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Bunions, Hallux Abductovalgus, and Hallux Limitus Resources
A bunion is a bony prominence that typically occurs on the inner side of the forefoot at the base of the big toe. The problem is also associated with a big toe that is deviated towards or under the second toe. The medical term for this condition is called hallux abductovalgus (with bunion).
The bunion is not a growth of bone or a calcium deposit. The bunion is actually the rounded end of the first metatarsal bone (the bone just in back of the big toe joint) that is slowly dislocating towards the inner side of the foot. As the big toe dislocates towards the second toe, the first metatarsal buckles in the opposite direction towards the inner side of the foot.
The condition is not always painful, but can be, if the deformity is large enough, activities are strenuous enough, or shoes are too tight or have heels that are too high. When pain is present, it usually results from shoe pressure on the bunion. Other times, pain can also occur at the top of the joint if it is jamming with activities or with wearing heels. Rarely, pain can be cause by degenerative arthritis in the big toe joint that can develop in long-standing advanced cases of hallux abductovalgus.
The condition usually develops slowly over a period of years. During this time, both the big toe deviation and the bunion size progress. The condition usually starts at a young age and slowly progresses over time, resulting in a deformity large enough to cause pain in the 40s or later. However, the condition can occasionally be seen to progress more rapidly and become large enough to cause pain in late childhood and early adolescence.
The condition develops as a result of abnormal mechanics of the foot in general and the big toe joint in particular. The biggest factor that plays a role in determining abnormal foot mechanics is heredity. Therefore, heredity is the biggest factor in determining whether someone develops this condition. Nevertheless, there are other causation factors and usually there are a combination of these factors that ultimately determine whether someone develops a bunion, and how fast the condition progresses.
Factors that can lead to hallux abductovalgus with bunion
- Heredity / Abnormal mechanics of the foot and big toe joint
- Poor shoes - especially tight shoes, pointy shoes, and high heels
- Injury
- Arthritis disorders - rheumatoid arthritis, gout
- Demanding activities - V ballet, running, rock climbing
- Tight calf muscle
The condition can be found equally developed on both feet (symmetrical), but in other cases, one foot may have a more pronounced deformity than the opposite foot (asymmetrical). When the condition is asymmetrical, it is usually more pronounced on the side of a leg that is longer than the other, or less frequently, on a foot that has previously developed a collapsed arch from isolated Posterior Tibial Tendon Problems.
Treatment of the condition falls into non-surgical and surgical categories. The goal of non-surgical treatment is to eliminate pain and/or prevent progression of the deformity. The goal of surgical treatment is to eliminate pain and correct the deformity. Non-surgical treatment usually does not correct the deformity.
For more on background information about bunions and hallux abductovalgus, please take the time to complete Kaiser's EMMI interactive online program: "Understanding Bunionectomy Surgery".
Also, keep in mind that hallux limitus/rigidus can affect also the same area of your foot. Hallux limitus is the term used for the condition that is associated with limited movement of the big toe joint in the upward direction. In other words, the big toe joint does not bend enough when the heel rises off the ground with walking or wearing a heeled shoe. Hallux rigidus is the term that is sometimes used interchangeably, but usually refers to the condition when the joint mobility is more severely limited, or rigid.
When the big toe joint does not bend enough when the heel rises off the ground with walking or wearing a heeled shoe, the joint jams and can cause pain. Over a period of years, the joint cartilage may become worn out by repetitive jamming. Furthermore, the joint may develop bony prominences on top of the joint (called osteophytes), or enlargement of the joint as a whole. These joint changes are degenerative arthritis, and can progress over the years.
Pain usually is felt at the top of the joint, resulting from joint jamming at the top of the joint with walking or other activities that require the joint to bend (like running, squatting, or wearing high heels). In some cases, the bony prominence can become painful from direct shoe pressure. In advanced cases, the degenerative joint disease (degenerative arthritis) can cause deep aching in the joint at the end of the day as well.
The condition usually develops as a result of abnormal mechanics of the big toe joint. The most common cause of abnormal mechanics of the big toe joint that leads to hallux limitus is an inherited malposition of the first metatarsal bone (either too long or too elevated). Therefore, heredity is the leading cause. Nevertheless, there are other causation factors and sometime there are combinations of these factors that ultimately lead to hallux limitus.
Factors that can lead to hallux limitus / rigidus
- Heredity / Abnormal mechanics of the foot and big toe joint
- Injury
- Arthritis disorders (like gout)
- Demanding activities – ballet, running, squatting
- Poor shoes – high heels
- Neuromuscular conditions
Like bunions / hallux abductovalgus, treatment of hallux limitus/rigidus falls into non-surgical and surgical categories. The goal of non-surgical treatment is to eliminate pain and/or prevent progression of the deformity. The goal of surgical treatment is to eliminate pain and correct the deformity. Non-surgical treatment usually does not correct the deformity.
Non-surgical Treatment
Wear appropriate shoes. For bunions (hallux abductovalgus) and hallux limitus/rigidus alike, the shoes should have ample toe box width and should be made of soft upper materials. High heels must not be worn. Purchase your shoes only after being properly measured for your length and width, and preferably later in the day. Additionally, for hallux limitus, you should use shoes with a stiff sole and possibly a rockersole. Clogs are one example of such shoes, as are MBT shoes or Sketchers Shapeups.
Have your shoes stretched at a shoe repair shop. Ask the shoe repairperson to "spot stretch" just the spot on the shoe that is overlying the bunion. Some people have also obtained great relief by cutting an x in the shoe at the spot that overlies the bunion.
Use orthotic inserts in your shoes.Foot orthotics help to control the abnormal mechanics of the foot that may be at the root of the problem.
- Over-the-counter orthotics are pre-fabricated, usually based on shoe size, are less expensive than custom-made orthotics, and may be less effective than custom foot orthotics. For over-the-counter foot orthotics, we prefer Superfeet orthotics. You can purchase them at the Depot Store next to the Department of Foot and Ankle Surgery in MOB4.
- Custom foot orthotics are made from plaster molds of your feet, are more expensive than over-the-counter orthotics, and are usually more effective than over-the-counter foot orthotics. Custom foot orthoses are not a covered benefit of the Kaiser Health Plan. Custom foot orthoses may be needed if you fail to respond adequately to over-the-counter arch supports, or if your foot shape creates the need. Prescription made custom foot orthoses from plaster cast molds of your feet can also be purchased by starting the process through the Depot Store.
Use padding. There are numerous types of pads that are available over-the-counter. We recommend silicone gel bunion cushions. Also, a silicone gel toe separator between the first and second toes may be helpful. You can purchase these items at the Depot Store next to the Department of Foot and Ankle Surgery in MOB4.
Perform calf stretching exercises for 30-60 seconds on each leg at least two times per day. Stand an arm's length away from the wall, facing the wall. Lean into the wall, stepping forward with one leg, leaving the other leg planted back. The leg remaining back is the one being stretched. The leg being stretched should have the knee straight (locked) and the toes pointed straight at the wall. Stretch forward until tightness is felt in the calf. Hold this position without bouncing for a count of 30-60 seconds. Repeat the stretch for the opposite leg. Here's a picture demonstrating the stretch.
Use ice on the painful area for 5-10 minutes, 1-3 times per day - especially in the evening. Fill a styrofoam or paper cup with water and freeze it. Peel back the leading edge of the cup before application. Massage the affected area for 15-20 minutes. CAUTION: AVOID USING ICE WITH CIRCULATION OR SENSATION PROBLEMS.
Use an oral anti-inflammatory medication. We recommend over-the-counter ibuprofen. Take three 200mg tablets, three times per day with food - breakfast, lunch, and dinner. To obtain the proper anti-inflammatory effect, you must maintain this dosing pattern for at least 10 days. Discontinue the medication if any side effects are noted, including, but not limited to: stomach upset, rash, swelling, or change in stool color. IF YOU TAKE ANY OF THE FOLLOWING MEDICATIONS, DO NOT TAKE IBUPROFEN: COUMADIN, PLAVIX, OR OTHER PRESCRIPTION OR OVER-THE-COUNTER ORAL ANTI-INFLAMMATORY MEDIACTIONS. IF YOU HAVE ANY OF THE FOLLOWING HEALTH CONDITIONS, DO NOT TAKE IBUPROFEN: KIDNEY DISEASE OR IMPAIRMENT, STOMACH OR DUODENAL ULCER, DIABETES MELLITUS, BLEEDING DISORDER.
Use over-the-counter glucosamine sulfate, chondroitin sulfate, and/or MSM. If you have degenerative joint disease in the big toe joint, these supplements may be of some benefit.
Your doctor may inject the joint with cortisone. This procedure is used more often for hallux limitus/rigidus than for bunions / hallux abductovalgus - particularly if degenerative joint disease id present and the joint is significantly inflammed and painful. Injection of cortisone is a potent way to reduce inflammation and joint pain. The risks of cortisone injections for hallux limitus/rigidus include, but are not limited to: increased pain for 24-72 hours following the injection, depigmentation of the top of the joint, weakening of remaining joint cartilage and progression of degeneration, and infection. Systemic side effects of this type of injection are extremely rare.
Surgical Treatment
Bunions / hallux abductovalgus There are a number of different procedures that are used for the surgical correction of hallux abductovalgus with bunion. In general, the surgery involves more than simply "shaving off the bunion". The surgical correction usually involves rebalancing the tendons and ligaments around the big toe joint and perhaps bone cuts near the big toe joint to improve the alignment of the big toe. Most importantly, the abnormal position of the first metatarsal must be surgically corrected by either a bone cut of the first metatarsal or a fusion near the midfoot. Furthermore, additional surgical procedures may be required to correct associated deformities (like Hammertoes) or predisposing factors (like a tight calf muscle). The number and nature of the procedures required for correction of your foot is determined by an examination of your foot clinically and with x-rays.
Typically, the surgery is performed on only one foot at a time. Usually bone screws are used to stabilize bone cuts or fusions and stay implanted permanently. The surgery is usually performed on an outpatient basis. Depending on the actual procedures required, you may or may not be allowed to walk on the foot after surgery and you may or may not be required to be in a cast.
Full recovery may take 4-6 months, or more. Depending on the type of work that you do, you will be advised to remain off work for as little as 2 weeks (for a completely sedentary job with no mobility requirements) to as much as 2-3 months (for a job that requires standing/walking).
The success rate is approximately 85%. Approximately 12% are improved, but may still have some limitations or footwear or activities. About 3% are no better or worse. Risks include, but are not limited to: undercorrection, overcorrection, recurrent deformity, stiffness of the big toe joint, weakness of the toe, transfer of pain or callus to an adjacent bone or area, broken pins or hardware, intolerance of pins or hardware, delayed or non-healing of bone, nerve injury or entrapment, delayed incision healing, painful or unsightly scar, prolonged recovery, recurrent pain, incomplete relief of pain, no relief of pain, worsened pain, and circulation impairment or loss of the toe.
Hallux limitus/rigidus There are a number of different procedures that are used for the surgical correction of hallux limitus/rigidus. If the limitation of range of motion of is severe, or if the joint is significantly involved with degenerative arthritis, salvage of the joint is probably not possible. On the other hand, if the limitation of range of motion is not severe, and the degenerative arthritis is mild, then it might be possible to salvage the joint.
If the joint is not salvageable, there are three possible surgical options – fuse the joint (called arthrodesis), replace the joint, or simply remove the joint. Arthrodesis is the most common approach, offering a lasting correction of the pain and bony prominence. Arthrodesis eliminates all motion of the big toe joint (although the amount of motion present before surgery is already quite limited and painful). Joint replacement retains motion at the joint, but is not favored as much as an arthrodesis because replacement is more likely to result in pain under the ball of the foot near the base of the second toe, and the joint replacement can wear out and require future surgery. Simple removal of the joint is seldom suggested because it significantly destabilizes the joint – leaving it as an option only for those patients that cannot tolerate arthrodesis or replacement.
If the joint is salvageable, then removal of spurring around the joint (called cheilectomy) is usually combined with various bone cutting and repositioning procedures of the first metatarsal bone in order to reduce pain and improve joint mobility. It is possible that even if the joint is successfully salvaged, pre-existing degenerative arthritis may still progress over the years and cause recurrent symptoms years after the procedure.
Typically, surgery is performed on only one foot at a time. Usually bone screws are used to stabilize bone cuts or fusions and stay implanted permanently. The surgery is usually performed on an outpatient basis. Depending on the actual procedures required, you may or may not be allowed to walk on the foot after surgery and you may or may not be required to be in a cast.
Full recovery may take 4-6 months, or more. Depending on the type of work that you do, you will be advised to remain off work for as little as 2 weeks (for a completely sedentary job with no mobility requirements) to as much as 2-3 months (for a job that requires standing/walking).
The success rate is dependent on the procedure and the severity of the condition, but usually approaches 85%. Approximately 12% are improved, but may still have some limitations or footwear or activities. About 3% are no better or worse. Risks include, but are not limited to: undercorrection, overcorrection, recurrent deformity, stiffness of the big toe joint, weakness of the toe, transfer of pain or callus to an adjacent bone or area, broken pins or hardware, intolerance of pins or hardware, delayed or non-healing of bone, nerve injury or entrapment, delayed incision healing, painful or unsightly scar, prolonged recovery, recurrent pain, incomplete relief of pain, no relief of pain, worsened pain, and circulation impairment or loss of the toe.
For more details about surgery for bunions, hallux abductovalgus, and hallux limitus/rigidus, please take the time to complete Kaiser's EMMI interactive online program: "Understanding Bunionectomy Surgery".
Links and Documents
Also click on the "Foot and Ankle Surgery Resources" section on the navigation bar to the left.
Kaiser's EMMI interactive online program: "Understanding Bunionectomy Surgery"
Bunions / Hallux Abductovalgus
Hallux Limitus / Hallux Rigidus
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