Hallux Valgus

What the term hallux valgus means

The words are anatomical. Hallux is the great toe. Valgus describes deviation away from the midline at the joint in question, so hallux valgus means the great toe has angled outward, toward the second toe, at the first metatarsophalangeal joint. Behind it, the first metatarsal drifts the opposite way, a position called metatarsus primus varus. The prominence on the inner border, the medial eminence, is the exposed head of that metatarsal with a reactive sac of tissue over it.

Two features make this more than a side to side angle. The first is rotation: as the toe deviates it also turns so the nail faces inward, so the deformity is three dimensional and correction must account for that. The second is the sesamoids, two small bones embedded in the tendon beneath the metatarsal head, which act as a fulcrum for push off. In hallux valgus the metatarsal head slides off them, leaving the tendon that should straighten the toe running along the outer side of the joint, where it pulls the toe further into deviation. Loss of the great toe as a lever also transfers load to the lesser metatarsals, which is why pain under the ball of the foot belongs to the same picture.

Symptoms that often bring people in

• Deviation of the great toe toward or under the second toe, with widening of the forefoot.
• Pain at the medial eminence where footwear presses, sometimes with an inflamed bursa.
• Pain within the joint on bending, which may indicate the cartilage surface is involved.
• Transfer pain and callus beneath the second and third metatarsal heads.

How it is evaluated

Assessment separates the components of the deformity, because correction is planned around them. Standing examination shows the true angle of the toe and the width of the forefoot, while seated examination shows whether the toe can be brought back toward neutral, distinguishing a flexible deformity from a fixed one. The examiner also tests motion at the first metatarsophalangeal joint and stability at the base of the metatarsal. On weight bearing X-rays the surgeon measures the angle between the great toe and its metatarsal, the angle between the first and second metatarsals, and the position of the sesamoids. Signs of arthritis are noted, since they change which procedures are appropriate.

Treatment options in general terms

Non-operative care is directed at symptoms and pressure; it does not alter the underlying angles.

• Accommodative measures. Wide, low heeled footwear, padding over the eminence and toe spacers to reduce friction and crowding.
• Load redistribution. Orthoses and metatarsal support to relieve transfer pain beneath the lesser metatarsal heads.
• Medication categories. Anti-inflammatory options a physician may discuss for an inflamed bursa or joint.

Surgical correction is directed at the anatomy, and the procedure is selected according to the severity of the angles, the flexibility of the deformity and the state of the cartilage.

• Osteotomy. A controlled cut in the metatarsal, near the head or further back along the shaft depending on the correction needed, with the fragments repositioned and fixed; a wedge from the toe bone may be added.
• Soft tissue balancing. Release of contracted structures on the outer side of the joint and repair of stretched structures on the inner side.
• Fusion procedures. Stabilizing the base of the ray when instability drives the deformity, or fusing the metatarsophalangeal joint when its surface is arthritic.

What to expect when you consult Dr. Wolfson

Dr. Wolfson is board certified in the United States and Canada and evaluates hallux valgus with attention to the anatomy of your foot rather than to a single standard operation. A consultation includes weight bearing examination and an explanation of which components of the deformity are present. Second opinions are welcome, and complimentary phone consultations can be arranged for patients outside the Bay Area.

This page provides general information about hallux valgus and is not medical advice. It is not a substitute for examination, imaging and diagnosis by a qualified physician. Every case is different and requires individual evaluation. If you have severe pain, an obvious deformity, loss of function, fever, or an injury from a significant accident, seek medical care promptly.

Contact Dr. Wolfson if you would like to setup an appointment. If you are a new patient, please book all in-person appointments with Dr. Wolfson via telephone.

If you live outside of the San Francisco Bay Area, you can request a complimentary phone consultation with Dr. Wolfson to assess your case. Please call or e-mail us to set up your complimentary consultation.

Call: (415) 221-4400

E-mail: [email protected]