Hallux valgus

Synonyms in further meaning

Bunion, hammer-formed foot, chilblains, hallux valgus, chronic bursitis of the big toe, inflammation of the ball of the foot, swollen foot, Hallux abductovalgus ....

German: Hallux valgus

Definition

Hallux valgus is the most frequent and significantly defective positioning of the toe in humans. It is characterized by an outward deviation of the big toe in the basic joint and an inward twisting of the toe (inward rotation). With the passage of time, the faulty stress of the joint leads to painful arthrosis in the joint of the big toe (Hallux rigidus).

Frequency

Hallux valgus is the most frequent toe deformity. It occurs nearly always in connection with splayfoot. In the course of one’s life, the defective position of the splayfoot becomes progressively worse. Consequently, the defective position of the Hallux valgus also increases with age. Both clinical pictures influence each other negatively later on. Women are significantly more frequently affected than men. The distinction between sexes is approximately 9:1 (female: male)

General information

The bulging of the big toe to the utmost margin of the foot/ towards the little toe is designated as an x-formed big toe or Hallux valgus. This malady is influenced by different factors. Constitutional components (heredity from mother or father), an imbalance of muscular tension caused by inadequate training of the foot muscles, and tight-fitting shoes are considered to be important factors. Through the chronic stress of the ball of the big toe, osseous, exophytic knobs (exophytes) arise in the area of the greatest stress on the head of the 1st metatarsal and they are accompanied by the creation of increasingly painful, slightly inflamed bursitis. One differentiates between different degrees of severity of this deformity. The goal of a surgical correction in the early stage is to retain the function of the big toe joint and thus to restore the complete, painless movement of the big toe.

The Hallux valgus – deformity is a classical consequence of western civilization. Thus, in countries and cultural groups where women do not wear any shoes or only wear open shoes (e.g. sandals), Hallux valgus seldom occurs. In the figure to the left, you can recognize the classical Hallux valgus deformity. In addition, the foot tendons are represented, which are significant for creating the defective position.

Figure of Hallux valgus: Long extensor tendon (tendon of the Musculus extensor hallucis longus) Stretching tendon (tendon of the Musculus adductor hallucis)

Causes

The causes for the creation of Hallux valgus are frequently a hereditary weakness of the ligaments and connective tissue, which affects the entire body. This leads to the establishment of flatfeet/ splayfeet. Through the reduced tension of the ligament apparatus, a flattening of the longitudinal arch of the foot occurs; upon rolling the foot, the strongly-burdened oblong arch spreads apart ever more and thereby manifests the weakness of the ligament connections between the metatarsal bones. Since one cannot revoke hereditary weakness of the ligament apparatus in a medical manner, only the symptoms of the malady receive therapy. This always means that only the consequences of splayfoot can be treated, but not the splayfoot itself.

By wearing comfortable shoes, our foot musculature is not trained and thus is unchallenged, which leads to a muscular imbalance of our foot muscles. Training of the short, inner foot musculature, which can counteract the splaying of the foot arch, will thus be prevented. Please consult the literature that is recommended hereto.

Especially unsuitable shoes, e.g. with a toe region that is too narrow or a heel that is too strongly elevated, which appreciably increase the pressure on the forefoot, play a significant role.

Through progressive, defective foot positioning, modified pulling directions of the a.m. tendons occur. Hereby, the inward rotation of the big toe is significantly caused. Upon progressive twisting of the big toe, the muscular counteraction becomes ineffective.

Symptoms

Hallux valgus is widely found, but it causes few complaints in most cases. There is no correlation between the degree of the deformity and the extent of the complaint. Significant deformities can cause minimal complaints and visa versa. Nevertheless, the greater the defective position is, the probability is also greater that premature cartilage attrition (arthrosis) will arise through the deformity. For many women it is merely a cosmetic problem. The initial complaints usually occur in the ball of the big toe. These balls of the big toe are designated medically as exostosis or pseudoexostosis. The foot is widest at this point; accordingly, shoes exert the most pressure here. Mechanical stress of the skin occurs and of the bursa that lies beneath it. Thereafter the bursa becomes thickened, in order to better protect the bone. Hereby the toe balls become widened even more and pressure is further increased in the shoe. Inflammation, swelling, non-microbial and even bacterial inflammations of the bursa (bursitis) can occur. In the subsequent course, a chronic, recurrent, painful bunion of the big toe can develop (chronic bursitis). In the final stage of the malady, persistent pains occur. As with each joint, the basic joint of the big toe was not designed for a crooked position (incongruity). Therefore, in the further course of the malady a premature attrition of the joint cartilage occurs (Hallux rigidus). The symptoms of the attrition are initially manifested in a limitation of movement of the big toe, which can painfully limit the rolling motion. Generally, a slow but chronically progressive (progredient) deterioration of the defective forefoot position occurs. The arthrosis of the basic joint of the big toe proceeds; pain and inflammation persist and the big toe can deviate by up to 90° from the basic position. In extreme cases, the big toe can hereby be situated above the second and third toe. corpuscles – like the tubular bones of the body.

Diagnosis

Complaints of the Patient: Through the deformity of the big toe and the associated forward-bending of the metatarsal heading, the shoe presses and the skin is susceptible to inflammations. A bursa is created via the metatarsal heading, which can become easily inflamed. Pain and pressure points arise on the foot. The bent big toe and the shifting of the smaller toes prevent a natural manner of walking. Complaints arise upon walking and the step length is shortened. . Often Hallux valgus is accompanied by hammer toe or claw toe. With the hammer toe, the big toe deviates downwards in its final joint. With the claw toe, the toe is bent upward in its basic joint. In both peripheral joints, they are bent downwards in a claw-like manner. Then painful pressure points arise on the bent surfaces; corns (clavus) and calluses are created. Through the accompanying splayfoot, pains often arise under the unnaturally (unphysiologically) stressed metatarsal heading 2-4 (metatarsalia) in the forefoot area of the foot sole, which is also designated medically as Metatasalgia.

Examination:

The external foot deformities can already be well recognized. They represent the condition as described above.

Roentgen (X-ray): To accurately evaluate the osseous deformity, an X-ray image of both feet will be prepared. Damage to the joint, which has eventually occurred, can be recognized. In addition, the extent of the deformity determines the surgical corrective procedure.

Therapie

Conservative Treatment

The contents of this treatment can be performed by the orthopedist as well as by the family doctor.

Since many factors originally influence the deformity of the forefoot, the prospects of a conservative treatment are very minimal in the sense of healing. A continuation of Hallux valgus can merely be arrested temporarily or slowed down. In this respect, a conservative treatment only has a chance of success in early stages, with slight deformities and thus for younger patients. But it is also performed with older patients, who cannot or do not wish to undergo an operation.

• Footwear

Patients with Hallux valgus should wear shoes with sufficient space and with flat heels, especially when walking for longer distances or for sporting activities, and also if one must stand or walk for long periods. High heels, pointed toes and tight spaces in the forefoot are not suitable and they accelerate the process of the forefoot deformity.

• Own Activity

Toe gymnastics that have been learned from a physical therapist should be performed at home. Routine splaying exercises of the big toe can positively influence the muscular imbalance. „Walking barefoot“ on suitable surfaces and with modifications that are not too strenuous or painful can also be helpful. Nevertheless, the permanent effects of physical therapeutic exercises are limited.

• Shoe Provision

Hallux valgus with flatfoot/ splayfoot should experience pressure relief of deformed big toes, for example, by expanding the upper shoe sideways. Furthermore, inserts with retrocapital support behind the metatarsal bones have been proven to be effective. Pressure-relieving foam-plastic padding can also reduce the complaints on the soles. If a significant arthrosis has already occurred in the big toe on the basis of an advanced illness, a Hallux rigidus – insert can alleviate this complaint. It is an insert with so-called rigid fields that permit an absorbing roll of the ball of the forefoot with a stiffened sole.

If an operation is not possible for health reasons and confection shoes can no longer be worn, prescribed orthopedic shoes can be custom made with all corrective measures.

• Foot Treatment

The Hallux valgus night-time splint, which is laid like a piece of foam-plastic or felt between the 1st and 2nd toe, can limit the progression of the deformity. Otherwise, this treatment with the night splint is rather reserved for patients after surgical correction in a re-treatment. Here, the effectiveness is significantly greater, in a prophylactic sense, i.e. preventing a renewed defective position of the toe. But by wearing such a night splint even for extended periods, the Hallux valgus cannot be eliminated.

Inflammations of the foot sole, e.g. by inflammation of the bursa, which bulges above the 1st metatarsal heading, can be treated with anti-inflammatory medicines, such as (NSAR, e.g. Diclofenac), local compresses with Rivanol or Polividon iodine.

Operative Treatment

Collectively, more than 200 different surgical procedures are known for the forefoot area. The six most common surgical procedures for Hallux valgus are as follows:

• Exostosis chiseling with medial capsule condensation according to Chevron / Austin • OP according to McBride • OP according to Keller-Brandes • Basic osteotomy of the Os metatarsale I (Base-Wedge-OP or also proximal conversion / correction) • OP according to SCARF

Exostosis Chiseling: The exclusive ablation of exostosis (bone protrusion of the 1st metatarsal heading, also called the pseudoexostosis), is only rarely performed today and it is applied with a very minimal expression of the Hallux valgus. The positive effect of the operation is only transitory, because only a symptom of the deformity is treated, but not the deformity itself.

Operation according to Chevron or Operation according to Austin: This OP method is applied for intermediate to severe forms of Hallux valgus. Prerequisite for this joint-conserving procedure is an arthrosis that exists at most moderately in the basic joint of the big toe and an intermetatarsal angle with a maximum of 16° (angle between the 1st and 2nd metatarsal bone). In addition to the exostosis ablation that is also performed, a 3-dimensional bone conversion with tendon relocation will be made, so that a functional, natural anatomy of the forefoot will be achieved again.

The re-treatment occurs in a forefoot stress shoe for about 3-4 weeks: thereafter, a comfortable shoe can already be worn with special inserts.

The operation can be performed ambulant as well as stationary.

Operation according to McBride (Weichteil-OP): This operation procedure is applied for a deformity of the big toe, which can still be corrected passively, without or at most with a minimal degree of arthrosis in the basic joint of the big toe. It deals with a preferential operation for younger patients, since no bones must be sawed off. The goal is the chiseling of the bone protrusion (exostosis) and the relocation and tightening of individual toe muscles (Musculus adductor hallucis) as well as the joint capsule. The re-treatment consists of elevating the affected foot, local cooling with ice, anti-inflammatory medicines (NSAR) as well as a thrombosis prophylaxis. Prerequisite to a good healing process is the restoration of the working ability of the foot after 6 weeks, depending on the foot stress in the respective job.

Operation according to Keller- Brandes: This operation is applied for older patients with a high degree of deformity of the big toe, advanced arthrosis in the basic joint of the toe and minimal daily stress demands of the forefoot. A disadvantage of this surgical procedure consists of shortening the big toe that is often regarded as cosmetically disturbing. Hereby, the second toe exceeds the length of the big toe. The goal of the operation is a 1/3 ablation of the basic joint of the big toe, as well as chiseling of the bone protrusion on the inner side of the metatarsal bone. It deals with a relatively easily performed and rapid surgical procedure.

Basic Osteotomy on the 1st Metatarsal Bone (Base-Wedge-OP): For severe forms of Hallux valgus (angle more than 50 degrees and intermetatarsal angle of more than 20 degrees), a separation and conversion of the basis of the 1st metatarsal bone must be made. Hereby, a small bone wedge will be removed from the base; the 1st toe joint (phalanx) will be pivoted and screwed again in a new position. In comparison to Austin- or Chevron-OP (see above), approximately 2 weeks longer partial stress is needed here in a bandage shoe / forefoot relief shoe. Nevertheless, stress on the heel is also permitted here as of the 1st post-operative day, as with all of the a.m. OP procedures. .

Prognosis

Fundamentally, it can be stated that upon proper diagnosis and appropriate selection of the surgical procedure, the long-term prognosis is good for Hallux valgus that has been surgically treated. It is important that the proper surgical procedure finds application for the individual case.

Provided that no advanced arthrosis has yet been observed in the basic joint of the big toe, a joint-retaining operative procedure should be applied (e.g. Chevron or McBride etc). In numerous investigations, the results thereby were good to excellent for more than 90 percent of the patients. For each of the above-mentioned forefoot corrective operations, one must reckon with longer working and sporting incapacity. Patients are often not sufficiently informed about this fact. For procedures with bone correction, one should assume a convalescent period of between 3-6 months. From the viewpoint of social medicine, that can represent a significant problem.

The successful treatment of forefoot complaints requires moreover a close coordination with an orthopedic technician. It is therefore advantageous, if an experienced orthopedic technician can be consulted each time that a visit is made to an orthopedist. Such cooperation is only possible from a practical viewpoint in a health center where foot surgery is routinely performed.