Big toe deformity: treatment

Static foot deformities are degenerative diseases of the skeleton that seriously impair its supporting functions.Normally, the load is not distributed evenly over the entire area of the sole, but is located along the main points and axes - from the heel tubercle along the outer edge to the toes.This structure ensures the formation of the arch of the foot - a set of bone formations and soft tissues that has shock-absorbing properties.

Accordingly, damage to this formation leads to the development of a fairly common disease - flat feet.When it is mentioned, people usually imagine a longitudinal variant of the pathology, which causes the arch of the foot to drop along the inner edge.But the transverse form of the disease, which is accompanied by a characteristic curvature of the big toe, also refers to flat feet.

This type of pathology occurs mainly in mature and elderly women, often being an acquired condition.It is associated with wearing uncomfortable or ill-fitting shoes, which over time contributes to the displacement of the bones of the forefoot.The result of hallux valgus is constant unpleasant symptoms that accompany a person both when wearing familiar shoes and when walking normally.

Concept

In orthopedics, valgus deformity is the deviation of any segment of the musculoskeletal system outward from the median axis.In this case, curvature can also occur in the joints - then the direction of the angle between the bones is assessed.The development of transverse flatfoot corresponds precisely to this mechanism, ultimately leading to irreversible damage to the metatarsophalangeal joint of the first toe.

Although this condition often develops over decades, patients seek help in the later stages.Therefore, it is necessary to indicate the characteristic features inherent in hallux valgus:

1. The first and main symptom is the curvature of the first metatarsophalangeal joint with the formation of an angle open to the outside.The formation of pathology occurs gradually, but it progresses irreversibly.In the later stages of the disease, the deformity of the big toe reaches such severity that the angle in the joint becomes almost 90 degrees.
2. The next important sign is the formation of a characteristic “bone” located on the inner edge of the foot, where normally the head of the metatarsal bone protrudes slightly.Its appearance is associated with a compensatory deviation of this bone inward under the force of gravity.
3. The latest manifestation is a hammer-shaped curvature of the second finger, also caused by pathological pressure from the adjacent joint and the surrounding soft tissues.

Hallux valgus is characterized by the appearance of additional (non-permanent) signs - pain in the forefoot, gait disturbance, the appearance of dense corns on the sole under the middle toes.

Formation mechanism

Like other degenerative skeletal diseases, transverse flatfoot goes through two stages in its development.At the first stage, only functional changes occur in soft tissues, leading to a decrease in their supporting and elastic properties.And at the second stage, deformations of the joints or bones themselves are already formed:

• The trigger factor is always improper loading of the forefoot due to wearing unsuitable shoes - especially those with narrow toes and heels.
• This leads to chronic damage to the soft tissues - the ligaments and muscles that hold the base of the toes and metatarsals in an elevated position.
• Repeated trauma causes the front arch to gradually drop, after which the maximum load begins to fall on the midfoot.
• In this case, there is a deviation of the peripheral metatarsal bones in opposite directions.
• The first metatarsophalangeal joint normally experiences maximum load, and therefore the force of pathological pressure on it is maximum.Its capsule gradually stretches, causing further inward displacement of the metatarsal bone.
• The stability of the joint decreases, which leads to the formation of subluxation of the phalanx of the first finger.The progression of hallux valgus is precisely associated with the continuous and slow course of this process.
• Deformed soft tissues - ligaments and muscles - are fixed in this position over time, which explains the irreversibility of the curvature.
• Chronic injury leads to the development of deforming arthrosis of the first metatarsophalangeal joint, which causes loss of the functional capabilities of the joint.

Further tactics of assistance depend on the severity of the changes - in the early stages, conservative measures are sufficient, and already in advanced cases, only surgery will eliminate persistent deformity.

Conservative treatment

Valgus deformity of the big toes can be eliminated using traditional methods only if the functionality of the joint is fully preserved.This is explained by the condition of the ligaments and muscles, the damage to which at an early stage is reversible.In this case, assistance is provided in three successive stages:

1. First, the patient is prescribed passive treatment methods, which involve fixing the finger in the correct position.The joint is artificially returned to its normal configuration, which is carried out using various orthopedic means.Usually this period takes at least 6 months, necessary for the adaptation of soft tissues.
2. At the second stage, the active phase begins, which involves special training techniques to strengthen the muscles of the foot.To achieve this, physical therapy classes, massage sessions, and physiotherapy procedures are simultaneously combined.
3. The final period is indefinite, since hallux valgus is an incurable disease.Therefore, the patient consolidates the results of treatment for the rest of his life and is engaged in preventing the progression of the disease.

The choice of means and methods for therapy is completely individual - the patient’s age, concomitant diseases, as well as the characteristics of the curvature itself are taken into account.

Passive procedures

The first stage of treatment is the most difficult for the patient, since fixation of the foot rarely occurs unnoticed by the patient.The return of the normal anatomical structure of the arch of the foot is much more difficult and noticeable than the development of pathology.For these purposes, the following means are used in orthopedics:

• The standard for starting to help is to completely get rid of shoes or boots that have a narrow toe box.Now the patient should use only loose shoes, wide or open in the front.Individual tailoring of orthopedic boots is considered ideal, but it is extremely rare that patients can afford such a luxury.
• For minor deformities, a special bandage made of adhesive plaster is used, which is applied to the back of the foot.It is fixed in such a way that when walking, external and internal deviation of the metatarsal bones is excluded.
• A more convenient and reliable option is orthopedic fixation of the foot - treatment in this case is much more effective.For this purpose, various types of orthoses or bandages are used, the rigidity of which is selected depending on the degree of deformation.

Wearing support devices should be almost constant - during the first month it is recommended to remove them for no more than 2 hours during the day.

Active procedures

The transition to the second stage is determined individually - after a doctor has assessed the symptoms, as well as an X-ray examination.The absence of progression of the disease, as well as at least slight positive dynamics, allows us to begin an active fight against the deformity.The following methods are used for this:

• First, physical therapy procedures are gradually introduced to prepare the joint and surrounding soft tissues for the upcoming load.Warming and distracting procedures are carried out, which can be used on the foot.They include laser, magnet, applications with paraffin or ozokerite, ultrasound therapy.
• After a few days, massage sessions are added, which begin with superficial heating of the tissues.Gradually, the specialist should move on to warming up the actual muscles of the foot, which play an important role in eliminating curvature.
• When the unpleasant symptoms completely disappear, the patient proceeds to independent physical exercise.It is not recommended to include many exercises in the program at once, so as not to cause muscle fatigue.It is better to increase the load gradually, allowing the soft tissues to adapt to the work being performed.

To achieve the full effect, the listed activities must be carried out daily in order to prevent pathological processes from returning.

Surgical treatment

Indications for surgery should always be justified, since long-term rehabilitation is required after they are performed.Therefore, they are not performed on patients in the early stages of hallux valgus, in whom the curvature of the finger can be corrected naturally.Surgical intervention is required only in case of irreversible changes in the joint or surrounding tissues:

1. When there are signs of fixed transverse flatfoot - that is, the front arch of the foot is deformed both during load tests and in the resting position.This conclusion appears after an X-ray examination assessing the location of the heads of the metatarsal bones.
2. With pronounced curvature in the first metatarsophalangeal joint, accompanied by persistent dislocation between the bones that form it.The absolute indication in this case is an additional curvature of the adjacent joint, which leads to a change in the position of the second finger.
3. Even with initial signs of arthrosis in the first metatarsophalangeal joint, which indicates irreversible damage to the surrounding soft tissues.The muscles and ligaments are securely fixed in a vicious position, so it will not be possible to carry out correction in a conservative way.

The choice of intervention method depends entirely on the individual characteristics of the course of the disease - it is usually performed on the most affected component of the arch of the foot.

Ligament surgeries

This surgical treatment option is more suitable for those patients who do not yet have signs of direct damage to the joint tissues.Therefore, the leading mechanism of deformation in them becomes pathological muscle traction associated with a change in the position of the arch of the foot.To correct it, the following intervention options are used:

• The first type of operations includes all forms of transposition (movement) of the tendons attached to the first metatarsal bone.It is the pathological contraction of the muscles that leads to a gradual increase in the deviation between it and the phalanx of the finger.Therefore, the ligament is removed or partially split and attached to a new place - in the area of the outer edge of the metatarsal bone.Changing the point of application of muscle force allows you to gradually return it to its original place.
• The second type of operation involves the creation of various types of ties - the creation of an artificial transverse arch of the foot.All metatarsal bones are fixed in the correct position, after which a section of another ligament, or a synthetic prosthesis, is sewn to them.But this option is only possible with “mild” deformation, when displaced bones can be easily returned to their original place.

According to the results of observations, all operations on ligaments are still temporary in nature - without correction of pathological factors, the displaced tendons quickly stretch again.

Joint operations

If there is significant curvature in the joint, orthopedic interventions are required to eliminate bone tissue defects.To do this, resections are performed - removal of certain areas of the affected bone.This method makes it possible to artificially return the joint to its normal position.The following options for such operations are currently used:

• The main method for eliminating deformity is Schede-Brandes osteotomy.This intervention includes two manipulations - removal of the pathological growth on the first metatarsal bone (ossicles), and resection of a triangular fragment at its base.After fusion of the bone tissue, the deformed finger returns to its normal position.
• Less commonly used are operations in which resection of both areas is carried out in the area of the metatarsal head.Due to massive damage, the risk of developing complications that will not allow the fragments to heal properly is too high.
• In advanced cases of the disease, palliative forms of interventions are performed - not restoring mobility, but eliminating pathological displacement.For this purpose, arthrodesis is performed - excision and closure of the joint cavity between the metatarsal bone and phalanx.

Nowadays, these interventions are rarely performed in isolation - they are usually combined with simultaneous tendon plastic surgery, which eliminates improper muscle traction.

Combined operations

Performing complex manipulations is a priority in modern orthopedics, which leads to an increase in the frequency of combined interventions.Typically, a combination of gentle bone resection and relocation of one of the ligaments that moves the thumb is performed:

• The modified Schede-Brandes operation involves the removal of standard sections of the metatarsal bone - resection in the area of the head and base.Additionally, the abductor pollicis muscle is transposed onto its outer surface, the pressure of which leads to subluxation in the joint.
• It is also possible to perform an osteotomy in combination with the formation of an artificial arch.Moreover, in one operation it is possible not only to return the metatarsal bone to its original place, but to give the remaining structures the correct position.
• In severe cases, interventions are combined to simultaneously eliminate deformities in the first and second metatarsophalangeal joints.

This type of operation is characterized by the greatest severity - a large volume of destruction requires long healing and increases the rehabilitation period.

Recovery

Completion of conservative and surgical treatment is the beginning of the recovery period, which continues in such patients for the rest of their lives.Without following special recommendations, the disease may return, reminding itself again with unpleasant symptoms:

1. First of all, all patients are required to wear special orthopedic insoles with additional Seitz bolsters.They will not only ensure the correct position of the foot when walking, but will create additional support for its arches.
2. You also need to pay attention to your shoes - completely exclude from your wardrobe any boots or shoes with a narrow front.
3. You need to take care of your own weight - maintaining normal body weight significantly reduces the load on the arches of your feet.
4. Regularly performing preventive daily exercises keeps muscles in normal tone, which prevents displacement of the metatarsal bones.

The main difficulties for patients arise with the physical therapy program, since most recent patients do not even know the exercise technique.Therefore, to perform them correctly, you first need to study with an instructor in an individual or group form.