Hallux Valgus (Bunion)

What is Hallux Valgus (Bunion)?

A bunion, also known as Hallux Valgus (HV), is a fairly common foot deformity. It occurs when the bone at the base of your big toe (known as the proximal phalanx) moves sideways or outwards, while the head of one of the main foot bones (the first metatarsal) moves inwards. This shift makes the first metatarsal bone stick out on the side of the foot and results in the well-known protrusion known as a bunion. The exact cause of bunions isn’t entirely clear. However, they’re more commonly seen in women than in men – as much as 15 times more likely according to one study – and more common in people who wear tight shoes or high heels.

Typically, a doctor can diagnose a bunion with a simple physical check. However, an X-ray or other imaging could be used to gauge whether there is any damage to the first joint of the big toe (the MTP joint). When it comes to treatment, doctors usually suggest trying non-surgical measures first, like switching to wider shoes, wearing supporting shoe inserts (orthotics), or using a splint at night. If these steps don’t help, surgery may be suggested. People generally handle surgery well, and the bone usually fully heals – or reaches “bony union” – about 6 to 7 weeks after the surgery.

What Causes Hallux Valgus (Bunion)?

The exact cause of HV (hallux valgus) deformity, often known as a bunion, isn’t completely understood, but there are several theories. It’s likely that HV deformity is due to a combination of factors. These may include your genetic makeup, a short or tilted at an angle first metatarsal (the bone connecting your big toe to your foot), a foot that leans inward or flat foot, a tight calf muscle, irregular foot movements, and unusually flexible joints.

Interestingly, certain types of arthritis like gout, psoriasis-associated arthritis, and rheumatoid arthritis have shown to make people more prone to HV deformity. Also, people with connective tissue disorders like Marfan syndrome and Ehlers-Danlos syndrome, or Down syndrome are more likely to have HV deformity.

A muscle imbalance in the foot due to conditions such as stroke, cerebral palsy, or myelomeningocele (a type of Spina Bifida where an infant’s spine doesn’t form normally) can also lead to an HV deformity.

Although wearing tight shoes or high heels is often blamed for causing HV deformity, the condition is also quite common in men who generally wear comfortable footwear. Additionally, many women who wear tight fitting footwear do not develop any deformities. This suggests that footwear likely worsens an already existing bone abnormality rather than being the main cause of the deformity.

Risk Factors and Frequency for Hallux Valgus (Bunion)

Hallux Valgus (HV) deformity, is quite widespread, particularly among adults. About 23% of adults between 18 to 65 years old, and up to 36% of adults over 65 years old experience it. When focusing on adult women, up to 30% may have HV deformity. The condition is more prevalent in individuals who regularly wear shoes or heels, compared to those who are often barefoot. Intriguingly, among barefoot populations, women are twice as likely as men to experience HV deformity.

• HV deformity is a fairly common among adults.
• About 23% of adults between 18 and 65 years and up to 36% of adults older than 65 are affected.
• In adult women, HV deformity can occur in as many as 30% of cases.
• People who regularly wear shoes or heels are more likely to have HV deformity compared to those who often go barefoot.
• Among barefoot populations, women are twice as likely as men to have HV deformity.

Signs and Symptoms of Hallux Valgus (Bunion)

Hallux valgus (HV) deformity, often associated with bunions, usually shows up gradually over time. The main signs include a turning in of the big toe and turning out of the bone at the base of large toe, often leading to redness and pain. A common symptom is a sharp or severe pain centered in the joint of the big toe that gets worse when walking. Sometimes this pain is described as an ache felt at the base of the second toe. As the bunion grows and the deformity worsens, the pain becomes more frequent, lasts longer and increases in severity.

Another fairly common symptom is a tingling or burning sensation in the upper part of the deformity, which could indicate inflamed nerves that are being compressed by the deformity. This discomfort can boil down to several factors:

• The bunion being located on the inside of the foot
• The other toes being squished by the big toe’s turn
• Increased pressure on the bones of the remaining toes

Other issues patients might experience include blisters, sores, thickened skin between the toes, and irritated skin next to the deformity. These symptoms can significantly affect patients’ lives, often making physical activities more challenging.

In regards to the physical examination of the problem, doctors will typically look for possible causes of the deformity. Some key aspects to evaluate include various foot, ankle, and leg alignments and flexibility issues, as well as how the heel rests when standing. The examination is often split into two parts: non-weight bearing and weight bearing. These assessments include looking at the positioning, range of motion, and quality of movement in the big toe and its joint in different conditions: when patients are both standing and sitting.

Testing for Hallux Valgus (Bunion)

If your doctor suspects a metabolic or whole-body disease, they may order laboratory tests alongside a typical check-up. They could test for things like rheumatoid factor, antinuclear antibody, C-reactive protein, erythrocyte sedimentation rate, uric acid, and complete blood count. These tests are different ways to check for inflammation or other signs of disease in your body. If there’s a strong belief that there might be an infection in your bone, called osteomyelitis, your doctor could also use an MRI or radionuclide imaging for further assessment.

Usually, your doctor can diagnose a condition just by examining you physically. But if there could be damage to the joint at the base of your big toe, imaging tests can help figure out the extent of the problem. A typical way to evaluate this is with simple X-ray of the foot demonstrating the direction and degree of the big toe deviation.

By looking at the X-rays, your doctor can gauge just how much the big toe has drifted away from its normal position. Usually, this diversion is along a side-to-side direction, but conditions such as hallux valgus, a fancy term for a bunion, can cause the toe to rotate so much that the toenail faces inward. Once the severity of the deformity is established, the doctor can decide on the most suitable procedure.

Your doctor would refer to the degree of the shift of your big toe as mild, moderate, or severe. They will do this by analyzing the X-rays taken of your foot from different angles. This will allow them to examine the structure of your foot better. The X-rays can show different aspects like the angles between the different bones of your foot, the state of the joint at the base of the big toe, the top growth of bony spurs or osteophytes, the density and pattern of the bones, and any changes in the foot bones near the toe, known as sesamoids.

Here’s a small guide to what the angles mean:

• Normal: big toe deflection less than 15 degrees and less than 9 degrees between the first and second toe bones (metatarsal bones).
• Mild: big toe deflection 15 – 30 degrees and 9 – 13 degrees between the first and second metatarsal bones.
• Moderate: big toe deflection 30 – 40 degrees and 13 – 20 degrees between the first and second metatarsal bones.
• Severe: big toe deflection over 40 degrees and over 20 degrees between the first and second metatarsal bones.

These angles will help your doctor decide on the best treatment plan.

Treatment Options for Hallux Valgus (Bunion)

If you have a bunion (also known as Hallux Valgus or HV deformity), your doctor will typically try non-surgical treatments first. However, there’s no definitive proof that these non-surgical treatments always help. The American College of Foot and Ankle Surgeons still recommends trying these treatments before considering surgery. It’s crucial to try things like wider footwear and shoe inserts before moving on to more invasive treatments.

The objective of non-surgical treatment is to manage the symptoms without correcting the physical deformation of the foot. Some options include wearing low-heeled, wide shoes, using shoe inserts to improve foot alignment and support, using painkillers like acetaminophen or NSAIDs, applying ice to reduce inflammation, using bunion pads to prevent irritation, and stretching exercises to help maintain flexibility in the affected joint.

If these non-surgical treatments don’t control the pain, surgery could be considered next. Reasons for surgery mainly depend on symptoms like difficulty walking and pain. Interestingly, the appearance of the bunion on x-ray does not play a significant role. The presence of arthritis and the severity of the deformation help guide surgeons in choosing the most suitable surgical procedure. There are over 150 surgical procedures available for bunions, but they all fall into some basic categories:

• Osteotomy: This is where a cut is made in the first metatarsal bone (the bone in your foot that connects to your big toe), and put into a less crooked position.
• Arthroplasty: This procedure preserves the mobility of the big toe joint while relieving the pain. It might involve replacing the joint with an implant or removing some or all of the joint.
• Arthrodesis: This involves fusing the big toe joint into the correct position. This is only performed when the joint is severely damaged and unlikely to regain functionality.
• Soft tissue procedures: These mainly involve changing the soft tissue around the toe. One example is the McBride procedure which involves removing a bone called the fibular sesamoid.

In general, patient satisfaction after surgery has improved as surgical techniques have advanced, now ranging from 50 to 90%. Interestingly, happy surgical outcomes do not always match patient satisfaction, possibly due to unmet post-surgical expectations.

Postoperative care, including dressings and weight-bearing restrictions, largely depends on the type of procedure performed. Once the surgical wound heals, the patient can begin exercises to regain their range of motion and gradually start weight-bearing activities. Regular imaging is typically recommended as patients become more active to monitor their recovery progress.

In the long run, it’s important to understand the exact cause to ensure the bunion doesn’t come back. If identified, these causes should be treated. Even patients who’ve had surgery may still benefit from shoe inserts, especially for diseases like rheumatoid arthritis that speed up joint degeneration. By managing these factors better, the best possible results from surgery can be achieved.

What else can Hallux Valgus (Bunion) be?

When a patient might have HV deformity, doctors need to think about several other conditions that could cause similar symptoms. These conditions include:

• Osteoarthrosis (a type of joint disease)
• Freiberg disease (a disorder that affects the foot’s joints)
• Hallux rigidus (stiff big toe)
• Morton neuroma (a painful condition that affects the ball of your foot)
• Turf toe (a sprain of the big toe joint)
• Gout (a type of arthritis)
• Septic joint (an infection in a joint)

What to expect with Hallux Valgus (Bunion)

Generally, the outcome for HV (Hallux Valgus/bunion) deformity is good. Initially, patients should try out non-surgical approaches to manage the condition. If they continue experiencing pain and difficulties in functioning, surgery can then be considered.

The amount of time needed to recover from surgery depends on the type of procedure performed. For any surgery involving the bones – known as an osteotomy – healing could take about 6 to 7 weeks, which is the time it takes for the operated bone to totally heal and unite. If the patient is a smoker, this healing process may take even longer. Usually, patients can go back to work between 6 to 12 weeks after the surgery. However, recorded improvements can be noticed up to a year after the operation.

There are different complications that could occur after surgery, which will vary depending on the type of surgical procedure and the technique used. Some of these complications could include improper union of the bones, blood clot formation, numbness, failure of the surgical hardware, bone infection, skin infection, death of bone tissue due to lack of blood supply, change in the direction of the big toe, limited joint movement, and recurrence of the deformity.

The recurrence rates – the chances of the deformity reappearing – can vary widely, ranging from 10% to 47% depending on the type of procedure performed. The cause is often a combination of factors, which could include but are not limited to anatomical predisposition, adherence to post-surgery instructions, other medical conditions, and poor surgical technique.

Possible Complications When Diagnosed with Hallux Valgus (Bunion)

Having a deformity of the foot known as HV can lead to numerous complications. These are:

• Bursitis (this is the most common complication)
• A second toe which is deformed, similar to a hammer (‘hammertoe’)
• The wearing down of the top of the bone in the foot (a condition known as ‘degenerative disease of the metatarsal head’)
• Pain in the middle of the foot (‘central metatarsalgia’)
• Compression or pinching of the nerve on the top side of the foot (‘medial dorsal cutaneous nerve entrapment’)
• Inflammation of the joint in the foot (‘MTP joint synovitis’)

Preventing Hallux Valgus (Bunion)

A bunion, also known in medical terms as HV deformity, is a common foot issue that affects the big toe. Your big toe starts bending towards your other toes and the joint where it bends can turn red and sore. While doctors don’t understand the exact reasons why bunions form, they do happen more frequently in women and in those who often wear tight shoes or high heels.

A bunion can typically be diagnosed by a doctor through a simple physical exam. However, getting an image of your foot, say through an X-ray, is crucial because it can show the degree of the bend in your toe. Initial treatment usually involves non-surgical methods like wearing more comfortable, roomier shoes or using shoe inserts and special splints at night. If these measures do not help, surgery may be recommended. Most people don’t have problems after surgery and the bone usually re-unites fully within 6 to 7 weeks after the operation.

However, if you smoke, the healing process might take longer and there is a higher chance of complications, such as the bone not healing properly or the surgical wound getting infected. You can generally expect to get back to work around 6 to 12 weeks after your surgery and improvements can continue to happen up to a year post-surgery.