Hallux valgus is a condition in which the big toe dislocates towards the second toe at the meta-tarsophalangeal joint. When this occurs, the head of the metatarsal moves towards the other foot and becomes prominent. Rubbing on footwear and increased load when walking leads to increased bone and cartilage and overlying connective tissue on the metatarsal head, creating what is commonly known as a bunion. Thus the subluxation of the great toe is the real problem, and the bunion the unpleasant consequence.
There are many factors that contribute to the formation of a hallux valgus deformity, including genetic factors, family history, and certain activities and footwear. Not all patients are troubled by the deformity. The most common complaint is the poor aesthetics of the foot, followed by pain over the bunion and inability to wear appropriate footwear.
How is hallux valgus diagnosed?
If your suspect you are developing this deformity, seek review with your local doctor. If your history and physical examination fit the diagnosis, you will be sent for plain X-rays of the feet and referred to an orthopaedic surgeon for further opinion.
What causes the toe to dislocate?
The underlying cause of the deformity is an imbalance of the muscles that run under the toe. One of the muscles that controls flexion of the toe has two tendons, one running either side of a ridge under the metatarsal head. Within each tendon is a sesamoid bone, which looks like a smaller version of your knee cap. Whether from trauma, connective tissue weakness or another cause, the two tendons end up on the outside of the metatarsal head. As you flex your toe, the pull is off centre and the toe is pulled to the outside. Over time, all the tissues holding the toe in its normal position stretch, and the toe subluxes. With long standing subluxation, the bone itself changes shape and the joint can become arthritic and painful.
Do my shoes cause the deformity?
There is certainly a strong link between the wearing of high-heeled shoes and development of hallux valgus. This is likely explained by the altered biomechanics in a foot that weight bears in extreme plantar flexion. There are those who will develop the deformity regardless of the footwear worn, and similarly those who can wear high-heels life long with no problems. The factors that contribute are clearly multi-factorial, with a genetic component and environmental factors all contributing.
How quickly will the deformity develop?
This is difficult to predict, with some patients developing this at a young age, and some later in life. If you have a family history of the condition, the experience of your relatives will usually be similar to yours. The deformity may halt its progress, it may slowly continue over many years, and in some can rapidly progress and be associated with painful, stiff arthritis.
Do I have to seek treatment for this?
No. If you have a deformity that is causing you no symptoms or impairment, you do not need specific treatment. However, experience has shown us that the deformity is likely to show slow progression. As such the recommendation would be to watch it closely, and if you feel it is getting worse, seek review with your local doctor and orthopaedic surgeon. It is worth keeping in mind that some treatments are best instituted early, rather than waiting for the situation to become dire.
What non-surgical treatment options are available?
As with all non-surgical treatment options, the simple aims are to remove any factors that may be causing the problem, treat the symptoms and try and slow the progression of the disease. For women, this can mean changing from high-heeled footwear with tight toe boxes to a flatter soled shoe with a wide toe box to accommodate the bunion. Simple analgesics and anti-inflammatory medications can be used if pain is a feature, and aggravating activities should be avoided where possible. A review with a podiatrist is recommended. They can assess your need to orthotics, and provide you with toe supports that can help hold the great toe in position. Not everyone can tolerate these, and the long term success of them has not been proven in the literature, but some patients do find they are more comfortable.
What surgical options are available?
When the pain and/or deformity have become severe enough to limit your daily function, surgery can be considered. In some patients surgery is selected as a treatment option earlier to prevent severe deformity from occurring. The surgery for correction of a hallux valgus is tailored to each individual case, and involves cutting and realigning displaced bones, removal of the bunion, tightening of the loose inside tissues and release of the tight outside tissues, and relocation of the displaced sesamoid bones under the metatarsal head. For those where the joint has advanced arthritis, a joint fusion is often added.
How long am I in hospital?
You will be in hospital overnight following your surgery, with a view to discharging home the following day once you are mobilising safely.
When can I return to work and sports?
As the surgery involves cutting and realigning bones, the healing time is that same as if the bones had broken – the bones will reunite after 6-12 weeks. You will be treated in a plaster or protective boot for the first 6 weeks, and will not be able to weight bear on the foot for this period. After 6 weeks you can commence gentle weight bearing, with a view to full weight bearing by 12 weeks. If you are involved in sedentary work, you can return to work sooner, but for those in heavy manual work and sports, you may need 3-6 months before you are fully functional.
What should I look out for following surgery?
If you develop any increasing redness or heat in your wound, or have ongoing wound discharge, you should seek review with Dr Host or your local doctor.
If you develop any symptoms such as chest pain or tightness, shortness of breath, or lower limb/calf swelling and pain, you should seek emergency review at your nearest hospital.