Hallux valgus (bunion): causes, symptoms and therapy

What is a hallux valgus?

With hallux valgus, the big toe deviates outwards (towards the little toes), while the first metatarsal bone drifts slightly inwards. This creates a prominent “ball” on the inside of the foot (head of the first metatarsal bone), which rubs and hurts in shoes. At the same time, the load distribution in the forefoot can change - often with pressure points and pain under the middle metatarsal heads (metatarsalgia).

Hallux valgus usually develops gradually. In addition to genetic predisposition, connective tissue and ligament laxity, foot shape (e.g. splayfoot) and footwear all play a role. The aim of the treatment is to reduce pain and improve function and shoe comfort - not the perfect “optical” correction at any price.

Anatomy and biomechanics of the metatarsophalangeal joint of the big toe

The metatarsophalangeal joint (MTP I) connects the big toe (basal phalanx) with the first metatarsal bone. It is stabilized by the capsule, ligaments, tendons and two small sesamoid bones on the sole of the foot. The interaction between bony alignment and muscular-tendon guidance is crucial for pain-free rolling.

• First ray: first metatarsal bone and big toe as a functional unit
• Sesamoid bones: small bones under the big toe that provide leverage and gliding function
• Band apparatus: holds the axle in the middle; Laxity can lead to decentration of the big toe
• Transverse arch of the forefoot: with splayfoot, the metatarsals move apart - the first beam becomes unstable

Hallux valgus often results in a slight rotational misalignment (pronation) of the big toe, a displacement of the sesamoid bones and an expansion of the angle between the first and second metatarsal bones. This promotes pressure on the medial ball of the foot and overloading of neighboring structures.

Typical symptoms

• Pressure pain and redness on the ball of the foot (medial eminence), increased in tight or hard shoes
• Burning or stabbing pain under the middle metatarsal heads (transfer metatarsalgia)
• Tendency to swell in the forefoot, especially in the evening or after prolonged exertion
• Shoe conflict, blisters, corns, calluses on the ball of the foot or under the forefoot
• Limited strength or rolling movement of the big toe, sometimes feeling unstable
• Misalignments of adjacent toes (hammer or claw toes) in advanced cases

The severity of the pain does not always correlate with the visible severity. Even slight misalignments can be a significant nuisance, while severe misalignments sometimes cause little discomfort.

Causes and risk factors

• Genetic predisposition, weak connective tissue, familial occurrence
• Splayfoot, hypermobility of the first ray, flattened transverse arch
• Footwear: tight, pointed, high-heeled shoes promote symptoms (trigger, not sole cause)
• Female gender, increasing age
• Inflammatory rheumatic diseases (e.g. rheumatoid arthritis)
• Neuromuscular factors, rarely after injury

Several factors usually work together. There is therefore no causal “individual therapy” – an individually tailored mix of measures is successful.

Diagnostics in practice

The diagnosis is based on history, clinical examination and – if necessary – stress x-rays. It is important to understand symptoms and everyday requirements in order to plan treatment realistically.

• Anamnesis: location and duration of pain, tolerance to shoes, previous treatments, goals
• Clinic: Inspection while standing and gait, axes, forefoot shape, pressure points, mobility MTP I, stability of the first beam
• Imaging: X-ray while standing (AP, lateral); Measurement of hallux valgus angle (HVA), intermetatarsal angle (IMA), position of the sesamoid bones
• Differential diagnoses: Hallux rigidus (osteoarthritis), gout attack, sesamoiditis, Morton's neuroma, stress fracture, soft tissue bursitis

Further imaging (ultrasound, MRI) is only useful in special cases, such as unclear soft tissue pain or suspected accompanying injuries.

Severity levels and stages

Angles in the stressed X-ray image are used for classification. Values ​​may vary depending on source; The classification helps especially with therapy planning.

• Mild: HVA about 15-20°, IMA slightly increased
• Medium: HVA about 20–40°, clear splayfoot component
• Pronounced: HVA >40°, often rotational component and significant sesamoid displacement

The complaints and functional limitations are ultimately decisive for the treatment - not just the measured angles.

Conservative therapy – the first step

Conservative measures can significantly alleviate symptoms and are the basis of treatment in our practice. This does not permanently “reset” an existing bony misalignment, but pain, swelling and pressure can be effectively reduced and the progression can sometimes be slowed down.

• Shoe advice: sufficient width in the forefoot, soft upper material, flat/moderate heels, good cushioning
• Pressure protection/padding: silicone bunion protection, toe separators, felt padding to relieve friction points
• Insoles supply: supportive insoles with transverse arch support/pad to relieve the pressure on the metatarsal heads (with splayed feet)
• Toe exercises and physiotherapy: strengthening of the short foot muscles (e.g. “short foot”), mobilization of the MTP I, gait training
• Taping/Orthoses: temporary correction and guidance, night splints can reduce irritation (no permanent correction expected)
• Inflammation management: cooling, topical NSAID gels; Oral painkillers only as needed and with medical advice
• Load adjustment: pain-adapted training, alternation between loading and unloading, weight optimization if necessary
• Injection for bursitic irritations: in selected cases, low-dose corticosteroid locally - sparingly and after informed consent

Regenerative procedures such as PRP themselves do not play a certain role in hallux valgus. If there is accompanying tendon pain, they can be considered in individual cases - the benefit is currently not sufficiently proven.

When does an operation make sense?

Surgery is an option if, despite consistent conservative therapy, persistent pain, stressful shoe conflicts, recurring inflammation or secondary problems (e.g. metatarsalgia, misaligned toes) persist. Cosmetic reasons alone do not justify surgery.

• The aim of the operation: to reduce pain, restore the most physiological statics possible, and improve shoe compatibility
• Decision made individually based on symptoms, foot shape, X-ray angles, ligament stability and everyday requirements
• Realistic expectations: 100% freedom from symptoms cannot be promised

Surgical procedure for hallux valgus

The choice of procedure depends on the severity, soft tissue situation, stability of the first ray and concomitant illnesses. We explain all options and create an individual plan.

• Distal osteotomy (e.g. Chevron/Austin): suitable for mild to moderate misalignments; Displacement of the metatarsal head with correction of the angle
• Diaphyseal osteotomy (e.g. Scarf): for moderate deformities with greater correction and stability
• Akin osteotomy: additional correction to the basal phalanx of the big toe for fine adjustment
• Proximal osteotomies: for more pronounced misalignments or for specific angular misalignments
• Lapidus arthrodesis (TMT-I arthrodesis): for hypermobility/instability of the first ray or degenerative changes at the tarsometatarsal joint
• Soft tissue balance: lateral release, medial capsule tightening; often as a supplement to bony corrections
• Minimally invasive techniques (MICA/PECA): via small skin incisions; potentially less soft tissue irritation, but not suitable for every foot and depends on experience

The type of anesthesia (regional or general anesthesia) and outpatient vs. short-term inpatient procedure depend on the procedure, general condition and home environment. We'll discuss this in the consultation.

Follow-up treatment and rehabilitation

The follow-up treatment is crucial for the result. It varies depending on the procedure and stability of the correction. A structured protocol supports healing and early functional gains.

• Forefoot relief shoe (variants depending on the operation) for approx. 4-6 weeks; Full weight bearing is often possible in special shoes
• Elevation and cooling for the first 10-14 days to reduce swelling
• Wound checks and dressing changes, thread removal after approx. 10-14 days (if not absorbable)
• Thrombosis prophylaxis depending on the individual risk constellation
• Early mobilization of the MTP I in consultation with the treatment team, followed by physiotherapy
• Return to comfortable sports shoes usually after 6-8 weeks; Swelling can last 3-6 (sometimes up to 12) months
• Ability to work: Office work often after 2-3 weeks, standing/walking activities later - varies from person to person
• Sport: Cycling/swimming usually after 4-6 weeks, running/jogging after 10-12 weeks at the earliest - depending on the healing process

Careful scar care, toe exercises and a slow transition into normal footwear improve comfort and function.

Possible risks and complications

Every procedure carries risks. We provide individual information and take measures to minimize risks. Complications can occur despite careful implementation.

• Wound healing disorders, infections, increased scarring
• Nerve irritation, numbness in the big toe
• Thrombosis/embolism (rare; dependent on risk factors)
• Lack of bone healing (pseudarthrosis) or delayed healing
• Insufficient correction, overcorrection (hallux varus), recurrence of the deformity
• Persistent metatarsalgia or new pressure points
• metal irritation; if necessary, later material removal

The prognosis is good in many cases with realistic goals and consistent follow-up treatment. However, a specific result cannot be guaranteed.

Prevention and everyday tips

• Prefer shoes with a wide toe box and soft upper material
• Regular foot exercises (short foot muscles), daily toe mobilization
• Use pressure protection and toe separators for longer periods of stress
• Individually adapted insoles for splayfoot inclinations
• Weight management and changing forms of exertion (e.g. cycling)
• Skin and foot care to prevent calluses/corns
• Increase stress gradually and take early warning signs seriously

Walking barefoot on soft, level surfaces can stimulate the foot muscles. If there is a pronounced misalignment or significant pain, restraint is advised - we will advise you individually.

When should I seek medical advice?

• Increasing pain or pain at night at rest on the ball of the foot/forefoot
• Frequent inflammation, redness or open spots due to shoe pressure
• Newly occurring sensory disturbances, loss of strength or significant swelling
• Persistent complaints despite appropriate footwear and insoles
• Uncertainty regarding sport and everyday stress

Early advice helps to make the most of conservative measures and avoid unnecessary irritation.

Our approach in Hamburg

At Dorotheenstrasse 48 in Hamburg, we take time for anamnesis, examination and transparent therapy planning. Conservative options are exhausted; We only discuss surgical options if there is a clear indication – with realistic expectations and individual follow-up treatment.

We follow current professional recommendations and discuss the advantages and disadvantages of each option so that you can make an informed decision.