ESCANABA — Bunions are part of the American lexicon, a term used with great comic effect in numerous shows and movies. Exactly what it is may be unclear to many, but most Americans at least realize it is some kind of foot deformity. Various misconceptions exist as to the specifics of a bunion, but it is a common development, with a third of our senior population afflicted. But this treatise is not a discussion of the ubiquitous bunion.

With this deformity, the big toe slides gradually over towards the lesser toes, with a bony prominence developing at the base of the great toe. But the opposite can occur, whereby the great toe moves gradually away from the smaller toes, towards the middle of the body. This motion, termed varus, makes this deformity hallux varus (since the great toe is the hallux).

This condition, a varus angulation of the great toe, is not a frequent occurrence. When it develops without prior surgery or trauma (basically the same thing), it’s usually due to the presence of certain deformities. The most common is a problem where all the metatarsal bones are angled excessively, in the same way, towards the middle. This is a very common finding, although it’s typically unrecognized by pediatricians or primary care when it is a milder variation.

Hallux varus is not usually a particularly painful problem, but shoe fit is an issue. Most modern day humans wear shoes most of the time (barring the rare trip to the beach when there’s an actual sunny weekend) and this particular abnormality does not fit any footwear properly, safely, comfortably.

There are other complications to hallux varus, most important the loss of efficient ambulation, referring to the complex sequence of events allowing for a healthy gait. This is a given when the big toe doesn’t line up correctly, straight ahead, in the direction of the body. When normal gait is altered or disturbed on a long term basis, it’s a safe assumption that some other structure will become stressed, leading to dysfunction or pain.

From a broader perspective, degeneration of the big toe joint cartilage is a predictable outcome, time dependent. Any time an articulation functions, regularly and consistently, in an abnormal position, there will be stress to this smooth, glassy material. The cartilage covering the two bones will wear and thin, leading to stiffness or discomfort, especially noticeable with gait.

Although various inherited factors can lead to the development of a hallux varus deformity, the most common cause, by far, is iatrogenic, meaning it’s the result of some type of intervention, i.e. a surgical procedure. The vast majority of the time, the procedure is a bunion correction.

There are a multitude of techniques used to correct a bunion deformity (aka hallux valgus), and some are more often associated with this complication. When an open procedure is utilized, as opposed to a minimally invasive approach, the work done on the capsule can result in a varus deformity. With the small incision methods, the joint capsule is not manipulated, and the development of a hallux varus is rare.

Often performed in bunion correction is a cut through the first metatarsal bone, followed by its repositioning. When this change angles the head of the bone inappropriately, the great toe may end up creeping over away from the other toes, leading to a varus deformity.

This abnormality rarely occurs as a result of an acute injury. But if surgery has recently been performed, the structures which serve to keep the joint in place are weakened. With the right (wrong) kind of trauma, the covering of the joint or the ligaments around it may tear or stretch out, and the big toe ends up misaligned. This is part of the reason individuals wear specialized, protective shoe gear after a bunion surgery.

Options for treatment of a hallux varus deformity are limited. Although rarely corrective, there are various straps and braces which can help to keep the hallux better positioned. Predictably, these tend to be painful when crammed into a shoe.

When the angled big toe is the result of an inherited condition and not a complication of surgery, prescription foot supports, aka foot orthotics, can keep things in better alignment. Unfortunately, many individuals receive foot supportive devices, and for a multitude of reasons, find them ineffective or downright uncomfortable. But foot orthotics can provide relief of hallux varus when properly prescribed.

For most who develop a hallux varus deformity, a surgical procedure is the seminal event leading to the condition. But an additional surgery to correct this complication is not a popular option. And yet, there are no other effective options. Naturally, because there are a variety of situations resulting in the varus great toe, different procedures are used to correct it.

Many individuals end up living with a hallux varus deformity. The big question pertains to the origin: was it the result of surgery? Although unsightly, if it is a flexible condition, complications may be minimal. Still, as with many health issues, getting all the facts, even different opinions, can help to guide you. Gather information so you can be an educated healthcare consumer. But beware of Dr. Google, who knows everything and nothing.

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Dr. Conway McLean is a physician practicing foot and ankle medicine in the Upper Peninsula, with offices in Escanaba, Marquette, and L’Anse. McLean has lectured internationally on wound care and surgery, being board certified in surgery, orthotic therapy and wound care. His articles on health and wellness appear in multiple local and national publications. Dr. McLean welcomes subject requests for future articles at drcmclean@outlook.com.