Hallux Valgus

Hallux Valgus (Bunion Deformity)


The big toe of the foot is called the hallux. If the big toe starts to deviate inward in the direction of the baby toe the condition is called hallux valgus. As the big toe drifts over into valgus, a bump starts to develop on the inside of the big toe over the metatarsal bone. This bone prominence on the inner edge for the metatarsal is referred to as a bunion. 

Bunions are commonly hereditary but may also be caused or aggravated by shoe wear. The condition is far more common in women than in men and rarely occurs in individuals who do not wear shoes. Once a bunion is present the deformity of hallux valgus worsens slowly over time. 

The treatment of a bunion depends entirely on how uncomfortable it is. Since the pain from a bunion is always aggravated by shoe wear, the symptoms will often depend on the type and size of shoes worn. The perception of pain or discomfort that people experience however is quite varied. There are some individuals who have small bunions that are very uncomfortable. This limits their ability to wear shoes comfortably. On the other hand, some individuals may have quite significant deformities that are annoying but do not limit their activities in anyway.

Realistically, there are only two ways to treat a bunion. Either change the size and shape of the shoe or change the size and shape of the foot.
Once a bunion gets to be irritating or painful and shoe wear is uncomfortable, surgery may be recommended. There are many different surgical procedures that can be performed. The decision to perform one type of surgery or another is based upon the extent and magnitude of the bunion deformity, the presence of arthritis in the big toe joint, and the space between the first and second metatarsals, which is called the intermetatarsal angle.

It is very rare that a bunion can be treated by simply shaving down the bump of the bone. Invariably, the deformity will recur and both the bunion and the hallux valgus will return. Therefore, the shaving of the bunion, called an exostectomy, is performed in conjunction with a cut of the first metatarsal bone (which is called an osteotomy).

Shaving of the bump or the bunion on the side of the metatarsal is not usually successful when performed on its own. Often a bone cut (an osteotomy) on the metatarsal needs to be done in addition to the bunionectomy.
Depending on the severity of the deformity, this osteotomy can be done either at the end of the metatarsal (a distal osteotomy) or if the deformity is more severe, the osteotomy is performed at the base of the first metatarsal (a proximal osteotomy).

One of the more common distal metatarsal osteotomies that is performed is called the chevron osteotomy. Typically a small screw is inserted into the bone to hold the metatarsal head in place and speed up bone healing. Following a chevron osteotomy, walking is permitted in a surgical shoe the next day after surgery, and the shoe is worn for approximately three to four weeks before a more comfortable walking/running type shoe is worn.

One of the more popular proximal metatarsal osteotomies that is performed is called the Myerson/Ludloff procedure. This operation is performed for more advanced deformity. Screws are inserted into the metatarsal to hold the bone cut secure and speed up bone healing. Walking is permitted in a surgical shoe following surgery. The shoe is worn approximately 5 weeks.

For very severe bunion deformities where there is considerable angulation between the first and second metatarsals an osteotomy of the metatarsal may not be sufficient, and for these patients, the joint between the first metatarsal and the cuneiform bone is fused with screws, called the  apidus procedure. This realigns the metatarsal completely and stabilizes the bone, preventing mobility and recurrent deformity.

For patients who have arthritis of the big toe joint associated with a bunion deformity an osteotomy is not performed. The deformity is corrected through the joint either with a fusion of the joint or by removing a portion of the joint (an arthroplasty). Fusion of the big toe joint is an excellent operation since it corrects the deformity, prevents the bunion from returning and eliminates the arthritis simultaneously.

What is a bunion (hallux valgus; hallux abducto valgus)?
A bunion is generally considered as an enlargement of the joint (a lump of bone) at the base and side of the big toe – (specifically, the first metatarsophalangeal joint). Bunions form when the toe moves out of place. As the big toe bends towards the others this lump becomes larger and the bunion can become painful – arthritis and stiffness can eventually develop. Hallux valgus or hallux abducto valgus (HAV) is the name used for the deviated position of the big toe and a bunion refers to the enlargement of the joint – most of the time the two go together and can just be referred to as ‘bunions’.
The word bunion is from the Latin “bunion,” meaning enlargement.

What are the symptoms of bunions?
Bunions starts as the big toe begins to deviate, developing a firm bump on the inside edge of the foot, at the base of the big toe. Initially, at this stage the bunion may not be painful. Later as the toes deviate more the bunion can become painful – there may be redness, some swelling, or pain at or near the joint. The pain is most commonly due to two things – it can be from the pressure of the footwear on the bunion or it can be due to an arthritis like pain from the pressure inside the joint. The motion of the joint may be restricted or painful. A hammer toe of the second toe is common with bunions. Corns and calluses can develop on the bunion, the big toe and the second toe due to the alterations in pressure from the footwear. The pressure from the great toe on the other toes can also cause corns to develop on the outside of the little toe or between the toes. The change in pressure on the toe may predispose to an ingrown nail.

What causes a bunion?
Wearing footwear that is too tight or causing the toes to be squeezed together are the most commonly blamed factor for the cause of bunions and hallux valgus and is undoubtedly the main contributing factor. This probably is the reason for the higher prevalence of bunions among women. However, studies of some indigenous populations that never wear footwear, show that they also get bunions – BUT, they are very uncommon. As they do get bunions, factors other than footwear must play a role in the cause, even though footwear is the main culprit for providing the pressure that causes the symptoms.
Bunions are most widely considered to be due to an imbalance in the forces that is exerted across the joint during walking. The resulting abnormal motion and pressure over the joint, over many years (combined with poor fitting footwear) leads to instability in the joint causing hallux valgus and bunions. Bunions are really only a symptom of faulty foot mechanics and are usually caused by a combination of the way we walk, the foot we inherit and inappropriate footwear use.

Bunions are not inherited, but do tend to run in families. What is inherited is the poor or faulty foot type, that mechanically can lead to the instability around the joint that will eventually lead to bunions – how soon, how quickly and how bad they are or become is assumed to be very dependant on the footwear. A number of other factors are known to play a role in the cause of bunions and hallux valgus. Bunions can follow foot injuries and develop in those with neuromuscular problems. Those with flat feet or pronated feet appear to be more prone to the instability about the joint and have a higher incidence of bunions. Some activities (eg ballet dancing) puts added pressure on the joint and may increase the chance of bunions developing.

Bunion treatment
There are many treatment options for bunions and they will vary with the type and severity of each bunion and will also depend on what is causing the symptoms. Bunions are almost always progressive and tend to get larger and more painful with time – how fast this happens may be a function of the fit of the footwear.
The initial goal of treatment options is to relieve pressure on the bunion and any symptoms that may be present and to halt or slow the progression of the joint deformity. There is no effective may be “get rid off” a bunion without surgery. There are a number of things that individuals (see below) and Podiatrists can do to help the symptoms and slow (if not halt) progression.

Some conservative approaches used to manage bunions and hallux valgus include:

  • Padding with a number of different materials (eg felt) to reduce pressure on the painful prominence of the bunion.
  • Physical therapy can be used to help with the symptoms and improve the range of motion (this is particularly helpful if the pain is coming from inside the joint, rather than from shoe pressure). Manipulation of the joint can be used to help with this (manipulation will NEVER correct the alignment of the joint).
  • Any corns and calluses that are causing symptoms should be treated.
  • Footwear advice – the correct fitting of footwear is essential for anyone who is serious about doing something about their bunions and hallux valgus – follow this advice!!!
  • It may be possible to have your shoes stretched over the area of the bunion to also relieve pressure.
  • Foot orthotics may be useful in helping with the instability about the joint. They may be more helpful if there are other symptoms in the foot as well, as their use in “treating” bunions is controversial. They may play a role in slowing progression and in the prevention of bunions developing again after surgical correction.
  • Exercises (see below) can be important in maintaining the mobility of the joint in those with bunions – this is especially important for the arthritic type pains that may be originating from inside the joint and for the prevention of these painful symptoms in the future.

Self management and exercises for bunions

What can you do yourself for bunions:
1. Follow the advice given by a Podiatrist
2. Use felt pads to help keep pressure off the painful area of the bunions.
3. Wear shoes that are wide and deep to accomodate the bunions. Fitting of footwear is very important. Avoid the use of high heel shoes.
4. Use exercises (see below) to keep the joint mobile
5. Night splints may help with the bunion symptoms (see below). The aim of these are to hold the toe in a more correct position.
Padding or foam between the big toe and the second toe is sometimes recommended – it should, generally, not be recommended as the big toe is usually so strong it just further ‘squeezes’ the lesser toes and can lead to problems between these toes. The padding between the two toes will not straighten the big toe. However, sometimes the padding may be needed to help with symptoms that originate inside the joint if the bunion is painful.

Exercises for bunions
Keeping the joint mobile is important as this goes a long way to helping and prevent the arthritic type pain that can develop inside the joint of those with bunions. Several exercises are recommended:
1. Grasp the big toe with one hand and do some ‘yoga’ like stretches on the joint in all directions. Hold the position at the
end range of motion for 10-15 seconds. Repeat several times in all directions.
2. Traction helps some people with spinal problems, and can also help keep the big toe joint mobile. Grasp the toe and the
foot and try and “pull” the toe “off”. Hold for 10-15 seconds. Repeat several times.
3. Find some sort of elastic band and loop it around both big toes. Spread your feet so that the toe is “straightened” – hold for several minutes. Repeat several times.
Exercises will NEVER be able to correct the position of the toe due to the adaption of bone that has gone on for many years as the bunion developed, but they are important to keep the toe flexible and mobile.

Night splints for a bunion
Wearing splints at night have been shown to provide some correction in adolescents with hallux valgus or bunions (where they are young enough for the bone to still adapt). Read about this evidence here. They may not be as effective in adults, but could be useful to help keep the joint mobile. As a bunion (hallux valgus) is a bony abnormality, it is much harder to change position of a toe permanently in adults.

Shoes for bunions
As footwear plays such an important role in the development and symptoms of bunions, proper fit is vitally important. It is poor fitting footwear in combination with the other factors mentioned above that is the cause of bunions. Footwear also provides the force that makes them painful – the use of the correct footwear is YOUR responsibility.

Surgery for Bunions
If the bunion symptoms does not respond to the conservative measures or if the bunion has progressed past a threshold where these measures are not effective, bunion surgery may be necessary to correct alignment and remove the bunion. A large range of types of surgical procedures for bunions are available and the choice will depend on things like what bone or bones are involved, the angular relationship between the different bones, the amount of damage to the joint and the presence of deformities other than the bunion.