Big Toe Pain

Bunions (hallux valgus; hallux abducto valgus)

What is a bunion (hallux valgus; hallux abducto valgus)?

A bunion is generally considered as an enlargement of the joint (a lump of bone) at the base and side of the big toe – (specifically, the first metatarsophalangeal joint). Bunions form when the toe moves out of place. As the big toe bends towards the others this lump becomes larger and the bunion can become painful – arthritis and stiffness can eventually develop. Hallux valgus or hallux abducto valgus (HAV) is the name used for the deviated position of the big toe and a bunion refers to the enlargement of the joint – most of the time the two go together and can just be referred to as ‘bunions’.

The word bunion is from the Latin “bunion,” meaning enlargement.

What are the symptoms of bunions

Bunions starts as the big toe begins to deviate, developing a firm bump on the inside edge of the foot, at the base of the big toe. Initially, at this stage the bunion may not be painful. Later as the toes deviate more the bunion can become painful – there may be redness, some swelling, or pain at or near the joint. The pain is most commonly due to two things – it can be from the pressure of the footwear on the bunion or it can be due to an arthritis like pain from the pressure inside the joint. The motion of the joint may be restricted or painful. A hammer toe of the second toe is common with bunions. Corns and calluses can develop on the bunion, the big toe and the second toe due to the alterations in pressure from the footwear. The pressure from the great toe on the other toes can also cause corns to develop on the outside of the little toe or between the toes. The change in pressure on the toe may predispose to an ingrown nail.

What causes a bunion

Wearing footwear that is too tight or causing the toes to be squeezed together are the most commonly blamed factor for the cause of bunions and hallux valgus and is undoubtedly the main contributing factor. This probably is the reason for the higher prevalence of bunions among women. However, studies of some indigenous populations that never wear footwear, show that they also get bunions – BUT, they are very uncommon. As they do get bunions, factors other than footwear must play a role in the cause, even though footwear is the main culprit for providing the pressure that causes the symptoms.

Bunions are most widely considered to be due to an imbalance in the forces that is exerted across the joint during walking. The resulting abnormal motion and pressure over the joint, over many years (combined with poor fitting footwear) leads to instability in the joint causing hallux valgus and bunions. Bunions are really only a symptom of faulty foot mechanics and are usually caused by a combination of the way we walk, the foot we inherit and inappropriate footwear use.

Bunions are not inherited, but do tend to run in families. What is inherited is the poor or faulty foot type, that mechanically can lead to the instability around the joint that will eventually lead to bunions – how soon, how quickly and how bad they are or become is assumed to be very dependant on the footwear.

A number of other factors are known to play a role in the cause of bunions and hallux valgus. Bunions can follow foot injuries and develop in those with neuromuscular problems. Those with flat feet or pronated feet appear to be more prone to the instability about the joint and have a higher incidence of bunions. Some activities (eg ballet dancing) puts added pressure on the joint and may increase the chance of bunions developing.

Bunion treatment

There are many treatment options for bunions and they will vary with the type and severity of each bunion and will also depend on what is causing the symptoms. Bunions are almost always progressive and tend to get larger and more painful with time – how fast this happens may be a function of the fit of the footwear.

The initial goal of treatment options is to relieve pressure on the bunion and any symptoms that may be present and to halt or slow the progression of the joint deformity. There is no effective may be “get rid off” a bunion without surgery. There are a number of things that individuals and Podiatrists can do to help the symptoms and slow (if not halt) progression.

Some conservative approaches used to manage bunions and hallux valgus include:

* Padding with a number of different materials (eg felt) to reduce pressure on the painful prominence of the bunion.

* Physical therapy can be used to help with the symptoms and improve the range of motion (this is particularly helpful if the pain is coming from inside the joint, rather than from shoe pressure). Manipulation of the joint can be used to help with this (manipulation will NEVER correct the alignment of the joint).

* Any corns and calluses that are causing symptoms should be treated.

* Footwear advice – the correct fitting of footwear is essential for anyone who is serious about doing something about their bunions and hallux valgus – follow this advice!!!

* It may be possible to have your shoes stretched over the area of the bunion to also relieve pressure.

* Foot orthotics may be useful in helping with the instability about the joint. They may be more helpful if there are other symptoms in the foot as well, as their use in “treating” bunions is controversial. They may play a role in slowing progression and in the prevention of bunions developing again after surgical correction.

* Exercises can be important in maintaining the mobility of the joint in those with bunions – this is especially important for the arthritic type pains that may be originating from inside the joint and for the prevention of these painful symptoms in the future.

Self management and exercises for bunions

What can you do yourself for bunions:

1. Follow the advice given by a Podiatrist
2. Use felt pads to help keep pressure off the painful area of the bunions.
3. Wear shoes that are wide and deep to accomodate the bunions. Fitting of footwear is very important. Avoid the use of high heel shoes.
4. Use exercises to keep the joint mobile
5. Night splints may help with the bunion symptoms . The aim of these are to hold the toe in a more correct position.

Padding or foam between the big toe and the second toe is sometimes recommended – it should, generally, not be recommended as the big toe is usually so strong it just further ‘squeezes’ the lesser toes and can lead to problems between these toes. The padding between the two toes will not straighten the big toe. However, sometimes the padding may be needed to help with symptoms that originate inside the joint if the bunion is painful.

Exercises for bunions

Keeping the joint mobile is important as this goes a long way to helping and prevent the arthritic type pain that can develop inside the joint of those with bunions. Several exercises are recommended:

1. Grasp the big toe with one hand and do some ‘yoga’ like stretches on the joint in all directions. Hold the position at the end range of motion for 10-15 seconds. Repeat several times in all directions.

2. Traction helps some people with spinal problems, and can also help keep the big toe joint mobile. Grasp the toe and the foot and try and “pull” the toe “off”. Hold for 10-15 seconds. Repeat several times.

3. Find some sort of elastic band and loop it around both big toes. Spread your feet so that the toe is “straightened” – hold for several minutes. Repeat several times.

Exercises will NEVER be able to correct the position of the toe due to the adaption of bone that has gone on for many years as the bunion developed, but they are important to keep the toe flexible and mobile.

Night splints for a bunion

Wearing splints at night have been shown to provide some correction in adolescents with hallux valgus or bunions (where they are young enough for the bone to still adapt). Read about this evidence here. They may not be as effective in adults, but could be useful to help keep the joint mobile. As a bunion (hallux valgus) is a bony abnormality, it is much harder to change position of a toe permanently in adults.

Shoes for bunions

As footwear plays such an important role in the development and symptoms of bunions, proper fit is vitally important. It is poor fitting footwear in combination with the other factors mentioned above that is the cause of bunions. Footwear also provides the force that makes them painful – the use of the correct footwear is YOUR responsibility.

Surgery for Bunions

If the bunion symptoms does not respond to the conservative measures or if the bunion has progressed past a threshold where these measures are not effective, bunion surgery may be necessary to correct alignment and remove the bunion. A large range of types of surgical procedures for bunions are available and the choice will depend on things like what bone or bones are involved, the angular relationship between the different bones, the amount of damage to the joint and the presence of deformities other than the bunion.

Bunion Surgery

Bunion surgery is almost always contemplated at some stage by almost all those who have them – most reject the idea outright and others can’t wait to have it done. Most would benefit from a surgical consultation, if only to get an opinion. The aim of surgery is to correct what was the cause of the bunion and prevent it happening again.

Conservative management before bunion surgery:

Several studies have shown that 85-90% of those who have bunion surgery are satisfied with the results. But, before bunion surgery is considered, non-surgical approaches or conservative care of the bunion should be tried. Check the bunions page for more information on conservative care. If this fails, bunion surgery should be considered.

Indications for bunion surgery:

Bunion surgery is indicated if:

If there is severe foot pain that limits your activities, especially work and being able to walk when wearing reasonable shoes.

Chronic inflammation of the big toe is present and doesn’t respond to conservative care.

A significant deformity of the toe (this drifting of the big toe towards the small toes is usually called hallux valgus or hallux abducto valgus).

The big toe joint is stiff and does not bend so that it interferes with walking.

There is no pain relief with the use of nonsteroidal anti-inflammatory drugs.

There is a failure to respond to other conservative treatments such as changes in padding, exercises, footwear, etc.

Beware of unrealistic claims that bunion surgery can give you a “perfect” foot. The goal of surgery is to relieve as much pain, and correct as much deformity as is realistically possible. Unrealistic claims and expectations are are common cause of dissatisfaction with bunion surgery.

Types of bunion surgery:

It has been suggested that when it comes to bunion surgery that there are more different surgical techniques for this than there is for any other surgical condition. They range from the “simple” or “minimal” surgical procedures to the major forefoot reconstructions. The choice of procedure will depend on so many things, all of which will be evaluated and taken into consideration by the surgeon.

Some of the procedures include:

a simple bunionectomy just, literally, cuts off the lump of bone (it does not realign the big toe)

tendons and ligaments around the big toe can be out of balance, so this may be surgically corrected (this is often used in conjunction with other procedures)

an osteotomy is when a wedge of bone is taken out of the big toe and or metatarsal to ‘straighten’ the big toe (screws, plates or wires are used to hold the bones in place while they heal)

the damaged joint surfaces can be removed and the joint fused together (usually reserved for when there is severe arthritis present; or other types of procedures have failed). In less severe cases, a plastic joint spacer may be used to replace the damaged joint.

Expectations of bunion surgery:

Unrealistic expectations can be a common cause of dissatisfaction with bunion surgery. It is important that expectations are realistic. Bunion surgery will help relieve pain and result in an improvement in the alignment of the toe in the vast majority of cases. Bunion surgery will not allow you to wear a narrower shoe or smaller shoes. Tight fitting shoes are a major contributor to bunions in the first place, so returning to this type of footwear is a risk for the bunion reoccurring. It is important that you discuss your expectations with the surgeon.

Bunion surgery complications:

There are risks associated with any surgery and these should be discussed by the surgeon. Less than 10 percent of patients experience complications from bunion surgery. These can include infection, a recurrence of the bunion, damage to the nerves, and continued long term pain. Most of these are treatable.

 

Gout

Gout is one of the most common forms of arthritis or inflammation of a joint. It most commonly affects the big toe joint (first metatarsophalangeal joint), but can affect any joint. Gout usually starts as an acute attack that often comes on overnight. Within 12-24 hours there is usually severe pain and swelling in the joint.

“Screw up the vise as tightly as possible – you have rheumatism; give it another turn, and it is gout” – Anonymous

Symptoms of Gout:

Gout usually only affects one joint at a time (sometimes two) – most often the feet and ankles. The joint at the base of the big toe is the most common site. If there is no treatment the gout attack usually subsides in a week or so. After the first attack there may be intervals of many months or even years before there are other attacks. Over time these attacks tend to become more frequent and more severe and eventually may involve other and more joints. Eventually, without treatment, a state of chronic or continuous joint symptoms may develop with progressive joint damage.

Gout mostly affects men and is very rare in women until after menopause when it is seen quite often.

Gout is very painful. The joint becomes swollen and the skin over the joint can be shiny or glossy in appearance.

Cause of Gout:

The cause of gout is related to the physiology of uric acid, which is a chemical that is a natural part of the normal breaking down and building up of food and body tissues. When uric acid levels are higher, this is known as hyperuricaemia. Uric acid is normally dissolved in the blood, but when its high, microscopic crystals may be deposited in the joint. These crystals then set up the acute inflammation causes the gout.

As a result of this physiology, gout is common in those with hyperuricaemia. There are many causes of this and include:

Some people just have higher levels and is hereditary.
Obesity.
High alcohol intake .
High intake of food that contain purines (purines are broken down into uric acid).
Some of the drugs used to treat high blood pressure can precipitate a gouty attack .
Those with kidney disease may also develop high levels of uric acid.

Gout treatment:

The mainstay of gout treatment is correcting the factors that lead to the high levels of uric acid. This involves a combination of diet and drugs.

The following foods have higher levels of purines should be restricted or avoided:

Offal foods like liver, kidneys, tripe, sweetbreads and tongue.
Large amounts of red meat.
Shellfish.
Peas. lentils and beans.
Alcohol intake should be reduced.

Being overweight is a risk factor, so weight loss may be very important. High blood pressure (hypertension) is also a risk factor that your doctor may need to address.

When an acute attack of gout occurs, anti-inflammatory drugs (NSAID’s) are usually very effective to help gain control of the gout symptoms in the first 12-24 hours (these drugs have no effect at lowering uric acid levels). Rest and elevation of the foot is also important.

Over the longer term, if diet changes are not lowering the uric acid levels, drugs can be used to lower the levels (these drugs have no effect during an acute attack). The drugs must be taken on a continuous and long term basis if they are to be effective. There are basically two kinds of drugs – one increases the elimination of uric acid by the kidneys and the others block the formation of uric acid.

Self management of gout:

There are a number of thing that you can do to help yourself manage gout:

Take your medication as instructed by your doctor
Reduce weight
Take dietary advice to lower your intake of purines

Gout complications

If the uric acid levels have been high for a long time and acute attacks of gout has been frequent, there may be deposits of uric acid around the affected joint (and even elsewhere such as the ears) – these are called tophi. If they are present, there is an even greater need for long term drug treatment to lower the uric acid levels.