The big toe is also known as the “hallux”. If this begins to deviate, it is called hallux varus. This often causes swelling on the inner side of the metatarsophalangeal joint, which can be annoying in normal shoes and can also become inflamed.
What is hallux varus?
Hallux varus ( splay toe ) describes a condition in which the big toe points away from the second toe. The lateral joint capsule is insufficient or absent and the medial capsule contracts. In contrast to the ball of the foot, the 1st metatarsal remains in the anatomical position. The big toe, on the other hand, deviates towards the middle of the body. This very rare deformity is the opposite of a so-called hallux valgus.
Hallux varus is a very common complication of hallux valgus surgery. Other cases are either congenital or post-traumatic. Symptoms depend on how severe the deformity is. The abducted toe can press against the shoe. The skin in this area is then mechanically irritated, becomes red and painful, which can result in inflammation.
Hallux varus is a very common complication of hallux valgus surgery. If there is excessive soft tissue correction during surgery or the lateral sesamoid bone is removed, there is an increased risk of hallux varus developing as a result. The misalignment can show up shortly after the surgical procedure or develop over time.
The misalignment is often favored when walking due to a load on the outer edge of the foot. But other causes can also lead to this disease, for example a congenital malformation. This is known as hallux varus congenitus. In some cases, hallux varus is also caused by growth disorders, spastic diseases or complex syndromes.
Occasionally, accidents that lead to injuries, such as getting caught with the big toe, can also lead to hallux varus. The misalignment can often be observed in people who walk barefoot in middle age.
Symptoms, Ailments & Signs
Typical symptoms of hallux varus include pressure pain on the big toe caused by the axial deviation. In addition, the forefoot widens in the shoe. Movement-related pain often occurs in the metatarsophalangeal joint of the big toe. The pressure in the shoe and the snagging, for example when putting on stockings, are particularly annoying for those affected. Occasionally, the misalignment can also lead to an ingrown nail.
Diagnosis & History
Diagnosis is fairly simple as it is easy to see the big toe pointing from the second toe towards the center of the body. During the examination, the medial lateral deviation of the big toe is determined in degrees. In addition, manual redressability and mobility in the metatarsophalangeal joint are checked. The forefoot is also evaluated radiologically in two planes in order to be able to assess the condition of the big toe metatarsophalangeal joint, the position of the sesamoid bone and the extent of the big toe deformity.
In many children, the deformity corrects itself over the course of development. In other cases, the prognosis is usually good. Only in a few cases that remain untreated, hallux varus can lead to restricted movement, pain and arthrosis in the long term. Above a certain degree, this misalignment cannot be tolerated either functionally or cosmetically and should therefore be corrected as soon as possible. If there is pain when walking or the abduction is significantly larger, treatment is advisable.
Hallux varus usually causes problems in the big toe. Swelling in particular occurs, which can lead to considerable pain and thus to restrictions on walking and running. Especially in shoes, this swelling can be very annoying and often leads to inflammation.
The pain can spread to the entire foot and thus lead to a malposition of the foot or the entire leg. Osteoarthritis can also develop and the quality of life of those affected is significantly reduced by hallux varus. It is not uncommon for strenuous movements to be avoided, and it is also no longer possible for the patient to perform various sports.
The malposition usually also causes a cosmetic complaint, so that those affected feel ashamed of this complaint and suffer from reduced self-esteem. This can sometimes lead to an inferiority complex. There are no further complications during the treatment.
Hallux varus can be treated with suitable footwear. In serious cases or in the case of severe misalignments, an operative intervention can also be carried out. There is no reduction in life expectancy.
When should you go to the doctor?
If pressure pain is noticed on the big toe, hallux varus may be the cause. A doctor should be consulted if the symptoms do not go away on their own or other symptoms develop. In the event of side effects such as an ingrown toenail, pressure points and edema, a doctor should always be consulted.
Hallux varus must be clarified and treated to avoid further complications. If the malposition remains untreated, chronic symptoms can set in, which usually represent a great burden for those affected.
For this reason, unusual symptoms should be observed and medically evaluated. If the symptoms occur after hallux valgus surgery, the responsible doctor must be informed. Then another operation is usually necessary to correct the misalignment.
People who have a congenital malformation of the foot or big toe are particularly susceptible to hallux varus. Patients with growth disorders or spastic diseases are also among the risk patients who should have unusual symptoms examined quickly. In addition to the family doctor, an orthopedist can be called in.
Treatment & Therapy
Treatment of the condition depends on the cause. In children with a tight adductor tendon, it is recommended that treatment be aimed at lengthening the tendon, such as through stretching exercises or toe splinting. A misalignment of the big toe below 10° usually does not require any treatment. Larger misalignments can be compensated for with suitable footwear with a narrow forefoot area if the hallux varus can be corrected.
This means that the big toe can be pushed back into its original position. Conservative therapy includes manual therapy to stretch the medial soft tissues. Acute therapy includes redressing bandages and splints. If the misalignment is unsuccessful with conservative treatment, surgery may be necessary. The toe is brought into a neutral or straight position. In the case of hallux varus, which has arisen as a complication of a hallux valgus operation, additional corrective interventions are often required.
The surgical therapy measures consist of lengthening the medial parts of the capsule and tightening the lateral parts. In rare cases, severe deformities may require arthrodesis of the metatarsophalangeal joint. The scope of the operation ultimately always depends on the degree of malposition. The earlier the disease is recognized and treated, the easier the corrective interventions are. Restraining the big toe for several months is necessary to ensure the success of the therapy.
Outlook & Forecast
The prognosis for hallux varus can be classified as extremely favorable. This is not only due to the fact that the deformity in children usually resolves itself. Surgical treatment also promises lifelong freedom from symptoms. In many cases, even conservative therapy is sufficient.
Often there is only a deformity of 10 degrees. In these cases, doctors do not intervene because there is no real impairment. A treatment would be more of a cosmetic nature. In addition, one does not have to automatically choose the operation. Conservative therapy is often successful. The experience of therapists in the context of soft tissue stretching shows good results. Traction therapy is also used.
There are hardly any other risks associated with an operation than with other interventions. Infections, bleeding, thrombosis or damage to nerves are conceivable, but represent a general risk. The functionality of the big toe is reduced very rarely. Patients can contribute a lot to the positive outcome after an operation. Recommended footwear must be worn and training exercises to strengthen the muscles must be observed. After a good six months, swelling and restricted movement will decrease.
When hallux varus is hereditary, there is usually no way to prevent it from occurring. To prevent the disease, it can help to avoid internal rotation of the foot when the infant is in the prone position. When the first signs of hallux varus appear, medical advice should be sought. If necessary, measures against the disease can be taken as early as possible in this case.
Depending on the healing process, the big toe should be stabilized with a rein bandage for at least four weeks after the operation. This is to prevent the healing part of the bone from coming loose again and the toe from returning to the wrong position. Restraint is also advised as part of conservative therapy.
The bandage not only fixes the big toe in the desired position. Through slight compression, it also helps to improve venous activity and drain blood and lymph fluid more easily. This minimizes the internal pressure on the wound, which counteracts swelling. The initial bandage is applied by a specialist. However, after the instructions have been given, the patient can take over the regular changing himself.
A forefoot relief shoe helps to protect yourself after the operation and to support the healing process. Nevertheless, it is recommended to roll the foot over the big toe again as soon as possible and to return to a normal gait pattern.
In any case, regular follow-up examinations by a specialist are essential. Swelling and restricted mobility in the metatarsophalangeal joint should subside in the first six months after the procedure, but can also last much longer in individual cases. However, if neither the surgical nor the conservative therapy is successful, or if the patient continues to struggle with pain and restricted mobility, immobilization through joint fusion should be considered.
You can do that yourself
A splay toe very often develops as a result of hallux valgus surgery. The so-called bunions, on the other hand, usually develop as a reaction to permanent incorrect loading of the foot. Instead of the heel, the body weight is transferred to the toes.
The reason for this is very often fashionable, but from an orthopedic point of view completely nonsensical footwear. The best form of self-help is to wear healthy, well-fitting shoes. Shoes, especially those that are worn regularly and over a longer period of time, should neither have high heels nor taper to the front. Shoes with flat, thick soles and a high-quality footbed help to prevent foot and toe misalignments.
However, a splay toe does not always have to be treated. In children, the disorder often resolves on its own as they grow up. From middle age, hallux varus is also very common in people who go barefoot a lot. Those affected usually do not suffer from pain and do not have to take any countermeasures, provided that the visual impairment does not irritate them.
In the early stages, however, the progression of hallux varus can also be stopped or at least delayed by changing behavior. Instead of constantly walking barefoot, those affected should have special orthopedic shoes fitted. Such footwear can also help to reduce pain when walking or standing in more pronounced forms of hallux varus. In this way, an operation can be avoided or at least delayed.