Patients › Foot

Hallux valgus

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What you're feeling¶

Hallux valgus is the medical name for a bunion. It means your big toe has drifted sideways, towards your other toes, while the long bone in your foot behind it has shifted the other way. The bump this creates on the inner side of your foot is called the medial eminence.

The most common symptom is pain over that bump, where your shoe presses on it. Many people also get pain in the joint itself at the base of the big toe. Another common spot is pain under the ball of your foot, beneath your second toe. This happens because your big toe is not taking its normal share of the load, so the pressure moves across to the smaller toes.

The deformity can make shoes hard to wear. Narrow or tight shoes rub on the bump and can leave the skin over it red and swollen. The skin can also thicken into a callus from repeated rubbing. Some people notice numbness on the inner side of the big toe from constant pressure inside a shoe. Standing, walking and sport can all become uncomfortable, and you may find yourself choosing wider shoes or avoiding longer walks.

The toe can slowly drift further over time. As it leans across, the tendons that straighten and bend the toe slide out of line, which pulls it even further in that direction. The joint capsule, the sleeve of tissue around the joint, stretches on the inner side and tightens on the outer side, holding the toe in its new position. The two small bones under the big toe joint, called sesamoids, can also slide out of place.

Your foot will be examined while you stand and walk, because the deformity often looks different when you are bearing weight. Weight-bearing X-rays are used to measure the angles of the toe and the long bone behind it. These measurements help decide which type of correction suits your foot.

What's actually happening¶

A bunion is a slow shift in the balance of your big toe joint. The long bone behind your toe, the first metatarsal, drifts inwards while your toe leans the other way, towards your smaller toes. The end of that bone pushes out on the inner side of your foot, and that is the bump you can see and feel.

This happens because the soft tissues holding the toe straight gradually give way. Think of them as guy ropes holding a tent pole upright. The sleeve of tissue on the inner side of the joint stretches out, while the tissues on the outer side tighten up. Once that happens, the tendons that bend and straighten your toe sit to the outer side of the joint instead of straight down the middle, so every step pulls the toe further across. The two small bones under the joint, the sesamoids, slide out from beneath the toe as well, so your big toe takes less of your weight and the ball of your foot under your second toe takes more. That is why pain there often goes with a bunion.

Several things raise the chance of this happening. It runs in families: about 70% of people with a bunion have a relative who has one too. It is about ten times more common in women than men, and it usually shows up between the ages of thirty and fifty. Shoes with a narrow toe box play a part, because they squeeze the toes together. So can loose ligaments, the shape of the joint itself, and conditions such as rheumatoid arthritis, which is wear-and-tear of the joints caused by inflammation rather than use.

As the toe leans further across, it can crowd and push on your second toe, sometimes bending it into a hammer toe. The toe can also rotate, so the nail turns towards your other toes. These changes tend to build slowly over years, which is why the bump and the drift seem to creep up rather than appear overnight.

What we can do about it¶

Dr Kieran Hirpara, an orthopaedic foot and ankle surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your foot. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your first visit we take a history, examine your foot, and use weight-bearing X-rays to measure the angles of the deformity. Those measurements, along with how much the toe can be pushed back into line, help us match the treatment to your foot.

Non-operative care cannot straighten the toe once it has drifted, but it can settle the symptoms. Wider shoes with a roomy toe box take pressure off the bump. Toe spacers and a splint worn at night can ease discomfort, though they are unlikely to correct the deformity. Simple pain medication and anti-inflammatories can help you stay active. We usually suggest giving these measures a fair trial before talking about surgery.

Surgery is considered when non-operative care has not given you enough relief, or when the deformity is severe. The operation is tailored to your foot: the type and severity of the deformity decide which correction is used. Options range from cutting and realigning the metatarsal through small incisions, to fusing joints when the deformity is large or the joint is arthritic. For children and teenagers whose bones are still growing, surgery is usually delayed and non-operative care is tried first, because the toe is more likely to drift back after surgery in that age group. We will talk through the options with you and decide together which suits your foot and your goals.

What to expect¶

A bunion is a slow-moving problem. The drift tends to build gradually over years rather than appear suddenly, and it does not usually settle on its own. Because the toe leans further across as time passes, the discomfort you feel now is likely to continue, and may grow, if the underlying causes are left alone.

Non-operative care can make a real difference to how your foot feels day to day. Wider shoes, spacers and simple pain relief cannot pull the toe back straight, but they can settle the symptoms enough for many people to stay active without surgery. If those measures stop working, or the deformity becomes severe, surgery is the step that actually corrects the position of the toe.

Surgery works well for most people. Reported success rates range from 80% to 95%. The type of correction used is matched to your foot, and mild to moderate deformities and severe ones each have reliable options. Age on its own does not change the outlook for one common procedure, and carrying extra weight has not been shown to spoil the result of another. For severe deformities, 86% of people said the operation was worthwhile eight years later.

It is honest to say that results are not perfect for everyone. When people are followed up many years after surgery, about 25.9% report they were dissatisfied. The main reasons are a deformity that was not fully corrected in the first place, or pain under the ball of the foot that develops later. There is also a small chance the toe drifts back again over time, which is more likely in children and teenagers whose bones are still growing. If that happens, further surgery is possible and newer keyhole techniques can correct a recurring bunion with a low rate of complications.

Recovery after surgery takes weeks to months rather than days, and your surgeon will talk you through what that looks like for your particular operation. The realistic goal is a straighter, more comfortable foot that lets you wear normal shoes and walk without the pain you have now.

When to see someone¶

See your GP if the pain over the bump or under the ball of your foot keeps troubling you despite wider shoes and simple pain relief, or if shoes have become genuinely hard to wear. Ask for a specialist review if your big toe is drifting further over time, if it is crowding or bending your second toe, or if the toe has started to rotate so the nail turns towards your other toes. Numbness on the inner side of the big toe from shoe pressure is also worth having checked. Seek review sooner if the skin over the bump becomes red, swollen or ulcerated, or if you notice changes in the circulation or feeling in your foot, such as absent pulses or skin that looks dusky.

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