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Hallux Valgus (Bunions)

Hallux valgus refers to a subluxation of the 1st metatarsophalangeal (MTP) joint with lateral or valgus deviation of the great toe and medial or varus deviation of the 1st metatarsal, leading to a bony prominence at the medial aspect of the joint (medial eminence or bunion).


SYMPTOMS 

Increasing stiffness, aching pain and typical deformation of MTP I without preceding trauma. Often the symptoms are bilateral. This condition is commonly presented by middle-aged recreational athletes or sedentary people, predominantly female, but it can occur in younger individuals.


AETIOLOGY 
The aetiology is unclear but there is possibly a genetic predisposition to this disease, which causes a typical mal-alignment of MTP I with secondary bursitis and joint degeneration.


Risk Factors
  • Constrictive footwear and high-heeled shoes
  • Pes planus and forefoot pronation lead to increased pressure on the medial aspect of the great toe and attenuation of the medial capsular structures at the 1st MTP joint.
  • A rounded MTP articulation is more prone to lateral subluxation then a flat articulation.
  • Metatarsus primus varus and an increased 1st and 2nd intermetatarsal angle are often implicated in juvenile or adolescent hallux valgus.
  • Tight Achilles tendon
  • Hypermobility of the 1st metatarsocuneiform joint
  • Neuromuscular disorders and collagen-deficient disorders
  • Asymptomatic hallux valgus does not need treatment.

CLINICAL FINDINGS

  • Hallux valgus is diagnosed when there is more than 10 degrees of malformation, with adducted distal phalanges and localized swelling, redness and tenderness on palpation over the MTP I joint.
  • Pain over the medial eminence aggravated by tight or rigid footwear is the most common complaint.
  • Pain under the 2nd metatarsal head with a plantar keratosis is also common.
  • Blisters, swelling, callus formation, or bursitis over the medial eminence may occur with athletic activities.
  • Patients may describe forefoot widening or difficulty wearing shoes comfortably.
  • Numbness or tingling of the medial aspect of the great toe may occur from pressure on the medial dorsal cutaneous nerve to the hallux.
  • Radiographs are typically unnecessary for conservative management of hallux valgus.

Image shows radio-graph of Hallux Valgus
Hallux Valgus

Treatment

  • Preliminary treatment consists of footwear modification and patient education.
  • Wider footwear with a roomy toe box will help in reduction of pressure and friction on the medial eminence.
  • Shoes with flexible and non-constricting stitching over the medial eminence are advised
  • High-heeled shoes should be avoided.
  • Medial longitudinal arch support may reduce pressure on the 1st metatarsal, especially in patients with pes planus.
  • Activity modification in joggers and runners may significantly decrease symptoms and stress on the forefoot.