Bunions: (also referred to as hallux valgus)

Q:  What exactly is a bunion and how did I get this?

A:  A bunion forms when your great toe pushes against your second toe forcing the joint of your great toe to push out into your shoe.  This diagnosis can become increasingly uncomfortable with improper footwear with continued activity.   Common causes include uneven pressures throughout the joints/tendon in your feet while weight-bearing.  The imbalance creates an unstable joint that can become increasingly painful.  The inequity in pressure can be due to footwear, genetics, previous injuries, and or congenital deformities. Often, people will have direct relatives with bunions, and this can be caused by poor foot structure, and overall alignment of the lower body (hip, knee, toes) and the effect this has on the forces in the foot.

Q:  How do I know I have a bunion?

A:  A bunion presents as a bump or bulge on the great toe with other common signs including:   redness/swelling/soreness over the great toe.  One may experience callus formation over the great toe, or on the outside of the toe where it hits shoe wear with increased pressure. There also may be persistent pain and/or restricted movement.  Pain, of course, is the most common condition associated with the great toe when experiencing a bunion. An MD or Podiatrist will perform an x-ray to visualize the bones in the toes, foot and ankle, to assess alignment. Often with pain in the foot that persists, people may also have an MRI performed to look at the tissue structures in addition to the bone.  In the event that advanced treatment is needed, it is important for the surgeon to have all of the information at hand with regards to bones, ligaments, tendons, bursal areas, fascial tissue, swelling, scar tissue and more. This will make any treatment more successful and efficient.

Q:  How do I prevent making the bunion worse?

A:  Conservative treatment with the help of your physical therapist includes hands-on manual therapy treatment to increase range of motion and decrease pain, strengthening of the ankle and foot as well as hip region, gait analysis, and inflammation control.  Your PT may suggest changing shoes, instruction on tape/padding.  If changing shoes, often getting properly fitted by a professional is recommended. Shoes choices will include a wide toe box, supportive mid foot, arch support, and mesh versus hard top. Your MD/DPM may prescribe medications to control pain/inflammation- which can be topical or oral- or may provide cortisone injection depending on your signs/symptoms, personal preference, and pain tolerance and levels.

Q:  How do I decide which treatment is best for me?  Surgical vs. Conservative treatment?

A: Every diagnosis should be treated on an individual basis.  If/when the pain/swelling/range of motion restrictions start affecting your quality of life, discussion of further intervention with your MD/DPM is reasonable.  Surgery may be your best option when you are unable to participate in activities that you once enjoyed. At times, surgery may be performed earlier than when pain is the deciding factor. Often, gait will change with the bunion due to limitations of toe motion, which will cause the use of different muscles in walking, standing, stair climbing and squatting.  In this case, pain in the knees, hip and back may ensue making the surgical decision occur sooner.

Hammer/Mallet Toe:

Q:  What is exactly is a hammer or mallet toe and how did I get this?

A:  A hammer or mallet toe is when your toe is either stiff or permanently positioned in a downward position usually as a result of injury or chronic pressure from footwear (i.e. footwear with a narrow toe box).  A rigid type hammer toe has an abnormal permanently flexed middle joint of the toe and a mallet toe has a permanently flexed joint that is nearest to the toenail.  The “flexible” version of both of these is where the toes are in these positions, but manually can be moved and stretched and have not yet completely stiffened. These diagnoses most commonly occur at the second toe. They can, however, also exist at the pinky toe, or fifth toe as well, and most likely just occur curved or flexed downward.

Q:  How do I know I have a hammer/mallet toe?

A:  Hammer/mallet toe is diagnosed by observation and/or x-ray.  This diagnosis can occur in one or more toes with decreased range of motion and increased complaints of pain.  A callus can appear at the joint where hammer/mallet toe occurs causing increased friction.

Q:  How do I prevent making the hammer/mallet toe  worse?

A:  Your physical therapist/DPM/MD will advise you to avoid wearing shoes with pointed toes/narrow toe box.  You should avoid all high heels; gym shoes will allow more room with ability to adjust tightness of shoe.  Varying ways to tie laces can help with pressure. As well, gym shoes with mesh on the top or softer material often help to prevent rubbing, callus formation, and blisters. Inserts may be an option depending on the severity of your diagnosis; if your toe has reasonable ROM (range of motion), inserts can be used to reposition the toe to relieve pressure and/or pain. At times, people will “wrap” the toe to try to straighten it, or take pressure off of the joints. This can work in some cases, but will inevitably not fix the actual issue. People also pad the joint that is rubbing to prevent pain, blistering, or increase callus formation.

Q:  How do I decide which treatment is best for me?  Surgical vs. Conservative treatment?

A:  If conservative treatment fails, surgical treatment may be necessary to release the tendon so that the toe can rest in a more neutral position.  Your surgeon may also need to clean out (debride) the joint to help straighten your toe.

Hallux Rigidus:

Q:  What is exactly is hallux rigidus and how did I get this?

A:  Hallux rigidus is arthritis of the great toe, causing motion to be decreased and often pain.   Females are more commonly affected than males, and it most of the time affects adults between ages 30-60 years old.  This condition can be associated with previous trauma; however, it is most commonly associated with wear and tear of the first metatarsophalangeal (MTP) joint.

Q:  How do I know I have hallux rigidus?

A:  Most patient report pain in the great toe with activity, especially while pushing off throughout gait cycle.  Swelling and/or stiffness can occur with possible bone spur formation due to aggravation from friction against the inside of your shoe.  One may experience pain or stiffness while standing, bending, running, or squatting.

Q:  How do I prevent making hallux rigidus worse?

A:  There is no specific way to prevent hallux rigidus, although you may be able to slow progression by keeping the joint mobile, resting when you experience increased pain and wearing shoes with appropriate space in the toe box.  Early diagnosis and treatment is imperative to avoid more invasive treatment. For athletes, this is often not possible, given shoe wear that is demanded, workout schedule, and years of repetitive activity that pushes the joint into abnormal positions and often subjects it to trauma as well.  Keeping the ankle, other toes, and foot joints mobile can allow for less pressure on the big toe. Keeping the gait or performance patterns as biomechanically perfect can also help (i.e. run gait, releve’ position in dance).

Q:  How do I decide which treatment is best for me?  Surgical vs. Conservative treatment?

A:  Early/conservative treatment may include physical therapy, custom orthotics, improved footwear, anti-inflammatory medication and/or cortisone injection.  If conservation treatment does not resolve signs and symptoms, the patient may have to undergo surgery as the only method to eliminate pain.  Surgical options are provided once patient is unable to fully participate in activities of daily living (ADL’s) without exacerbation of symptoms.  Surgery can range from bone spur removal to an osteotomy in which the 1^st MTP is repositioned to a possible fusion of the joint.  The surgery involving implants to replace the ball/socket component of the joint have the best record for improving long term function and independence. With fusions, of course, there is permanent limitation of motion in the joints that are fused, causing a chain reaction effect to the other joints (ankle, knee, hip, back) for new and non-normal patterns and compensations with walking, running, squatting, rising to balls of the feet and more. Most of the time, the Physical Therapist can teach you how to compensate in the most efficient way possible to achieve your goals, as long as they are attainable and safe for both the surgical area as well as surrounding joints.

In general:  healthy advice to keep your feet ready for your top performance:

-The foot and ankle are prime candidates for injury in sport: do not hesitate to follow up with your MD/DPM to rule out more severe problems.  To return to sport/ADL’s/ambulation, it is important to go through an extensive physical therapy program to improve range of motion, strength and balance.  Once an injury occurs, you may be more likely to suffer repeated injuries leading to instability.  You can potentially avoid further re-injury with quality physical therapy and compliance with a home exercise program.

-Purchase your shoes at the end of the day due to increased swelling with increased time in full weight-bearing.  Being slightly big is often better than being small. However, there are side effects to both. Let the experts help fit you in the appropriate shoe.  Your PT will know the local shoe and specialty stores that have well educated staff members and a professional fitting process and knowledge of various shoe companies, styles and brands. Proper footwear can make all of the difference upon your return to activity/return to sport. In this case, cheaper is not better!

-Keep your feet healthy and clean-foot wounds can become easily infected and can be difficult to treat-especially if you have any type of circulatory or other issues, such as diabetes, gout, neuropathy and more.