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Article

Mobility of the First Ray in Feet with and Without Hallux Valgus

by
Patricia Granados-Gómez
1,
María Reina-Bueno
1,*,
Mercedes Gómez-Castro
2 and
Pedro V. Munuera-Martínez
1
1
Department of Podiatry, University of Seville, Avicena Street s/n, 41009 Seville, Spain
2
Junta de Andalucía, A. Manuel Siurot 50, 41013 Seville, Spain
*
Author to whom correspondence should be addressed.
J. Am. Podiatr. Med. Assoc. 2026, 116(4), 52; https://doi.org/10.3390/japma116040052
Submission received: 20 December 2024 / Revised: 2 March 2025 / Accepted: 6 March 2025 / Published: 24 July 2026
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Abstract

Background: This study aimed to describe the dorsiflexion and plantarflexion motion of the first ray in feet with and without hallux valgus. Methods: Eight hundred feet were examined and classified into normal feet without hallux valgus (n = 227) and feet with hallux valgus (n = 387). Dorsiflexion and plantarflexion of the first ray were quantified with a handheld ruler. Univariate comparisons of the first ray mobility were made between feet with and without hallux valgus. A two-stage cluster analysis was performed to define the range of dorsiflexion and plantarflexion values in both groups. Odds Ratios were obtained to determine whether dorsiflexion or plantarflexion showed more influence on hallux valgus. Multinomial logistic regression was used to predict the probability of having or not having hallux valgus, given dorsiflexion and plantarflexion of the first ray as independent variables. Results: Dorsiflexion showed statistically significant differences between groups (p = 0.011) but with a small effect size (Rosenthal’s r = 0.10). Plantarflexion showed statistically significant differences between groups (p < 0.001) with a larger effect size (r = 0.71). Range of dorsiflexion was between 6 and 7 mm in both normal and hallux valgus feet. Range of plantarflexion in normal feet was 6–7 mm, and in hallux valgus feet 4–5 mm. Logistic regression showed that plantarflexion of the first ray had higher influence on HV than dorsiflexion. Conclusions: In hallux valgus feet, plantarflexion of the first ray was significantly lower than in normal feet, suggesting that a decreased range of plantarflexion is strongly related to hallux valgus.

1. Introduction

The first ray is formed by the first metatarsal and medial cuneiform as osseous components. It is considered a fundamental element in the stability of the foot and has long been recognized as an important component in the midstance and push-off phases of gait [1,2]. It has been suggested that the instability of the first ray may be a causative factor for the development of various pathologies, such as hallux valgus (HV) [3], hallux limitus (HL)/hallux rigidus (HR) [4], or low back pain [5].
The first ray range of motion is not easy to quantify due to the number of small joints that participate in it. The movements in the sagittal and frontal planes are considered to be simultaneous when the first ray mobility is clinically examined, thus performing dorsiflexion-inversion and plantarflexion-eversion [2]. Many methods have been described to measure first ray mobility. Traditionally, in clinical practice, the examination of the mobility of the first ray was estimated visually by performing dorsiflexion and plantarflexion movements by manually moving the first metatarsal in the dorsal and plantar directions with one hand while the other hand stabilizes the second to fifth metatarsals [6]. Klaue et al. [7] and Glasoe et al. [8] developed reliable and valid instruments to quantify the mobility of the first ray that have provided first ray mobility data with high accuracy over the years. Other authors have designed simpler and lighter instruments aiming at simplifying the procedure, as has been claimed by some authors [6]. Munuera-Martínez et al. [9] validated in 2020 a new first ray mobility meter that had the advantages of being light, portable, simple and easy to use in daily clinical practice. The normal value of first ray mobility obtained with this instrument in a large sample of normal feet is not yet known.
According to Root et al. [10], abnormal pronation of the subtalar joint could cause hypermobility of the first ray, with excessive inversion and dorsiflexion of this segment, which in turn may lead to the abnormal function of the first ray responsible for the subluxation of the first metatarsophalangeal joint that will predispose to HV. Other authors have also related the first ray hypermobility to the deformity of HV over the past years [11,12], taking into account that dorsal first ray mobility usually ranges between 3 and 8 mm and measurements exceeding 8 mm indicate first ray hypermobility [13,14]. Dorsiflexion of the first ray has been the main focus of attention when the relationship between HV and first ray mobility has attempted to be established over the years. However, plantarflexion has not been studied enough. Therefore, according to the aforementioned reasons, this study aimed to describe both the dorsiflexion and plantarflexion motion of the first ray in normal feet, measured with a simple handheld ruler, and to compare them with those of feet with HV.

2. Methods

A cross-sectional study was conducted between November 2021 and June 2023. The study population consisted of women and men over 18 years and under 65 years of age, who were recruited from the Clinical Podiatry Area of the University of Seville and other private clinics in Seville, Spain. All the participants gave their written consent and agreed to participate voluntarily. This research has been approved by the authors’ affiliated institutions.

2.1. Participants

Inclusion criteria were healthy adults over 18 years and under 65 years of age, with and without HV. Normal feet had to meet the criteria for normality described by Kirby [15], had no limitation of the mobility of the first metatarsophalangeal joint (MTPJ), and had a normal Foot Posture Index (FPI) score, i.e., between +1 and +5. HV feet had to present as grade B (mild prominence of the first metatarsal head without affecting the hallux), C (moderate prominence of the first metatarsal head and mild hallux involvement) or D (severe prominence of the first metatarsal head with moderate-severe hallux involvement) according to the Manchester Scale [16,17]. People with hallux limitus (HL) or rigidus (HR), or who had undergone surgery on the first ray, had suffered from trauma or fractures on their feet or lower extremities, suffered from systemic diseases with repercussions on the morphology of the foot (i.e., rheumatoid arthritis, Charcot’s foot, etc.) and people with dementia, difficulty of expression and difficulty of mobility, were excluded. Since one person may have only one normal foot (not both), or one foot with HV, feet were counted instead of persons for analysis.

2.2. Measures

A form was completed for each participant with socio-demographic data and medical antecedents. Dorsal flexion of the first (MTPJ), FPI, and dorsiflexion and plantarflexion of the first ray were quantified. All these measurements were performed by the same person, with more than 6 years of experience in foot examination.
To measure the dorsiflexion of the first MTPJ, the center of a goniometer was placed in the head of the first metatarsal, the fixed arm parallel to the bisection of the diaphysis of the first metatarsal, and the distal arm parallel to the bisection of the proximal phalanx of the hallux, moving the hallux to its maximum dorsal flexion.
Measurement of the first ray mobility was quantified with a handheld ruler previously used in other studies (Fresco Podología SL, Barcelona, Spain) [9,18,19]. This device consists of two parts that slide along a central rail (Figure 1). The horizontal branches of each part were placed in the dorsal area of the metatarsal heads, with the shorter one on the first metatarsal head. One hand held the horizontal branch over the heads of the 2nd to 5th metatarsals and the other hand held the horizontal branch against the head of the first metatarsal. The first metatarsal head was placed in the plane of the lesser metatarsal heads (Figure 2), and from this position the head of the first metatarsal was moved upwards and downwards to record how many millimeters of dorsiflexion and plantarflexion it marked [9,19]. This measurement was done 3 times on each foot, and the mean was used for the statistical analysis.

2.3. Data Analysis

To calculate the sample size, the simple random sampling formula was applied to estimate the mean for infinite populations, assuming a relative sampling error (or coefficient of variation) of 5% and a confidence interval of 95%, using the statistical data of a pilot sample of 20 participants as estimators. The necessary recruitment number was n = 393. Finally, a total of 400 participants were recruited for the study.
The statistical analysis of the data was carried out via the SPSS Statistics® software, version 27 (IBM Corp, Armonk, NY, USA). For the descriptive analysis, the absolute frequency (n), relative frequency (%), mean values, and standard deviation (SD) were calculated.
To assess intra-observer reliability, a subset of 40 feet (20 right and 20 left) was randomly selected, and dorsiflexion and plantarflexion measurements were repeated by the same evaluator at two different time points, with a 15-day interval between assessments. The degree of agreement was analyzed using the intraclass correlation coefficient (ICC), applying a two-way mixed-effects model, consistency type, and average measures.
The Kolmogorov–Smirnov test was used to determine if the data followed a normal distribution. To determine whether there were differences between groups, the Mann–Whitney U test was used as the variables did not follow a normal distribution. The effect size was calculated using Rosenthal’s r when p-values were <0.05, considering <0.2 no effect, 0.2–0.5 small effect, 0.5–0.8 medium effect and ≥0.8 large effect.
A two-stage cluster analysis using the silhouette measure of cohesion and separation coefficient was performed to define the range of values of dorsiflexion and plantarflexion and to know whether these ranges reflected evidence that a cluster structure exists, that is, to know if ranges “overlap” between groups or not, and if there is internal cohesion within each group (normal feet and hallux valgus feet). Odds Ratios (OR) were obtained by means of binary logistic regression to know which movement (dorsiflexion or plantarflexion) showed more influence on HV. Multinomial logistic regression was used to predict the probability of having or not having HV, given dorsiflexion and plantarflexion of the first ray as independent variables. A confidence level of 95% was considered, so that the experimental p-value was compared with a significance level of 5%.

3. Results

Four hundred people (331 women) with a mean age of 42.2 ± 11.0 years old, and BMI of 24.7 ± 4.4 kg/m2 took part in the study. Of the 800 feet sampled, 227 were normal feet, and 387 had HV. One hundred and eighty-six feet did not fit the criteria for normal or HV feet. Table 1 summarizes the descriptive data of normal and HV feet.
Table 2 showed excellent repeatability in all assumptions, with ICC values very close to the maximum value exceeding the value of 0.9 in all four pairs of measurements. The values of dorsiflexion and plantarflexion of the first ray, as well as the comparison of these variables between normal and HV feet, are shown in Table 3. The p-value was calculated and, when statistically significant, the effect size was added. As can be seen, although the differences were statistically significant in all cases, the effect size closest to a large value is that of the plantarflexion movement.
The results of the two-stage cluster analysis, which contributed to defining what values would be in the normal and HV feet group, are summarized in Figure 3. For dorsiflexion, the range of values was between 6 and 7 mm in normal feet and 6–8 mm in HV feet. However, for plantarflexion in normal feet, the range of values was also between 6 and 7 mm, but in HV feet it was 4–5 mm. The silhouette measure of cohesion and separation coefficient for plantarflexion was 0.799, which indicates that the data reflect strong evidence that a cluster structure exists.
To determine which of the motion variables (dorsiflexion or plantarflexion of the first ray) had a greater relationship with HV, a binary logistic regression was performed, and an odds ratio was calculated for these variables. In addition, multinomial logistic regression was used to predict the probability of having or not having HV, given the interaction of dorsiflexion and plantarflexion of the first ray (Table 4). A decreased plantarflexion of the first ray increased the probability of having HV by 88% according to the results of the univariate analysis, and by 93% according to the multivariate analysis. On the other hand, having HV is 1.2 times more likely with high values of dorsiflexion, increasing up to 3.7 times in the multivariate analysis.

4. Discussion

The aim of this study was to determine the dorsiflexion and plantarflexion of the first ray in normal feet measured with a first ray handheld ruler, and to compare it with that of feet with HV. To the authors’ knowledge, this is the first study to provide normal values for dorsiflexion and plantarflexion of the first ray in a large sample of normal and HV feet using the measuring device described by Munuera-Martinez et al. [9]. In addition, this is the first study to describe a relationship between HV and limited plantarflexion of the first ray.
Root et al. established that the normal motion of the first ray was 5 mm of dorsiflexion and 5 mm of plantarflexion in the sagittal plane, without the aid of any measuring instrument [10]. They compared dorsiflexion with plantarflexion of the first ray, with hypermobility identified when dorsiflexion exceeded plantarflexion. Later studies have determined that normal dorsiflexion of the first ray in healthy adults ranges from 3 to 8 mm [6,7,20,21,22,23]. Klaue et al. stated that the normal dorsiflexion of the first ray was 5.3 mm, obtained with a measuring instrument specifically developed for their research [7]. Other authors who have subsequently used the same measurement technique have obtained dorsiflexion values ranging from 4.4 mm to 7.2 mm [12,24,25,26]. Glasoe et al. obtained 4.2 mm dorsiflexion of the first ray in normal feet using a measuring instrument designed for their study [20]. Cornwall et al. [27,28], using the instrument designed by Glasoe et al., stated that the normal range of dorsiflexion was approximately 6.2–6.6 mm. Glasoe and Coughlin established that the normal mean dorsiflexion in healthy adults was about 5 mm, and that if this movement exceeded 8 mm, hypermobility of the first ray existed [29]. The dorsiflexion reported in this study in normal feet (mean = 6.6 mm, median = 7 mm, range from cluster analysis = 6–7 mm) falls within an expected range and is similar to that reported in the literature using other mechanical measuring instruments with good validity and reliability data [12,27].
Dorsiflexion of the first ray has been the focus of attention of several studies over the years. However, plantarflexion movement has not been considered in these investigations. Although the results obtained in the present study may not be comparable to those from the studies that employed Klaue’s or Glasoe’s devices because we have used a handheld ruler, these results suggest that plantarflexion of the first ray is as important, or more, than dorsiflexion in HV, since it is the movement that has shown the strongest relationship with this deformity. Other authors have previously reported values of mobility of the first ray in small samples of normal feet using the same measuring device as in the present work. Munuera-Martínez et al. [9] obtained a mean dorsiflexion and plantarflexion of 6.49 ± 0.97 mm and 5.26 ± 0.89 mm, respectively, in normal feet, and 7.20 ± 1.37 mm and 5.99 ± 1.04 mm, respectively, in feet with HV. Although the mean values were different from those in the present study, it can be observed that a similar difference existed between dorsiflexion and plantarflexion. In the present study, dorsiflexion was 6–7 mm, and plantarflexion was 6–7 mm in normal feet. In patients with HV feet, the dorsiflexion was 6–8 mm, and plantarflexion was 4–5 mm.
Other authors have studied the mobility of the first ray in normal feet and feet with HV using different measuring methods and have reported an increased dorsiflexion in feet with HV. Swanson et al. [30] included 19 women with HV in their study and observed that the first ray was more dorsiflexed than in participants with normal feet. Kimura et al. [31] concluded that there was greater mobility and greater dorsiflexion in the first ray in patients with HV. This was also supported by other authors [23,32]. The results of studies by Lee and Young [23], Glasoe et al. [20] and King and Toolan [32] also suggest that people with HV have hypermobility of the first ray, which is greater than the normal range of dorsiflexion. Geng et al. [33] performed CT scans under loading conditions in normal and HV feet. They observed that at the cuneometatarsal joint, normal feet had a mean dorsiflexion of 1.18 degrees, and HV feet 2.91 degrees. Swanson et al. [30] acquired weight-bearing magnetic resonance (MR) images to replicate the position of the foot during the stance phase of gait on subjects with normal feet and with HV. They observed that the dorsiflexion of the first ray was 11 degrees in normal feet and 12 degrees in feet with HV.
In the present study, it has been observed that decreased plantarflexion motion is strongly related to HV deformity. This could not be the only first ray pathology associated with a decrease in plantarflexion. Távara-Vidalón et al. [19] compared the mobility of the first ray in normal feet and in feet with HL using the same measuring device as in the present study. HL patients showed increased dorsiflexion and decreased plantarflexion compared to normal feet. Although other investigations have reported significant differences in dorsiflexion of the first ray in feet with HR compared to normal feet [34,35], similar to what occurs in HV, the plantarflexion of the first ray has not usually been the focus in this pathology either. Pronation of the foot limits plantarflexion of the first ray since it must load greater ground reaction forces under the medial aspect of the forefoot. The relationship between abnormal foot pronation and HV deformity has been widely described for years [10]. The maintenance over time of this situation could be the explanation for the reduced range of plantarflexion in HV feet. A dorsiflexed position of the first ray could become progressively structured, limiting the ability of the first metatarsal to achieve the plantarflexed position required for a complete stabilization of the first metatarso-digital segment and the medial column. Further research would be needed to determine whether decreased plantarflexion motion is present in the early stages of HV, or whether it is a consequence of the development of this deformity.
This study has certain limitations deserving mention. All participants came from the same geographical area, so we must be cautious when extrapolating these results to the general population. Another limitation is that the movement of the first ray was not differentiated by joint level (cuneonavicular and tarsometatarsal joints). An attempt was made to quantify the mobility of the first metatarsal head, as this is the anatomical area considered in the manual assessment of the first ray mobility and is a maneuver traditionally performed in daily clinical practice.
This study provides normal values for the mobility of the first ray using a quick and simple measurement technique that can be performed in daily clinical practice, with a valid and reliable measuring instrument. This can serve as a basis to be considered when making decisions during patient care. For example, it could help clinicians to quantify the thickness of some elements for foot orthoses, to choose between different surgical techniques for first ray deformities based on their mobility, or to assess the mobility of the first ray before and after surgery to check whether instability has been reduced.

5. Conclusions

In conclusion, both dorsiflexion and plantarflexion of the first ray obtained with the first ray measuring ruler in normal feet without HV was 6–7 mm. In HV feet, dorsiflexion was 6–8 mm and plantarflexion 4–5 mm. Therefore, it has been noted that plantarflexion was lower in HV feet than in normal feet. This study suggests that a decreased range of plantarflexion of the first ray is strongly related to the HV deformity. Longitudinal studies are necessary to determine whether the cause of a decrease in plantarflexion of the first ray is greater dorsiflexion of the first ray related to hypermobility or the type of foot. It remains unknown whether the limited plantarflexion is a causative factor or a result of HV.

Author Contributions

Conceptualization, P.V.M.-M.; methodology, P.V.M.-M. and M.R.-B.; formal analysis, M.G.-C. and P.V.M.-M.; investigation, P.G.-G.; data curation, M.G.-C. and P.V.M.-M.; writing—original draft preparation, P.G.-G.; writing—review and editing, P.V.M.-M. and M.R.-B.; visualization, M.R.-B.; supervision, P.V.M.-M. and M.R.-B.; project administration, P.V.M.-M. and M.R.-B.;. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of Virgen Macarena and Virgen del Rocío Hospitals of Seville (protocol code 2244-N-19 and date of approval 4 September 2023).

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

The raw data supporting the conclusions of this article will be made available by the authors on request.

Conflicts of Interest

The authors declare no conflicts of interest.

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Figure 1. Hand-held ruler for measuring the first ray mobility. White arrows show the vertical branches, the black arrow shows the bigger horizontal branch for the head of the lesser metatarsals, and the dotted arrow shows the shorter horizontal branch that must rest on the head of the first metatarsal.
Figure 1. Hand-held ruler for measuring the first ray mobility. White arrows show the vertical branches, the black arrow shows the bigger horizontal branch for the head of the lesser metatarsals, and the dotted arrow shows the shorter horizontal branch that must rest on the head of the first metatarsal.
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Figure 2. Initial position (a) for measurement of the first ray mobility. The first metatarsal head was placed in the plane of the lesser metatarsal heads, and from this position the head of the first metatarsal is moved upwards and downwards to record dorsiflexion (b) and plantarflexion (c). Dorsiflexion of the first MTPJ (d).
Figure 2. Initial position (a) for measurement of the first ray mobility. The first metatarsal head was placed in the plane of the lesser metatarsal heads, and from this position the head of the first metatarsal is moved upwards and downwards to record dorsiflexion (b) and plantarflexion (c). Dorsiflexion of the first MTPJ (d).
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Figure 3. Two-stage cluster analysis, which contributed to defining what range of values would be in the normal and HV feet group, indicates that the data reflects strong evidence that a cluster structure exists.
Figure 3. Two-stage cluster analysis, which contributed to defining what range of values would be in the normal and HV feet group, indicates that the data reflects strong evidence that a cluster structure exists.
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Table 1. Descriptive data of normal feet and HV feet.
Table 1. Descriptive data of normal feet and HV feet.
GroupMeanSDMedianIQRp
AgeNormal39.911.54031–47<0.001 1
HV44.110.54536–53
BMINormal25.04.224.621.6–27.5<0.001 1
HV24.04.123.421.0–25.5
Male
n (%)		Female
n (%)		p
SexNormal62 (27.3)34 (8.8)<0.001 2
HV165 (72.7)353 (91.2)
1 Mann–Whitney U test for independent samples. 2 Chi-squared.
Table 2. Intraclass correlation (ICC) coefficients between mobility variables.
Table 2. Intraclass correlation (ICC) coefficients between mobility variables.
MovementsICC
Dorsiflexion right feet0.979
Plantarflexion right feet0.931
Dorsiflexion left feet0.998
Plantarflexion left feet0.973
Table 3. Descriptive values of dorsiflexion and plantarflexion of the first ray in both normal feet without HV and feet with HV, and results of the comparison of these variables between groups.
Table 3. Descriptive values of dorsiflexion and plantarflexion of the first ray in both normal feet without HV and feet with HV, and results of the comparison of these variables between groups.
nMeanStandard DeviationMedian Interquartile Rangep 1Effect Size 2
DorsiflexionNormal feet2276.61.176–70.0110.102
HV feet3876.81.176–8
PlantarflexionNormal feet2276.51.066–7<0.0010.709
HV feet3874.51.044–5
1 Mann–Whitney U test for independent samples. 2 Rosenthal’s r.
Table 4. Odds ratios of dorsiflexion and plantarflexion of the first ray in normal feet compared to hallux valgus feet.
Table 4. Odds ratios of dorsiflexion and plantarflexion of the first ray in normal feet compared to hallux valgus feet.
Binary Logistic
Regression		Multivariate Logistic Regression
Normal Feet
n = 227 (37%)		HV Feet
n = 387 (63%)		OR
(95% CI)		p-ValueOR
(95% CI)		p-Value
MeanSDMedianIQRMeanSDMedianIQR
Dorsiflexión6.61.176–76.81.176–81.20 (1.03–1.40)0.0153.7 (2.7–5.0)<0.001
Plantarflexión6.51.066–74.51.044–50.12 (0.09–0.17)<0.0010.07 (0.04–0.10)<0.001
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MDPI and ACS Style

Granados-Gómez, P.; Reina-Bueno, M.; Gómez-Castro, M.; Munuera-Martínez, P.V. Mobility of the First Ray in Feet with and Without Hallux Valgus. J. Am. Podiatr. Med. Assoc. 2026, 116, 52. https://doi.org/10.3390/japma116040052

AMA Style

Granados-Gómez P, Reina-Bueno M, Gómez-Castro M, Munuera-Martínez PV. Mobility of the First Ray in Feet with and Without Hallux Valgus. Journal of the American Podiatric Medical Association. 2026; 116(4):52. https://doi.org/10.3390/japma116040052

Chicago/Turabian Style

Granados-Gómez, Patricia, María Reina-Bueno, Mercedes Gómez-Castro, and Pedro V. Munuera-Martínez. 2026. "Mobility of the First Ray in Feet with and Without Hallux Valgus" Journal of the American Podiatric Medical Association 116, no. 4: 52. https://doi.org/10.3390/japma116040052

APA Style

Granados-Gómez, P., Reina-Bueno, M., Gómez-Castro, M., & Munuera-Martínez, P. V. (2026). Mobility of the First Ray in Feet with and Without Hallux Valgus. Journal of the American Podiatric Medical Association, 116(4), 52. https://doi.org/10.3390/japma116040052

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