Hallux Valgus

Are you experiencing pain in your big toe? Or finding it difficult to wear shoes? Do you have a bump on your big toe? You could have something called a hallux valgus deformity, commonly called a bunion. Hallux valgus is the most common deformity of the foot and toes. It is present in approximately 1 out of 4 adults. About 1 out of 3 people over the age of 65 have a hallux valgus deformity. It is often called a bunion or ganglion, although there is a subtle difference between these deformities.

Keep reading to learn more about the toe deformity called hallux valgus, including what exactly it is, who is at risk of developing it, and how it is diagnosed and treated. Also find out if you can benefit from conservative treatment for mild hallux valgus or you need hallux valgus surgery for a severe hallux valgus deformity.

What is hallux valgus?

Hallux valgus is a misalignment of the first metatarsal bone in the big toe, such that it points toward the outer edge of the foot. This is a toe deformity that causes pain, inflammation, and swelling. It affects the metatarsal head in the metatarsophalangeal joint (MTP joint or toe joint), causing it to bulge and push against footwear.

A hallux valgus deformity almost always occurs in conjunction with a splayfoot (spreading of the metatarsal bones and widening of the front of the foot). In people with hallux valgus, the big toe tendon is no longer parallel and straight in the joint. Rather, it deviates from the normal alignment and causes a sideways skewing of the big toe. This leads to a painful protrusion of the big toe which characteristically points outwards.

The formation of the soft tissue and bony prominence leads to increasing friction with footwear. This in turn can lead to inflammation of the bursa (a small fluid-filled sac near the toe joint that reduces friction). As a result, people with a hallux valgus deformity experience not only foot pain and swelling but also functional disability and reduced quality of life. Severe hallux valgus deformity can affect a person's gait (walk).

What causes this problem?

A hallux valgus can be an acquired foot deformity, for example, from wearing high heeled shoes or as the result of foot injuries or trauma. There is also a genetic component to this toe deformity - it tends to be common in some families. Gender also plays a role and women are affected more than men, believed to be due to weaker connective tissue in the foot. People with other foot deformities such as splayfoot, hammer toes, claw toes, arthritic changes, or certain neurological disorders can also develop hallux valgus. Hallux valgus interphalangeus deformity occurs due to an anatomical abnormality in the first phalanx.

Why does hallux valgus deformity develop?

Hallux valgus develops due to a strain on the tendon in the big toe, causing the toe to rotate out of the first metatarsophalangeal joint. This can be likened to a tense bowstring causing a bow to curve. With the big toe curving inward, the other toes become crowded and ultimately become deformed as well.

Hallux Valgus Angle

One of the things to be aware of is the hallux valgus angle. This is the angle between the lines that bisect the first metatarsal and proximal phalanx longitudinally. A hallux valgus angle of less than 15° is considered normal. People with angles of 20° and greater are labeled as having a hallux valgus deformity. An angle of over 45° qualifies as a severe deformity and requires hallux valgus correction, often needing surgical correction with a corrective osteotomy.

Is hallux valgus a cosmetic problem?

In the early stages, a hallux valgus deformity may not be painful and it may not have any impact on daily life. Therefore, people might consider it a cosmetic problem at this stage. The deviated metatarsal bone in the big toe looks unsightly, especially in open toed footwear, but doesn't cause any symptoms. However, treatment of hallux valgus and straightening of the metatarsal head is not generally performed for purely cosmetic reasons. This is because there are considerable risks associated with hallux valgus surgery as well as the significant limitations during recovery.

In people with a progressively severe hallux valgus, conservative treatment or a surgical procedure are often needed and the problem is medical, not cosmetic. Surgical procedures, often called bunion surgery, are offered even if the patient does not have severe pain. This is to prevent the deformity from continuing to progress. During surgical treatment by a foot ankle surgeon, such as with a procedure called distal metatarsal osteotomy, the position of the big toe is corrected.

What's the difference between a hallux valgus and a bunion?

As mentioned, hallux valgus is a condition in which the big toe is skewed from its normal position and angles inwards towards the adjoining second toe. The term bunion refers to an enlarged bony bump that sometimes has an inflamed bursa within it. While there is a technical difference between the two; however, hallux valgus and bunion deformity are often used interchangeably.

How do you recognize hallux valgus?

A hallux valgus deformity can be quite obvious to the naked eye. There is usually reddening and enlargement of the metatarsophalangeal joint or MTP joint. The big toe can become stiff with reduced movement and flexibility - this is known as hallux rigidus. There is a noticeable lateral deviation (skewing to the side) of the toe, which may also be rotated or turned on its axis. With severe deformities, there can be reddening and callus formation in the second through fourth toes as well.

What symptoms do people with hallux valgus experience?

Hallux valgus is a very common foot deformity, but it does not cause severe symptoms in all patients. Many patients believe it is a cosmetic problem rather than something that bothers them with symptoms. The symptoms of hallux valgus, when present, can include pain, soreness, redness, swelling, stiffness, and corns or calluses on the big toe. The pain can be worse after prolonged standing or walking.

Who is at risk of developing hallux valgus?

Age, Gender, and Family History

Age is a factor - older individuals are at risk of developing lateral deviation of the big toe. While the prevalence of this toe deformity is around 23% in the adult population, it is over 35% in people above the age of 65 years. Bunion deformity and hallux valgus is also up to 10 times more common in women than in men. There is also a genetic predisposition to hallux valgus deformity - roughly 7 out of 10 patients have a family history of this condition.

Lifestyle Factors

Other risk factors include wearing tight pointed shoes and high heeled shoes, especially as a young adult, which can cause hallux valgus deformity later in life.

Other Foot Deformities

The presence of other foot conditions like hammer toes, flat feet, Achilles tendon tightness, or hypermobility of the toe joint also increases the risk of hallux valgus. The deformity can occur in association with degenerative joint disease such as hip and knee osteoarthritis. Interestingly, people with a higher BMI (body mass index) have a lower risk of hallux valgus.

How do doctors diagnose hallux valgus?

Hallux valgus is usually obvious even to someone without medical training. An orthopedist or foot ankle surgeon can easily recognize a hallux valgus deformity by looking at a patient's foot. There is frequently a visible enlargement of the angle in the metatarsophalangeal joint. The physician's suspicions are confirmed by the patient’s description of their symptoms.

Patients with hallux valgus may demonstrate other deformities of the foot, such as splayfoot, a reduced front arch of the foot, and sunken metatarsal head. To confirm the diagnosis, identify the exact location of the deformity, and measure the hallux valgus angle or geometric deviation in the toe, a doctor may order X-rays or magnetic resonance imaging. MRI can detect damage to the cartilage, soft tissues, and bones.

When it is not possible to obtain imaging of the foot, a scale called the Manchester scale is used to label hallux valgus as absent, mild, moderate, or severe. This is based on comparison to standardized photos.

Can hallux valgus be treated?

Doctors can treat a hallux valgus deformity to reduce pain, improve joint mobility, slow down the progression of the foot deformity, and help with recovery of function in the big toe and first metatarsophalangeal joint.

Conservative treatment of hallux valgus

There are various ways to treat a mild hallux valgus deformity without surgery. This includes physical therapy exercises to encourage movement of the big toe and strengthen the arch of the foot; devices such as toe spreaders, insoles, and hallux valgus splints to support the foot, reduce pressure on the big toe, and prevent the deformity from progressing; and painkillers like ibuprofen for symptom control. Lifestyle changes, such as wearing flat shoes with enough room in the toe box, may also be recommended. Skincare for pressure spots is also an important component of treatment of hallux valgus. Foot ankle doctors may also advise an orthosis for severe pes planus (flat foot) and treatment for Achilles tendon contracture with stretching or lengthening.

Indications for hallux valgus surgery (proximal metatarsal osteotomy)

Patients with severe hallux valgus may require hallux valgus surgery for pain relief and to prevent further progression to severe deformities. Treatment of hallux valgus involves surgical straightening of the metatarsophalangeal joint (MTP joint). The surgeon can employ more than a hundred different surgical approaches to accomplish this. Metatarsal osteotomies such as a distal chevron osteotomy, scarf osteotomy, proximal metatarsal osteotomy, or distal osteotomy can be done. The goal of the distal soft tissue procedure is to correct the tendon and joint capsule and straighten the big toe to eliminate pain, improve joint mobility, reduce joint wear and tear, and normalize gait (walking). Surgical procedures also help to prevent further deformities in the forefoot.

How can I prevent hallux valgus?

Some risk factors for hallux valgus, such as your age, gender, or a hereditary predisposition are not preventable. However, you can do several things for preventing hallux valgus deformity. For instance, you should wear footwear that fits properly and is not too tight. Avoiding high heels is also a way of preventing severe deformity. It's a good idea to alternate between different heel heights so that there is no prolonged pressure on any one part of the foot. Walking barefoot as often as possible also helps. Foot exercises to strengthen the intrinsic foot muscles are another way to reduce your risk of toe deformity.

Hallux Valgus: Conservative Treatment vs Surgery

Whether you need hallux valgus correction with conservative measures or you need hallux valgus surgery depends on the severity of your symptoms, the amount of deviation in the first metatarsal bone, and the severity of your foot deformity. Treating hallux valgus with conservative measures is usually attempted first before surgical treatment is advised for the hallux deformity. In people with severe hallux valgus deformity and severe hallux rigidus or other severe deformities of the foot, surgical correction can help relieve symptoms and prevent progression of the condition.

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