Hallux valgus deformity (bunion)
- Jill Ferrari, PhD, BSc
Jill Ferrari, PhD, BSc
- Senior Lecturer, Podiatry
- University of East London, United Kingdom
- Section Editor
- Patrice Eiff, MD
Patrice Eiff, MD
- Section Editor — Adult Orthopedics; Sports-Related Injuries
- Professor of Family Medicine
- Oregon Health & Science University
- Deputy Editor
- Jonathan Grayzel, MD, FAAEM
Jonathan Grayzel, MD, FAAEM
- Senior Deputy Editor — UpToDate
- Deputy Editor — Emergency Medicine (Adult and Pediatric)
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Assistant Professor of Emergency Medicine
- University of Massachusetts Medical School
Valgus malformation of the great toe, commonly known as a bunion, is a very common and potentially painful and debilitating condition of unclear etiology. This topic review will provide an overview of the relevant anatomy, pathophysiology, diagnosis, and management of hallux valgus. Toe and foot injuries are discussed elsewhere. (See "Toe fractures in adults" and "Metatarsal shaft fractures".)
CLINICAL ANATOMY AND BIOMECHANICS
Basic forefoot anatomy — By convention, toes and their respective metatarsals are numbered from one (great toe) through five (little toe). The great toe has two phalanges, while the second through fifth toes typically have three (figure 1 and figure 2 and figure 3). Tendons and ligaments insert at the bases of each phalanx. The digital artery and nerve pass together along each side of each toe.
●Hallux valgus deformity – This deformity is defined as a lateral deviation of the hallux (great toe) on the first metatarsal (figure 4). The deviation of the hallux occurs primarily in the transverse plane. The deformity often also involves rotation of the toe in the frontal plane causing the nail to face medially (ie, eversion). These two deviations have led to the use of different terms to describe the deformity. In orthopedic texts, it is often called "hallux valgus" (HV) whereas many podiatry texts prefer the term "hallux abductovalgus (HAV)." The public is more familiar with the expression "bunion."
●Hallux abductus (or hallux valgus) angle – The angle created by the bisection of the longitudinal axis of the hallux and the longitudinal axis of the first metatarsal (figure 4 and image 1). Historically, a hallux abductus (HA) angle of greater than 15 degrees was considered abnormal, but such deformities are not always symptomatic, and some cases of an HA angle greater than 15 degrees occur naturally due to the shape of the articular surfaces involved [1,2]. Contemporary research suggests an HA angle of 20 degrees or greater is abnormal .
●Intermetatarsal (IM) angle – The angle determined by the bisection of the longitudinal axes of the first and second metatarsals (figure 4). An IM angle less than 9 degrees is considered normal.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- HARDY RH, CLAPHAM JC. Observations on hallux valgus; based on a controlled series. J Bone Joint Surg Br 1951; 33-B:376.
- Piggott, H. The natural history of hallux valgus in adolescence and early adult life. J Bone Joint Surg 1960; 42B:749.
- Tanaka Y, Takakura Y, Takaoka T, et al. Radiographic analysis of hallux valgus in women on weightbearing and nonweightbearing. Clin Orthop Relat Res 1997; :186.
- Mann R, Coughlin M. Adult hallux valgus. In: Surgery of the Foot and Ankle, Coughlin M, Mann R (Eds), Mosby, St. Louis 1999. p.150.
- Phillips D. Biomechanics in Hallux Valgus and Forefoot Surgery, Churchill Livingstone, New York 1988. p.39.
- Turan I. Correlation between hallux valgus angle and age. J Foot Surg 1990; 29:327.
- Nix S, Smith M, Vicenzino B. Prevalence of hallux valgus in the general population: a systematic review and meta-analysis. J Foot Ankle Res 2010; 3:21.
- SHINE IB. INCIDENCE OF HALLUX VALGUS IN A PARTIALLY SHOE-WEARING COMMUNITY. Br Med J 1965; 1:1648.
- Maclennan R. Prevalence of hallux valgus in a neolithic New Guinea population. Lancet 1966; 1:1398.
- SIM-FOOK L, HODGSON AR. A comparison of foot forms among the non-shoe and shoe-wearing Chinese population. J Bone Joint Surg Am 1958; 40-A:1058.
- Wilson DW. Hallux valgus and rigidus. In: The Foot, Helal B, Wilson D (Eds), Churchill Livingstone, New York 1988. Vol 1, p.411.
- Nix SE, Vicenzino BT, Collins NJ, Smith MD. Characteristics of foot structure and footwear associated with hallux valgus: a systematic review. Osteoarthritis Cartilage 2012; 20:1059.
- Root ML, Orien WP, Weed JH. Forefoot deformity caused by abnormal subtalar joint pronation. In: Normal and Abnormal Functions of the Foot, Clinical Biomechanics, Root ML, Orien WP, Weed JH (Eds), Clinical Biomechanics Corporation, Los Angeles 1977. Vol 2, p.376.
- La Reaux RL, Lee BR. Metatarsus adductus and hallux abducto valgus: their correlation. J Foot Surg 1987; 26:304.
- Griffiths TA, Palladino SJ. Metatarsus adductus and selected radiographic measurements of the first ray in normal feet. J Am Podiatr Med Assoc 1992; 82:616.
- Faber FW, Kleinrensink GJ, Verhoog MW, et al. Mobility of the first tarsometatarsal joint in relation to hallux valgus deformity: anatomical and biomechanical aspects. Foot Ankle Int 1999; 20:651.
- Fritz GR, Prieskorn D. First metatarsocuneiform motion: a radiographic and statistical analysis. Foot Ankle Int 1995; 16:117.
- Brahm SM. Shape of the first metatarsal head in hallux rigidus and hallux valgus. J Am Podiatr Med Assoc 1988; 78:300.
- Ferrari J, Malone-Lee J. The shape of the metatarsal head as a cause of hallux abductovalgus. Foot Ankle Int 2002; 23:236.
- Cralley JC, McGonagle W, Fitch K. The role of adductor hallucis in bunion deformity: Part I. J Am Podiatry Assoc 1976; 66:910.
- Bozant JG, Serletic DR, Phillips RD. Tibialis posterior tendon associated with hallux abducto valgus. A preliminary study. J Am Podiatr Med Assoc 1994; 84:19.
- Carl A, Ross S, Evanski P, Waugh T. Hypermobility in hallux valgus. Foot Ankle 1988; 8:264.
- McNerney JE, Johnston WB. Generalized ligamentous laxity, hallux abducto valgus and the first metatarsocuneiform joint. J Am Podiatry Assoc 1979; 69:69.
- Haas C, Kladny B, Lott S, et al. [Progression of foot deformities in rheumatoid arthritis--a radiologic follow-up study over 5 years]. Z Rheumatol 1999; 58:351.
- Dimonte P, Light H. Pathomechanics, gait deviations, and treatment of the rheumatoid foot: a clinical report. Phys Ther 1982; 62:1148.
- Kirkup JR, Vidigal E, Jacoby RK. The hallux and rheumatiod arthritis. Acta Orthop Scand 1977; 48:527.
- Jahss M. Disorders of the hallux and first ray. In: Disorders of the Foot and Ankle: Medical and Surgical Management, Jahss M (Ed), Saunders and Company, Philadelphia 1991. p.946.
- Haas M. Radiographic and biomechanical consideratiosn of bunion surgery. In: Textbook of Bunion Surgery, Gerbert J, Sokoloff T (Eds), Futura Publishing, New York 1981. p.55.
- Rosen JS, Grady JF. Neuritic bunion syndrome. J Am Podiatr Med Assoc 1986; 76:641.
- Nix SE, Vicenzino BT, Collins NJ, Smith MD. Gait parameters associated with hallux valgus: a systematic review. J Foot Ankle Res 2013; 6:9.
- Galica AM, Hagedorn TJ, Dufour AB, et al. Hallux valgus and plantar pressure loading: the Framingham foot study. J Foot Ankle Res 2013; 6:42.
- Vanore JV, Christensen JC, Kravitz SR, et al. Diagnosis and treatment of first metatarsophalangeal joint disorders. Section 1: Hallux valgus. J Foot Ankle Surg 2003; 42:112.
- Ferrari J, Higgins JP, Prior TD. Interventions for treating hallux valgus (abductovalgus) and bunions. Cochrane Database Syst Rev 2004; :CD000964.
- Budiman-Mak E, Conrad KJ, Roach KE, et al. Can foot orthoses prevent hallux valgus deformity in rheumatoid arthritis? A randomized clinical trial. J Clin Rheumatol 1995; 1:313.
- Torkki M, Malmivaara A, Seitsalo S, et al. Surgery vs orthosis vs watchful waiting for hallux valgus: a randomized controlled trial. JAMA 2001; 285:2474.
- Juriansz, A. Conservative treatment of hallux valgus: a randomised controlled clinical trial of a hallux valgus night splint, King's College, University of London, Thesis/Dissertation 1996.
- Bek, N, Kurklu, B. Comparison of different conservative treatment approaches in patients with hallux valgus. Artroplasti Artroskopik Cerrali 2002; 13:90.
- Tehraninasr A, Saeedi H, Forogh B, et al. Effects of insole with toe-separator and night splint on patients with painful hallux valgus: a comparative study. Prosthet Orthot Int 2008; 32:79.
- Bayar B, Erel S, Engin I, et al.The effects of taping and foot exercises on patients with hallux valgus: a preliminary study. Turk J Med Sci 2011; 41:403. http://journals.tubitak.gov.tr/medical/issues/sag-11-41-3/sag-41-3-6-0912-499.pdf (Accessed on September 25, 2014).
- Mirzashahi B, Ahmadifar M, Birjandi M, Pournia Y. Comparison of designed slippers splints with the splints available on the market in the treatment of hallux valgus. Acta Med Iran 2012; 50:107.
- du Plessis M, Zipfel B, Brantingham JW, et al. Manual and manipulative therapy compared to night splint for symptomatic hallux abducto valgus: an exploratory randomised clinical trial. Foot (Edinb) 2011; 21:71.
- Brantingham JW, Guiry S, Kretzmann HH, et al. A pilot study of th efficacy of conservative chiropractic protocol using graded mobilization, manipulation and ice in the treatment of symptomatic hallux abductovalgus bunion. Clin Chiro 2005; 8:117. http://www.clinchiropractic.com/article/S1479-2354(05)00047-7/abstract (Accessed on January 31, 2012).
- Khan MT. The podiatric treatment of hallux abducto valgus and its associated condition, bunion, with Tagetes patula. J Pharm Pharmacol 1996; 48:768.
- Resch S, Stenstom D, Jonsson K, Reynisson K. Results after chevron osteotomy and proximal osteotomy for hallux valgus: a prospective, randomised study. The Foot 1993; 3:91.
- Klosok JK, Pring DJ, Jessop JH, Maffulli N. Chevron or Wilson metatarsal osteotomy for hallux valgus. A prospective randomised trial. J Bone Joint Surg Br 1993; 75:825.
- Sherman KP, Douglas DL, Benson MK. Keller's arthroplasty: is distraction useful? A prospective trial. J Bone Joint Surg Br 1984; 66:765.
- O'Doherty DP, Lowrie IG, Magnussen PA, Gregg PJ. The management of the painful first metatarsophalangeal joint in the older patient. Arthrodesis or Keller's arthroplasty? J Bone Joint Surg Br 1990; 72:839.
- Faber FW, Mulder PG, Verhaar JA. Role of first ray hypermobility in the outcome of the Hohmann and the Lapidus procedure. A prospective, randomized trial involving one hundred and one feet. J Bone Joint Surg Am 2004; 86-A:486.
- Turnbull T, Grange W. A comparison of Keller's arthroplasty and distal metatarsal osteotomy in the treatment of adult hallux valgus. J Bone Joint Surg Br 1986; 68:132.
- Deenik A, van Mameren H, de Visser E, et al. Equivalent correction in scarf and chevron osteotomy in moderate and severe hallux valgus: a randomized controlled trial. Foot Ankle Int 2008; 29:1209.
- Saro C, Andrén B, Wildemyr Z, Felländer-Tsai L. Outcome after distal metatarsal osteotomy for hallux valgus: a prospective randomized controlled trial of two methods. Foot Ankle Int 2007; 28:778.
- Martínez-Nova A, Sánchez-Rodríguez R, Gómez-Martín B, et al. The effect of adductor tendon transposition in the modified McBride procedure. Foot Ankle Spec 2008; 1:275.
- Basile A, Battaglia A, Campi A. Comparison of chevron-Akin osteotomy and distal soft tissue reconstruction-Akin osteotomy for correction of mild hallux valgus. J Foot Ankle Surg 2000; 6:156.
- Resch S, Stenström A, Reynisson K, Jonsson K. Chevron osteotomy for hallux valgus not improved by additional adductor tenotomy. A prospective, randomized study of 84 patients. Acta Orthop Scand 1994; 65:541.
- Lee HJ, Chung JW, Chu IT, Kim YC. Comparison of distal chevron osteotomy with and without lateral soft tissue release for the treatment of hallux valgus. Foot Ankle Int 2010; 31:291.
- Blitz NM, Lee T, Williams K, et al. Early weight bearing after modified lapidus arthodesis: a multicenter review of 80 cases. J Foot Ankle Surg 2010; 49:357.
- Shurnas PS, Watson TS, Crislip TW. Proximal first metatarsal opening wedge osteotomy with a low profile plate. Foot Ankle Int 2009; 30:865.
- Krannitz KW, Fong HW, Fallat LM, Kish J. The effect of cigarette smoking on radiographic bone healing after elective foot surgery. J Foot Ankle Surg 2009; 48:525.
- Kristen KH, Berger C, Stelzig S, et al. The SCARF osteotomy for the correction of hallux valgus deformities. Foot Ankle Int 2002; 23:221.
- Dux K, Smith N, Rottier FJ. Outcome after metatarsal osteotomy for hallux valgus: a study of postoperative foot function using revised foot function index short form. J Foot Ankle Surg 2013; 52:422.
- CLINICAL ANATOMY AND BIOMECHANICS
- Basic forefoot anatomy
- First ray anatomy
- Pathophysiology of HV deformity
- DIAGNOSIS AND CLINICAL FINDINGS
- ASSOCIATED INJURIES
- Conservative management
- - Orthoses
- - Splinting
- - Mobilization and manipulation
- - Other
- - Patient satisfaction
- - Arthrodesis
- - Arthroplasty
- - Osteotomy
- - Soft tissue procedure
- POSTOPERATIVE RECOVERY
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS