Hallux Valgus, a slow-developing problem, is evident when the big toe or hallux angles off towards the outside of the foot, frequently practically overlapping or bumping into the adjacent toe. In addition, a bump, called a Bunion, often occurs on the inside of the big toe. Bunions can get pretty ugly -- and not just because they look funny, but because with the big toe angled so oddly, the foot loses the normal function of that joint and changes how a person walks. They can also be very painful. Hallux Valgus pain is usually felt during weight-bearing activities such as walking or prolonged standing, but if a bunion has developed, a "numbing" or "burning" pain in the big toes can be felt at rest.
The joint between the big toe and the first metatarsal (the first metatarsal-phalangeal) is the genuine problem, and not the bone, itself. It is the damage to this joint that produces the pain and deformity associated with hallux valgus. The challenge is usually the after effect of wear and tear over a long period of time from factors such as over-pronation that causes aberrant pressure on the big toe and first metatarsal during walking.
Another cause of hallux valgus is inflammatory arthritis that can damage the joint and cause degenerative changes. A broken toe that does not heal properly can also predispose a person to hallux valgus. However, one of the most recognizable causes of the problem is the high-heeled and pointed shoes that women often wear. These shoes not only put added stress on the joint, but also help in pushing the big toe to the outside.
The anatomy and movement of the joints in the first (big) toe are quite complex. By analyzing the joint in three dimensions (3-D) utilizing the computerized 'Footmaxx' gait scan analysis available in Dr. Pisarek's office at Advanced Healthcare, it's possible to see that the joint functions like a pin around which the bones rotate. This is called a joint axis.
The shape of the arch of the foot affects the axis of the first metatarsal (big toe). As the arch drops down, the first metatarsal axis becomes more vertical (aligned up and down). Shifting of the hallux and first metatarsal occur and that affects the joint axis, too. Pressure on and stretching of the ligaments and cartilage around the joint further weaken the support of the bony structures.
With the right kind of support, the metatarsal axis can be oriented more toward the horizontal (straight across from side to side). In this way, the arch can help support the weight of the body without collapsing, shifting the arch, and altering the alignment of the foot. The words of the song Dem Bones (the toe bone is connected to the foot bone, the foot bone's connected to the ankle bone) are quite right. A shift in one arch affects joint axis, bones, ligaments, alignment, and so on.
Non-Surgical Conservative Approaches to Managing Bunions:
1. Custom Orthotics for Bunion Relief - As bunion formation is often greatly influenced by mid-foot instability, adding arch support with mid-foot and hind-foot control and correcting the foot position can slow the worsening of bunion deformities. Some modifications and corrections can be built into the customized orthotic shoe insert to 'off-weight' pressure to the bunion area.
It's possible that the use of an orthotic to support the arch early on may prevent this unsightly deformity. At least that's what a group of Chiropractors at the University of Minnesota Medical School are proposing. If that's true, it will be the first treatment discovered to affect bunions in any way other than surgery. And that would be good news for bunion sufferers!
2. Adjunctive Therapy - may involve physiotherapy, low level laser therapy, chiropractic joint mobilization and ankle/foot exercises. However, some severe chronic bunion sufferers may eventually require a surgical consultation if no relief is attained through non-surgical methods.
3. Shoes - Appropriate shoes can greatly reduce bunion pain. Avoid shoes with a tight, narrow toe box that pushes the big toe toward the second toe. A more rounded and wider toe box will reduce pressure influencing and pushing the bunion and big toe into a progressively worse position. In terms of heel height, flats aren't recommended, nor are high heels. Choose something in the middle.
4. Exercise & Stretching - Stretching exercises and range of motion maneuvers can help reduce bunion discomfort. The 1st metatarsal and big toe begin to assume a position that is out of alignment. Pushing and manipulating the 1st metatarsal over and straightening the big toe, then moving the big toe joint up and down can encourage better motion and position of the big toe. It can also help prevent stiffening of the big toe joint in a misaligned position.
5. Activity Modification - While we hate to recommend a less active lifestyle, if bunions begin to hurt, it may be wise to modify activities. For exercise, choose activities that don't include repetitive pressure on the ball of the foot (things like lunges and step aerobics may be contributing to bunion pain). There are plenty of exercise with lower stress on bunion areas, like stationary bike, rowing machine, swimming, weight training, etc.
6. Bunion Pads - There are a host of padding options for bunions. These include silicone gel sleeves that cushion directly over the bunion prominence. Moleskin can reduce rubbing in certain shoes. Toe spacers placed between the big and 2nd toe can help better align the big toe.
7. Bunion Splints - There are bunion night splints that place a corrective stretch on the bunion and big toe joint. They can be very helpful to keep the joint stretched out, avoid stiffening in the misaligned position, and can help slow the worsening of the bunion.
8. Prescribed Medications - Whether topical, oral, or injected, anti-inflammatory medications can reduce pain temporarily, steroid or cortisone injections can help short term but are quite negative to the soft tissue structures and should be used very sparingly. They can thin the skin and joint capsule. Topical medications like compound creams, Orthogel, BioFreeze, Voltaren emugel, Lidocaine patches can all help reduce pain and inflammation. They don't fix bunions, but can make them complain less. New techniques such as PRP or amniotic membrane injections can improve a painful joint.
Can a Bunion Be 'Cured' Without Surgery?
Please keep in mind that the only “real cure” for bunions is surgery. However, these conservative tips above for smart conservative choices and management can help reduce pain and slow the worsening of bunions.
When is it Time for Bunion Surgery?
Many patients ask "When should I have surgery?" In most cases, it is recommended to consider surgery when it is regularly painful, and has begun to limit your desired activities and important shoe choices (such as you cannot wear dress shoes and you need to dress up). When this happens, it may be time for surgery.
If you wait too long, the problem begins to expand to include arthritis in the big toe joint, sesamoid pain and arthritis, 2nd hammertoe deformity, joint dislocations, and so on. It's best to fix bunions before they become a more global forefoot problem.
If you are experiencing hallux valgus, Dr. Pisarek can examine your foot to determine which factors are contributing to your challenge, and then use a number of chiropractic techniques, modalities and/or orthotics to lessen pain and improve the function of your foot.
If your condition does not improve, then Dr. Pisarek will refer you to a Podiatrist or medical health provider for further evaluation if prescribed medication, over-the-counter (OTC) medications or surgical intervention will be appropriate in a patient's particular case management for bunions.