Hallux Valgus – A Case Study of Bunion Treatment

A bunion case study to treating Hallux Valgus

Bunions can be a debilitating condition for many patients that ultimately could result in significant big toe pain with even the most simple activities like walking. The anatomical term for bunions is Hallux Valgus. This is often a result of progressive tightness of the extensor hallicus longus and breves muscles which control the big toe moving upwards or into what we call extension. Knowing the origin and insertion of these muscles can help aide the understanding of this biomechanical problem and attack the root cause of the issue.

Do I have Hallux Valgus?

The best way to know for sure is to seek out a licensed medical professional who can properly assess your movement problem. We provide full body movement screens and mobile Physical Therapy in Destin Florida. Not in the area? We also do Virtual Physical Therapy or Telehealth appointments online. 

Anatomy

The extensor hallucis brevis Originates on the lateral side of the calcaneus (heel) and traverses across the top of the foot at a sharp angle before following the first metatarsal and finally inserting on the dorsal or top side of the proximal phalanx of the 1st toe. Severe restrictions here may lead to the more “classic bunion” with the big toe driving inwards towards the other toes at the Metatarsal Phalangeal (MTP) joint. The extensor hallucis longus originates on the anterior or front of the fibula courses nearly straight down the front of the leg following the first metatarsal and ultimately attaching to the dorsal or top side of the distal phalanx. This muscle is much larger than the brevis and tightness here may related to a more interphalangeal hallux Valgus or where the end joint of the big toe drives towards the other toes. 

 

  

Extensor Hallucis Brevis                                                                                                                       Extensor Hallucis Longus 

Check out more information about bunions here.

Background: 

Another common cause of this condition is excessive pronation (movement towards the arch of the foot) of the forefoot which alters the angle of the ground reaction force coming up through the toes and feet. Instead of the line of force going directly vertical or straight up if we have neutral midfoot and ankle, in this scenario the force from the ground is directed at an oblique angle so as to push the big toe towards the other toes. Think of every time we go to take a step our foot rolls excessively towards our arch which will over time begin to deform our big toe by pushing it towards our other toes. Taking one step with a foot that pronates excessively is not much of a concern but, consider 10,000 steps a step, every day, for years. Now we can start to see a chronic pattern where altered forces directed at the big toe can cause some serious problems if left untreated. 

The joint most often affected is the MTP joint, where the base of the big toe joins the foot. Many people refer to this common condition as a bunion and consider surgical options to correct it. Typically, the surgery entails removing a wedge shape of the metatarsal bone to straighten out the big toe. Often these surgeries are only marginally successful and I have witnessed many patients have significant and prolonged big toe pain following surgery. 

One of the many contributing factors to this prolonged great toe pain is swelling. We know that swelling occurs naturally after an injury or surgery. Unfortunately, gravity can have a less than desired effect on our swelling as often when we are on our feet or even sitting with our feet on the ground. Swelling then pools in the lowest point of the chain, out feet. In this instance, the insult is at the big toe which means the swelling is already at the end of the chain. With the prolonged amount of time in a gravity-dependent position feet/ankle/toe injuries are notorious for significant and prolonged swelling. Even with proper elevation, compression, and movement, the management of edema or swelling can be very difficult. 

The most common joint affected by this Hallux Valgus deformity is the metatarsophalangeal joint (MTP) or the first joint articulation of the big toe. We still see the interphalangeal joint (IP) being affected here as well. The IP joint is the end joint of the big toe. 

Case Study:

Recently we treated a middle-aged woman, we’ll call her Mary, who was suffering from left big toe pain related to a bunion or hallux Valgus. This poor lady had been suffering for years and like so many of us had decided to “just deal with it.” Without proper treatment, we understand that many of these joint problems are progressive or will continue to get worse as time goes on. This was certainly the case for Mary. She told me that it seemed like every year the bump on the outside of her big toe got a little larger and a little more painful. The longer this went on the harder it has become for Mary to complete her daily morning walk and now she has had to shorten it to just a block due to her big toe pain. 

Evaluation Findings: 

We ran Mary through a detailed functional movement screen to investigate all movement limitations that she may have. 

        • Severe tissue restrictions in the extensor hallucis longus and brevis muscles 
        • Marked fascial restrictions around her L foot and ankle
        • Global ankle weakness in regard to her ability to control movement at the subtalar joint (supination and pronation) 
        • Poor single-leg balance
        • L glute weakness in standing

For the sake of this post, we will address the glute and ankle weakness in another article more focused on ankle stability. 

Manual Intervention: 

Being a manual or hands-on therapist my first intervention for Mary was to address the muscle tightness in her extensor hallicus muscles. I used a combination of soft tissue techniques including trigger point release, strumming, and longitudinal strokes to improve the pliability of the soft tissues. Next, the fascial restrictions were addressed using a whole hand gentle pressure for prolonged amounts of time to improve the fascial tissue mobility. By decreasing the muscle and fascial tension that for years had been pulling Mary’s big toe sidewards towards her other toes, there was immediately less pressure on the MTP joint and she experienced some pain relief. No not all of her pain had magically vanished but, a positive change in her pain complaints was noted on the very first treatment. This shows me that we are on the right track to empowering Mary to return to morning walks without big toe pain. 

Self Care: 

For home care, I suggested a medial heel wedge for the time being to help correct some of her calcaneal eversion which was contributing to her excessive pronation in her midfoot. We also make sure to provide each patient with at least one and no more than two home exercises to continue the improvement. For Mary, her home exercise stretch was simple, oppositely stretch her big toe that it was being pulled from her tight extensor hallicus muscles. This means to plantarflex the ankle, flex the big toe, and gently pull away from the other toes.  Ideally, we want the stretch to be felt across the muscle bellies of the hallicus longus and brevis muscles (Please see the above paragraph to better understand the locations of these muscles). If too much stress or pressure is felt across one of the joints, alter the stretch by changing the foot and/or toe position to feel the stretch in the desired area. Consider subtle rotations of the toe joint to maximize the stretch across the muscle belly with less stress on the joints.  

Results: 

After a few short weeks, Mary returned to her daily walks with minimal big toe pain. Remember our goal was to return Mary to function and her desired function was walking for longer. Pain relief may or may not come, in this case, her pain improved, but our ultimate focus is improvement in her function. The actual bump deformity of the big toe may only marginally change with this type of treatment. But once again if our patients return to full pain-free function we are much less concerned about aesthetics. Happy walking Mary!

Wrapping up: 

Is Mary’s case similar to yours? Sometimes it may sound similar but this post is purely designed to give free information concerning bunions and hallux Valgus. The best way to ensure a successful treatment approach is to reach out to a local movement professional so they can properly access your movement limitations and accurately prescribe exercise and/or manual intervention. 

We provide Mobile Physical Therapy in Destin Florida. Not in the area? We also do Virtual Physical Therapy or Telehealth appointments online. 

Until next time, keep that body moving and be well, 

Robert Linson, PT, AFS, FMR, TPS

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