Hallux valgus
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Bunion, also referred to as hallux valgus, is a complex, progressive deformity of the forefoot. It involves the lateral deviation of the big toe toward the other toes and the medial displacement of the first metatarsal bone. This leads to widening of the forefoot and a prominence in the area of the first metatarsophalangeal joint, colloquially called a bunion. The bony changes are accompanied by an imbalance of muscles, tendons, ligaments, and sesamoid bones located beneath the head of the first metatarsal bone. The deformity can cause pain, bursitis, calluses, corns, difficulty finding properly fitting footwear, and an altered gait. Diagnosis is based on clinical examination, and qualification for surgical treatment usually also requires foot X-rays taken in a standing position.
Bunion - what it looks like
The most characteristic symptom is the deviation of the big toe toward the second toe. At the same time, the head of the first metatarsal bone becomes visible on the medial side of the foot as a hard prominence. Therefore, the term „bunion” describes the entire deformity, not just the protruding bone.
The presentation of hallux valgus may include:
- widening of the forefoot, associated with the medial displacement of the first metatarsal bone,
- redness, swelling, and tenderness over the bony prominence,
- pain in the first metatarsophalangeal joint, worsening during walking and wearing narrow footwear,
- limited mobility of the big toe or pain during its flexion,
- rotation of the big toe, causing the nail to partially turn toward the other foot,
- overlapping of the big toe over the second toe or sliding under the second toe,
- hammertoes and deformities of the lesser toes,
- calluses under the metatarsal heads and corns at sites of chronic pressure,
- impaired push-off phase of the foot during gait.
The severity of the deformity is evaluated clinically and radiologically. A weight-bearing foot X-ray is used to analyze, among other things, the hallux valgus angle, the angle between the first and second metatarsal bones, the alignment of the sesamoids, and the congruency of the articular surfaces. The appearance of the foot alone poorly reflects the severity of the symptoms. A minor deformity may cause significant pain, whereas an advanced deviation of the big toe can sometimes be well tolerated for a period of time.
Bunion - where does it come from
Hallux valgus has a multifactorial etiology. The deformity develops as a result of the interplay of anatomical, hereditary, and biomechanical predispositions, as well as long-term environmental stresses. It is usually difficult to point to a single cause.
An important role is played by:
- familial occurrence of the deformity, especially in cases with onset at a young age,
- abnormal structure of the first ray of the foot, including an increased angle between the metatarsal bones,
- hypermobility of the first ray and impaired stability of the medial part of the foot,
- flat feet and overpronation, that is, increased inward rolling of the foot during weight-bearing,
- muscle imbalance around the first metatarsophalangeal joint,
- displacement of the sesamoid bones, which weakens the stabilizing mechanism of the great toe,
- Achilles tendon contracture and limited ankle dorsiflexion,
- inflammatory joint diseases, especially rheumatoid arthritis,
- neuromuscular diseases and generalized ligamentous laxity.
Narrow footwear with a tapering front increases pressure on the toes. High heels shift a greater part of the load to the forefoot. Both factors promote the manifestation and progression of the deformity in an individual with anatomical predispositions. Footwear is therefore an important modifying factor, but it usually acts together with intrinsic conditions.
As the disease progresses, the tendons running along the great toe shift laterally and begin to act like a bowstring, exacerbating the deviation. The joint capsule on the medial side becomes stretched, and the lateral structures undergo contracture. The pressure distribution under the foot changes, which can lead to metatarsalgia, or pain in the region of the metatarsal heads.
Bunions - who is most commonly affected
Hallux valgus occurs in every age group, including children and adolescents. The prevalence of the deformity increases with age. Contemporary meta-analyses indicate that it affects approximately one-fifth of the population, although results vary depending on the age of the subjects, geographic region, and the diagnostic method adopted.
Women are affected significantly more often than men. This association is related to the anatomical structure of the foot, a higher incidence of ligamentous laxity, the influence of hormonal factors, and long-term use of footwear that constricts the space for the toes. The deformity also occurs in men, and its significant severity requires the same orthopedic evaluation.
Groups with an increased likelihood of developing hallux valgus include:
- individuals with a family history of hallux valgus,
- patients with flat feet, excessive pronation, or joint laxity,
- individuals performing work that requires standing for many hours,
- dancers and representatives of disciplines that place heavy stress on the forefoot,
- patients with rheumatoid arthritis,
- individuals with deformities of other toes and lower limb alignment disorders,
- older adults in whom long-term stress is combined with degenerative changes.
Body weight can increase the load on a painful forefoot, but its direct association with the development of hallux valgus remains less clear than the significance of age, sex, family history, and foot anatomy. Patient evaluation should encompass the entire lower limb, gait pattern, type of footwear used, and the presence of systemic diseases.
Bunion - can it be reversed without surgery
In an adult, a fixed osteoarticular deformity retains its shape despite conservative therapy. Non-surgical methods primarily serve to reduce pain and pressure, improve foot function, and slow down the consequences of overload. Their use may be sufficient when symptoms remain mild or moderate.
Conservative management includes:
- footwear with a wide and high toe box, a soft upper, and a stable sole,
- limiting high heels, which increase pressure on the forefoot,
- individually selected insoles or orthoses, especially with coexisting pronation and metatarsalgia,
- toe separators and prominence shields, reducing friction and local pressure,
- exercises for the short muscles of the foot, the abductor hallucis muscle, and arch control,
- stretching of the triceps surae muscle, when limited dorsiflexion is present,
- activity modification, tailored to the sources of pain,
- pain management, conducted in accordance with individual medical indications,
- professional management of calluses and corns, which develop as a result of altered pressure distribution.
Separators, splints, and exercises can temporarily improve hallux alignment when offloaded and reduce symptoms. Permanent correction of fixed bony changes requires changing the axis of the first ray, which is achieved through surgical methods. It is worth evaluating the effectiveness of therapy through the lens of pain, walking ability, footwear tolerance, and quality of life, rather than solely by the angle of hallux alignment.
Hallux valgus - when is surgery necessary
Surgical treatment is considered in the case of persistent pain, limitation of daily activities, difficulty selecting appropriate footwear, and progression of the deformity despite properly conducted conservative treatment. The appearance of the foot alone is a weak indication for surgery. The decision should be based on a combination of symptoms, clinical examination, patient expectations, and radiological imaging.
Urgent orthopedic consultation is required for a deformity accompanied by:
- recurrent inflammation and significant pain in the joint area,
- wounds, ulcerations, or skin damage over the prominence,
- progressive overlapping of the toes,
- severe metatarsalgia and painful plantar calluses,
- loss of stability while walking,
- stiffness or degenerative changes of the first joint,
- rapid worsening of the deformity.
The choice of procedure depends on the degree of bone deviation, joint congruity, mobility of the first ray, sesamoid position, bone quality, and the presence of osteoarthritis. Osteotomies (controlled cutting and realignment of the bone), soft tissue correction procedures, fusion of the first tarsometatarsal joint using the Lapidus method, or arthrodesis of the first metatarsophalangeal joint are used. Simple removal of the bony prominence without correcting the biomechanical cause is associated with a high risk of recurrence.
Surgery requires a healing period, gradual weight-bearing, and rehabilitation. Possible complications include infection, impaired bone healing, stiffness, nerve irritation, chronic swelling, overload of adjacent metatarsal bones, overcorrection, and recurrence of the deformity. Proper patient selection and tailoring the technique to the anatomy of the foot increase the chances of lasting functional improvement.
Podiatric treatments for hallux valgus
Podiatric care alleviates the skin and nail consequences of hallux valgus. At Ambasada Urody, procedures are available for changes caused by pressure, friction, and abnormal load distribution:
- podiatric consultation and examination with an assessment of the skin, nails, pressure points, and foot biomechanics,
- basic podiatric treatment, including the management of nails, nail folds, and physiological calluses,
- extended podiatric treatment, intended for numerous or extensive skin and nail lesions,
- basic medical pedicure, used for calluses, hyperkeratosis, dryness, and nail plate changes,
- specialist callus removal, which reduces the hyperkeratotic layer formed in areas of increased pressure,
- corn removal, especially lesions on the medial side of the joint and between the big toe and the second toe,
- custom pressure relief devices and dressings, protecting painful areas from further friction,
- management of thickened or deformed nails when the alignment of the toes hinders their proper care,
- ingrown toenail therapy, including tamponade, orthonyxia braces, or the Arkada's Cube method, if the hallux deformity disrupts the growth path of the nail plate.
Podiatric procedures improve walking comfort and reduce local complications, but leave the bone axis unchanged. A recurring callus or corn indicates persistent overload, which is why treating the lesion should be combined with footwear modification, pressure relief, and orthopedic evaluation. Particular caution is required for individuals with diabetes, neuropathy, circulatory disorders, rheumatic diseases, and those taking medications that affect blood clotting.
