The big toe is also known as the “hallux.” If this begins to deviate, it is called a hallux varus. In this case, a swelling often develops on the inner side of the metatarsophalangeal joint of the big toe, which can be bothersome in normal footwear and can also become inflamed.
What is hallux varus?
Hallux varus (splay toe) describes a condition in which the big toe points away from the second toe. In this condition, the lateral joint capsule is insufficient or absent and the medial capsule is contracted. Unlike the bunion, the 1st metatarsal remains in its anatomic position. The big toe, on the other hand, deviates toward the middle of the body. This very rare deformity refers to the opposite of a so-called hallux valgus. Hallux varus very often occurs as a complication of hallux valgus surgery. Other cases are either congenital or post-traumatic. Symptoms depend on how severe the deformity is. The splayed toe may press against the shoe. The skin in this area then becomes mechanically irritated, red and painful, which can result in inflammation.
Causes
Hallux varus very often occurs as a complication of hallux valgus surgery. If excessive soft tissue correction occurs during surgery or the lateral sesamoid bone is removed, the risk of developing hallux varus as a result is increased. The deformity may become apparent shortly after surgery or may develop over time. The deformity is often promoted during walking due to a load on the outer edge of the foot. However, other causes can also lead to this condition, such as a congenital deformity. This is called hallux varus congenitus. In some cases, hallux varus is also caused by growth disorders, spastic diseases or complex syndromes. Occasionally, accidents that result in injury, such as getting caught with the big toe, can also lead to hallux varus. In barefoot people, the deformity is common in middle age.
Symptoms, complaints and signs
Typical symptoms of hallux varus include pressure pain on the big toe caused by the axial deviation. In addition, the forefoot widens in the shoe. There is often also movement-dependent pain in the metatarsophalangeal joint of the big toe. The affected person is particularly disturbed by the pressure in the shoe as well as by hanging, for example when putting on socks. Occasionally, the malposition can likewise lead to an ingrown nail.
Diagnosis and course
Diagnosis is fairly simple, as it is easy to see how the big toe points from the second toe toward the center of the body. On examination, the medial lateral deviation of the big toe is determined in degrees. In addition, manual redressability and mobility in the metatarsophalangeal joint of the big toe are checked. The forefoot is also evaluated radiographically in two planes to assess the condition of the metatarsophalangeal joint, the position of the sesamoid bone, and the extent of the big toe deformity. In many children, the deformity regresses on its own as they develop. In other cases, the prognosis is usually good. Only in a few cases that remain untreated can hallux varus lead to restricted movement, pain and even arthrosis in the long term. Above a certain degree, this deformity is neither functionally nor cosmetically tolerable and should therefore be corrected as soon as possible. If there is pain when walking or the abduction is significantly greater, treatment is advised.
Complications
Hallux varus usually causes discomfort in the big toe. In particular, swelling occurs, which can lead to considerable pain and thus to restrictions when walking and running. Especially in a shoe, this swelling can be very disturbing and not infrequently leads to inflammation. The pain can spread to the entire foot and thus lead to a malposition of the foot or the entire leg. Furthermore, arthrosis can also develop and the quality of life of the affected person is considerably reduced by Hallux Varus. It is not uncommon for strenuous movements to be avoided as a result, and it is also no longer possible for the patient to perform various types of sports.The malposition usually also causes cosmetic discomfort, so that those affected feel ashamed of this discomfort and suffer from reduced self-esteem. Under certain circumstances, this can also lead to inferiority complexes. There are no further complications with the treatment. Hallux varus can be treated with appropriate footwear. In severe cases or in case of severe deformity, surgical intervention can also be performed. There is no reduction in life expectancy.
When should you go to the doctor?
If pressure pain is noticed on the big toe, there may be an underlying hallux varus. A doctor should be consulted if the discomfort does not subside on its own or if other symptoms are added. For example, a doctor should always be consulted in the event of accompanying symptoms such as an ingrown toenail, pressure sores and edema. A hallux varus must be clarified and treated to avoid further complications. If the deformity remains untreated, chronic complaints can develop, which usually represent a great burden for the person affected. For this reason, unusual symptoms should be observed and medically examined. If the complaints occur after a hallux valgus operation, the responsible physician must be informed. Then, another surgery is usually needed to correct the deformity. People who have a congenital deformity of the foot or big toe are particularly susceptible to hallux varus. Patients with growth disorders or spastic diseases are also at risk and should have any unusual symptoms investigated quickly. In addition to the primary care physician, an orthopedist may be called in.
Treatment and therapy
Treatment of the condition depends on the cause. In children with a tight adductor tendon, it is recommended that treatment be aimed at stretching the tendon, for example, through stretching exercises or splinting of toes. Malalignment of the big toe less than 10° usually does not require therapy. Larger deformities can be compensated by appropriate footwear with a narrow forefoot area if the hallux varus can be redressed. This means that the big toe can be pushed back into its original position. Conservative therapy includes manual therapy to stretch the medial side soft tissues. Acute therapy includes redressing bandages and splints. If the deformity is unsuccessful with conservative treatment, surgery may be required. In this case, the toe is brought into a neutral or straight position. In the case of hallux varus, which is a complication of hallux valgus surgery, additional corrective surgery is often required. The surgical therapeutic measures consist of lengthening the medial portions of the capsule and tightening the lateral portions. In rare cases, arthrodesis of the metatarsophalangeal joint may be necessary for severe deformities. The extent of the operation ultimately always depends on the degree of deformity. The earlier the condition is detected and treated, the easier the corrective surgery will be. Reining in the big toe for several months is necessary to ensure the success of the therapy.
Outlook and prognosis
The prognosis for hallux varus disease can be classified as extremely favorable. This is not only due to the fact that in children the deformity usually regresses on its own. Surgical treatment also promises lifelong freedom from symptoms. In addition, conservative therapy is sufficient in many cases. Often there is only a deformity of 10 degrees. In these cases, physicians do not intervene because there is no real impairment. Treatment would be more cosmetic in nature. Furthermore, surgery does not have to be chosen automatically. Conservative therapy not infrequently also leads to success. The experience of therapists in stretching the soft tissues show good results. In addition, one resorts to a traction therapy. In case of surgery there are hardly any other risks than in other interventions. Infections, bleeding, thrombosis or damage to nerves are conceivable, but are a general risk. Extremely rarely, the functional range of the big toe is reduced. Patients can contribute much to the positive outcome after surgery. Recommended footwear should be worn, and exercise exercises to strengthen the muscles should be followed.After a good six months, swelling and movement restrictions subside.
Prevention
If hallux varus is hereditary, its development usually cannot be prevented. To prevent the condition, it may help to avoid internal rotation of the foot when the infant is in the prone position. When the first signs of hallux varus appear, medical advice should be sought. If necessary, in this case, measures can be taken against the disease as early as possible.
Aftercare
Depending on the healing process, the big toe should be stabilized with a rein bandage for at least four weeks after surgery. This is to prevent the healing bone site from loosening again and the toe from returning to its malposition. Reining is also advised as part of conservative therapy. The bandage not only fixes the big toe in the desired position. It also helps to improve venous activity and drain blood and lymphatic fluid more easily by providing light compression. This minimizes internal pressure on the wound, which counteracts swelling. The initial dressing is applied by a specialist. However, once instructed, the patient can do the regular changing themselves. A forefoot relief shoe helps to take it easy after the operation and to support the healing process. Nevertheless, it is advised to roll the foot over the big toe again as soon as possible and to return to a normal gait pattern. In any case, regular follow-up examinations by a specialist are indispensable. Swelling and movement restrictions in the metatarsophalangeal joint should subside in the first six months after the operation, but in individual cases they can persist considerably longer. However, if neither surgical nor conservative therapy shows success, or if the patient continues to struggle with pain and limited motion, immobilization by joint fusion should be considered.
What you can do yourself
A splay toe very often develops as a result of hallux valgus surgery. The so-called bunions, on the other hand, usually develop as a reaction to a permanent incorrect load on the foot. Instead of the heel, the body weight is transferred to the toes. The cause of this is very often fashionable, but from an orthopedic point of view completely nonsensical footwear. The best form of self-help is to wear healthy and well-fitting shoes. Shoes, especially those that are worn regularly and over a long period of time, should not have high heels or be pointed at the front. Shoes with flat, thick soles and a quality footbed help prevent foot and toe deformities. However, a splay toe does not need to be treated in every case. In children, the disorder often resolves itself as they grow up. From middle age, a hallux varus is also very often seen in people who walk barefoot a lot. Those affected usually do not suffer from pain and do not have to take any countermeasures, provided the visual impairment does not irritate them. In the early stages, however, the progression of hallux varus can also be stopped or at least delayed by adapting one’s behavior. Instead of walking barefoot all the time, those affected should have special orthopedic shoes fitted. Such footwear can also help to reduce pain when walking or standing in more pronounced forms of hallux varus. Surgery can thus be avoided or at least delayed.
