What is the Hallux valgus and how is it treated?

Hallux valgus, popularly called “Gout”, is actually a deformity of the first toe with an outward bend at the level of the metatarsophalangeal joint.

The picture shows Hallux valgus.

The disease develops gradually, and progresses even more with age. Pain worsens while walking, and patients may also experience nighttime pain. With high degree deformities, there are difficulties with movement in the first metatarsophalangeal joint. Diagnosis is determined on the basis of clinical signs and X-rays. In the early stage, conservative and symptomatic treatment is carried out. Surgical correction is performed in severe deformities.

General information about Hallux valgus

Hallux valgus is a valgus deformity of the metatarsophalangeal joint of the first toe. As a result of the deformity, the toe bends outward. Among women, this disease occurs 10 times more often than among men. It is believed that this difference is due to a number of reasons: weakness of the ligament apparatus, wearing uncomfortable and narrow shoes, as well as high-heeled shoes. This disease is widespread and can occur in every age group.

Causes

The main cause of deformity development, in most cases, is a lack of connective tissue. This can be detected in transverse flatfoot, excessive joint mobility, varicose veins, as well as high tension of ligaments, fasciae and skin. Hereditary predisposition – as a rule, similar deformities occur in close relatives (mothers and grandmothers). Other factors include: high-heeled shoes; uncomfortable, narrow and small shoes are secondary factors and lead to the formation of Hallux valgus. The primary causes of Hallux valgus are congenital deformities, foot injuries, and diseases related to nerve conduction disorders in the muscles of the shin and foot.

Pathogenesis of Hallux valgus

In addition to ligament weakness, a certain role in the development of the disease is played by: uneven tension in the adductor and abductor muscles of the first toe, genetic predisposition to develop exostosis of the inner surface of the head of the first metatarsal bone. As the deformity progresses, the uneven muscle tension increases even more, and the metatarsophalangeal joint becomes unstable.

The inner surface of the joint is constantly irritated by contact with the shoes, and as a result the head of metatarsal bone changes its position, forming a bony protrusion, which in turn further increases the deformity. Because the shape of the foot changes, the load distribution also changes – when walking, most of the load is on the heads of the second and third metatarsal bones. This leads to pain and arthritis formation not only in the area of the first metatarsophalangeal joint, but also in the joints of the second and third toes.

Symptoms of Hallux valgus

Patients complain of pain in the area of the first metatarsophalangeal joint. The pain increases with prolonged walking or standing, and subsides with relaxation. Nocturnal pain, especially in the heel area, may occur after heavy exertion. Depending on the severity and nature of the pain syndrome, it can range from mild discomfort (usually in the early stages) to acute, pressing, and even constant, aching pain. The pain syndrome does not always depend on the severity and extent of the deformity, but despite this, the symptomatology becomes clearer when the head of the first metatarsal bone changes position.

During the progression of the deformity, the foot further loses its normal shape, the first toe overlaps the second toe, which often leads to the development of a second toe deformity. All of these factors and bone deformation at the level of the first metatarsophalangeal joint affect the appearance of the foot. Therefore, the reason patients go to an orthopedist is not only pain, but also a cosmetic defect and problems arising in the choice of shoes. Complaints about these problems most often arise in young women.

When examined, the foot is deformed. There is a visible deformity of the first metatarsophalangeal joint and mild to moderate skin hyperemia. The big toe may be curved to the outside of the foot. Palpation may be painless or acutely painful; bone exostosis and thickening of the skin in the area of the first metatarsophalangeal joint are noted. Local edema may be present. There is usually stiffness of motion at the level of the first metatarsophalangeal joint (stiffness of motion may be observed on a larger scale); pain may occur when flexing the thumb as much as possible.

Diagnosis of Hallux valgus

The diagnosis of Hallux valgus is made on the basis of symptoms and radiological examination. The X-Ray of the foot is taken. The severity of Hallux valgus is determined on the basis of two indicators: the angle between the first and second metatarsal bones (Intermetatarsal angle) and the bend angle of the first toe in respect to the first metatarsal bone. Below are the degrees of severity of Hallux valgus.

• Light degree – the angle of Hallux valgus is less than 20 degrees, the angle between the metatarsal bones is less than 11 degrees.
• Medium degree – the angle of Hallux valgus is 20-40 degrees, the angle between the metatarsal bones is less than 16 degrees.
• Severe degree – the angle of Hallux valgus is more than 40 degrees, the angle between the metatarsal bones is more than 16 degrees.

After viewing the X-rays, in addition to determining the severity of the deformity, attention is paid to the presence of severe arthritic changes. Osteoarthritis is indicated by narrowing of the articular cleft, articular surface deformity, osteosclerosis of the subchondral area, and marginal osteophytes.

In some clinical cases, patients are referred for MRI and CT scanning in order to more accurately identify pathological changes in the foot.

MRI is used to evaluate soft tissues, while CT is used to evaluate bony structures. In case of diseases accompanied by neuromuscular conduction disorders, the patient needs to consult a neurologist.

Conservative treatment of Hallux valgus

A complete cure of Hallux valgus is impossible without surgical treatment. However, conservative treatment should be used in young women with a mild degree of the disease and in elderly patients with any degree of deformity. The main goal of such treatment is to reduce pain and prevent the progression of the disease.

The conservative treatment of Hallux valgus includes night orthoses and daytime silicone pads.

The following figure shows the conservative treatment methods: night orthoses and daytime silicone pads

Outpatient treatment is performed by an orthopedic surgeon. During painful sensations, the patient is advised to take anti-inflammatory medications and ointments. During remission of arthrosis of the first metatarsophalangeal joint, the patient is referred to physical therapy. Patients are advised:

• Weight reduction (if overweight) – in order to reduce the load on the foot.
• Load optimization: make a program make a program of specific exercises to strengthen the ligamentous apparatus and muscles of the foot; limit the time of long walks and prolonged standing on their feet.
• Use special orthopedic shoes – to reduce the excessive load on the first metatarsophalangeal joint.
• Use a partition between the first and second toes – in order to prevent the first toe from bending even more.

Surgical treatment of Hallux valgus

Surgical treatment is used when conservative treatment is ineffective. There are about 300 surgical options used to treat Hallux valgus. Operative methods of treatment can be divided into 3 groups:

1. Surgical interventions on soft tissues
2. Surgical interventions on bony structures
3. Surgical interventions on the soft tissues and on the bony structures

Soft tissue surgery is effective only in the first stage of the disease. Silver and McBride surgeries can be used. Silver surgery severes the tendon of the thumb adductor muscle; McBride changes the place of the thumb adductor muscle. The purpose of these surgeries is to balance the tension of the adductor and abductor muscles. These surgeries are often performed in parallel with the removal and displacement of the subcutaneous sac (Shade surgeries) in the area of the bony protrusion of the first metatarsophalangeal joint.

Currently, one of two surgical procedures is used for the surgical treatment of second- and third-degree of Hallux valgus: a zig-zag osteotomy and a Scarf osteotomy. In a zig-zag osteotomy, a small “V” shaped fragment is excised at the distal end of the first metatarsal bone. During the Scarf osteotomy, a “Z” shaped osteotomy is performed over the entire surface of the first metatarsal bone; then the sites of the bone fragments are changed to reduce the angle between the first and other metatarsal bones. The fragments are then fixed with screws.

The figure shows the different types of osteotomies used for the surgical treatment of Hallux valgus

All surgical interventions are performed in the department of Traumatology and Orthopedics. In the postoperative period, the patient is fitted with a special orthesis and allowed to put light weight on the leg. The orthesis must necessarily be used for three weeks. During this period, the leg is elevated and excessive strain is avoided. The patient is allowed to wear loose shoes, some exercises from the physical therapy program and foot massage with a tennis ball.