Bunions and Hallux Valgus
The Highlights
Hallux Abducto-Valgus (HAV) or Hallux Valgus is a largely hereditary deformity leading to an outward positioning of the 1st metatarsal and an inward positioning of the big toe. A bunion (which is a separate issue) is the protrusion/bump on the side of the toe that commonly exists alongside HAV.
These conditions may or may not be painful and may involve secondary arthritis and deformities to other toes. These secondary problems are more often the reason people seek our help.
No conservative treatments can permanently reposition the toe (only surgery can) but many treatments can make it more comfortable including footwear advice, mobilisation techniques and, if arthritis is also present, the use of foot orthoses (specialist insoles) and steroid injections.
What is it and what are the symptoms?
The terms "bunion" and "hallux abducto-valgus" (HAV) are often used interchangeably, even by healthcare professionals, but they are in fact two different but connected things: Hallux valgus describes the positional deformity of the 1st metatarsal bone relative to the bones on either end of it; the medial cuneiform behind and the proximal phalanx in front (1st bone in your big toe) whereby the metatarsal drifts outward from the others and the toe drifts inward toward the others. A "bunion" describes the outward "bump" made of bone and sometimes bursa that develops on the medial side of the big toe joint because of this deformity.
For bunions, the pain is located specifically over the medial bump, usually brought on my pressure from narrow shoes (and relieved of course when they come of). There may be associated redness and swelling which worsens throughout the day.
For HAV, any pain involved is likely due to the uneven forces applied to the big toe joint leading to secondary arthritis. This pain will tend to be more over the top of the toe joint and hurts when the toe is bent upward or downward.
It is important to note that symptoms don't always match the severity of the deformity; some with mild changes have extraordinary pain whilst some, even with severe HAV and bunion deformities, report no pain.
Why does it happen?
Research now tells us that HAV and the bunions that may co-exist with it are highly hereditary - you can blame the family tree and your parents or grandparents for passing on their genes and not so much those bad shoes! Some footwear and biomechanical factors around how your feet function could in theory speed the progression of HAV and bunions but does not appear to cause them in the first place. Sorry folks - it's just luck of the draw!
What are the treatment options?
Conservative treatment of bunions and HAV centres around symptom relief - there is no good evidence that conservative (non-surgical) treatments like splints, braces and insoles can correct a bunion. Yes these things might help with pain relief but they won’t “correct” anything.
Regarding bunions, reducing pressure over the area is important and footwear is key to this. Finding well-fitting shoes is a frequent complaint of many patients and we can offer our experience in finding solutions. We can also provide offloading pads and devices to assist with this further.
In the rather common situation where osteoarthritis is in fact the cause of pain and not the bunion itself (which is why it's important to see an expert to find out), there are perhaps better conservative options we can give you such as foot orthoses (specialist insoles) and corticosteroid injections.
The other common issues to address include pathology affecting the other toes (most often the 2nd). As the 1st toe isn't "behaving itself" there tends to be knock-on effects on the lesser toes. Indeed, people with often visit our clinic specifically about this and have no concern over the HAV / bunion whatsoever.
In many cases, this is a good example of a problem where we will happily refer you to one of our orthopaedic colleagues, either in the NHS of Private Practice, to seek a surgical opinion. HAV and bunion surgery have excellent success rates with many options available depending on your needs.
