What is Hallux Varus?
Hallux varus is a condition where the big toe deviates towards the inside of the foot at the main toe joint. It’s a problem often encountered by orthopedic and foot doctors and requires a comprehensive approach for effective treatment. This condition can vary in severity, causes, and symptoms.
Hallux varus in adults is typically caused by previous surgery for hallux valgus, which is when the big toe deviates towards the other toes. Whether it’s caused by surgery or present since birth, hallux varus can affect a person’s ability to walk, cause discomfort and change the appearance of the foot. It can also make it difficult for a person to wear shoes. If the condition is mild, it can be managed with stretching exercises and splints. However, if the symptoms start affecting daily life, then surgery might be an option.
What Causes Hallux Varus?
Hallux varus, a condition where the big toe points away from the other toes, is rarely present from birth. Without an identified genetic link, this condition often results from a mix of naturally occurring abnormalities in the foot’s structure or function. These can include a shorter than usual first long bone of the foot (metatarsal), the presence of extra bones, or an unusual fibrous band by the main toe joint. Sometimes, babies can have Flexible hallux varus, which reflects the position their feet were in while in the womb. This usually corrects itself when they start walking.
More often, hallux varus is the result of foot surgery meant to correct the opposite issue – hallux valgus, where the big toe points towards the other toes. This can happen if the surgery was overcorrected, the tissues on the outer edge of the foot were overly released, too much bone was removed from the inner edge of the foot, the inner part of the joint was overly tightened, or the foot was improperly positioned after surgery. This accidental cause of hallux varus after surgery meant to correct hallux valgus is reported to occur in 2% to 13% of cases. Other causes can include injuries, and inflammatory diseases such as psoriasis and rheumatoid arthritis.
Hallux varus that is not caused by surgery includes:
– Congenital hallux varus, although rare, can be categorized into three types:
– Primary hallux varus is due to an overly active muscle (abductor hallucis) on the side of the big toe.
– Secondary hallux varus can be associated with conditions like having more than one big toe, unusual bone growth, or a foot deformity where the bones of the foot turn inwards.
– Tertiary hallux varus can be associated with more serious conditions like dwarfism.
– The big toe pointing away from others in babies can also be caused by the abnormal insertion of the toe muscle.
In adults, hallux varus can be an outcome of inflammatory joint diseases, including those caused by psoriasis and rheumatoid arthritis. This condition tends to result from the destruction of the joint surfaces, loosening of the ligaments around the joint, changes to the muscles, and inflammation. It can also occur because of sports-related injuries that lead to tearing of the ligaments and tendons on the side of the big toe.
Congenital hallux varus can be seen in conditions like Marfan syndrome and Ehlers-Danlos syndrome, where the body’s connective tissues are impacted. Other associations can include Down syndrome and neuromuscular disorders like cerebral palsy. However, in some cases, hallux varus is noticed for no identifiable reason.
Risk Factors and Frequency for Hallux Varus
After surgery to fix a deformity of the big toe, also known as hallux valgus, it’s possible for another condition known as hallux varus to develop as a result of the surgery – this happens in 2% to 14% of cases. If the surgeon used a specific technique known as crescentic osteotomies, the rate of hallux varus goes up to 10%. We don’t know much about the frequency of this condition when it happens naturally, during childhood or after an injury.
Signs and Symptoms of Hallux Varus
Hallux varus is a deformity that doesn’t always cause symptoms. However, some people may experience issues such as trouble wearing shoes, instability, and weakness when pushing off with their foot. Other symptoms can include chronic pain, difficulties with walking and standing for a long time, foot weakness, and even in-grown toenails. A person might also have limited movement in the joint of the big toe, swelling, redness, or ulceration of the toe. Typically, symptoms worsen when tight shoes that compress the toes are worn. The usual cause of pain in this condition is the irritation of the toe due to ill-fitting shoes, which could further indicate an underlying arthritic condition.
In order to plan the treatment, it’s important to gather information about any previous surgeries you may have had. Things like the type of surgery, how the healing was fixed, and how long ago the surgery took place could influence future treatment choices.
A doctor’s examination will focus on any deformity of bones or joints, check the flexibility and sturdiness of the joints, and assess soft tissue balance. During the examination, they will likely:
- Look for any deformity in the bone, such as the rotation of the big toe to the wrong side or the medial sesamoid not being in the correct place.
- Check the flexibility and integrity of the joint, which could include contractions in the big toe or the joint next to it. The extent the joint extends when it has weight on it and whether walking affects the deformity will also be considered.
- Examine the soft tissue balance. This typically involves checking the medial displacement of the EHL muscle, which might create bowstring deformity. They will also look at the bottom of the foot for any hardened skin (callosities).
Testing for Hallux Varus
Taking x-rays while you’re standing up can give doctors a better understanding of the extent of the deformity in your foot, and what treatment options might work best for you. Your doctor will measure different areas of your foot in the x-ray to determine the severity of the problem. For instance, an abnormal bend of 16 to 24 degrees in your big toe, a condition known as hallux varus, is considered to be a significant deformity.
Further evaluation of the joint in your toe can also help check for any twisting deformities, arthritic changes, or malformations in the bone. Knowing the exact kind of deformity in your foot can guide the doctors toward the right form of treatment.
As per the doctors, deformities in the big toe can be broken down into three types:
- Type 1: This is a bone deformity.
- Type 2: This one involves deformities in the muscles or ligaments of the toe.
- Type 3: This type is a combination of both bone and muscle/ligament deformities.
Lastly, a blood test may be conducted if your doctor suspects an infection or an inflammation is causing the problems in your foot.
Treatment Options for Hallux Varus
Non-surgical strategies for dealing with foot issues often include changing or modifying your shoes. You might use shoes with wider toe spaces and padding for more comfort. Taping or splinting the toes can help with misaligned toes, particularly after surgery for conditions like bunions. These correction methods should typically continue for about 12 weeks to allow soft tissue healing. If you still experience extreme discomfort or are unable to wear shoes, surgery may sometimes be required.
The objective of foot surgery is usually to ensure normal walking and bearing of weight, align the sesamoid bones in the foot, correct the body’s positioning while sitting and standing, and hopefully preserve the range of movements in the first toe’s main joint wherever possible.
When planning for surgery, your doctor will typically take into consideration the type of misalignment (whether flexible or rigid), the extent of the misalignment, and if there is arthritis in the first main toe joint. If the misalignment is flexible, treatment may involve a soft tissue procedure, such as lengthening the structures on the inner part of the capsule of the toe joint. This might be enough if the misalignment isn’t very severe.
For advanced but flexible misalignments, different procedures can be performed alone or in combination. These might include reattaching certain tendons, translocating tendons, releasing certain parts of the medial capsule, or moving some tendons to act as stabilizers. In some cases, another surgical option is arthroplasty, which is the surgical reconstruction or replacement of a joint.
If a tendon transfer procedure is being considered, certain conditions like degenerative and inflammatory joint diseases, active infections, problems with nerves and blood flow, excessive resection of one side of the big toe joint, or a fixed misalignment of the main toe joint may make this procedure not suitable.
If the misalignment is rigid, the range of motion in the first main toe joint is limited, or there are arthritic changes in the first main toe joint, the surgeon may consider a procedure called arthrodesis, which is the fusion of joint bones. In cases of iatrogenic hallux varus, a condition resulting from an overcorrection during a bunion surgery, other procedures, such as a specific type of osteotomy, which is surgical cutting of a bone, can be used.
What else can Hallux Varus be?
It’s typically easy to spot hallux varus (a foot condition where the big toe deviates away from the other toes) through a physical check-up and an X-ray. However, there are certain health conditions that can contribute to hallux varus, and these should be taken into account. Some of these include:
- Osteoarthritis: This condition causes the wear and tear of joints which can cause the big toe to move towards the inside of the foot. An X-ray can help differentiate if the hallux varus is because of osteoarthritis or it was caused by another disease or birth defect.
- Rheumatoid arthritis: This type of arthritis affects the cells that help make up our joints and can lead to various symptoms. While it commonly causes the big toe to bend towards the other toes, hallux varus can also happen in a small number of cases. Blood tests can help confirm if rheumatoid arthritis is present.
- Charcot-Marie-Tooth disease: This is a nerve disorder that first shows up as muscle and nerve problems in the foot. Over time, it can also affect the lower part of the leg. This imbalance in muscles and tendons can often result in a deformity like hallux varus.
- Avascular necrosis (AVN) of the metatarsal head: AVN is a condition where bone tissue dies due to a lack of blood supply. It can cause the big toe to point away from the other toes. Despite being commonly reported after a specific type of bunion surgery, recent medical literature indicates it’s less frequent. This condition can range from having no symptoms to triggering significant pain, deformity, and the collapse of bone.
What to expect with Hallux Varus
Surgery can help improve the overall position of the big toe, but it doesn’t always improve its movement. In instances when the big toe has been turned inward abnormally due to previous treatments (a condition known as flexible iatrogenic hallux varus), shifting the tendon and releasing some soft tissue has been reported to provide lasting correction.
Moreover, it’s also good to know that patients have expressed high satisfaction rates of 94% after a surgical procedure called arthrodesis, which is used to treat fixed deformities. This means that the majority of patients have been happy with the results after this type of surgery.
Possible Complications When Diagnosed with Hallux Varus
People who go through conservative treatments may find that the treatments have limited effect, or they may experience negative reactions to devices like braces or splints. Adjustments or alternative treatments might be required because of these issues. Furthermore, putting off treatment or not following the after-surgery recovery instructions can lead to adverse effects and worsen existing problems.
Even with careful planning and procedures, complications can still arise from surgical treatment of a condition called hallux varus. Some potential complications include:
- Soft tissue problems, such as infection, poor wound healing, and nerve damage or irritation
- Instability of the MTP joint, which is a joint in the foot
- Return of hallux varus
- Under-correction or over-correction of the condition
- Loss of blood supply to the head of the metatarsal bone
- Stiffness in the foot
- Mechanical failure of any installed devices
- Increase in degenerative changes in the MTP joint
- Shortening of the medial column in the foot
- Transfer metatarsalgia, which is a type of foot pain
To lessen the risk of complications and to make any interventions more successful, it’s crucial to have a thorough assessment before surgery, good patient education, and careful monitoring after treatment.
Recovery from Hallux Varus
After surgery to correct hallux varus, a condition where the big toe deviates away from the other toes, the aftercare needed really depends on what kind of surgery was done. If the surgery involved work on soft tissues – like tendon transfers, tenodesis (stitching a tendon to bone), or releasing tight tissues – then the patient can put weight on the foot as much as they’re comfortable with, wearing a stiff-soled shoe. For surgeries that involve bone correction, the aftercare is similar to another condition of the toe called hallux valgus, where the big toe deviates towards the other toes. If the bone at the base of the big toe has been operated on, the patient is limited to wearing a special post-operative shoe and can put weight on it. If the joint where the toe joins the foot (arthrodesis) has been operated on, then no weight can be put on that foot for a time.
Preventing Hallux Varus
The main ways to manage a toe condition known as hallux varus include preventative measures and educating the patient. The goal is to stop the condition from getting worse and to get the best possible results from treatment. Through education, doctors can give patients the necessary knowledge about what causes the condition, the factors that increase the risk of getting it, and the potential results if left untreated.
It is important to stress the need for early action and changes in lifestyle, such as choosing the right footwear and doing toe exercises. This enables patients to take a hands-on approach to their own care, help manage their symptoms and slow down the progression of the deformity. Additionally, understanding the possible risks if treatment is delayed or if recommended measures are ignored can serve as a wake-up call, encouraging patients to get medical help promptly and to follow the treatment plan given by their doctor.
By instilling a sense of urgency and educating patients effectively, patients are more likely to follow their treatment plan and take an active role in their own care, which ultimately means better results for individuals with hallux varus.
