Big toe deformity: treatment

Static foot deformities are degenerative diseases of the skeleton that seriously impair its supporting functions.Normally, the load is not evenly distributed over the entire surface 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 have shock-absorbing properties.

As a result, damage to this formation leads to the development of a fairly common disease - flat feet.When we talk about it, we generally 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, often being an acquired pathology.It is associated with wearing uncomfortable or ill-fitting shoes, which over time contributes to the shifting of the bones in 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 midline.In this case, curvature can also occur in the joints - the direction of the angle between the bones is then assessed.The development of transverse flat foot 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 later stages.It is therefore 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 exterior.The formation of pathology occurs gradually, but it progresses irreversibly.In 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 normally the head of the metatarsal bone protrudes slightly.Its appearance is associated with a compensatory deviation of this bone inwards under the effect of gravity.
3. The final manifestation is a hammer-shaped curvature of the second finger, also caused by pathological pressure exerted by the adjacent joint and surrounding soft tissues.

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

Training mechanism

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

• The trigger is always inappropriate stress on 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 a gradual drop in the front arch, 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 pathological pressure force on it is maximum.Its capsule gradually stretches, causing the metatarsal bone to further shift inward.
• 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 injuries lead to the development of deforming osteoarthritis of the first metatarsophalangeal joint, which leads to a loss of functional capabilities of the joint.

Further assistance tactics depend on the severity of the changes - in the early stages, conservative measures are enough, and already 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 fully preserved.This is explained by the state of ligaments and muscles, the damage to which is reversible at an early stage.In this case, assistance is provided in three successive stages:

1. First of all, the patient is prescribed passive treatment methods, which consist of fixing the finger in the correct position.The joint is artificially returned to its normal configuration, which is achieved using various orthopedic means.Usually this period lasts 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 foot muscles.To achieve this, physiotherapy courses, massage sessions and physiotherapy procedures are combined simultaneously.
3. The final period is indefinite, since hallux valgus is an incurable disease.Thus, the patient consolidates the results of treatment for the rest of his life and undertakes to prevent the progression of the disease.

The choice of means and therapeutic methods 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, because foot fixation rarely goes unnoticed by the patient.The return of the normal anatomical structure of the arch 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 a narrow toe.From now on, the patient should only use loose, wide or open-front shoes.Individual tailoring of orthopedic boots is considered ideal, but it is extremely rare that patients can afford such luxury.
• For minor deformities, a special adhesive plaster bandage 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 practical and reliable option is orthopedic fixation of the foot - treatment in this case is much more effective.For this purpose, different types of orthoses or bandages are used, the rigidity of which is chosen 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 per day.

Active procedures

The transition to the second stage is determined individually - after a doctor assesses the symptoms, as well as an x-ray examination.The absence of progression of the disease, as well as at least a slight positive dynamics, makes it possible to begin an active fight against deformation.The following methods are used for this:

• First, physiotherapy procedures are gradually introduced to prepare the joints and surrounding soft tissues for the upcoming load.Warming and distraction procedures are performed, 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 a superficial heating of the tissues.Gradually, the specialist should start warming up the 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 several 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 should be performed daily in order to avoid the return of pathological processes.

Surgical treatment

Surgical indications must always be justified, because long-term rehabilitation is necessary after their completion.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 only necessary if there are irreversible changes to the joint or surrounding tissues:

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

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

Ligament surgeries

This surgical treatment option is more suitable for patients who do not yet show signs of direct damage to the joint tissues.Therefore, the main mechanism of deformation in them becomes pathological muscle traction associated with a change in the position of the arch.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 which leads to a progressive 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 muscular force allows it to gradually return to its original place.
• The second type of operation involves the creation of different types of links - 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 possible only with “mild” deformation, when the displaced bones can be easily returned to their original place.

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

Joint operations

In case of significant curvature of the joint, orthopedic interventions are necessary to eliminate defects in bone tissue.To do this, resections are carried out - removal of certain areas of the affected bone.This method allows the joint to be artificially returned to its normal position.The following options for such operations are currently used:

• The main method of eliminating deformities is Schede-Brandes osteotomy.This procedure 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 performed at the level of the metatarsal head.Due to the 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 carried out - not restoring mobility, but eliminating pathological displacement.For this purpose, an arthrodesis is performed - excision and closure of the joint cavity between the metatarsal bone and the phalanx.

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

Combined operations

Carrying out 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 at the level of the head and base.Additionally, the abductor pollicis muscle is transposed onto 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.Moreover, in one operation it is possible not only to return the metatarsal bone to its original place, but also to give the correct position to the remaining structures.
• In severe cases, interventions are combined to simultaneously eliminate deformities of the first and second metatarsophalangeal joints.

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

Recovery

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

1. First of all, all patients must wear special orthopedic insoles with additional Seitz bolsters.They will not only ensure the correct position of the foot when walking, but also create additional support for its 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 pay attention to your own weight: maintaining a normal body weight significantly reduces the load on the arch of the foot.
4. Regularly performing preventive daily exercises keeps the muscles in normal tone, which prevents displacement of the metatarsal bones.

The main difficulties for patients come from the physiotherapy program, because most of the recent patients do not even know the exercise technique.Therefore, to perform them correctly, you must first study with an instructor in individual or group form.