Hallux valgus

Hallux valgus. So as we go through this section of the talk, we are going to try and think of these problems as their primary pathology and their secondary manifestations and that is going to drive how we treat these problems. This is going to be a situation where someone is going to present to you with a painful bunion. The medial eminence of their foot rubs in a shoe, it gets sore, it gets red, it hurts them. In very severe cases, they are also going to complain bitterly of the fact that the second toe just doesn’t behave, cocks up and rubs in the top of the shoe, and they may have even more painful callous or even an open sore right there at the PIP joint because that is where the apex of the deformity, is and it’s just rubbing at the top of the shoe every time they walk. They also can have calloses on the under surface of their foot, but this is a lady who basically came in wearing beach sandals to see me. She couldn’t wear closed toe shoes, and even in the winter time, she put on wool socks over these beach sandals because this hurt too much in her shoes. What is the primary pathology here; well the way that I see the problem with hallux valgus and have been taught to look at it, it is hypermobility at the tarsal metatarsal joint. That is the joint right about here, that’s the joint that separates the first metatarsal from the cuneiform, so the junction of the midfoot and the forefoot, and over time, as weight bearing occurs, you develop laxity here, so instead of this being a rigid stabilizer when the first metatarsal head strikes the ground, it actually drifts off. Well, as the first metatarsal head drifts off, that is going to decrease the medial longitudinal arch here, and as you can see, this lady doesn’t have much of an arch. She came to see me because her bunion was bothering her, and was rubbing in her shoe and her second toe was bothering her, but she said, oh yes, I sort have been losing my arch over time. Also, as the arch collapses here, there is also a problem with the Achilles tendon. It becomes contracted.

As the arch drifts down, you can sort of think of the heel as drifting up, shortening the distance for the Achilles tendon mechanism to work. It becomes contracted. It begins to overload the forefoot even more, more hypermobility develops, more bunion problems. Here is an example of that hypermobility that I’m talking about. Here, we’re looking from the side of the lady’s foot. What I’ve done here is demonstrate that I have the first metatarsal aligned with the other metatarsals. As you can see, here is the first metatarsal, there are the toes and they all seem to be in alignment. When I try to displace the first metatarsal dorsally with my thumb, you can see how that rises up and now you can’t see across the foot, you can just barely see the second toe here, where before you could see it clearly. Another thing you can notice is that bunion, which looks prominent there, looks even more prominent here, because as that metatarsal drifts up, it is also drifting out, so if you were looking at this slide, it’s drifting out into your direction, so it’s going to rub even harder in the shoe. Again, as the hypermobility develops back here at the tarsal metatarsal joint and this first metatarsal drifts medially and up, hallux valgus develops at this joint. Because this first metatarsal head doesn’t touch the ground well, weight goes to the second metatarsal, a lot of overload occurs at the second metatarsal head and the second MTP joint. That weakens the structures on the plantar aspect of that joint and the toe begins to cockup or hammer-up, and there this lady circled her point of pain. This is constantly rubbing in her shoe. Also, the arch side begins to worsen, again, as the first metatarsal comes up, the arch starts to hit the ground.

So what’s the treatment for this? Well it needs to be directed at the primary problem, then we can also deal with the secondary manifestations. We need an orthotic to support the arch, we need to deal with that arch sag and that hypermobility that is going along at the tarsal metatarsal joint.

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