What is bunion?
Hallux valgus is a deformation of the first toe, which appears deviated laterally towards the other fingers, with simultaneous medial protrusion of the first metatarsal bone. This bone deformity is usually associated with a constant or recurrent inflammation of the mucosal bursa located at the base of the hallux implant itself.
Symptoms
To learn more: Symptoms of Hallux Valgus
The clinical picture is mainly represented by a deformation of the first metatarsophalangeal joint, which is painful and swollen. In some cases, functional changes can be associated with alterations affecting the painful joint, which compromises the dynamics of the foot. At the level of the bony prominence on the outer edge of the foot, the skin shows redness or hyperkeratosis (thickening of the epithelial layer of the skin). These symptoms can also affect neighboring fingers (such as when the big toe is superimposed on the second toe). Many people do not experience symptoms in the early stages of the disorder; these often become evident when the disorder progressively tends to worsen, especially if you are wearing some types of footwear that do not fit the foot correctly (shoes with a narrow toe and / or with a high heel).
When hallux valgus symptoms appear, they may include:
- Pain in the affected area, even at rest;
- Redness, numbness and swelling;
- Thickening of the skin, which appears hard and calloused;
- Changes to the overall shape of the foot;
- Difficulty walking (due to pain).
Consequences
Changes in foot shape and postural consequences
In addition to chronic pain and inflammation, hallux valgus can lead to bone lesions, ulcerations, calluses and, if particularly severe, a functional alteration of the dynamics of the foot. Over time, the disorder can develop into a real postural syndrome (considering that the big toe is used in walking to push forward and balance).
Local consequences
| Postural consequences
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Causes
Anyone can be affected by hallux valgus, but it is usually more common in females. The disorder tends to appear, with greater incidence, in a mature or senile age.
The causes of hallux valgus can be:
- Congenital : people with alterations of the foot present from birth (example: flat feet ) are more likely to develop hallux valgus in the age of growth. There are also some predisposing factors connected to a positive family history ( heredity ), especially in cases of juvenile hallux valgus.
- Acquired or secondary : for the stunted, traumatic, inflammatory forms etc. responsibility can be attributed above all to models of footwear that are inadequate to the physiology of the foot, such as, for example, shoes with narrow toes, too small or with high heels. Shoes that do not adapt adequately force the big toe into a non-natural position and do not support the correct pronation of the foot. Also some pathologies, such as rheumatoid arthritis and gout, may be responsible for the onset of hallux valgus. Several other conditions make it vulnerable to the development of the disorder, such as the length of the first metatarsal, the hypermobility of the metatarsal joint, the low muscle tone, some neuromuscular diseases and connective tissue (such as Marfan syndrome).
Diagnosis
Generally, observation is sufficient to diagnose hallux valgus, as the deformity is evident on the side of the foot or at the base of the big toe. The clinical evaluation makes use of the baropodometric examination, which allows the distribution of loads on the foot and the degree of hallux compromise to be measured in a static and dynamic position. The doctor can proceed with an X-ray (in a position under load) to get an indication of the degree of the deformity and to evaluate the changes that have occurred in the foot. This investigation also allows to determine the angle between the big toe and the foot: the disorder is defined properly, in fact, when the angle between the first and second metatarsal bone is greater than 8 ° (or 9 ° according to other authors ). Hallux valgus tends to progressively worsen over time, so once the extent of the alteration has been defined, the doctor can develop a treatment protocol suited to the patient's needs.
Conservative treatment
The conservative treatment of the hallux valgus uses measures to alleviate the symptomatology of the foot, which however is not able to regress the deformity itself or to improve the aesthetic appearance of the foot.
Several measures allow the management of hallux valgus symptoms:
- Avoid activities that force you to stand for long periods of time.
- Ice packs : applying an ice pack several times a day to the affected area can provide pain relief and help reduce inflammation.
- Choose appropriate footwear : the best shoe to wear takes up the natural shape of the arch, providing support, protection from impact and containment of the foot. The sole should fit comfortably in the heel and the front should be spacious and flexible enough to accommodate the tip of the foot and accommodate its movements (like most sports shoes). The heel should not exceed 4-5 cm, as excessively high heels force the foot to an unnatural position, shortening the Achilles tendon and destabilizing the weight distribution on the foot.
- Insoles : they are devices placed inside the shoes, which help to realign the bones of the foot and for this, it is important that they adapt properly. The insole helps to avoid overloading the front of the foot and helps to minimize the pain symptoms. Spacers are also available to prevent friction between the fingers, adhesive pads and special splints for joint correction and to straighten toe alignment. However, it is important to note that there is no evidence of efficacy related to the use of these devices over the long term.
- Customized orthoses: in some cases, customized orthoses can be recommended to support the foot and ankle.
- Physiotherapeutic treatments : can help reduce symptoms and some active exercises can alleviate pain.
- Medications : non-steroidal anti-inflammatory drugs (NSAIDs) may be indicated orally, such as paracetamol or ibuprofen, to reduce pain and inflammation.
- Injection therapy : although rarely used in the treatment of hallux valgus, injections of corticosteroids can be useful in the treatment of inflammation.
If the symptoms are severe and conventional treatments are not effective, surgery can be considered. The type of surgery used will depend on the level of deformation, the severity of the symptoms, the age of the patient and the presence of other associated medical conditions.
Surgery
Surgery is the only valid option to correct the hallux valgus. Surgical treatment can be recommended if conventional measures fail to provide relief, if the disorder causes a lot of pain or if it interferes with daily activities.
To achieve the best outcome, different surgical techniques can be planned: some act on the bone, others on the soft tissues.
The purpose of surgical treatment is to restore the anatomically correct position to the big toe and mainly includes:
- Correction of the arrangement of bones, ligaments, tendons and nerves, to realign the big toe with respect to adjacent fingers;
- The removal of the bony protrusion from the first metatarsal, that is the bone tissue in excess of the "onion" level;
- The valgus angle is improved, re-aligning the cartilaginous surfaces of the big toe and repositioning the sesamoid bones under the first metatarsal.
The type of operation most frequently used is called osteotomy (percutaneous or open). This surgical technique is performed under local anesthesia and involves performing some cuts on the bone to allow correction of the metatarsal deviation. Osteotomy allows rapid functional recovery. Other surgical techniques contemplated are arthrodesis and resection arthroplasty (Keller).
When deciding which procedure is best for you, the surgeon must consider different types of adapters, including:
- Age : in children, hallux valgus surgery is often postponed due to an increased risk of the hallux valgus returning (the bones are still growing). Furthermore, for some patients, conventional treatments are a better choice than surgery.
- General health conditions : after surgery, the risk of developing problems is increased if there are other medical conditions that prevent or slow down the healing process (eg rheumatoid arthritis, diabetes or circulatory problems).
- Professional activity and lifestyle : if the patient is a professional dancer or a sportsman, hallux valgus surgery can only be recommended in some specific cases. In fact, after the operation, the toes may be less flexible and the possibility of returning to the same level of physical performance is not guaranteed.
- Expectations of surgery: the success of the operation depends on the skill of the surgeon, the severity of the disorder, the type of intervention and post-operative recovery.
- The severity of the symptoms : surgery is recommended if the extent of the deformation of the foot is severe and associated with significant pain or in the case where conventional treatment is not able to limit the progression of the disorder. In fact, there are several risks and complications associated with surgical treatment and for this reason it is not recommended for aesthetic correction only.
Many hallux valgus correction procedures can be performed as a day hospital, so hospitalization is not necessary. The operation can be performed under local or general anesthesia. The recovery time depends on the type of procedure performed (after about five weeks the bandage is permanently removed). After surgery, it may be necessary to wear a post-operative gypsum shoe to keep the foot in the correct position until the bones are firm. In the post-operative phase, weekly checks are scheduled to renew the dressing and, after three months, an X-ray will be performed to assess whether the degree of correction is acceptable.
Complications
Hallux valgus can get worse if untreated and can induce further disorders, such as arthritis in the hallux joints or the deformity of the second toe, pushed out of place. Complications can also result from corrective surgery. Surgery is generally effective (in 85% of cases it improves symptoms), but it is associated with some complications, which may include:
- Infection;
- Stiffness in the joints of the toes;
- Healing of the bone in the wrong position;
- Thickening of scar tissue;
- Hallux valgus recurrence, requiring further surgery.
Prevention
The best way to reduce the likelihood of developing hallux valgus is to wear shoes that fit comfortably and functionally: you need to make sure they are the right size and leave enough space to allow your toes to move freely.
