Bunions can strike anyone and any time in life. For athletes, visible changes in the feet can be a signal that other aspects of the lower extremities aren’t operating at optimum efficiency.
By Dr. Randall Kline, Allied Bone & Joint
According to a study published six years ago, 23 percent of adults aged 18 to 65, and 36 percent of adults over 65 years old are affected by Hallux Abducto Valgus, aka bunions.* This progressive and often disabling condition can occur with anyone, at any time in life, and may occur in conjunction with many other pathological processes within the feet and ankles, knees and hips. This becomes particularly important during athletic activity as the visible changes in the feet can be a signal that other aspects of the lower extremities aren’t operating at optimum efficiency.
What is Hallux Abducto Valgus (HAV)?
Referring to illustration A below, HAV is a progressive deformity of the first metatarsal, moving away from the adjacent second metatarsal. As this occurs, the great toe progressively moves closer to the second toe. Together these progressive and permanent changes in position create a condition called hallux abducto valgus. This malposition also creates a “bump” at the base of the great toe, as the first metatarsal head becomes prominent. This prominence is called a bunion (see #4 on photoA.)
What causes HAV?
The tendons, muscles and joints are all designed to work within their proper alignment. When the foot hyperpronates (rolls inward, flattening the arch), the pull against the joint becomes abnormal. These biomechanical changes in alignment create a pull that brings the metatarsal outward, and the great toe inward. Over time, “form follows function” and the change in position becomes permanent—while continuing to progress.
Those who tend to hyperpronate will also experience symptoms in the rearfoot, ankle, knee and hip over time. This means that not only would an athlete perform at a lower level than his or her potential, but at some point, structural fatigue will reach its failure point somewhere within the lower extremity. Referring to diagram B, hyperpronation is not just a flattening of the feet, but is accompanied by internal rotation of the leg at both the tibia and femur, creating significant stress on the knee and hip. The lower back can also be affected with chronic subluxations or muscle fatigue.
There are other possible causes of HAV including rheumatic (inflammatory arthritis) diseases, neuromuscular diseases, or traumatic injury. However, each of these includes an underlying perpetuation of biomechanical compromise.
Can you inherit HAV?
No. But patterns of structure and function are inherited, which is why many people begin to see foot deformity in their later years, similar to another family member. It might be comparable to tread wear mimicking another vehicle with the same tire alignment.
Can poor fitting shoes or high heels cause HAV?
This is a debated question in literature. To whatever extent your shoes perpetuate abnormal ambulation; they can accelerate any abnormal biomechanical process.
What can you do?
Once physical changes or pain is experienced in the great toe joint, the key is to determine the underlying cause. If the pain occurs suddenly, you should seek the consultation of a physician. However, the gradual onset of symptoms “usually” suggests overuse, biomechanical imbalances, or a combination of the two.
- One of the body’s greatest causes of hyperpronation is a tight Achilles tendon. Stretching faithfully three times a day is the best place to start. Employing the runner’s stretch with the knee flexed and straight will yield an excellent result, many times within the first three days.
- If you’re a runner, be sure to change your shoes every 6 months. Also, moving to a motion control shoe such as the Brooks Addiction/Beast, or Asics Foundation/Evolution could offer considerable relief.
- Over-the-counter arch supports may help reduce hyperpronation during walking or running.
- Over the counter NSAID’s such Ibuprofen or Naprosyn may be of help, however they may simply mask the pain without treating the underlying cause. Also, caution must be used with any medication to be sure there is no hypersensitivity, nor interactions with other medications you may be taking.
- As in all such discussions, a temporary change in activity may be needed. Lowering mileage (or not increasing mileage), may be necessary. Slowing speed or cross-training can also give your body the necessary rest to recover from a temporary set-back.
What can your podiatrist do?
- Of utmost importance, your physician can determine the underlying cause of your pain and treat it accordingly. This will most likely consist of a thorough discussion of activity, a biomechanical assessment, and x-rays. Keep in mind that pain at the base of the great toe in its early stages can result from many sources.
- Once it is determined that you have HAV, there are two approaches to its treatment. The first would be treatment of the underlying biomechanical cause. Gaining flexibility (particularly in the ankle), along with control of abnormal motion of the foot is the mainstay of conservative treatment. If your efforts have been unsuccessful (as outlined above), your podiatrist may recommend custom orthotics. A good pair will last many years and can be used with most shoes depending on their construction.
- Once the deformity has progressed to the point that you’re unable to wear shoes comfortably or walk without pain, surgical intervention may be necessary. There are many surgical approaches that vary with the severity of the deformity. When considering surgery, keep in mind the following: The goal is to restore function and relieve pain. If foot pain is the first thing you think about in the morning and the last thing you think about at night, it’s probably time to consider surgery.
You should expect four to six weeks of non-weight bearing, followed by several weeks of rehabilitation. Your podiatric surgeon can discuss the risks vs. benefits of the procedure that’s right for you.
As we approach the close of our fair-weather season, it is my hope that you will continue your fitness throughout the colder months. There are many reasonably priced gyms in the area and many local outlets from which you can also obtain all-weather running gear.
Run smartly and healthy my friends.
*J Foot Ankle Res. 2010; 3: 21.Published online 2010 Sept. 27. doi: 10.1186/1757-1146-3-21
Dr. Randall Kline is a board-certified podiatrist specializing in injury, wound and diseases of the foot and lower leg. Contact Allied Bone and Joint at (574) 247-4667 or visit the AlliedBoneandJoint.com website for more information.