Hallux valgus is a progressive deformation of the foot in which the base of the big toe (first metatarsal bone) is directed outwards while the tip points to the other toes.
This disorder can provoke intense foot pain in the front part with the formation of a ball on the big toe joint.
Hallux valgus is not the same as bursitis on the big toe, which would mean inflammation and swelling of the bursa.
When talking about hallux valgus, we usually mean the protrusion of the first metatarsal head on the inner edge of the foot and the bursa that covers it. Bursitis does not necessarily have to be present in hallux valgus.
Usually, hallux valgus occurs on both sides, but can also affect only one foot and it is easily possible for the second or third toe to change to a hammer toe at the same time.
Causes of hallux valgus
The origin of hallux valgus is somewhat controversial. Some cases are congenital and may be caused by an inclination of the tarsal and metatarsal joint.
Flatfoot and knuckle foot promote the formation of hallux valgus. If children have this deformity, hallux valgus can develop.
Other cases are almost certainly caused by external factors, such as footwear. Fashion shoes for women are tighter than men’s shoes.
According to many authors, in most cases of hallux valgus, footwear is the most important risk factor. This explains the 10:1 ratio between women and men with this disorder.
Symptoms of hallux valgus
The symptoms of hallux valgus are usually felt on the inside of the big toe joint.
Bursitis of the big toe is very painful.
A pronounced hallux valgus can be frightening because it becomes an aesthetic problem.
Finding suitable shoes can be difficult, especially for women who want to go with fashion but struggle to wear some types of shoes.
Finally, as the deformation progresses, the hallux shifts under the second toe, which is pushed upwards, which leads to the problem that it constantly rubs against the shoe.
In most cases of hallux valgus, this does not lead to any consequences because patients can walk without pain, but problems can occur during sports or jogging.
The hallux bends and is rotated due to the deforming forces as described above.
The study of the first metatarsal includes:
- Mobility of the joint between the metatarsal bone and the big toe.
- Sensitivity testing
- Assessment of associated malformations: flatfoot, hollow foot and other pathological foot forms
The X-ray is the most useful examination, the standard projections are anterior-posterior and lateral and are performed standing.
On the X-ray, one looks for a displacement of the sesamoid bone, which is found under the first metatarsal, but usually shifts laterally in this disease.
It is also important to evaluate the congruence of the joints and the degenerative changes of the bone in order to decide on the treatment to be carried out.
Therapy for hallux valgus
Treatment for hallux valgus can be conservative or surgical.
The treatment of hallux valgus almost always begins with an adaptation of the worn shoes to the foot.
In the early stages of the complaints, the progression of the deformity can be stopped by switching from a narrow shoe to a wide shoe.
Since the pain of bursitis is caused by pressure and friction of the shoe, the treatment focuses on eliminating the forces exerted by the shoe on the deformity.
Comfortable footwear reduces the pressure on hallux valgus.
Special pads can reduce pressure and friction of the shoe.
It is possible to wear silicone spreader pads between the toes to relieve the pain when walking. These options do not cure hallux valgus, but help to make the pain more bearable.
The perception of pain and discomfort is very different.
Many patients have no pain at all, even with severe deviation of the big toe joint.
There are people who have very little bursitis, but feel great discomfort.
This limits their ability to wear certain footwear.
On the other hand, some people may have a clear deformity, which is very disturbing, but does not limit their activities.
Patients with painful bursitis may benefit from a physiotherapy course of treatment, especially laser therapy.
The physiotherapist may recommend shoes that have a wide toe.
More space inside the shoe takes the pressure off the metatarsal bones.
A special cushion pad can be placed over the bale.
An orthopedic insole that supports the hollow arch and keeps the big toe in as straight alignment as possible may be prescribed.
These changes can allow immediate normal walking in the shoe, but activities should be reduced for a few weeks to allow inflammation and pain to subside.
Some therapies such as ultrasound and moist heat help to reduce the symptoms.
It is not possible to correct hallux valgus by simple exercises or a gymnastics program.
If bursitis causes severe pain and the shoes cause discomfort, the orthopedist can advise surgical intervention.
There are different types of surgery.
The choice of procedure depends on the extent and extent of the deformity of hallux valgus and whether arthritis is present at the big toe joint and what the space between the first and second metatarsal is like.
Anesthesia can be done locally or spinally, depending on the patient’s condition and the recommendation of the anesthesiologist.
Therefore, the correction of exostosis (bone formation) occurs together with the correction of the first metatarsal bone (called osteotomy).
Depending on the degree of malposition, osteotomy can be performed at the end of the metatarsal (distal osteotomy) or, in case of pronounced deformity, at the base of the first metatarsal (proximal).
One of the most common actions involves inserting a small screw in the metatarsal near the big toe to keep the metatarsal head in its seat and speed up bone healing.
In this type of osteotomy, you can walk in a surgical shoe from the day after the operation. The medical shoes must be worn for three to four weeks. After that, you can wear a comfortably fitting running shoe.
Proximal osteotomy of metatarsal (near the ankle) is the most common and is performed according to Ludloff’s procedure. This operation is used for very advanced deformations.
The screws are inserted into the metatarsus to fix the corrected bone in its place and favor healing.
You can walk in a surgical shoe after surgery. This shoe is worn for about 5 weeks.
In very pronounced malpositions of the big toe, where there is a considerable angle between the first and second metatarsal, osteotomy of the metatarsal bone is not sufficient. In these patients, the joint connection between the first metatarsal bone and the sphenoid bone is made by means of screws. This procedure is called surgery according to Lapidus.
In this way, the metatarsal is completely realigned and the bone is stabilized, preventing mobility and re-deformity.
In patients with arthritis in the big toe joint together with the deformity of hallux valgus, osteotomy is not performed. The deformity is corrected by merging or removing part of the joint connection (arthroplasty).
The fusion of the big toe joint is an excellent operation because it corrects the deformity, prevents a recurrence of hallux valgus and at the same time removes arthritis.
Rehabilitation after surgery
It takes about eight weeks for bones and soft tissues to heal.
A shoe with a wooden sole or a splint can be placed during this period to protect the bone during the healing period.
You may need crutches or Canadian sticks after surgery. A physiotherapist can explain the use of these walking aids.
It is likely that the operated part of the foot will have to be bandaged and medication will have to be applied until about a week after surgery. The stitches are usually removed after 10-14 days.
If, on the other hand, the surgeon has chosen a suture material that is absorbed, the stitches do not have to be removed.
During the check-up, an X-ray is taken. This allows the surgeon to track bone healing and determine the degree of correction of hallux valgus.