Big toe deformity: treatment

Static foot deformities are degenerative diseases of the skeleton that seriously impair its support functions.Normally, the load is not evenly distributed over the entire sole area, 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 absorption properties.

Consequently, damage to this formation leads to the development of a fairly common disease - flat feet.When mentioned, people usually imagine a longitudinal variant of the pathology, which causes the arch of the foot to descend 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, and is often an acquired condition.It is associated with wearing uncomfortable or ill-fitting shoes, which over time contributes to shifting of the bones in the forefoot.The result of hallux valgus is the 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 away from the median axis.In this case, curvature can also occur in the joints;The direction of the angle between the bones is then evaluated.The development of transverse flatfoot corresponds precisely to this mechanism and ultimately causes irreversible damage to the metatarsophalangeal joint of the first toe.

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

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

Training mechanism

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

• The triggering factor is always inadequate loading of the forefoot due to wearing inappropriate shoes, especially those with narrow toes and heels.
• This causes 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 loading and therefore the pathological pressure force on it is maximum.Its capsule gradually stretches, causing greater 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) become fixed in this position over time, which explains the irreversibility of the curvature.
• Chronic injury leads to the development of deforming osteoarthritis of the first metatarsophalangeal joint, which causes the loss of the functional capabilities of the joint.

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

Conservative treatment

Valgus deformity of the big toe can be eliminated by traditional methods only if the functionality of the joint is completely preserved.This is explained by the state 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 of all, 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 done using various orthopedic means.Usually this period lasts at least 6 months, necessary for the adaptation of the soft tissues.
2. In the second stage, the active phase begins, which involves special training techniques to strengthen the muscles of the foot.To achieve this, physiotherapy classes, massage sessions and physiotherapy procedures are combined simultaneously.
3. The final period is indefinite, since hallux valgus is an incurable disease.Therefore, the patient consolidates the results of the treatment for the rest of his life and is dedicated to preventing the progression of the disease.

The choice of means and methods of therapy is completely individual: the patient's age, concomitant diseases and 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 the fixation of the foot rarely goes 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 to start helping is to completely get rid of shoes or boots that have narrow toes.Now the patient should only wear loose, wide or open-front shoes.Individual tailoring of orthopedic boots is considered ideal, but it is extremely rare for patients to be able to afford this luxury.
• For minor deformities, a special bandage made of tape is used, which is applied to the back of the foot.It is fixed in such a way that when walking the external and internal deviation of the metatarsal bones is excluded.
• A more convenient and reliable option is orthopedic foot fixation;The treatment in this case is much more effective.For this, various types of orthoses or bandages are used, the rigidity of which is selected depending on the degree of deformation.

The use of supportive 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 evaluated the symptoms, as well as an X-ray examination. The absence of disease progression, as well as at least a slight positive dynamic, allows us to start an active fight against the deformity.For this, the following methods are used:

• First, physiotherapy procedures are gradually introduced to prepare the joint and surrounding soft tissues for the upcoming load.Warm-up and distraction procedures are carried out, which can be used on the foot.They include laser, magnet, paraffin or ozokerite applications, ultrasound therapy.
• After a few days, massage sessions are added, which begin with the superficial heating of the tissues.Gradually, the specialist should move on to warming up the muscles of the foot itself, 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 best to increase the load gradually, allowing the soft tissues to adapt to the work being done.

To achieve the full effect, the listed activities must be performed daily to prevent the reappearance of pathological processes.

Surgical treatment

The indications for surgery must always be justified, since long-term rehabilitation is required after its performance.Therefore, they are not performed in patients in 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 anterior arch of the foot is deformed both during load tests and in the rest position.This conclusion appears after a radiological examination that evaluates 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 osteoarthritis in the first metatarsophalangeal joint, indicating irreversible damage to the surrounding soft tissues.The muscles and ligaments are firmly fixed in a vicious position, so it will not be possible to carry out the correction conservatively.

The choice of the method of intervention depends entirely on the individual characteristics of the course of the disease;It is generally performed on the most affected component of the arch of the foot.

Ligament surgeries

This surgical treatment option is most suitable for those patients who do not yet have signs of direct damage to the joint tissues.Therefore, the main mechanism of deformation in them is 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 divided 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 bindings - 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 a “mild” deformation, when the displaced bones can easily return to their original place.

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

Joint operations

If there is a 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 allows the joint to be artificially returned to its normal position.The following options are currently used for such operations:

• The main method to eliminate the deformity is the Schede-Brandes osteotomy.This intervention includes two manipulations: the elimination of the pathological growth in the first metatarsal bone (ossicles) and the resection of a triangular fragment at its base.After fusion of the bone tissue, the deformed finger returns to its normal position.
• Operations in which the resection of both zones is performed in the area of the metatarsal head are used less frequently.Due to the massive damage, the risk of developing complications that do not allow the fragments to heal properly is too high.
• In advanced cases of the disease, palliative interventions are performed, not to restore mobility, but to eliminate pathological displacement.To do this, an arthrodesis is performed: excision and closure of the joint cavity between the metatarsal bone and the phalanx.

Today, these interventions are rarely done in isolation;They are usually combined with simultaneous tendon plastic surgery, which eliminates inadequate 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 move the thumb is performed:

• The modified Schede-Brandes operation involves the removal of standard sections of the metatarsal bone - resection in the head and base area.In addition, the abductor pollicis muscle is transposed to its outer surface, the pressure of which causes subluxation of the joint.
• It is also possible to perform an osteotomy in combination with the formation of an artificial arch.In addition, in a single operation it is possible not only to return the metatarsal bone to its original place, but also 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

The completion of conservative and surgical treatment is the beginning of the recovery period, which in these patients continues for the rest of their lives.Without following special recommendations, the disease can reappear and remind itself again with unpleasant symptoms:

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

The main difficulties for patients arise with the physiotherapy program, since most of the recent patients do not even know the exercise technique.Therefore, to do them correctly, it is first necessary to study with an instructor individually or in a group.