It's important to identify exactly what the patient is complaining of so advice or intervention can be directed at this. Typical complaints in hallux valgus include:
pain, swelling, shoe pressure and skin breakdown over the medial eminence
foot broadening leading to difficulty getting shoes to fit; bunionette is a common associated condition
metatarsalgia – the first ray takes less pressure with a hallux valgus and the lesser rays become overloaded
lesser toe problems with lesser MTPJ instability and the development of hammer or claw toes – the laterally deviated hallux may contribute to 2nd MTP instability by direct pressure in a valgus and/or upward direction
Be discriminating with complaints about footwear. Frey et al showed that American women wore shoes that were, on average, 1cm narrower than their feet. Informal study in our clinic shows much the same - the patient illustrated is typical. The patient must be willing to be realistic about footwear on no treatment will be of value. Make the shoes fit the feet, not the feet fit the shoes! Do not operate because the patient does not like the appearance of her feet. She will probably not like the appearance afterwards either. Do not convert an asymptomatic unloved foot into a painful hated foot.
"Before it gets any worse..."
Some patients are brought to the clinic not because of what their feet are like now, but because of concern about what they may become like, based on the experience of mother or grandmother.
Ask about any background that may have exacerbated mother's feet (especially inflammatory arthritis).
Unless the index patient has very severe hallux valgus with incongruity at a young age, when it may be best to offer at least a holding procedure, it is best to treat the feet on their own merits and take the opportunity for some education about shoes.
Always ask about...
- diabetes - may influence healing and infection risk; a bunion in a neuropathic foot may precipitate an ulcer and therefore prophylactic surgery may be justified
- inflammatory arthropathy - the outcome of standard bunion surgery in rheumatoid or other inflamatory arthritides is probably poorer and a fusion or excision arthroplasty may be better
- neurological disease - a few patients with neurological imbalance develop quite severe hallux valgus and the only reliable treatment is a fusion
- vascular disease - may influence the risk of surgery, in some cases to the point where the risks are disproportionate to the benefits
- trauma - hallux valgus occasionally develops after a forced dorsiflexion or valgus injury to the joint, in which case there may be significant intra-articular injury warranting evaluation by MR and/or arthroscopy, realistic outcome may have to be revised downwards, and a fusion or excision arthroplasty advised.