Hallux valgus (bunion)

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What is a hallux valgus?

A hallux valgus is the medical term for a deviation in alignment of the big toe. This involves the joint at the base of the big toe developing a sideways angle. It is also known as a bunion.

Common causes for developing a hallux valgus include:

Poor ankle & foot alignment (termed biomechanics) such as a flat foot posture
Previous ankle, foot or metatarsophalangeal (MTP) joint injury
Degenerative change due to other conditions such as age-related osteoarthritis or rheumatoid disease
Repeated use of poorly-fitting footwear or everyday use of high-heeled footwear
There may be a genetic element, and hallux valgus sometimes runs in families

Common symptoms

The first symptom of a hallux valgus may be noticing the big toe pointing towards the other toes, resulting in the base of the big toe sticking out. As the hallux valgus worsens, pain may be felt primarily across the top and the inside of the base of the big toe. Often the pain is associated with a stiffness of the joint and there may be swelling or thickening of the skin on the inside of the joint as the skin reacts to being rubbed against footwear. This may become red and inflamed , known as Bursitis.

How is a hallux valgus diagnosed?

A hallux valgus can be reliably diagnosed by your doctor or physiotherapist taking a history of your condition and by conducting a physical examination.

The main feature on examination is the characteristic angulation of the big toe MTP joint.

X-rays are not routinely required, but may be requested if symptoms are severe enough that surgery is being considered or to assess the degree of osteoarthritis at the big toe joint.

How is hallux valgus treated?

Non-surgical management
Mild hallux valgus can be managed effectively by non-invasive measures as described below.

Footwear
The most effective measure is wearing the most appropriate footwear and orthotics (insoles).

Hallux valgus splint
Splints may be purchased for symptomatic relief.

Exercises
Regular exercises to maintain flexibility to the ankle and foot.

Using painkillers when needed
Over-the-counter analgesia is available through pharmacies when needed. Paracetamol is most commonly prescribed. Anti-inflammatories are also used eg Ibuprofen, but as there is little or no inflammation involved in osteoarthritis these are best avoided without discussing with your GP. Side effects are even more common than with paracetamol so please ensure to take appropriate medical advice. There is a good booklet on the Versus Arthritis website with information about the various drug options.

https://www.versusarthritis.org/about-arthritis/treatments/drugs/painkillers-and-nsaids/

Surgical management
There are several different types of surgery which can be performed to correct a hallux valgus. If needed, the most suitable surgery for your age, activity level and the anatomy of your joint prior to surgery will be considered. The most commonly performed surgeries are a scarf osteotomy or a chevron osteotomy both of which involve a bone cutting procedure and then realigning the deviated big toe to a straight position.

Any surgical option will usually require you to wear a heel weight-bearing shoe or boot for 6-8 weeks and you will need to use crutches, to ensure that the operated area can heal properly. You will not be able to drive during this time. Most people are not able to wear their normal footwear for about 6 months.

Surgery will only be considered in patients who:

- Have trialled a course of non-surgical management without success

- Have consistent, disabling pain significantly limiting mobility

- Have a satisfactory Body Mass Index (BMI) or have made lifestyle changes to lose excess bodyweight