II. Epidemiology

  1. Most common in women (26% of women ages 18 to 65 years, 36% over age 65 years)

III. Definition

  1. Lateral Deviation of the Great Toe (first ray)
  2. Deviates at first Metatarsal-phalangeal joint (MTP)

IV. Risk Factors

  1. Strong familial predisposition
  2. Hypermobility of first Metatarsal
  3. Predisposing rheumatic conditions
    1. Rheumatoid Arthritis
    2. Gouty Arthritis
    3. Psoriatic Arthritis
  4. Environmental risks
    1. Wearing pointed, restrictive shoes (narrow toe box)
    2. Friction over medial first Metatarsal head
  5. Predisposing functional disorders
    1. Metatarsal primus varus
    2. Foot pronation
    3. Tight heel cord
    4. External Tibial Torsion

V. Associated Conditions

  1. Hammer toe deformity of second toe
  2. Osteoarthritis of the great toe MTP joint

VI. Symptoms

  1. Pain or deformity at great toe

VII. Signs

  1. Increased valgus angle at first MTP joint
    1. Valgus angle at first MTP joint usually <15 degrees
    2. Valgus angle in severe cases >30 degrees
  2. Bunion and inflamed overlying bursa
    1. Bony and soft tissue enlargement
    2. Occurs over medial Metatarsal head of great toe
    3. Soft tissue over Bunion may be inflamed and tender
  3. Painful callus development on 2nd toe
    1. Forced into hyperextension by deviated great toe

VIII. Radiology: Foot XRay

  1. Medial exostosis (Bunion)
  2. Hallux Valgus
    1. Lateral displacement proximal phalanx
  3. Degenerative changes
    1. First Metatarsal-phalangeal joint (great toe MTP)

IX. Management: Conservative Management

  1. Relieve pressure over painful Bunion prominence
  2. Correct functional factors
    1. Correct excessive pronation
    2. Correct Achilles tendon tightness
  3. Properly fitted, low heeled stiff-soled shoes
    1. Wide, square shaped toe box
    2. Toe portion stretched to accommodate Bunion (from custom shoemakers who stretch the material)
    3. Extra-depth shoe accommodates dorsiflexed second toe
    4. No inseam where shoe contacts medial Metatarsal head
  4. Functional foot Orthosis worn 5-6 hours on most days
  5. Splint separates first and second toe (may be effective, but no evidence to support)
  6. Avoid tight hose
  7. Acute Pain Management
    1. Rest
    2. Apply moist heat

X. Management: Surgery

  1. Numerous surgical approaches are described elsewhere
    1. See resources below
    2. Surgery should correct biomechanical factors
      1. Simple Bunionectomy alone may not be effective
  2. Indications
    1. Severe deformity or Bunion pain
    2. Refractory to conservative management above
  3. Efficacy
    1. Reduced pain and improved function at 12 months, but no benefit at 2 years
    2. Torkki (2003) Acta Orthop Scand 74(2): 209-15 [PubMed]

XI. Complications

  1. Bunion ulceration and drainage
  2. Significant pain limiting activity
  3. Osteoarthritis of the first MTP joint

XII. Resources

  1. Textbook of Hallux Valgus and Forefoot Surgery
    1. http://www.ocpm.edu/hallux/index.asp

XIII. References

  1. Richardson in Canale (1998) Campbell's Ortho, p. 1621-4
  2. Martin in Ruddy (2001) Kelley's Rheumatology, p. 551
  3. Frykberg in Noble (2001) Primary Care Medicine, p. 1211
  4. Becker (2018) Am Fam Physician 98(5): 298-303 [PubMed]
  5. Torkki (2001) JAMA 285:2474-80 [PubMed]

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