The role of first-ray insufficiency in plantar hyperkeratosis: Implications for physical therapy assessment and intervention

First-ray insufficiency is a critical yet often overlooked factor in the development of plantar hyperkeratosis, commonly observed in hallux rigidus, hallux valgus, cavus foot, and flatfoot deformities. While hyperkeratosis itself may not always be painful, the biomechanical alterations it signifies can contribute to metatarsalgia and functional impairment. From a physical therapy perspective, understanding the interplay between first-ray function and foot-loading mechanics is essential for designing targeted interventions. This brief report presents a viewpoint that explores the implications of first-ray insufficiency in foot biomechanics, highlights rehabilitation strategies to mitigate metatarsalgia, and discusses the potential role of custom orthoses and therapeutic exercises in reducing plantar stress.