Big toe deformity: treatment

Static foot deformities are degenerative diseases of the skeleton that seriously impair its support functions.Typically, 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 have shock-absorbing properties.

Consequently, damage to this formation leads to the development of a fairly common disease - flat feet.When it is mentioned, people often imagine a longitudinal variant of the pathology, which causes the arch of the foot to droop 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 the use of uncomfortable or ill-fitting shoes, which over time contributes to the displacement of the bones in the forefoot.The result of hallux valgus is constant and 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 - then the direction of the angle between the bones is assessed.The development of the 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 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 progresses irreversibly.In the later stages of the disease, the deformity of the big toe reaches such severity that the angle at 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 shift of this bone inward under the force of gravity.
3. The most recent manifestation is a hammer-shaped curvature of the second toe, also caused by pathological pressure from 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 calluses on the sole, under the middle fingers.

Formation mechanism

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

• The triggering factor is always inadequate loading of the forefoot due to the use of unsuitable shoes - especially those with narrow toes and heels.
• This leads to chronic damage to soft tissues - the ligaments and muscles that hold the base of the toes and metatarsals in an elevated position.
• Repeated trauma causes the frontal arch to gradually sag, 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 greater displacement of the metatarsal bone 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 injury leads to the development of deforming arthrosis of the first metatarsophalangeal joint, which causes loss of functional capabilities of the joint.

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

Conservative treatment

Valgus deformity of the big toes can only be eliminated using traditional methods if the functionality of the joint is fully preserved.This is explained by the state of the ligaments and muscles, whose damage 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 artificially returns to its normal configuration, which is done by various orthopedic means.This period generally takes 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 foot muscles.For this, physiotherapy classes, massage sessions and physiotherapy procedures are combined simultaneously.
3. The final period is undefined, as hallux valgus is an incurable disease.With this, the patient consolidates the results of the treatment for the rest of their life and strives to prevent the progression of the disease.

The choice of means and methods of 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, as foot fixation 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 way to start helping is to completely get rid of shoes or boots that have a narrow toe box.Now the patient should only wear wide, wide or open-front shoes.Individual making of orthopedic boots is considered ideal, but it is extremely rare that patients can afford such a luxury.
• For small deformities, a special bandage made of adhesive tape 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 stiffness of which is selected depending on the degree of deformation.

The use of support devices should be almost constant - during the first month it is recommended to remove them for a maximum of 2 hours during the day.

Active procedures

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

• First, physiotherapy procedures are introduced gradually to prepare the joint 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, paraffin or ozokerite applications, ultrasound therapy.
• After a few days, massage sessions are added, which begin with superficial tissue heating.Gradually, the specialist should begin to warm up the foot muscles themselves, which play an important role in eliminating curvature.
• When the unpleasant symptoms completely disappear, the patient begins independent physical exercises.It is not recommended to include too many exercises at the same time in the program, so as not to cause muscle fatigue.It is better to increase the load gradually, allowing the soft tissues to adapt to the work performed.

To obtain the full effect, the listed activities must be carried out daily to prevent the return of pathological processes.

Surgical treatment

Surgical indications must always be justified, as long-term rehabilitation is necessary after surgery.Therefore, they are not performed on patients in the early stages of hallux valgus, in whom the curvature of the toe can be corrected naturally.Surgical intervention is necessary only in case of irreversible changes in the joint or surrounding tissues:

1. When there are signs of a fixed transverse flat foot - that is, the anterior arch of the foot is deformed both during load tests and in the resting position.This conclusion comes after a radiographic examination evaluating 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 firmly fixed in a vicious position, making correction impossible conservatively.

The choice of intervention method depends entirely on the individual characteristics of the course of the disease - it is usually carried out 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 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 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 fixed in a new place - in the area of the outer edge of the metatarsal bone.Changing the point of application of muscular force allows you to gradually return it to its original place.
• The second type of operation involves the creation of several 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 is sewn to them, or a synthetic prosthesis.But this option is possible only with “light” 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 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 necessary to eliminate bone tissue defects.To do this, resections are performed - removal of certain areas of the affected bone.This method allows you to artificially return the joint to its normal position.The following options for such operations are currently used:

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

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

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 moves 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 region.Furthermore, the abductor pollicis muscle is transposed to its outer surface, the pressure on which leads to subluxation of the joint.
• It is also possible to perform an osteotomy in combination with the formation of an artificial arch.Furthermore, in one operation it is possible not only to return the metatarsal bone to its original place, but also to give the other structures the correct position.
• In severe cases, interventions are combined to simultaneously eliminate deformities of the first and second metatarsophalangeal joints.

This type of operation is characterized by greater 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 continues in these patients for the rest of their lives.Without following special recommendations, the disease may return, reminding again of unpleasant symptoms:

1. Firstly, all patients are required to wear 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 also need to pay attention to your shoes - completely exclude any boots or shoes with a narrow front from your wardrobe.
3. You need to watch your own weight - maintaining normal body weight significantly reduces the load on the arches of your feet.
4. Regularly performing daily preventive exercises keeps the muscles in normal tone, which prevents displacement of the metatarsal bones.

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