Clinical synthesis based on the 2020-2024 meta-analyses (Hurn 2022, Cai 2023, Hernandez-Castillejo 2020, Singh 2020), the 2024 Cochrane review (Dias) and the ACFAS 2022 consensus, with systematic assessment of PubMed and DOI references.

1.1. How is this condition defined, who does it affect and what are the risk factors?

Hallux valgus (HV), commonly called a bunion, is a complex, progressive three-dimensional deformity of the first ray of the foot¹. It combines a lateral deviation of the proximal phalanx of the great toe at the metatarsophalangeal joint (MTP1) and an adduction (medial deviation) of the first metatarsal, generating the characteristic bony prominence of the inner border of the foot².

The most recent global meta-analysis (Cai et al., J Foot Ankle Res 2023, 45 included studies) establishes a pooled prevalence of 19 % (95 % CI: 13-25 %) in the adult population³. The reference meta-analysis Nix 2010 (78 papers, with no language restriction) had already reported 23 % in adults and 35.7 % in those aged >=65 years⁴. The regional gradient, brought to light in 2023, is notable: Oceania 29 %, Asia 22 %, Europe 18 %, North America 16 %, Africa 3 %³.

Risk factors are multifactorial. Two Mendelian randomisation analyses using two samples, published in 2025, provide arguments for causality, subject to the instrumental assumptions and without independent replication: they are compatible with an effect of smoking (lifetime smoking OR 1.79; 95 % CI 1.27-2.51; smoking initiation OR 1.23) and of high BMI (OR 1.17; 95 % CI 1.06-1.29)⁵. A meta-analysis of 23 observational studies (Zhang 2026) nevertheless finds no association with BMI, and confirms female sex (OR 2.57).¹³ By contrast, rheumatoid arthritis, gout, knee osteoarthritis and hip osteoarthritis do not emerge there as causal factors (p > 0.05), unlike acquired flat foot⁶. The hereditary character is strongly documented: the Framingham Foot Study (Hannan 2013, n=2,446) reports an overall heritability of 0.29 (adjusted for age, sex and BMI), reaching 0.89 in women under 60 and not significant in men⁷.

• Intrinsic factors (observational associations): female sex (adjusted OR 2.64; 95 % CI 2.26-3.08 in Roddy 2008⁸), advanced age (adjusted OR 1.61 per decade⁸), strong heritability (Hannan 2013⁷), nodal osteoarthritis (OR 1.66⁸), self-reported rheumatoid arthritis (OR 2.04⁸), first ray hypermobility (Faber 2004 RCT n=101⁹, role debated).
• Extrinsic factors: smoking and high BMI, the two lifestyle factors for which the 2025 MR analysis finds an argument for causality⁵, the association with BMI not being found in the observational meta-analysis (Zhang 2026). Wearing constraining footwear (narrow toe box, high heels) is associated with progression in the prospective Menz 2023 cohort (n=1,482, 7 years)²,¹⁰.

1.2. What happens in the body and how does hallux valgus naturally evolve?

From a biomechanical standpoint, hallux valgus results from progressive instability of the MTP1 joint (Perera, Mason & Stephens, JBJS Am 2011)¹. The imbalance of tendon forces (extensor and flexor of the hallux displaced laterally, "bowstring effect") amplifies the deviation in a vicious circle¹. The sesamoid complex subluxes, abductor hallucis loses its correct mechanical insertion and the adductor takes over.

The natural history is progressive and generally continuous. The prospective cohort Menz 2023 (n=1,482, mean age 62.9 years, 7 years of follow-up) shows:

• Cumulative incidence: 21.3 % (1 adult in 5 develops HV within 7 years)¹⁰.
• Progression in 33.7 % of existing cases (1 in 3)¹⁰.
• Predictive factors of progression: older age, impaired physical health (low SF-12 PCS), foot pain at baseline and use of constraining footwear¹⁰.

Functional consequences include transfer metatarsalgia on the central rays (impaired propulsion of the great toe), secondary deformities (hammer toes, claw toes), and an increased risk of falls in older adults¹¹. The discordance between radiographic severity and symptoms is one of the major clinical paradoxes of the condition: a patient may have an HVA >35° without pain, and conversely (ACFAS Consensus 2022)¹².

2.1. Which questions should you ask to understand the patient and their history?

The history is the cornerstone of clinical reasoning. It must map five dimensions :

• Pain characteristics : location (medial prominence, articular MTP1, sesamoids, lateral metatarsals), intensity (NPRS 0-10 or VAS), rhythm (mechanical, aggravated by walking, vs inflammatory, nocturnal), triggering and relieving factors. Central plantar pain indicates a transfer of load to the lateral metatarsals¹.
• History of the deformity : age of onset, speed of progression, inflammatory episodes (bursitis), initial trauma. Rapid progression points towards an inflammatory aetiology (rheumatoid arthritis, recurrent gout).
• Past history and comorbidities : family history (heritability up to 0.89 in women under 60, Hannan 2013²), rheumatoid arthritis (adjusted OR 2.04³), nodal osteoarthritis (OR 1.66³), gout, diabetes (impact on post-operative healing).
• Footwear habits : type, heel height, width of the toe box, age of the current shoes. Cited as a major progressive factor in the Menz 2023 cohort⁴.
• Functional impact and quality of life : use a validated PROM at baseline. The MOXFQ (Manchester-Oxford Foot Questionnaire, Morley 2013) offers 16 items in 3 domains with a single index score (alpha = 0.93)⁵. The FFI (Foot Function Index, Budiman-Mak 1991) remains widely used (23 items, 3 subscales)⁶.

2.2. Which clinical tests should be performed and which other conditions must be ruled out?

The examination is performed barefoot, weight-bearing. Inspection assesses overall alignment (calcaneal valgus, collapse of the medial arch frequently associated). Palpation looks for:

• Painful point of the medial bursitis.
• MTP1 joint pain (early osteoarthritis = hallux rigidus, Coughlin & Shurnas 2003⁷).
• Sub-sesamoid pain (sesamoiditis, stress fracture, osteonecrosis).
• Passive reducibility of the deviation ("flexible" vs "rigid" HV = different surgical prognosis).

The diagnosis of hallux valgus is above all clinical. Weight-bearing radiography (dorsoplantar and lateral views) is the reference complementary examination when an objective quantification or surgical planning is being considered⁹,¹⁰.

2.3. Should patients with hallux valgus be classified, and for what benefits?

Classification has three aims: to standardise communication, to guide the therapeutic decision and to monitor progression. Two tools are essential in practice:

• Manchester Scale (Garrow et al. 2001; radiographically validated by Menz & Munteanu, Rheumatology 2005¹¹). Four standardised photographs visually grade the deformity (none / mild / moderate / severe). Good inter-rater reliability. Tool of choice for non-surgical follow-up.
• Weight-bearing radiographic measurements :
  • HVA (Hallux Valgus Angle): angle between the axis of the 1st metatarsal and the phalangeal axis. Normal < 15°; mild 15-25°; moderate 25-40°; severe > 40°¹,⁹.
  • IMA (InterMetatarsal Angle): angle between the 1st and 2nd metatarsals. Normal < 9°¹,⁹.
  • DMAA (Distal Metatarsal Articular Angle): orientation of the articular surface; influences the surgical choice.
  • TSP (Tibial Sesamoid Position): Hardy-Clapham scale 1-7; position > 4 = major risk factor for postoperative recurrence.

Criticism and controversy

The radio-clinical discordance remains the major paradox of hallux valgus¹². A patient may present with an HVA of 35° without pain, and conversely suffer from a highly symptomatic "mild" HV. The ACFAS 2022 consensus explicitly recommends that the therapeutic decision be based on the pain and functional disability reported, and not on the HVA alone¹².

The AOFAS score, historically used, has been criticised for the absence of formal validation and an excessive weighting of the clinician's judgement. Contemporary recommendations (NIH Consortium, COMET, IDEOM) favour pure PROMs such as the MOXFQ or the FAOS⁵.

Finally, the role of first ray hypermobility remains debated: the Faber 2004 RCT (n=101, 5 years) showed no difference in outcome between Hohmann and Lapidus according to preoperative mobility¹³, which questions its relevance as a decision criterion.

3.1. Where do you start? What is the recommended hierarchy of interventions?

The recent literature converges on a hierarchised multimodal approach, with a low certainty of the evidence according to the GRADE system (Hurn 2022)¹. The recommended sequence is:

1. Education and behavioural advice (appropriate footwear, weight management, adaptation of activities). This is the intervention with the best benefit-risk ratio, integrated into all multimodal approaches¹,².
2. Active exercises (intrinsic muscles of the foot, abductor hallucis, Kim 2015 toe-spread-out³, short foot exercise).
3. Passive therapies : joint mobilisations, plantar orthosis, toe spacer, night splint (Tehraninasr 2008⁴).
4. Adjunctive modalities : shock waves, kinesio taping: limited data. A network meta-analysis of 11 trials (Zhu 2026, 401 patients, mild to moderate hallux valgus) ranks first, for angle and pain, exercise combined with taping and then with orthoses, without a certainty rating in its abstract;¹³ a 2021 network meta-analysis (Ying) ranked first, for angle, exercise combined with a toe separator, night splints and dry needling.¹⁴
5. Surgery reserved for documented failures (3-6 months of well-conducted conservative management) with persistent pain and impaired quality of life (ACFAS 2022⁵, Cochrane Dias 2024⁶).

The pivotal trial Torkki 2001 (JAMA, n=209, 93 % women, mean age 48 years, 2 years of follow-up) compares immediate surgery / waiting with an orthosis / waiting without an orthosis⁷. At 1 year, the surgical group has less pain, but at 2 years the three groups converge. The meta-analysis Hernandez-Castillejo 2020 (Acta Orthop) confirms that surgery improves quality of life in the physical domains but with variable effect sizes⁸.

3.2. What is the role of exercise and is there a superior approach?

Therapeutic exercise is one of the best-documented modalities within the conservative approach. The SR/MA Hurn 2022 (Arthritis Care Res, 18 studies included) concludes that the certainty is low, but with a favourable trend towards pain reduction more marked than angular correction¹.

Three key RCTs structure practice:

• Kim et al. 2015 (J Phys Ther Sci, RCT n=24): 8 weeks of toe-spread-out exercise combined with wearing an orthosis significantly reduces the active HVA and increases the cross-sectional area of abductor hallucis on ultrasound³. Versus orthosis alone, the difference is statistically significant (p < 0.05).
• Abdalbary 2018 (JAPMA, RCT n=56): programme combining joint mobilisations + strengthening exercises (hallux plantarflexion + abduction + toe grip) + stretching + toe separator, 36 sessions over 3 months. Radiographic reduction in HVA of approximately 9° at 12 months⁹.
• Tehraninasr 2008 (Prosthet Orthot Int, RCT n=30 women aged 19-45): orthosis with toe spacer vs night splint. Pain reduction in both groups; limited effect on angles⁴.

3.3. Manual therapies and technologies: how effective are they really?

The SR/MA Singh 2020 (J Clin Orthop Trauma) shows that MIS gives less pain in the early phase and shorter operating and hospital stay times, with no significant difference in HVA, IMA, AOFAS or VAS at last follow-up¹². The Cochrane review Dias 2024 (CD013726) concludes low certainty of evidence for the surgical advantage in the long term⁶.

3.4. Beyond the physical: how do you educate the patient and address psychological factors?

Education should address three points:

• Nature of the condition : progressive deformity, the conservative aim is symptomatic and not structural (transparency about the evidence; Hurn 2022)¹.
• Major role of footwear : wide toe box, heel <= 3 cm. Wearing constraining footwear is an independent progression factor in Menz 2023 (n=1,482, 7 years)⁹.
• Shared decision-making according to the Hoffmann-Montori 2014 framework: set out the options (multimodal conservative management vs surgery) and their evidence, and integrate the patient's preferences¹⁰. Particularly crucial in the face of radio-clinical discordance.

4.1. How do you make the patient an agent of their own recovery through self-management?

Self-management underpins long-term success. It is built around five axes:

• Understanding the condition : transparent information on the progressive nature and the limits of conservative treatment (Hurn 2022: pain improves more than the angle)¹.
• Appropriate footwear : wide, flexible toe box, low heel (<3 cm), avoid narrow pointed toes. Cited as a modifiable progression factor in Menz 2023².
• Home exercises : programme drawn from Kim 2015 (toe-spread-out) and Abdalbary 2018 (mobilisations + strengthening + toe separator); 3 times a week, for at least 8 weeks to observe effects³,⁴.
• Management of painful flares : cryotherapy, temporary offloading, assessment of triggering factors (footwear, excessive activity).
• PROM monitoring : MOXFQ or FFI every 3 months to objectify progress⁵,⁶.

4.2. Vulnerable subpopulations: older adults, juveniles, rheumatoid arthritis

Three populations deserve a distinct clinical strategy.

Older adults (>=65 years): risk of falls

The prevalence of HV in those aged >=65 years reaches 35.7 % (Nix 2010)⁷. The meta-analysis Menz, Auhl & Spink 2018 (Maturitas) shows that foot problems, including HV, significantly increase the risk of falls in the community-dwelling population⁸. HV is associated with an increased fear of falling and with an impairment of dynamic balance. Practical implications: fall screening (Timed Up and Go, FES-I), advice on stable footwear, particular attention to orthosis reimbursement.

Juvenile hallux valgus (adolescent): a specific challenge

The juvenile form shows a historically high postoperative recurrence rate because of growth plates that are not yet closed. An expert review (Foot Ankle Clin, Coughlin 2007 on juvenile HV, and recent paediatric publications) recommends delaying surgery as long as possible and favouring the conservative approach (footwear, exercises, education). When surgery is unavoidable (disabling pain, severe progressive deformity), it must be scheduled after the end of growth (ideally).

Rheumatoid arthritis: rapid deformity and complex surgery

Rheumatoid arthritis is associated with HV in observational data (adjusted OR 2.04; 95 % CI 1.43-2.91; Roddy 2008)⁸, but the 2025 MR analysis of endogenous factors found no causal effect¹². RA patients often develop rapid and associated deformities (hammer toes, MTP subluxation), with:

• Impaired tissue quality (thin skin, fragile scarring).
• Residual inflammatory activity despite biologic therapies.
• Multidisciplinary approach mandatory (rheumatologist + physiotherapist + podiatrist + orthopaedic surgeon).
• Favour joint-preserving techniques when the disease is controlled. A review (2024, ecios.org) shows favourable results with distal Chevron osteotomy in RA: JSSF Hallux 41 -> 88, recurrence 7.5 %¹⁴.

4.3. When and how should a safe return to sport and activities be planned?

After surgery, the timeline depends on the technique (distal Chevron, Scarf, Lapidus, MIS), on the fixation, and on the patient. The SR/MA Hernandez-Castillejo 2020 reports significant improvements in quality of life at 6-12 months in the physical domains⁹.

Schematic progression :

1. 0-6 weeks : rigid post-operative shoe, weight-bearing according to technique, oedema control (cryotherapy + elevation). Stationary cycling without resistance possible after validation.
2. 6-12 weeks : transition to adapted normal footwear after radiographic consolidation. Progressive strengthening, proprioceptive exercises. Low-impact activities (swimming, cycling).
3. 3-6 months : resumption of impact activities according to functional criteria. The median time to return to sport after distal osteotomy is 3 to 6 months in contemporary surgical series.

Objective criteria for return to sport (Return to Sport) :

• No pain during daily activities (NPRS <=2/10).
• Recovery of >=80 % of MTP1 dorsiflexion compared with the contralateral side.
• Symmetrical strength of the intrinsic muscles (heel rise test >15 repetitions).
• Satisfactory dynamic balance (Y-balance, single leg stance).
• MOXFQ or FFI in the range "minimal to no discomfort".

Criticism and controversy

The standardisation of postoperative rehabilitation protocols remains a major weakness. Most trials compare surgical techniques without controlling rehabilitation, which turns the latter into a "black box" in methodological terms. The debate between early vs delayed weight-bearing remains partly open: recent reviews tend to favour early weight-bearing when fixation allows it, without an increase in complications.

The prevention of long-term recurrence by conservative interventions lacks solid data beyond 12 months post-op. The Menz 2023 prospective cohort shows that 1 case in 3 progresses within 7 years, underlining the limits of purely structural conservative means².

5.1. Analysis of a typical conservative case: from assessment to resolution

The most frequent profile is that of a woman in her fifties with a moderate deformity, mechanical pain when walking in shoes and intermittent medial bursitis. In line with the data of Roddy 2008 (women OR 2.64; age >=50 years OR 1.61/decade) and the ACFAS 2022 consensus, the typical clinical sequence breaks down as follows¹,²:

• Initial assessment : interview (pain VAS 6/10, positive maternal history, wearing narrow town shoes), weight-bearing examination (bilateral HV, more marked on the right, Manchester Scale: moderate), standing radiograph (right HVA 28°, right IMA 12°, ACFAS classification mild to moderate)²,³.
• Baseline PROM : MOXFQ index = 38/100 (moderate discomfort) with a predominant "Pain" subscale⁴.
• Evidence-based multimodal plan : (a) footwear education with demonstration of a suitable shoe (Hurn 2022 ACR⁵, Menz 2023⁶); (b) exercise programme Kim 2015 (toe-spread-out) + Abdalbary 2018 (mobilisations + strengthening + toe separator) over 12 weeks⁷,⁸; (c) plantar orthosis + toe spacer at rest (Tehraninasr 2008)⁹.
• 3-month follow-up : MOXFQ index goes to 18/100, pain VAS to 2/10. Radiographic HVA stable at 26°. The pain improved more than the angle, in line with the conclusions of Hurn 2022⁵.
• 12-month follow-up : MCID reached on the MOXFQ. The patient reports a return to daily activities with minimal discomfort. Shared decision to continue conservative management in the absence of symptomatic progression (Hoffmann 2014)¹⁰.

This profile illustrates that multimodality + education + adherence can defer or avoid surgery in a majority of patients with symptomatic moderate HV, in line with the pivotal trial Torkki 2001 (convergence of the groups at 2 years)¹¹.

5.2. The diagnostic challenge: when the bunion hides an acute gout flare

A patient with a known HV may present as an emergency with sudden, intense, hyperalgesic MTP1 pain. The diagnostic trap is to attribute the flare to medial bursitis when it is in fact an inflammatory flare of a comorbidity. The 2025 Mendelian randomisation analysis of endogenous factors found no causal effect of gout on hallux valgus: the coexistence of the two conditions at the MTP1 remains a mere association.

Typical clinical picture of podagra :

• Sudden onset, often at night; pain >=8/10; allodynia on contact with the sheet.
• Red, hot, swollen MTP1; periarthritis; complete functional impairment.
• History: similar flares (wrist, ankle), known hyperuricaemia, excessive alcohol, diuretics, renal failure.
• Laboratory: raised CRP, hyperuricaemia (imperfect sensitivity: 30 % of flares have a normal serum uric acid).
• Confirmation: joint aspiration showing negatively birefringent monosodium urate crystals under polarised light. This is the gold standard.

Pitfalls to avoid :

• Confusing it with septic arthritis : any acute MTP1 episode in a diabetic or immunosuppressed patient, a recently operated patient or one with a cutaneous portal of entry must prompt exclusion of infection (aspiration + Gram stain + culture).
• Overlooking a stress fracture in an endurance athlete with abrupt onset without clear trauma.
• Treating as trivial a "medial bursitis" that does not settle within 7 days on NSAIDs: repeat the work-up.

The literature documents several real published cases in which gout has mimicked an infection or a bursitis in patients with bunions (see gout / bunion publications on PubMed). The clinical rule: in any intense acute presentation of the MTP1, never stop at the visual diagnosis of a bunion¹³.

5.3. Study of a complex case: juvenile hallux valgus and rheumatoid arthritis

Juvenile hallux valgus

A 15-year-old girl may consult for a visible and painful deformity, often with a strong genetic component (mother and grandmother affected, consistent with the heritability of up to 0.89 in Hannan 2013¹⁴). Specific features of management:

• Prolonged conservative approach : appropriate non-negotiable footwear, education on natural progression, intrinsic exercises.
• Delay surgery as far as possible until the end of skeletal growth (high risk of recurrence on an immature metatarsal).
• If surgery becomes unavoidable (disabling pain, severe progression beyond 35° HVA), favour techniques that respect the growth plates.
• Adapted adolescent MOXFQ follow-up, psychological support if anxio-depressive comorbidity (the aesthetic impact at this age can be significant).

Rheumatoid arthritis

Rheumatoid arthritis is associated with HV in observational data (adjusted OR 2.04; Roddy 2008)¹, with no causal effect found by the 2025 Mendelian randomisation. A 58-year-old woman with RA diagnosed 10 years earlier, on biologic therapy (anti-TNF), may present with rapid bilateral deformity with:

• Hammer toes of the 2nd to 5th, MTP2-3 subluxation.
• Diffuse plantar bursitis.
• Radiographic erosions characteristic of the metatarsal heads.
• Residual inflammatory activity (DAS28 = 3.5, moderate).

Management is multidisciplinary :

1. Coordination with the rheumatologist to optimise control of the underlying disease.
2. Complete podiatric assessment, custom-made orthosis with selective offloading of the central metatarsals.
3. Physiotherapy: passive mobilisations, education on therapeutic footwear (Comfort & Adapted).
4. If surgery: joint-preserving techniques when possible. A 2024 review shows favourable results with distal Chevron osteotomy in RA: JSSF Hallux score 41 -> 88, recurrence 7.5 %¹⁵.
5. Peri-operative management of biologics: decision of the rheumatologist and the surgeon, with diverging recommendations (ACR/AAHKS 2022, BSR 2019, 2023 Australian recommendation).

Criticism and controversy

Published clinical cases are by nature subject to selection bias : only exemplary or tricky cases are published, rarely ordinary failures. The great heterogeneity of protocols (moulded vs off-the-shelf orthosis, supervised programme vs paper leaflet) limits generalisation.

Controversy persists over the surgical threshold in adolescents and in older people. The ACFAS 2022 consensus explicitly recommends basing the decision on the functional complaint and not on the angles alone, but this requires structured communication with the patient (shared decision-making Hoffmann 2014)¹⁰.

6.1. When and to which other health professionals should you refer?

The physiotherapist with direct access must know how to recognise the situations that require a rapid or urgent referral. The reference framework is the International Framework for Red Flags of the IFOMPT (Finucane 2020 JOSPT, 100 experts from 19 countries)¹.

Beyond red flags, referral is justified by yellow flags (psychosocial factors predictive of chronicity: kinesiophobia, catastrophising, depression, low self-efficacy). Collaboration with a psychologist specialising in chronic pain may be proposed. The framework "Screening for Yellow Flags in Orthopaedic Physical Therapy" published in 2021 in JOSPT provides a practical outline².

Recommended interprofessional network :

• General practitioner : coordination, prescriptions, overall follow-up.
• Rheumatologist : suspected rheumatoid arthritis, gout, spondyloarthropathy.
• Foot and ankle orthopaedic surgeon : documented conservative failure, severe symptomatic deformity.
• Podiatrist : custom-made orthosis, nail care, selective offloading.
• Psychologist : yellow flags, chronic pain management.
• Dietetics : overweight (BMI: suggested by the 2025 Mendelian randomisation, OR 1.17, not replicated and not found in the 2026 observational meta-analysis).

6.2. How do you measure outcomes and overcome barriers to implementation?

Objective evaluation of outcomes is essential to adjust management and to demonstrate the value of care. Validated PROMs are now the patient-centred standard.

Practical implementation strategy :

• Baseline + 3 months + 6 months + 12 months.
• Integrate the PROM into the computerised patient record.
• Feed the scores back to the patient (reinforces self-efficacy and adherence).
• Use the MCID (Minimal Clinically Important Difference) to interpret changes.

Barriers to EBP and levers

The classic barriers to evidence-based practice (lack of time, access to resources, continuing education) have been widely documented in the physiotherapy literature. The high-value levers are:

• Synthetic tools : this type of article based on recent SR/MA; CATs (Critically Appraised Topics); guideline summaries.
• Facilitated access : PubMed Plus subscription, Cochrane Library, JOSPT, BJSM, FAI.
• EBP mentors within the practice or the professional network.
• Structured shared decision-making (Hoffmann 2014³): take 3-5 minutes to set out the options, their evidence and the patient's preferences. Significantly increases adherence.
• IFOMPT 2020 framework¹ for red flag triage: a memorisable table, applicable in a few minutes.

Criticism and controversy

The sensitivity vs specificity of red flags remains a permanent tension: a threshold that is too low leads to over-referral and patient anxiety, a threshold that is too high may let a serious pathology slip through. Clinical judgement combined with the IFOMPT framework remains the best current approach.

The "knowing-doing gap" remains the major challenge: even with knowledge of the recommendations and access to resources, practice change is slow. Economic models (fee-for-service payment), habits and time pressure constitute systemic barriers that go beyond individual effort.

Finally, the industrialisation of PROMs must not replace clinical dialogue: the risk is "treating the questionnaire" rather than the patient. Scores are tools in the service of reasoning, not ends in themselves.