Diseases of the big toe: hallux valgus and hallux rigidus

The big toe is a special area that is different from the other fingers. The thumb is considered to have two bones, while the other fingers have three bones. The toe is the most loaded area of ​​the foot after the heel, it is exposed to high loads during rapid progress, jumping, 90% of the body weight passes through the thumb. For this reason, thumb diseases are disturbing problems for patients, leading to significant loss of function. Two of the most common of these problems are hallux valgus (HV) and hallux rigidus (HR).

HALLUKS VALGUS HV

It is a clinical diagnosis that describes an increase in the lateral angulation of the axis of the thumb with respect to the axis of the first metatarsal. HV cases show many differences in terms of time of onset, stages and general medical condition of the patient. The severity of the finger deformity is not always associated with the level of clinical complaint. Due to these differences, there is no standard surgical treatment that can be applied in all cases, and many alternative interventions are described in the reference books.

Both patients and the majority of physicians believe that HV is due to wearing tight and high heels. However, it is not possible to explain not all phenomena, almost any phenomenon, for this reason alone. This deformity can be observed even in people who never wear shoes. We know that HV is just a deformity nomenclature and it occurs due to many reasons. For this reason, a typing based on etiology should be made by considering other accompanying problems, the course of the deformity, and even the patient’s family history.

A. Classic HV The most common type we encounter is the classic type HV.

B. Adolescent and juvenile HV It is the type with clinical findings in childhood.

C. Neuromuscular type HV Occurs due to imbalance between the muscles of the thumb

D. HV accompanying foot deformities. Deformities in the back or middle of the foot always affect the front of the foot.

E. HV associated with congenital anomalies While there may be congenital anomalies that can directly cause HV, thumb curvatures may occur secondary to some anomalies.

Clinical evaluation The two most prominent complaints of patients with classical type HV are outward curvature of the thumb and the appearance of a painful bony prominence (bunion) on the inner side. While wearing shoes, severe pain is felt on the bunion, there is no complaint when wearing shoes.

Very few patients state that their main complaint is an aesthetic problem.

Treatment HV patients express their expectations from treatment as first of all being able to walk comfortably and relieve the pain on the bunion, and then to be able to wear daily shoes comfortably. While being able to wear stylish shoes under the age of forty is among the top expectations, being able to wear casual shoes comfortably over the age of forty becomes a goal. Women ask for help to walk and men to work more comfortably.

No matter how our patient expresses it, it should never be ignored that aesthetic concerns are an important reason, especially in women. Conservative treatment Almost all HV patients have the expectation that their fingers will be corrected by a non-surgical method. It is not possible to increase the comfort in shoes with a treatment method other than surgery in a patient with a real complaint. On the other hand, surgeons should never forget that if wide-toed or custom-made shoes are preferred, all of the patient’s complaints will go away and this is a conservative approach. Three types of orthoses are sold in the market claiming to meet this expectation: night splints, flexor rollers. . Unfortunately, to date, these orthoses have not been shown to provide a lasting benefit.Bunion supports and toe rollers increase the space needed at the toe of the shoe, making it more difficult for many patients to wear shoes.

Surgical treatment

The goal of treatment in HV is to relieve the symptoms that have arisen. It is not appropriate to recommend surgical intervention in a patient who does not have any complaints, on the grounds that deformity may increase in the future. HV patients do not have any complaints when they do not wear shoes. The aim of the treatment should be to enable the patient to walk comfortably in his daily life with ready-made ready-made shoes in the market. Before the treatment, it should be clearly stated to the patients that they are not welcome to wear high heels or narrow shoes after the surgery.

HALLUKS RIGIDUS (HR)

HR is a clinical picture associated with calcification of the thumb joint, with limitation of movement and pain. It would be correct to use different nomenclatures when the limitation of movement is caused by extra-articular causes. This picture, which is a much more restrictive problem than HV, is seen in one of 40 people over the age of 50. Even though they are in different stages, 80% of the cases have bilateral involvement. Again, 80% of them have the same disease in their families. Although its causes can be caused by many reasons, the only reason that can be definitively established is trauma. Unilateral cases usually have a history of major trauma such as intra-articular fractures. Unnoticed and forgotten cartilage injuries can also cause calcification in the long term. Apart from trauma, systemic rheumatic diseases also cause calcification.

A typical HR patient presents with pain in the thumb joint while walking. The complaint of limitation of movement is much more in the background. Some patients in the advanced stage may express that their pain decreases as the movement decreases. A characteristic feature of the HR patient is that, unlike the HV patient, he/she is comfortable wearing shoes. These patients say that they have to walk with shoes even at home. Some of the patients complain of the pain caused by the contact of the swelling around the joint with the shoes. With shoe modification, a significant relief in daily life and a long-term delay in surgical intervention are provided. In patients with advanced edema and in the early stage, using intra-articular steroids to relieve the attack in a short time is one of the important weapons we have. After the steroid injection, which provides relief for two to three weeks, it is possible to open the gap between painful attacks by following it with hard-soled shoes. Problems caused by the contact of bone protrusions with shoes can be easily solved with high-toed shoes and silicone supports.

When pain is not relieved with all these treatments, we perform surgical interventions. As a result of surgical intervention, a painless gait is aimed. For this reason, the results of the intervention are very successful and we apply the surgery when simpler interventions do not work.

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