Introduction
Hallux Valgus is a condition which affects the joint at the base of the
big toe. The condition is commonly called a bunion
(above). The bunion actually refers to the bump that grows on the
side of the first metatarsophalangeal (MTP) joint. In reality,
the condition is much more complex than a simple bump on the side
of the toe. Interestingly, this condition almost never occurs in
cultures that do not wear shoes. Pointed shoes, such as high heels
and cowboy boots, can contribute to the development of hallux valgus.
Wide shoes, with plenty of room for the toes, lessen the chances
of developing the deformity and help reduce the irritation on the
bunion if you already have one. However, shoes
alone are not "solely" to
blame for the development of bunions. Abnormal
foot function comes into play in the development of almost all
bunions, and the most common abnormality is over-pronation or excessive
flattening of the foot, easily correctable with an orthotic.
Anatomy
The term hallux valgus actually describes what
happens to the big toe. Hallux (right) is the
medical term for "big
toe", and valgus is an anatomic term that means the deformity goes
in a direction away from the midline of the body. So, in hallux
valgus, the big toe begins to point towards the outside of the
foot. As this condition grows worse, other changes occur in the
foot that make the problem worse. The bone just above the big toe,
the first metatarsal (above), usually develops too much of an angle
(below) in the other direction. This condition is called metatarsus
primus varus. Metatarsus primus means "first metatarsal", and varus
is the medical term that the deformity goes in
a direction towards the midline of the body.
This creates a situation where the first metatarsal and the big
toe now form an angle (left) with the point sticking out at the
inside edge of the ball of the foot. The bunion that develops is
actually a response to the pressure (below) from the shoe on the
point of this angle. At first the bump is made up of irritated,
swollen tissue that is constantly caught between the shoe and the
bone beneath the skin. As time goes on, the constant pressure may
cause the bone to thicken as well, creating an even larger lump
to rub against the shoe.
   
Symptoms
The symptoms of hallux valgus usually center around the bunion. The bunion
is painful. The severe hallux valgus deformity is also distressing
to many, and becomes a cosmetic problem. Finding appropriate shoewear
can become difficult, especially for women who desire to be fashionable,
but have difficulty tolerating fashionable shoewear. Finally, increasing
deformity begins to displace the second toe upward, and may create
a situation where the second toe is constantly rubbing on the shoe.
Treatment
Treatment of hallux valgus nearly
always starts with adapting the shoewear to fit the foot. In the early stages
of hallux valgus, converting from a pointed toe shoe to a wider box toe shoe
may arrest the progression of the deformity. The pain that arises from the
bunion is due to pressure from the shoe. Treatment focuses on removing the
pressure that the shoe exerts on the deformity. Wider shoes reduce the pressure
on the bunion. Bunion pads may reduce pressure and rubbing from the shoe. There
are also numerous devices, such as toe spacers, that attempt to splint the
big toe and reverse the deforming forces.
If all conservative measures fail
to control the symptoms, then surgery may be suggested to treat the hallux
valgus condition. There are well over 100 surgical procedures described to
treat hallux valgus. The basic considerations in performing any surgical procedure
for hallux valgus are: to remove the bunion to re-align the bones that make
up the big toe to balance the forces so the deformity does not return
In some very mild cases of bunion formation, surgery may only be required to
remove the bump that makes up the bunion.
It is more likely that re-alignment of the big toe will also be necessary.
The major decision that must be made, is whether or not the metatarsal bone
will need to be cut and re-aligned as well. The angle made between the first
metatarsal and the second metatarsal is used to make this decision. The normal
angle is around 9-10 degrees. If the angle is 13 degrees or more, the metatarsal
will probably need to be cut and realigned.
This effectively reduces the angle between the first and second metatarsal
bones, narrowing the foot. The bone is held in the desired position with a
metal screw or pin.
In more severe bunion deformities, where the foot has widened considerably
and the big toe is way out of alignment, the first metatarsal is cut at the
near end of the bone (proximal osteotomy below).
The bone is re-aligned and held in place with screws or metal pins until it
heals. A cast is worn and the patient walks with crutches or a walker, not
bearing any weight on this foot or an extended period of time. Again, this
reduces the angle between the first and second metatarsal bones.
Re-alignment of the big toe is then done by releasing the tight structures
on the lateral side of the first MTP joint. This includes the tight joint capsule
and the tendon of the adductor hallucis muscle. As you can see, this muscle
tends to pull the big toe inward. The toe is realigned and the joint capsule
on the medial side of the big toe is tightened to keep the toe straight.
Once the surgery (.avi movie) is complete, it will take about eight weeks before
the bones and soft tissues are healed.
A picture of a foot showing an advanced bunion deformity which never received
treatment is available. It's not pretty.
After surgery is completed, it is essential that the two factors that caused
the bunion originally be eliminated: Tight shoes must be avoided and abnormal
foot function must be corrected.
LINKS TO MORE INFORMATION
Foot & Leg Center of
Mid Georgia - Bunions
Soar
Medical Associates - Bunion Hallux Valgus
The Rothman Institute at
Jefferson - Bunions
Society of Chiropodists and Podiatrists
- Bunions & other toe deformities
American College of Foot and Ankle
Surgeons- Bunion Deformities and Treatments
North Shore Podiatry Foot Care
Center - Bunions
Dr. Michael J. Marcus Bunion Deformities
SOAR
Medical Associates - Hallux Rigidus Stiff Big Toe Joint
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