pathology: hallux valgus

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Hallux valgus / Bunion

Definition of

Frequent, untreated , progressive foot deformities starting from the metatarsophalangeal joint, mostly affecting women, familial disposition; 1/3 of the population of people with walking difficulties are affected, 90% of them women. Hardly occurs in countries where the population walks barefoot a lot. The big toe moves towards adduction while its metatarsophalangeal joint moves away from the 2nd metatarsophalangeal joint. The deviation of the hallux from the course of the metatarsal bone results in a subluxation with extreme reduction of the articulation surface, which is the cause of arthrosis. There are usually other deviations in the metatarsophalangeal joint such as extension and rotation. As a special form of halux valgus interphalangeus, there may be no deviation of the metatarsophalangeal joint in the direction of the 2nd ray, but there is a deviation in the toe joint. The extent of the deviation of the 1st ray from the physiological course does not allow any conclusions to be drawn about the pain. If conservative therapy fails, surgery leads to a good or very good result in 85% of cases, if intervention takes place early enough.

ICD M20/Q66

Cause

  1. idiopathic/hereditary connective tissue weakness
  2. Trauma
  3. Coxarthrosis, gonarthrosis
  4. Foot deformities such as flat feet and incorrect weight-bearing
  5. Shortened Achilles tendon or triceps surae

Predisposing

– Behavior

  1. Inadequate footwear: single-edged or high heels

– Musculoskeletal system

  1. Hindfoot valgus, flatfoot (causes overload instability of the 1st ray)
  2. Splayfoot
  3. Congenital foot deformities
  4. apositionally healed fractures

– Health factors

  1. familial disposition
  2. RA

Diagnosis

  1. Valgidity of the big toe (usually endorotated)
  2. Medial protrusion on the 1st metatarsal head with subluxation
  3. Metatarsus primus varus

Symptoms

  1. Painful exertion, especially at the beginning
  2. Incorrect angle in the big toe joint with subluxation
  3. Progressive changes
  4. Medial redness and thickening of the skin
  5. Frequent: Development of claw toes, beginning with the 2nd year of life.
  6. Often exostosis of the metatarsal bone 1
  7. Frequent internal rotation of the hallux
  8. Lateral displacement of the flexor tendons and sesamoid bones
  9. Hyperpronation of the foot

Complications

  1. Osteoarthritis
  2. Pressure shift to small toes and transfer metatarsalgia
  3. Changed kinetics of walking due to displacement of the joint against the sesamoid bones
  4. Bursitis
  5. Morton neuroma
  6. Hallux rigidus
  7. Metatarsalgia
  8. Hammer toes of the subsequent toes
  9. Claw toe (hyperextension in the metatarsophalangeal joint) of the subsequent toes
  10. Subluxation or dislocation of the MTP of the subsequent toes
  11. Digitus secundus superductus: the deviation of the big toe is so strong that it pushes under the second toe, which has to hyperextend in the metatarsophalangeal joint to do so

Therapy

  1. an existing deformity does not usually heal spontaneously, the progression can mainly be delayed
  2. with early intervention, abduction training of the big toe and splayfoot-related training can be successful
  3. No constricting footwear
  4. when still weak: Barefoot walking
  5. Insoles, soft shoes, toe straighteners and pads, toe box, roll-off aid if necessary
  6. Active and passive exercises
  7. In more severe cases, surgery, especially if the metatarsal 1 is adducted by more than 10°. There are over 100 surgical techniques, mostly with osteotomy and correction of os metatarsale I and proximal phalanx of the hallux. For advanced osteoarthritis of the metatarsophalangeal joint: arthrodesis. Weight-bearing should be resumed as soon as possible after the operation. Minimally invasive surgery and laser methods are currently being tested.

Asana practice and movement therapy

Anatomically speaking, training the abductor of the big toe(abductor hallucis) must be one of the most important building blocks in the procedure, as this is the only muscle that moves the big toe to where it should be: at rest on the first toe ray and not adducted with pressure against the second toe. This big toe spreader has three origins (processus medialis tuberis calcanei of the calcaneus, superficial leaf of the retinaculum musculorum flexorum and plantar aponeurosis) and moves via its sesamoid bone to the medial-plantar proximal phalanx of the big toe. This movement must be discovered and practiced again and again; this can be done with or without footwear. It may be useful to first try out this movement without shoes and visual control. If this movement is successful and is then practiced in shoes, this has the advantage that the pressure exerted can be felt directly, so a non-visual control of success is possible at any time. A similar exercise can be performed with a suitable elastic band placed around the metatarsophalangeal joint of the small toe and the big toe so that abduction can be practiced against resistance.

The adductor hallucis in particular, which has two heads that both run over the inner sesamoid bone, one transverse head that lies deep in the transverse arch of the foot and one that runs obliquely backwards to the calcaneus. The transverse head is all the more important here as hallux valgus usually develops on the basis of an existing splayfoot. As a collapse of the transverse arch of the foot indicates that the muscles running transversely in the forefoot do not have sufficient tension, this must also be trained.

In general, all kinds of exercises for mobilizing the foot are recommended in the literature. It is certainly not a mistake to follow such recommendations, as the foot is often very neglected and intra-articular and at the same time frequently overloaded. Even if the tension of the abductor and adductor of the hallux is what counts in purely functional terms, there are certainly some useful synergy effects from other foot exercises. In the asanas, the various movements of the big toe in particular(adduction and especially abduction) can be incorporated as a variation as long as it does not impair the execution of the posture. Symmetrical postures are therefore much better suited to this than balancing postures or those with a small physical base of support. Deviating from the usual maxim of not pressing the toes to the floor, standing postures can also be practiced with the toes pressed to the floor. Of course, symmetrical postures without a balancing character are more suitable for this than those with a narrow physical base of support. Postures in which the metatarsophalangeal joints can be passively flexed 90° by pressing the toes against the wall while the soles are on the floor, such as setu bandha sarvangasana against the wall, are recommended.

Another component of the approach is, of course, the passive promotion of flexibility of the big toe in the abduction position. In addition to typical medical supply store products, the toe spreadercan be used for this purpose.

Asanas

  1. Asanas in 971: Stretching the toe flexors
  2. Spreading toes