How to recognize hallux valgus and how to treat it

"Hallux valgus is a lateral deviation of the phalanges of the big toe from a physiological axis. A valgus angle between 8° and 10° is considered physiological, but if it is higher, it becomes a pathological condition. This does not mean that surgery needs to be done immediately, but it does mean that the big toe is taking a deviation beyond the limits that could cause pain," Dr. Alberto Patelli explains. 

It is easy to recognize with the naked eye because the big toe appears laterally deviated, with the 2 phalanges going toward the other toes. The alarm bell, however, in addition to pain, is the reddening of the medial prominence of the metatarsal head, the so-called "onion" (a bulge caused by friction between the bone and nearby soft tissues), associated with swelling.

Diagnosis involves a thorough physical examination by evaluating the patient in both a sitting and standing position and, subsequently, an X-ray of both feet taken in a loaded position, that is, with the patient placed in an upright position during the examination.

Hallux valgus affects just about everyone, including men and adolescents, but particularly women aged 45 to 50. There is also heritability with respect to the occurrence of hallux valgus.

High heels and pointed shoes promote the occurrence of hallux valgus, but there are also anatomical causes such as:

• a very varus first metatarsal bone (with inward deviation), from morphological point of view;
• feet that pronate a lot, that is, those that have a tendency to fall inward. 

It depends on both the severity of hallux valgus and the possible presence of other foot conditions such as metatarsalgia, hammertoes, Morton's neuroma, and/or joint stiffness. 

When a hallux valgus is not particularly severe, nonsurgical treatment may be provided. In mild cases, the trend is conservative, i.e., averting the use of surgery and opting for orthotic appliances, spacers, corrective stockings, orthotics, braces, and wide-fitting footwear useful for slowing the progression of hallux valgus.

In more severe cases, however, surgery must be contemplated.

How surgery works 

The use of surgery to correct hallux valgus is not indicated for everyone. It should be evaluated very carefully for:

• diabetic patients;
• those with rheumatoid arthritis;
• those with metabolic syndromes;
• people who are overweight;
• heavy smokers (because of possible postoperative circulatory consequences). 

The intervention includes: 

• overnight stay of at least 1 night (for pain management);
• anesthesia, usually spinal, to numb the limb to be operated on;
• operation that takes approximately 35 to 40 minutes. 

As with all surgeries, there are postoperative complications, such as: 

• infections;
• wounds that do not heal;
• vascular issues (necrosis of the metatarsal head);
• defects in calcification of bone that does not weld properly;
• algodystrophic syndrome (chronic condition characterized by intense pain);
• typical complications of hallux (a few days after surgery or within a longer time), which can recur even after its surgical correction while not bringing the pain suffered before the operation.

Return to everyday life

One could return to walking right away but, as a precaution, it is preferred to prescribe 7 to 10 days of rest with minimal activity, resorting to small expedients useful in this healing phase (high foot and ice).

Once the initial dressing is done and the good condition of the foot is confirmed, one can return to walking with crutches and orthopedic shoes that will have to be used for 21 and 40 days, respectively.

The postoperative period is delicate: the big toe joint, in fact, tends to stiffen causing other problems to occur for which it would be appropriate to undertake a specific physiotherapy course.