Hallux-Valgus (Bunions) – Causes, Symptoms, Treatment

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Overview

Hallux valgus is part of  the static forefoot disorders. Hallux valgus-site (“bunion”) represents the prominence of the metatarsal head ( the bone at the base of the hallux), by its medial movement towards the inner part of the leg. In no case is it a bone or a recently appeared cartilage, as it is still considered.

Article Contents:

Overview

Causes

Physipathological mechanism

Reasons for consultation / Symptoms

Recommended doctors for treatment

Diagnosis

Investigation

Differential diagnosis

Evolution

Prophylaxis

Treatment


Causes

The causes are unknown, instead we can not talk about the favourable factors and risk factors:

1. Factors favouring the appearance of bunions:

- Some foot morphotypes (constitutional types), through the size relation particular to bones, favours static disorders;

- The predominance of this deformation over women (95%) can be explained by the ligamentous laxity, conditioned by the hormones (that is, exacerbated at puberty and menopause); forefoot ligaments cease, favouring the movement and the prominence of the first metatarsal.

- Inflammatory diseases of the type rheumatoid arthritis can destabilize the entire foot and produce among others hallux-valgus a rapidly evolving hallux-valgus;

- Anterior traumas that have embrittled the osteo-ligamentous structures of the foot and have changed the relation between them;

- Lack of the second toe  through amputation (traumatic and especially iatrogenic) is a known factor (which is the reason why the second toe amputation should be avoided).

2. Risk Factors

- “elegant” and uncomfortable shoes, tight and with heels, long demonized, do not generate hallux-valgus, they only worsen an already existing one;

- Family history stands out, because daughters “inherit” the mother’s leg over 50% of the cases;

- Flat foot (pes planus) may favour to a certain extent the appearance of deformation by the relative mechanical extension of  ray 1.

- Obesity or rapid weight loss through their own mechanisms of action may favour the appearance of deformation.


Pathophysiological mechanism

The pathophysiological mechanism can be described briefly in several stages:

- The metatarso-sesamoido-phalangeal joint is in a complex but unstable equilibrium, having as a weak link the medial metatarsophalangeal ligament, which gradually gives up to the action of some stimuli.The initial stimulus is the more difficult to distinguish, as long as there are two major types of hallux valgus-: the congenital one, which occurs in adolescence and the acquired one, which occurs in adulthood, peri-menopausal.

- A  local complex movement takes place:

1. The hallux is leaning towards the other toes, circling around or (directing its nail towards the interior of the foot) and pushing the other toes, forcing them to ” get up” one on the other because of the lack of space necessary to each one  of them.

2. The metatarsal moves medially (varus), rotates and rises, its head protrudes under the skin and it represents the typical deformation.

- The tendons of the extrinsic muscles form a “rope” which is opposed to the return of the hallux at normal, ligaments and intrinsic muscles retract and the deformation continues to exist.

- These changes produce the functional insufficiency (of support) of ray 1 and, therefore, the overuse of the lateral metatarsophalangeal joints, with progressive appearance of:

1. metatarsalgia (with plantar hyperkeratosis, “corns”)

2. hammer toes

3. Taylor’s bunion deformation, which is the final panel of the complex deformation called “triangular foot.”

- Secondary, there may occur “corns”, ingrown nails, hygroma or wounds that can become infected.


Reasons for Consultation / Symptoms


- The progressive deformation of the forefoot and footwear: prominent metatarsal head and hallux displacement into the valgus, “disgraceful” aestethics of the foot;

- Major pain at rest or when making an effort (walking);

- Associated deformations: hammer toes, Taylor’s Bunion, metatarsalgia. Very often only one of these symptoms can be a cause for concern and, therefore, for consultation;

- Hyperkeratosis (“cornf”) is a symptom of static disorders and a fine indicator of the plantar hyperpressure;

- Inflammation of the skin near the “bunion”, up to hygroma and even serious infections caused by the same mechanical conflict with shoes.


Doctors recommended for treatment


- The only true physician to be recommended is the orthopedic surgeon, preferably the one who is specialized in foot surgery and has large specific experience.

- The rheumatologist and the balneo-physiotherapist may apply palliative procedures in order to reduce pain and increase the walking perimeter. Attention, cortisone infiltrations are completely prohibited at the level of the forefoot!

- Your GP may prescribe a symptomatic, painkilling and anti-inflammatory treatment, while waiting for the specialized medical consultation.


Diagnosis


The diagnosis is mainly clinical, based on:

- The case history: the history of the appearance of symptoms, the type of shoes used, the factors that aggravate the pain,the patient’s activity, previous treatments, etc..

- The thorough physical examination studies not only the forefoot, but the whole locomotor system, at rest, pregnancy and walking, and last but not least the shoes.


Investigation

- Radiography is useful:

1. to eliminate other diagnoses, which would require emergency treatment;

2. preoperatively, in order to choose the optimal surgical procedure;

3. Attention! The radiography technique requires precise and extremely demanding execution in order to be relevant.

- Very rarely, a CT scanner, especially for an extremely precise study of the bony structures and the relations between them, may be recommended.

- Biological bloog analyses can diagnose microcrystalline arthropathy (gout), rheumatoid arthritis, local infections, all of which can simulate the hallux-valgus suffering;

- The local puncture at the level of a fluid collection can differentiate between an inflammation and an infection.


Differential diagnosis

- Microcrystalline arthropathy (gout) can simulate the “bunion” because of its prominence, but the pain is acute, of brutal installation and metatarsal displacement lacks.

- Osteoarthritis (hallux rigidus) has specific clinical and radiological features.


Evolution

- It is inevitably towards a slow and progressive deterioration, but the rate varies depending on the two main forms:

1. the juvenile or congenital type, occurring in adolescence, progresses slowly and becomes symptomatic (painful) towards the age of 40 years;

2. the static type, which occurs around the age of menopause, has instead an accelerated evolution towards forms of complex deformation of the entire leg.

- it can be stopped by applying curative surgery;

- it may be slowed by respecting the local therapeutic measures, providing an acceptable comfort to the daily life and to the professional activities;


Prophylaxis

- There is no specific prophylaxis because hallux valgus (“bunions”) it’s difficult to prevent. There are however some methods that may give results, there is no guarantee. Watch the video below to see them!

- Physical exercises can not stop the evolution of the disease, instead, applied inappropriately, they can worsen it.

 


Treatment

Treatment must restore the patient’s confidence by rebuilding a harmonious, aesthetic and functional leg, painless and able to handle daily or leisure activities.

The “natural” treatment deserves special attention because of a widely spread mythology and literature.

- Those who propagate such treatments start from an absolutely false assumption that says that the “bunion” is a kind of wart or excrescence of bones and cartilage, which they try to remove it by all kinds of local applications: concentrated iodine, salt diluted in water, comfrey , celandine, lemon, potatoes, raw fish, dissolved aspirin, macerated garlic, etc.

- These substances are not only absolutely unnecessary, but often extremely dangerous, causing local burns and extremely serious infections that can maim the foot.

- the only substance which is allowed locally is the neutral vaseline in order to protect the skin from the irritating mechanical action of the shoe.

The conservative treatment includes:

-The adaptation of physical, professional or sporting activity to reduce local suffering. Avoid prolonged orthostatism (standing position of the body), and aggressive sports (jogging, football) will be replaced by more gentle ones (swimming, cycling).

- Adapting footwear is extremely important and the major requirement is comfort. There is no miracle recipe in this respect, the fact is that we have to lower our sights to a proper size and model, having as a main goal the avoidance of conflict and the provision of a comfortably and painless walking.

- Plantar orthoses ( the supporters) which correct the static foot can be useful, provided they are well executed. By harmonizing the plantar pressures, they improve the metatarsalgias associated with hallux-valgus, but they do not change the evolution of  the deformation.

- cosmetic-palliative measures: special protective dressings and digital dividers can allow putting the shoes on the foot by avoiding the local conflict.

- “hallux-valgus orthoses” should be avoided completely . Acting symptomatically and not causally, like most surgeries practised in Romania, they have a devastating effect on the joint, respectively rapid arthrosic degeneration.

- analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs) may reduce pain and inflammation, but they should be consumed with discernment and on a short term, given the gastric aggressiveness, the possible complications or medicamentary interference.

- the local cortisone infiltration must be absolutely prohibited throughout the entire foot. The consequences of their abusive use can be devastating: tendon or ligament tears, followed by the destruction of the foot’s architecture and serious infections.

- the treatment of local inflammation (hygroma) requires a lot of discernment, given their great frequency, and especially to avoid their suprainfection.


Surgical treatment

Overview

- it is the only one able to remove the deformation, to relieve pain and allow an almost normal shoe, a normal practice of the profession and sporting or leisure activities.

- the time for surgery will be chosen by the patient in collaboration with the surgeon, after an exhaustive information about the possible techniques and complications.

- it presupposes a reasonable horizon of expectation: foot surgery does not recreate a “new” ley but it tries to restore an architectural harmony lost with the passing years.

- without being urgent, the treatment should applied on time in order to avoid the appearance of deformations difficult to treat and which involve irreversible operations such as blocking some joints.

- althouh the interventions have a spectacular aesthetic result, this surgery should not become an aesthetic one, but it sshould remain purely functional, caused by pain and difficulty in walking. The patient’s desire to have a balanced body, with aesthetic features should not outrun the functional criteria.

- The presence of a well trained surgeon, eventually specialised on foot is extremely important: the one that performs these operations frequently and successfully can minimize the rate of complications.

 

Principles

- aim at recreating a quasinormal support and walking organ, with a harmonious architecture, painless and able to fulfill every daily or occasional activities.

- the patient’s expectations must be reasonable: the degree of deformation largely determines the result of the surgery, and sometimes some functional sacrifices are needed. No foot resembles the other and the surgeon can not always make a perfect leg.

- There are two seemingly contrary interests, in fact complementary, that must be harmonized: the patient wants to wear again a stylish shoes, and what the surgeon really wants is to restore normal biomechanics, leading to a normal gait and long lasting results.

 

Aims

- the removal of the deformation (“bunions”) does not mean simply cutting the protuberant bone: this  negative and blamable process is unfortunately very widespread in Romania and determines the patients immense dissatisfaction and the negative reputation of the operation of “bunions”. This technique has an unacceptably high degree of relapses and it is absolutely illogical from all points of view.

-The major goal of any intervention is the early walking which avoids all types of major complications caused by immobilization. Avoid any proposed operations which involve prolonged plaster immobilization, walking with crutches or simply immobilization in bed. Immobilization is forbidden!

- There are nowadays enough reliable operative techniques which allow walking even  from the first day after surgery, rapid resumption of professional activities and wear of elegant footwear.

Techniques

Techniques are multiple and their development was exponential over the past 15 years. Each one of them has advantages and risks, leaving to the surgeon the task of applying them depending on the local conditions and especially on his experience.

The principle of any intervention is to restore the normal axis of ray 1,which was deformed by the movement of the hallux and the corresponding metatarsal. For this reason the metatarsal must be cut and moved to its place, in this way normalizing the metatarso-sesamoido-phalangeal apparatus in order to have a quasinormal biomechanics.

Major requirements of the techniques:

1. to keep as much as possible of the bony capital

2. to be simple, reliable and reproducible

3. performant fixing, often done by using special screws made of titanium.

4. to allow an easy resumption in case of relapse or failure correction.

- The operative maneuvers are multiple, depending on the nature and severity of the deformation, and based on:

1. Selective selection of some muscles or ligaments, in order to decompress the joints and maintain relaxation;

2. metatarsal osteotomies: distal, metaphyseal, basal or combined with the osteotomy of the proximal phalanx;

3. Global forefoot surgery, for complex deformities.


Pain Control


- Complete removal of pain is essential and desirable.

- The control of pain is fundamental, the proof being – the widespread, negative reputation of forefoot surgery. This type of surgery requires the application of modern anesthetic procedures, effective for a period of 36 to 48 hours ( the critical period). It is actually the only reason why this surgery can not be “ambulatory”, of the type  “one-day-surgery”.

- The only effective anesthesia is the loco-regional one, of the type sensory nerve perineural block, which allows long-term pain relief and especially the early resumption of walking. The spinal anesthesia (peri-or epidural rachianesthesia) are proscribed, not being able to allow early mobilization and walking and being reputed for frequent postoperative complications.

- The analgesics with morphine are fully justified as a recommendation and use. Overcoming pain is also justified by the need to avoid the algodystrophy syndrome, a redoubtable complication often attributable to pain.

- After the first 48-72 hours analgesics from the tylenol class are sufficient in most cases.


Contraindications

- The diabetic foot is a major but not absolute contraindication

- obliterative arteriopathy (“arteritis”)

- Peripheral venous insufficiency (” varicose veins”) should be thoroughly evaluated by the vascular surgeon

- The patient must understand that this surgery is not an absolutely necessary emergency, it can be and should be avoided in particular conditions, which may even endanger his life. There is always the conservative solution, with the adjustment of footwear or the manufacturing of a special orthopedic footwear.


Complications

Any surgical procedure may be followed by complications or failure; most of them can be prevented through a careful selection of patients,through the recommendation of operation, the application of the appropriate procedure and the carefully watched evolution. There are specfic treatment protocols for each of these complications:

- Failure correction represents the maintenance of the deformation after surgery, attributable to the surgeon, it is generally well tolerated and it can be corrected;

- Hyper-correction (exaggerated correction), called hallux-varus, is a redoubtable complication and poorly tolerated, but benefiting from correction techniques;

- Relapse is the reproduction of the initial deformation, eventually of increased severity; contrary to the spread myths, recurrence is not caused by “elegant” footwear, but it is the result of some obsolete surgical procedures, maiming for the joints and, unfortunately, very widespread in Romania; the major problem is the psychological part, because the disappointed patient refuses a new surgical operation.

- Transfer metatarsalgia occurs after inadequate treatment and requires, as a resumption, a “global” type surgery;

- Infection is an inherent complication of any surgical procedure. The strict application of the internal rules of sterility, as well as the use of minimally invasive procedures can reduce infection rates;

- Algodystrophy, joint stiffness and venous thrombosis are complications due to immobilization and insufficient analgesia, sometimes the particular vascular land (varicose veins);

- Shortening of the hallux, cook-up deformation and retraction of the sesamoids, necrosis of the metatarsal head and rapidly progressive osteoarthritis,  unconsolidating and secondary movement are the result of an improper procedure or “bricolage” with insufficient technical means.


Results

- In the hands of a specialist, modern procedures provide excellent results, both aesthetic and functional: the foot regains its form and function and it can use an elegant shoe

- The results are stable over time: modern techniques have a relapse rate of about 2-5%, compared to the “classic” ones, renowned for their relapse of more than 50-60%.

- The satisfaction of patients is quite exceptional, the evidence being their request to operate the other leg or some relatives and close friends.

- Relapse may be related to the decompensation of a rheumatoid arthritis, sudden weight gain, the existence of some extremely complex deformations, foot-flat, etc..

- This surgery is growing, always appearing unique procedures, the abandonment of the existing ones, multi-disciplinary approaches.

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