Associated changes and clinical presentation
Hallux valgus is not just a toe curvature, but a whole cascade of pathological changes. Patients develop deforming arthrosis of the metatarsophalangeal joints, exostoses form on the head of the 1st metatarsal bone, and chronic bursitis occurs. The 1st metatarsal bone itself deviates into varus and pronation, which exacerbates the transverse splayfoot.
Patients complain of pain and a feeling of stiffness in the forefoot, especially when walking and after physical exertion. Choosing regular or even orthopedic shoes becomes extremely difficult. Upon examination, a pronounced cosmetic defect is striking. In areas of constant friction against shoes, the skin becomes irritated, leading to long-healing wounds and ulcerations. The nail plate is deformed, sometimes progressing to ingrown nails. Additionally, clinical examination reveals heel pronation, extension and abduction of the foot at Chopart's joint, as well as a positive too many toes sign.
Pathogenesis of weight-bearing loss
The most unfavorable complication of this pathology is the reduction of the weight-bearing capacity of the anteromedial forefoot. This process develops in stages:
- Muscle imbalance is formed. Tendons shorten and tighten, acting like a "bowstring".
- The head of the 1st metatarsal bone slips off the medial sesamoid bone.
- Pathological weight redistribution occurs: the main load falls on the heads of the middle metatarsals.
- Painful calluses and cornons form on the sole in the projection of overloaded bones.
- Sharp pain develops, which significantly impedes independent walking.
Radiological diagnosis and grades
To accurately determine the severity of the pathology, radiography is performed. On the images, the physician draws three main lines: along the axis of the 1st metatarsal bone, along the axis of the 2nd metatarsal bone, and along the axis of the proximal phalanx of the 1st toe. The degree of deformity is assessed in degrees based on two key angles.
| Grade | Angle between the 1st and 2nd metatarsal bones | Angle of deviation of the 1st toe |
|---|---|---|
| I | 10 — 12° | 15 — 20° |
| II | 15° | 30° |
| III | 20° | 40° |
| IV | > 20° | > 40° |
Treatment approaches
Transverse splayfoot in adults is considered a hard-to-reverse deformity. The ligamentous apparatus constantly experiences static loads, and there are currently no effective methods for its complete functional recovery.
Treatment is divided into conservative and surgical. Conservative therapy includes:
- Mandatory wearing of specialized orthopedic shoes.
- Use of various orthotic designs for foot offloading.
- In mild forms (grade I), wide foam pads are used between the first and second toes to mechanically prevent valgus deviation, and a special bolster is applied.
To understand the pathogenesis, recall the "bowstring" concept: shortened tendons tighten, pulling the toe outward, causing the metatarsal head to slip off the sesamoid bone, and weight bearing to shift to the middle metatarsals.
Class and exam questions
Why is transverse flatfoot in adults poorly responsive to treatment?
This pathology is considered difficult to reverse due to the constant static load on the foot and the lack of methods capable of fully restoring the function of the stretched ligament apparatus.
How to properly assess the degree of toe deviation on a radiograph?
It is necessary to draw three axes: along the 1st and 2nd metatarsals, as well as along the proximal phalanx of the 1st toe. The severity grade is determined in degrees according to the formed angles.
What does conservative care entail for initial (grade I) deformity?
Patients are prescribed orthopedic shoes, orthoses, and a bolster as well as wide foam pads between the 1st and 2nd toes to restrain valgus deviation.
What else to study on this topic
- Stiff big toe (Hallux rigidus) and its clinical manifestations.
- Hammertoe deformity of the lesser toes: symptoms of friction and pressure.
- Acquired clubfoot: etiological and anatomical classifications (pes cavus, etc.).
- Drop foot: assessment criteria and types of deformities.
- Radiological criteria for assessing clubfoot (Meary’s Angle, Calcaneal Pitch).
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