Hallux valgusBMJ 2010; 341 doi: http://dx.doi.org/10.1136/bmj.c5130 (Published 27 September 2010) Cite this as: BMJ 2010;341:c5130
- Robert Choa, orthopaedic and plastic surgery trainee1,
- Robert Sharp, consultant orthopaedic surgeon1,
- Kamal R Mahtani, academic clinical fellow2
- 1Department of Foot and Ankle Surgery, Nuffield Orthopaedic Centre, Oxford, UK
- 2Department of Primary Health Care, University of Oxford, Oxford OX3 7LF
- Correspondence to: K R Mahtani
- Accepted 6 September 2010
A 52 year old woman consults you because she is worried about the shape of her feet. She mentions that over the past few months her shoes have become increasingly uncomfortable, and she was finding it hard to replace them with better fitting ones. On examination you note bilateral hallux valgus.
What you should cover
Hallux valgus, also known as a bunion, refers to lateral deviation of the first toe at the metatarsophalangeal joint (figure⇓). It commonly presents with medial foot pain, which is especially noticeable to the person when he or she is wearing shoes.
The cause of hallux valgus can be extrinsic or intrinsic.
Footwear is the principal extrinsic contributor to hallux valgus (such as narrow high heels).1 Postulated intrinsic causes include family history (rates of a family history of the condition of about 83% have been reported 2), association with pes planus (flat foot),3 and contracture of the Achilles tendon.4
Differential diagnoses include hallux rigidus (arthritis of the joint), sesamoiditis, fractures, gout, rheumatological disease, neurological pain (usually diabetes), and infection.
What you should do
Avoid examining the patient standing up as this exaggerates the deformity.
Observe the foot arch, looking for pes planus. Ask the patient to stand up and turn around and stand on tip toe (pain permitting).
Distinguish hallux valgus from hallux rigidus, which is managed differently. With hallux rigidus the patient has pain and stiffness mainly within the first metatarsophalangeal joint without dorsiflexion.
Note the severity (degrees of lateral deviation of the proximal phalanx from the first metatarsal: <15° normal, <20° mild, 20-40° moderate, >40° severe).
Other important features include involvement of the second toe (which may be at risk of dislocation), skin quality (callous indicates points of overload; skin breakdown is a possible precursor to foot ulceration), and pulses and sensation. Stiffness of the first metatarsophalangeal joint suggests arthritis; consider hallux rigidus, as the management differs.
Conservative management most importantly includes modification of footwear—wide shoes with a soft sole and low heel are recommended. Over the counter devices such as felt bunion pads and bunion posts may improve symptoms further. If these measures fail, chiropody referral for custom made night splints can be beneficial in some patients—for example, for those with deformity who decline surgery. Some studies have shown that orthotics substantially improve foot pain associated with hallux valgus.5 Hallux valgus is normally slowly progressive, so the risk of trying initial conservative management is low as it has been shown not to jeopardise the final outcome.6
Surgery can be considered if symptoms remain despite conservative measures or if the deformity has progressed (box). Risks of surgery for hallux valgus include hallux varus (overcorrection), recurrence, and worsened function. Not all patients will return to their previous level of activity, and up to a third will not be able to wear their shoe of choice postoperatively.7
Reasons for referral to secondary care
Diabetic or neurological history
Breakdown of skin
Failure of conservative measures
Involvement of second toe
Surgery is generally a daycase procedure. Patients can expect to walk with crutches for two weeks, and then gradually increase weight bearing up to normal at about 6 weeks.
Patient UK (www.patient.co.uk/health/Bunions-(Hallux-Valgus).htm)—Evidence based information written by general practitioners
eMedicine (http://emedicine.medscape.com/article/1232902-overview)—Evidence based information, updated regularly
Robinson AHN, Limbers JP. Modern concepts in the treatment of hallux valgus. J Bone Joint Surg [Br] 2005;87-B:1038-45.
Cite this as: BMJ 2010;341:c5130
This is part of a series of occasional articles on common problems in primary care. The BMJ welcomes contributions from GPs
Funding: No special funding.
Competing interests: All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous 3 years; no other relationships or activities that could appear to have influenced the submitted work.
Provenance: Not commissioned; externally peer reviewed.
Patient consent obtained.