What is a Hallux valgus or Bunion Deformity?
When the big toe moves towards the second toe beyond a certain angle, it is termed "hallux valgus" or “hallux abducto valgus”. This is Latin and means a turning outward (valgus) of the big toe (hallux). The bone which joins the big toe, the first metatarsal, becomes prominent on the inner border of the foot and moves away from the 2nd metatarsal forming an increased “intermetatarsal” angle. The bigger this angle, the larger the deformity. His increases the width of the foot, making footwear fitting more difficult and less comfortable. Unless the bump of the joint is accommodated in wider shoes, it will rub causing pain and inflammation in the joint and the surrounding soft-tissue. Frequently, a soft-tissue fluid-filled lump also forms, which is termed a bursitis.
In over 80% of cases we see, there is a positive family history of bunion problems. Changing footwear, wearing pads and straps and splints can certainly be attempted to relive pain. However, the only curative treatment for bunions is surgical correction. Fortunately, newer techniques and advances in technology and anaesthetics, has made the surgery much successful and less painful. In most cases, our patients are fully weight-bearing one week after bunion surgery. Our bunion surgery carries a high satisfaction rate of 93%. All surgery carries risks and potential complications and we encourage our patients to thoroughly read the advice leaflets we supply, which also details the risks, so they are fully informed about the risks of bunion surgery.
The term ‘bunion’ usually refers to the prominent bump of bone with soft-tissue swelling on the side of the joint at the base of your big toe, but the terms hallux valgus and bunion are for all intents and purposes, interchangeable.
As well the soft-tissue bump, the bone itself can increase in size on the inside of the metatarsal head, forming a bone bump. The bump itself is due to increased bone being laid down due to constant shoe-rub causing inflammation. Over time this bone bump can become quite large and itself increase shoe-rub and pain in closed footwear. As the big toe leans into the second toe, the long bone to the toe (1st metatarsal) moves outwards, increasing the width of the foot. The progression of a deformity varies from person to person and also depends on whatever causative factors are involved. However, it is certain that any bunion deformity will increase over time, and this is normally a cause for more symptoms and further difficulties during exercise. You may wish to initially try buying wider than normal footwear to accommodate the bump and shoe-repairers may also be able to stretch the leather over the bump.
A major warning sign of when a bunion is likely to worsen is when the big toe starts to displace the next (2nd toe). In some cases, the big toe can ride over the 2nd toes, although more frequently the 2nd toe over-rides the big toe. Once the 2nd toe is pushed out of the way, the big toe is free to deviate and deform even further towards the little-toe side of the foot (lateral side). This can then develop into a hammertoe, which rubs on shoes and increases the depth of the foot. See below:
In this case the hammertoe will also have to be corrected. Once a 2nd toe displaces completely over the big toe, a bunion can become significantly worse, see below:
If the hammertoe deformity worsens, the 2nd toe joint can undergo a slow dislocation (subluxation). This can lead to pain in the “ball” of the foot as the ligament joining the 2nd toe to the underside of the 2nd metatarsal gets inflamed and stretched. In some cases this ligament – termed the “plantar plate” can tear, causing a plantar plate rupture, which requires a surgical repair. If this is diagnosed (usually by an ultrasound scan or a MRI scan) a surgical repair of the damaged ligament will be necessary.
Although a bunion can be seen easily on x-rays, a plantar plate rupture requires a soft-tissue scan such as ultrasound or MRI scan for confirmation. The facilities for x-rays and soft-tissue scans are all available at our centre in 9 Harley Street, London.
Are there different types of hallux valgus or bunions deformity?
What are the symptoms?
Early symptoms may begin with pain over the prominent bump mainly from shoe-rub. This could be just soft-tissue inflammation initially where redness is seen over the bump on the side of the joint. Joint pain is normally very common and made worse by tighter fitting footwear, although the pain is not always relieved by simply switching to roomier footwear.
With time and often with a long-standing bunion, the 2nd toe can develop into a hammertoe (see above). In long-standing bunion deformities where the big toe has pushed right across and into the toes, hammertoe deformities of all 3 middle toes is not uncommon. Patients who go on to develop this “bunion foot” where the big toe has pushed all the smaller toes into a deformed position may require a more complex surgery, called a forefoot reconstruction.
Secondary joint wear and tear to the cartilage on each side of the joint (osteoarthritis) - is quite common, especially in more long-standing bunion deformities. This may cause continued pain and a stiff joint, even after corrective surgery, although small areas of wear in the cartilage can be repaired during surgery.
In more elderly patients an ulceration and infection can occur from shoe-rub where the skin will be thinner and inflamed over a bunion bump. A simpler procedure called a “Silvers” bunionectomy, can be performed here, where the aim is to reduce the painful bone pump to stop further ulceration occurring.
Finding comfortable shoes with a bunion can become increasingly difficult especially as the big toe moves towards the second toe and the width of the forefoot increases and can cause a “splay" foot. It is also quite common for patients to have a Tailor’s bunion on the little toe joint together with a bunion on the big toe joint. Obviously when this double bunion deformity occurs, the option to correct both sides is available. In our practice we call this the Cinderella surgery procedure, because after surgery, when full recovery is achieved, patients should then be able to fit into a more fashionable shoe with greater comfort. The surgery to both sides of the foot is often combined with correction of any long toes or hammertoes. This type of surgery involving both bunions and toe surgery on one foot, would only be performed on one foot at a time, although we are happy to perform surgery to correct two big-toe (hallux valgus) bunion deformities at the same time (see below).
Below is a picture to show the effects of a corrective double bunion surgery – aka Cinderella surgery. As stated above, we can only perform the surgery on one foot at a time due to post-op pain and immobility, complexity and length of surgery, and safe anaesthetic limits. As stated, in our practice, where patients have hallux valgus of the big toe joint (without Tailor’s bunions), we are able to offer a surgery to both feet (bilateral surgery) at the same time; either under a local or a general anaesthetic.