When is a Bunion Not a Bunion?

Bunion or Not a Bunion

A woman came in asking for bunion surgery. She had put up with the pain in her big toe for years and finally had enough. Many friends told her to wait until she couldn’t stand the pain in her foot before discussing surgery. She assumed any pain in the great toe accompanied by a bump was a “bunion” or Hallux Abducto Valgus. Unfortunately, in this case, she was wrong. The patient actually had Hallux rigidus also known as osteoarthritis of the great toe joint. If she sought treatment sooner, her joint may have been salvaged. Now, her joint was too damaged and she needed a joint replacement or fusion, which is not what she wanted to hear. In her mind, she came in the office asking for a simple bunionectomy and left needing a joint destructive procedure. 

What’s the difference between Hallux valgus and Hallux rigidus? 

Hallux valgus is a deformity of the great toe joint characterized by medial deviation of the first metatarsal and lateral deviation of the hallux. 

Over a period of years the great toe moves closer with the second toe and eventually drifts under or over the second toe. At the same time, the first metatarsal drifts medially toward the center of the body making the distinctive bump. This starts out as a minor annoyance, but then quickly becomes a shoe problem with rubbing on the bump. Most people seek the attention of a surgeon when the bump is rubbing in their shoe and becomes painful. If the deformity is allowed to progress, the great toe joint can actually start to dislocate and the patient will start to experience joint pain and degeneration. 

Hallux rigidus is wear and tear arthritis or osteoarthritis of the great toe joint. Many people are predisposed to this problem by the underlying biomechanical function of their joint. It becomes much worse after an injury or repetitive trauma from high-heeled shoes, ballet or sports. The symptoms are different than Hallux valgus. Hallux rigidus usually starts with a feeling of stiffness of the joint, which can be accompanied by swelling and redness that is sometimes misdiagnosed as gout. This usually progresses to a decrease in range of motion, a distinctive crunching feeling when moving the joint, and then a bump that forms more toward the top of the joint – not on the side like Hallux valgus. 

Hallux valgus and Hallux rigidus can occur together in a more complex foot deformity. Usually, the bunion deformity has progressed and then is injured by repetitive trauma or a distinctive injury. This starts the progression of the arthritic change. 

Why is treatment of Hallux rigidus so important in the early stages? 

Once the cartilage is destroyed in the great toe joint, nothing can be done to increase space. Hallux rigidus in the early stages can be controlled with a functional shoe orthotic to control the biomechanics. A clean-up procedure known as a cheilectomy can help remove all the debris from the joint and get rid of much of the crunching. This may slow down the progression of this process. Some patients can benefit from a surgical procedure via a decompressional osteotomy to allow for better joint biomechanics and more joint space. Unaddressed Hallux rigidus can lead to complete joint destruction and the need for a fusion or joint replacement. The bottom line is don’t ignore pain in your patient’s great toe joint. Early treatment of Hallux rigidus can save your patient from a fusion or joint replacement. 

 

Author
Dr. Wenjay Sung

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