planes. J Clin Med. 2018 Nov 21;7(11).
47. Glasoe WM, Allen MK, Saltzman CL. First Ray Dorsal Monility in Relation to Hallux Vlagus Deformity and First Intermetatarsal Angle. Foot Ankle Int. 2001 Feb 14;22(2):98–101.
48. Kim J-Y, Hwang SK, Lee KT, Young K won, Jung JS. A Simpler Device for Measuring the Mobility of the First Ray of the Foot. Foot Ankle Int. 2008 Feb;29(2):213–8.
49. Doty JF, Coughlin MJ, Hirose C, Stevens F, Schutt S, Kennedy M, et al. First Metatarsocuneiform Joint Mobility. Foot Ankle Int. 2014 May 21;35(5):504–11.
50. Coughlin MJ, Shurnas PS. Hallux Valgus in Men Part II: First Ray Mobility after Bunionectomy and Factors Associated with Hallux Valgus Deformity. Foot Ankle Int. 2003 Jan 28;24(1):73–8.
51. Roling BA, Christensen JC, Johnson CH. Biomechanics of the first ray. Part IV: The effect of selected medial column arthrodeses. A three-dimensional kinematic analysis in a cadaver model. J Foot Ankle Surg. 2002 Sep;41(5):278–85.
52. Kawakami W, Takahashi M, Iwamoto Y, Shinakoda K. Coordination Among Shank, Rearfoot, Midfoot, and Forefoot Kinematic Movement During Gait in Individuals With Hallux Valgus. J Appl Biomech. 2019 Feb;35(1):44–51.
53. Geng X, Wang C, Ma X, Wang X, Huang J, Zhang C, et al. Mobility of the first metatarsal-cuneiform joint in patients with and without hallux valgus: in vivo three-dimensional analysis using computerized tomography scan. J Orthop Surg Res. 2015 Sep 15;10(1):140.
54. Greisberg J, Assal M, Hansen ST, Sangeorzan BJ. Isolated Medial Column Stabilization Improves Alignment in Adult-acquired Flatfoot. Clin Orthop Relat Res. 2005 Jun;NA;(435):197–202.
55. Cowie S, Parsons S, Scammell B, McKenzie J. Hypermobility of the first ray in patients with planovalgus feet and tarsometatarsal osteoarthritis. Foot Ankle Surg. 2012 Dec;18(4):237–40.
56. Heng ML, Krishnasamy P, Kong PW. First ray mobility and posterior tibial tendon dysfunction (PTTD) in persons with flatfoot: A case control study. Foot. 2018 Dec;37:57–60.
57. Cornwall MW, Fishco WD, McPoil TG, Lane CR, O’Donnell D, Hunt L. Reliability and validity of clinically assessing first-ray mobility of the foot. J Am Podiatr Med Assoc. 2004;94(5):470–6.
58. Tavara-Vidalón SP, Monge-Vera MÁ, Lafuente-Sotillos G, Domínguez-Maldonado G, Munuera-Martínez P V. Static Range of Motion of the First Metatarsal in the Sagittal and Frontal Planes. J Clin Med. 2018;7(11).
59. TE K, WA W. First metatarsal head shape in juvenile hallux abducto valgus. J Foot Surg. 1991 Sep 1;30(5):506–8.
60. Greisberg J, Prince D, Sperber L. First Ray Mobility Increase in Patients With Metatarsalgia. Foot Ankle Int. 2010 Nov;31(11):954–8.
61. Glasoe WM, Allen MK, Yack HJ. Measurement of Dorsal Mobility in the First Ray: Elimination of Fat Pad Compression as a Variable. Foot Ankle Int. 1998 Aug 17;19(8).
62. Glasoe WM, Getsoian S, Myers M, Komnick M, Kolkebeck D, Oswald W, et al. Criterion-Related Validity of a Clinical Measure of Dorsal First Ray Mobility. J Orthop Sport Phys Ther. 2005 Sep;35(9):589–93.
63. Fritz GR, Prieskorn D. First Metatarsocuneiform Motion: A Radiographic and Statistical Analysis. Foot Ankle Int. 1995 Mar 28;16(3):117–23.
64. Cruz FD. Literature Review of Hypermobile First Ray. North Ohio Foot Ankle J 3 3. 2016;
65. Martin H, Bahlke U, Dietze A, Zschorlich V, Schmitz K-P, Mittlmeier T. Investigation of first ray mobility during gait by kinematic fluoroscopic imaging-a novel method. BMC Musculoskelet Disord. 2012 Dec 9;13(1):14.
66. Kimura T, Kubota M, Suzuki N, Hattori A, Marumo K. Comparison of Intercuneiform 1-2 Joint Mobility Between Hallux Valgus and Normal Feet Using Weightbearing Computed Tomography and 3-Dimensional Analysis. Foot Ankle Int. 2018 Mar 4;39(3):355–60.
67. Swanson JE, Stoltman MG, Oyen CR, Mohrbacher JA, Orandi A, Olson JM, et al. Comparison of 2D-3D Measurements of Hallux and First Ray Sagittal Motion in Patients With and Without Hallux Valgus. Foot Ankle Int. 2016 Feb 8;37(2):227–32.
68. Stiglitz Y, Cazeau C, Klouche S, Bauer T. Reliability of a new dynamic ultrasound test for quantifying first-ray mobility. Orthop Traumatol Surg Res. 2019 Oct;105(6):1131–6.
69. Bednarz PA, Manoli A. Modified Lapidus Procedure for the Treatment of Hypermobile Hallux Valgus. Foot Ankle Int. 2000 Oct 26;21(10):816–21.
70. Lee KT, Young K. Measurement of first-ray mobility in normal vs. hallux valgus patients. Foot ankle Int. 2001 Dec 28;22(12):960–4.
71. Smith BW, Coughlin MJ. The first metatarsocuneiform joint, hypermobility, and hallux valgus: What does it all mean? Foot Ankle Surg. 2008 Jan;14(3):138–41.
72. Nix S, Smith M, Vicenzino B. Prevalence of hallux valgus in the general population: a systematic review and meta-analysis. J Foot Ankle Res. 2010 Dec 27;3(1):21.
73. Mansur NSB, de Souza Nery CA. Hypermobility in Hallux Valgus. Foot Ankle Clin. 2020 Mar;25(1):1–17.
74. Davenport KL, Simmel L, Kadel N. Hallux Valgus in Dancers: A Closer Look at Dance Technique and Its Impact on Dancers’ Feet. J Danc Med Sci. 2014 Jun 15;18(2):86–92.
75. Biz C, Favero L, Stecco C, Aldegheri R. Hypermobility of the first ray in ballet dancer. Muscles Ligaments Tendons J. 2012 Oct;2(4):282–8.
76. Shibuya N, Roukis TS, Jupiter DC. Mobility of the First Ray in Patients With or Without Hallux Valgus Deformity: Systematic Review and Meta-Analysis. J Foot Ankle Surg. 2017 Sep;56(5).
77. Coughlin MJ, Jones CP, Viladot R, Glanó P, Grebing BR, Kennedy MJ, et al. Hallux Valgus and First Ray Mobility: A Cadaveric Study. Foot Ankle Int. 2004 Aug;25(8):537–44.
78. Coughlin MJ, Jones CP. Hallux Valgus and First Ray Mobility. A prospective study. J Bone Jt Surg. 2007 Sep;89(9):1887–98.
79. Coughlin MJ, Grebing BR, Jones CP. Arthrodesis of the First Metatarsophalangeal Joint for Idiopathic Hallux Valgus: Intermediate Results. Foot Ankle Int. 2005 Oct 28;26(10):783–92.
80. Kim J-Y, Park JS, Hwang SK, Young KW, Sung IH. Mobility changes of the first ray after hallux valgus surgery: clinical results after proximal metatarsal chevron osteotomy and distal soft tissue procedure. Foot ankle Int. 2008 May;29(5):468–72.
81. Ellington JK, Myerson MS, Coetzee JC, Stone RM. The Use of the Lapidus Procedure for Recurrent Hallux Valgus. Foot Ankle Int. 2011 Jul;32(7):674–80.
82. Rush SM, Christensen JC, Johnson CH. Biomechanics of the first ray. Part II: Metatarsus primus varus as a cause of hypermobility. A three-dimensional kinematic analysis in a cadaver model. J Foot Ankle Surg. 2000 Mar;39(2):68–77.
83. Myerson M, Kadakia AR, Preceded by: Myerson M. Reconstructive foot and ankle surgery : management of complications. 3rd edition. Elsevier, editor. 2018. 13–26 p.
84. Li S, Myerson MS. Evolution of Thinking of the Lapidus Procedure and Fixation. Foot Ankle Clin. 2020 Mar;25(1):109–26.
85. Galli MM, McAlister JE, Berlet GC, Hyer CF. Enhanced Lapidus Arthrodesis: Crossed Screw Technique With Middle Cuneiform Fixation Further Reduces Sagittal Mobility. J Foot Ankle Surg. 2015 May;54(3):437–40.
86. Blackwood S, Gossett L. Hallux Valgus/Medial Column Instability and Their Relationship with Posterior Tibial Tendon Dysfunction. Foot Ankle Clin. 2018 Jun;23(2):297–313.
87. Willegger M, Holinka J, Ristl R, Wanivenhaus AH, Windhager R, Schuh R. Correction power and complications of first tarsometatarsal joint arthrodesis for hallux valgus deformity. Int Orthop. 2015 Mar 28;39(3):467–76.

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