Understanding why hallux valgus occurs and fixing it without surgery

Posted on January 18, 2017

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Below is the table of contents for A Guide to Correcting Hallux Valgus. Afterwards there is the understanding section, which is free. You’ll then find the purchase button to get access to the fixing section, along with more info as to what’s in it. Or if you’re of the “Just tell me what to do mindset,” you can purchase right away:

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  • Understanding
    • Quickly defining
      • Bottom of the big toe vs top of the big toe
    • Why does hallux valgus happen?
      • (it’s more than footwear!)
      • Differences in gender
      • Why two people can wear the same shoes but not get the same results
        • Differences in foot shape
        • Differences in how people walk
      • Why a person can wear the same shoes but one foot looks worse than the other
        • Differences in how you walk
    • When does it start?
      • Another thing we can blame Mom and Dad for, and Michael Jordan
      • Setting us up for how much improvement someone can expect
  • Fixing
    • Footwear considerations
      • Sizing
      • Understanding heel lifts- you don’t have to go to zero
      • Stiffness
      • Some brands to think about
    • What to do when you’re not wearing shoes
      • Spreading the toes with help
      • Spreading the toes yourself
    • Knowing when you’re forcing it
    • Exercise
      • Eight exercises along with progression considerations
    • Understanding what may be necessary
      • Sets, reps, days per week, and more
    • Tradeoffs for athletes
      • Runners
      • Football players
      • Rock climbers
      • Stiffness again

Understanding

Quickly defining

If you’re reading this, you more or less have come to “hallux valgus, also called a bunion, is when the big toe angles in.”

The podiatrists / pedants will want us to point out there is a difference in where the big toe angles in. Notice in the above the angling is pretty low, around the bunion area. But the big toe could also be turned in higher up:

hallux-interphalangeus-2

Credit: http://www.thefootandankleclinic.com/imgid371article102gallery23section13.htm

Hallux valgus on left; hallux interphalengeus on right:

For our purposes “big toe angled in” is sufficient.

Why does hallux valgus happen?

Initially this is simple. We’re born with smack-you-in-the-face-cute toes like these:

Which then turn into everybody-run-and-hide monsters. We don’t see this change as frequently in non-shoe wearing societies => shoes are the cause. And the longer one wears shoes, the more hallux valgus happens:

hallux-valgus-shoe-wearing-timeline-percentages

Credit: Incidence of Hallux Valgus in a Partially Shoe-wearing Community (http://www.bmj.com/content/bmj/1/5451/1648.full.pdf)

It’s not hard to imagine wearing a pointy shoe can make one’s toes pointy.

Now we can understand one reason women suffer this more than men- they wear narrower shoes.

But there is more to it than that. While some male shoes, mainly dress shoes, can be awfully narrow, they never have the heel lift women’s high heels do.

woman-high-heels-hallux-valgus

Because of this lift, notice the woman has much more of her weight going into her toes. If you think of the shoe like a ramp holding a ball, as the ramp inclines, the ball gets pushed forward. Looking at the shoe from the side:

shoe-ball-analogy-1shoe-ball-analogy-2shoe-ball-analogy-3

But we know we don’t have a rectangular shoe. We have a pointed one. So our ball gets pushed inward. Looking at the shoe from the front:

-> While your big toe may be your concern, your pinky toe(s) may also be pointing in:

right-foot-toe-in-with-pinky-line

So not only are women likely wearing shoes which compress the big toe more, they’re also likely putting more of their bodyweight into the big toe, where the shoe then pushes back.

foot-moving-down-shoe-hallux-valgus-gif

Slow motion:

Why two people can wear the same shoes but not get the same results

Not all feet are shaped the same way. Many of us have heard of narrow and wide feet.

Right away we can see why we might not always have a clear relationship between wear X shoes => feet end up like Y. If you have a narrower foot, your toes are going to be better able to fall into the toe box. If you have a wider foot though, you’re more likely to compress that big toe.

Narrow left; wide right:

narrow-vs-wide-foot-hallux-valgus-gif

Another aspect is some people’s feet curve inward. Notice how this foot doesn’t go straight.

Meaning the big toe is more likely to curve into the toe box and be pushed into hallux valgus.

Not everyone walks the same either. What if you’re somebody who turns / drags your foot, also known as overpronation. Each time you roll that foot in you are pushing the big toe in. If you don’t see it at first, it’ll be in slow motion the third time:

walking-hallux-valgus-pronation

We have these bones on the bottom of our first metatarsal (green):

called sesamoid bones:

Notice these bones can get pushed inwards, such as in overpronation. If we zoom in on the sesamoids and say we’re on even ground with them:

first-metatarsal-sesamoid-bones-flat-ground-hallux-valgus

Image created from: The Pathogenesis of Hallux Valgus.

But with excessive pronation we’re not hitting the ground evenly. We’re hitting the inside sesamoid more:

sesamoid-bones-first-metatarsal-with-ground

Where the first metatarsal can “fall off” the sesamoid bones.

sesamoid-bones-anteroposterior-view-with-movement

Which would cause an angling of the big toe:

Rather than do something like push the top of the big toe in, we’ve pushed the bottom of it out, causing the same effect.

hallux-valgus-sesamoids-closer-up-first-metatarsal-lines-more-lines

We looked at this image earlier. Now we can point out the sesamoid bones (orange) the first metatarsal is no longer on top of:

hallux-valgus-bones-2-with-sesamoid-line

Whereas below the sesamoids are underneath:

hallux-interphalangeus-with-sesamoid-lines

And there’s no guarantee the muscles which control the big toe would move outwards to compensate. Notice the EHL in this photo, Extensor Hallucis Longus, has stayed still:

sesamoid-bones-anteroposterior-view-with-movement

You can see the ligaments right below the foot stretch out too. This is another reason women are more likely to suffer from hallux valgus. They’re more lax to begin with, and respond more favorably -for better or worse- to stretching. It’s easier for an already lax person to become excessively lax than it is a stiff person.

Furthermore, you may only do this on one leg. Maybe you had an ankle injury from way back when where you never quite got back your ability to push off. Instead of using that foot to push upwards, you instead started dragging it some / turning it out. Subsequently one big toe ends up suffering this but the other doesn’t. Or maybe you suffer from a flat foot, rather than flat feet. Where one foot naturally caves in more than the other to begin with.

Lastly, this is one reason hallux valgus becomes more common with age. One of the first areas to atrophy causing a functional deficit is the foot and ankle complex. Namely, the ability to push off. So what might one do if they can’t push their foot as high in the air? They swing it around instead.

An older person walks more like on the left, where a younger person is more likely to have some bounce in their step:

When does it start?

As we mentioned, hallux valgus isn’t really an issue in non-shoe wearing cultures. Thus, we can say the issue has potential to start the moment we put shoes on. Unless you have parents who were concerned about how wide the toe box of your toddler shoes were, you could have started cramming your toes together from a very young age, when your parents wanted everyone to “look at the baby, look at the baby!” throwing some infant Jordans on you.

To appreciate the importance of this we can look at baseball players. The most noteworthy aspect of their physicality is the ability to do this:

External rotation pitching

The ability to lay their arm back. This is an acquired ability, and it’s where the expression “throw like a girl” comes from. It’s not that women can’t acquire this. It’s that for so many years girls didn’t grow up throwing. By the time you saw them attempt to throw as a late adolescent or adult, they end up pushing the ball because their arm can’t rotate back like above. The same thing happens to guys who don’t grow up throwing.

The first takeaway here is bone is more malleable at a young age. We start out as essentially balls of cartilage, progressively hardening with age. While bone can still adapt in the adult years, it’s much more limited in changing range of motion. (It’s still very good at changing bone density.)

So if from your earliest years you started doing this to your toes,

hallux-valgus-bones-2

Credit: http://foothyperbook.com/elective/hav/havInvest1.htm

There is a chance your body has acquired that position, at least to some degree, where now your neutral / normal involves some angling in. Much like the pitcher has acquired a different bone structure in one arm.

The second takeaway is then not everyone can expect to get back to baby toes. Where everything is seemingly perfectly aligned. The bad here is aesthetically, you may not get the look you want. If you’re having pain though, or worried your feet are heading towards surgery, the good is you probably can get back to a non-pain free and better aligned state, and that you can prevent the valgus from progressing over time.

It’s important to reiterate the need to accept bone has a limited ability to change in the adult years. If you attempt to force your toes into a position they cannot acquire, you can actually make the problem worse. You end up jamming two bones together. No Bueno.

Correcting

To get access to this section you can purchase below for $10:

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  • Fixing
    • Footwear considerations
      • Width vs length and why they both matter
      • Differences in types of heel lifts
      • Soft shoes vs hard shoes
      • A couple brands which inherently help hallux valgus
      • Specific shoe recommendations
        • Active
        • Dress
        • Boots
    • What to do when you’re not wearing shoes
      • How to get the toes spread without having to buy anything
    • Knowing when you’re forcing it
      • How do you know if you’re trying to splay the toes too much?
    • Exercise
      • Eight exercises along with progression considerations, sets, reps, form notes and video of each one
    • Understanding what may be necessary
      • The biggest mistake to avoid
    • Trade offs for athletes
      • The shoes which are best for performance may not be the best for your toes

Upon buying you’ll be given a password protected link. This will show up in your browser and you’ll receive an email for safe keeping.

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