Hallux valgus

Synonyms

bunion, frostbite, bunion, big toe bunion, bunion of the foot, bunion foot, clubfoot, hallux abductovalgus

Frequency distribution

Hallux valgus almost always occurs in combination with a splayfoot. In the course of life, the malposition of the splayfoot slowly increases. As a result, the malposition of the hallux valgus also increases with age.

Both clinical pictures influence each other negatively in the course of time. Women are affected significantly more often than men. The gender distribution is about 9 : 1 (female : male). Due to an increasing splayfoot, the big toe is pulled more and more into the hallux valgus deformity by the spreader tendon (tendon of the adductor hallucis muscle).

  • Long extensor tendon (tendon of the musculus extensor hallucis longus)
  • Spreader tendon (tendon of the Musculus adductor hallucis)

General information

As big toe-bale or Hallux valgus, the curvature of the big toe is called to the outer foot-edge-small toe. This disease is influenced by various factors. As important factors are considered:.

Due to the chronic strain on the ball of the big toe, bony attachments (exophytes) occur in the area of greatest strain on the head of the 1st metatarsal and are accompanied by an increasingly painful, easily inflammatory bursa formation (bursitis). There are different degrees of severity of the deformation. The aim of surgical correction in early stages is to preserve the function of the metatarsophalangeal joint of the big toe and thus to restore full, pain-free mobility of the big toe.

The “hallux valgus – malpositioning” is a classic consequence of our western civilization. Thus, in countries and cultures where women do not wear shoes or open shoes (e.g. sandals), hallux valgus rarely occurs. In the picture above you can see the classic hallux valgus malposition.

In addition, the tendons of the foot are shown, which are important for the development of the malposition.

  • A congenital component (inherited from mother and father)
  • An imbalance of the muscle trains due to a lack of training of the foot muscles and
  • Shoes too tight

The cause for the development of hallux valgus is often an inherited ligament and connective tissue weakness affecting the entire body. This causes the development of a flat splayfoot.

Due to the reduced tension of the ligamentous apparatus, the longitudinal arch of the foot flattens and the transverse arch, which is heavily loaded during rolling, diverges more and more widely, thus revealing the weakness of the ligament connections between the metatarsal bones. Since the weakness of the ligamentous apparatus cannot be corrected by a physician, only the symptoms of hallux valgus are treated. This means that only the consequences of the splayfoot can be treated, not the splayfoot itself.

By wearing comfortable shoes, our foot muscles are not trained and underchallenged, which leads to a muscular imbalance of the foot. A training of the short inner foot muscles, which can counteract the spreading of the arch of the foot, is thus prevented. In particular, unsuitable footwear, e.g. with too narrow a forefoot area or a heel that is raised too much, which increases the pressure on the forefoot many times over, plays an important role.

The increasing malpositioning of the foot leads to altered pulling directions of the above-mentioned tendons. This is the main reason for the inward rotation of the big toe. With increasing bending of the big toe, the muscular opponents become ineffective.

Shoes make a major contribution to the development of hallux valgus in many affected persons. Wearing the wrong shoes places a particularly heavy load on the forefoot, which promotes the development of hallux valgus. This is usually caused by high-heeled shoes, where the ball of the foot and the forefoot bear the largest part of the body weight.

Shoes that are pointed at the front also have a negative effect on hallux valgus. Due to the limited space available to the toes, such a malpositioning of the toes can also develop. The hallux valgus is widespread, but in most cases it causes few complaints.

There is no correlation between the degree of malpositioning and the extent of the complaints of hallux valgus. Large deformities can cause little discomfort and vice versa. However, the greater the malalignment, the greater the probability that the incorrect loading of the metatarsophalangeal joint of the big toe will cause premature wear and tear of the cartilage (arthrosis).

For many women, hallux valgus is a purely cosmetic problem.The first complaints usually occur over the ball of the big toe. This ball of the big toe is medically also called exostosis or pseudoexostosis. This is where the foot is widest, so shoes press here the most.

This leads to mechanical stress on the skin and the bursa underneath. The bursa then thickens to better protect the bone. This makes the ball of the foot even more protruding and the pressure in the shoe increases further.

Inflammation, swelling, non-bacterial and even bacterial bursitis can develop. In the further course of the disease, a chronically recurring, painful ball of the big toe can develop (chronic bursitis). In the final stage of the disease there is permanent pain.

Like every joint, the metatarsophalangeal joint of the big toe is not designed for a skewed position (incongruity). Therefore, in the further course of the hallux valgus disease, early wear and tear arthrosis of the articular cartilage (hallux rigidus) occurs. The symptoms of wear and tear initially manifest themselves in a restriction of movement in the big toe, which can painfully restrict the rolling motion of the joint.

In general, there is a slow but chronically progressive deterioration of the forefoot malposition. The arthrosis of the metatarsophalangeal joint of the toe progresses, pain and inflammation remain and the big toe can deviate outwards from the normal position by up to 90°. In extreme cases, the big toe can be positioned above or below the second and third toe.

Hallux valgus is a malpositioning of the big toe in which the base joint bends outwards. For most of those affected, hallux valgus causes few complaints apart from cosmetic aspects. Sometimes, however, a hallux valgus can cause severe pain, which should then be considered an indication for hallux valgus surgery.

The pain in hallux valgus has several causes: The ball of the big toe is already physiologically the widest part of the foot, which is why the shoe most likely pinches here. In the case of hallux valgus, this area is now even larger, which is why typical hallux valgus pain and pressure points occur there. Some patients also develop calluses or corns at the pressure points.

Long-term mechanical stress (for example, the pressure of a shoe) constantly irritates the bursa surrounding the joint. The bursa reacts by thickening to protect the bone and the joint, which starts a vicious circle. In addition, chronic overuse can lead to the development of bursitis, which can be either bacterial or non-bacterial and is one of the most painful clinical pictures of all.

Since the joint is also incorrectly loaded by the malposition, arthrosis can often develop on the floor of a hallux valgus (hallux rigidus). This means that the joint cartilage is increasingly worn away over time. This process also leads to pain, which is particularly noticeable when the joint is working, i.e. especially when walking at the moment when the foot is rolled over the ball of the foot.

Because the other 4 toes are displaced from their natural place and are thus also permanently incorrectly loaded, a painful feeling can also develop in these toes or even in the entire front foot. Initially, the pain usually only exists when the metatarsophalangeal joint of the big toe is loaded and/or pressure is exerted on the damaged area (for example, by a shoe), but in a resting phase, the affected person is free of pain again. With increasing time, however, they then develop into chronic permanent pain, which is accompanied by a major reduction in quality of life.

It is important to keep in mind that the clinical picture of hallux valgus does not necessarily give a direct indication of a patient’s pain intensity. Of course, it is more likely that someone with a pronounced hallux valgus also suffers from osteoarthritis and a marked lack of space in shoes, but even rather inconspicuous-looking bunion of the big toe can cause severe pain in the early stages of a hallux valgus, while already advanced deformities can sometimes be relatively painless. In a hallux valgus, the metatarsal bone is shifted to the side, while the big toe is bent in the direction of the other toes.

This creates a particularly vulnerable area at the metatarsophalangeal joint of the big toe. Often the skin there becomes inflamed because it rubs against the tissue of the shoe.If the hallux valgus persists for a longer period of time, the inflammation can go deeper and even affect tendons and bones. The malposition also leads to an incorrect strain on the muscles.

Therefore, the tendon of the big toe muscle no longer runs in a straight line across the bursa, so that this bursa can also become inflamed. An inflammation of the bursa (bursitis) is usually caused by hallux valgus at the ball of the toe. The starting point of this inflammation is often the friction between the metatarsophalangeal joint of the big toe and the shoe.

This superficial inflammation reaches deep into the toe and can affect the muscles, tendons and bursae there. However, bursitis can also be caused by incorrect strain on the muscles. The treatment of bursitis is usually done by immobilizing the affected part of the body.

In the case of hallux valgus, a bandage can be helpful. This corrects the malpositioning of the big toe and thus reduces the load on the bursa. If numbness occurs in the big toe as a result of hallux valgus, this is usually due to circulatory problems or nerve damage.

The malalignment can press on the vessels and nerves and damage them in such a way that their function is restricted. Nerve damage means that the information about touch, temperature, pressure, pain, etc. can no longer be passed on to the brain, so that the toe feels numb.

Hallux rigidus is the technical term for arthrosis in the metatarsophalangeal joint of the big toe. Due to the malpositioning of the metatarsal bone and the big toe itself, arthrosis develops between these two bones, i.e. in the metatarsophalangeal joint of the big toe. The malalignment triggers an incorrect loading of the joint surfaces, which in the long run leads to abrasion of the protective cartilage layer, whereupon a hallux rigidus develops.

Diagnosis of hallux valgus by means of the patient’s complaints: The malpositioning of the big toe and the protruding metatarsal head causes shoe pressure, the skin becomes susceptible to inflammation. A bursa forms over the head of the metatarsus, which can easily become inflamed. Hallux valgus causes pain and pressure points on the foot.

The angled big toe and the displacement of the little toes hinder the natural walking process. It causes discomfort when walking and a shortening of the stride length. It is not uncommon for a hallux valgus to be associated with a hammer toe or claw toe.

In the case of the hammer toe, the big toe deviates downward in its end joint. In a claw toe, the toe deviates upwards in its base joint, in the two (peripheral) joints far from the body it is bent downwards like a claw. Painful pressure points then occur on the bent surfaces, corns (clavus) and calluses are formed.

The accompanying splayfoot often causes pain under the unnaturally (unphysiologically) loaded metatarsal heads 2-4 (metatarsalia) in the forefoot area of the sole of the foot, which is medically also called metatarsalgia. Medical examination in the case of a hallux valgus: The deformities of the foot are already visible externally. They present themselves as described above.

X-ray: An X-ray of both feet is taken for a precise assessment of the bony malposition of the hallux valgus. Any joint damage that may already have occurred can be detected. In addition, the extent of the malalignment determines the surgical correction procedure.