Hallux Valgus

Aka: Hallux Valgus, Lateral Deviation of the Great Toe, Bunion

1. Definition
   1. Lateral Deviation of the Great Toe (first ray)
   2. Deviates at first Metatarsal-phalangeal joint (MTP)
2. Etiologies
   1. Strong familial predisposition
   2. Hypermobility of first Metatarsal
   3. Predisposing rheumatic conditions
      1. Rheumatoid Arthritis
      2. Gouty Arthritis
      3. Psoriatic Arthritis
   4. Environmental risks
      1. Wearing pointed shoes
      2. Friction over medial first Metatarsal head
   5. Predisposing functional disorders
      1. Metatarsal primus varus
      2. Foot pronation
      3. Tight heel cord
      4. External tibial torsion
3. Associated conditions
   1. Hammer toe deformity of second toe
   2. Osteoarthritis of the great toe MTP joint
4. Symptoms
   1. Pain or deformity at great toe
5. Signs
   1. Increased valgus angle at first MTP joint
      1. Valgus angle at first MTP joint usually <15 degrees
      2. Valgus angle in severe cases >30 degrees
   2. Bunion and inflamed overlying bursa
      1. Bony and soft tissue enlargement
      2. Occurs over medial Metatarsal head of great toe
      3. Soft tissue over Bunion may be inflamed and tender
   3. Painful callus development on 2nd toe
      1. Forced into hyperextension by deviated great toe
6. Radiology: Foot XRay
   1. Medial exostosis (Bunion)
   2. Hallux Valgus
      1. Lateral displacement proximal phalanx
   3. Degenerative changes
      1. First Metatarsal-phalangeal joint (great toe MTP)
7. Management: Conservative Management
   1. Relieve pressure over painful Bunion prominence
   2. Correct functional factors
      1. Correct excessive pronation
      2. Correct Achilles tendon tightness
   3. Properly fitted, low heeled stiff-soled shoes
      1. Wide, square shaped toe box
      2. Toe portion stretched to accommodate Bunion
      3. Extra-depth shoe accommodates dorsiflexed second toe
      4. No inseam where shoe contacts medial Metatarsal head
   4. Functional foot orthosis worn 5-6 hours on most days
   5. Splint separates first and second toe
   6. Avoid tight hose
   7. Acute pain management
      1. Rest
      2. Apply moist heat
8. Management: Surgery
   1. Numerous surgical approaches are described elsewhere
      1. See resources below
      2. Surgery should correct biomechanical factors
         1. Simple Bunionectomy alone may not be effective
   2. Indications
      1. Severe deformity or Bunion pain
      2. Refractory to conservative management above
9. Complications
   1. Bunion Ulceration and drainage
   2. Significant pain limiting activity
   3. Osteoarthritis of the first MTP joint
10. Resources
    1. Textbook of Hallux Valgus and Forefoot Surgery
       1. http://www.ocpm.edu/hallux/index.asp
11. References
    1. Richardson in Canale (1998) Campbell's Ortho, p. 1621-4
    2. Martin in Ruddy (2001) Kelley's Rheumatology, p. 551
    3. Frykberg in Noble (2001) Primary Care Medicine, p. 1211
    4. Torkki (2001) JAMA 285:2474-80