🦶 Hallux Valgus: Causes of the “Bunion,” Symptoms, and Correction Methods

Hallux valgus, commonly known as a “bunion” or “bump” on the foot, is one of the most common orthopedic problems. According to studies, it affects 23% of adults aged 18–65 and 36% of people over 65, with women affected 10 times more often than men. The deformity develops gradually, causing pain, making it difficult to find suitable footwear, and altering gait.

Foot Anatomy and the Biomechanics of the Deformity

The human foot is a complex structure consisting of 26 bones, 33 joints, more than 100 ligaments, and 20 muscles. Its main functions are to absorb shock during walking and running, distribute load, and provide stability. The first metatarsophalangeal joint, or big toe joint, bears a particularly heavy load: it supports up to 40–60% of body weight with each step, especially during push-off.

In hallux valgus, the first metatarsal bone deviates inward, toward the body’s midline, while the big toe deviates outward toward the other toes. The angle between them increases (normally it is up to 15°). The head of the metatarsal bone protrudes medially, forming the characteristic “bunion.” This is not a bone growth but a displacement: the bone shifts sideways, while the soft tissues over it become inflamed due to friction and pressure from footwear.

The deformity creates a vicious cycle: the displaced big toe presses against the adjacent toes, normal load distribution during walking is disrupted, and other parts of the foot become overloaded, leading to additional problems such as corns, calluses, and pain in the metatarsal region.

Causes

Hallux valgus results from the interaction of several factors:

• Heredity — genetically determined weakness of the ligaments and connective tissue is the main predisposing factor; if the mother has a bunion, her daughter is highly likely to develop one as well
• Flat feet — when the arch flattens, the load on the first metatarsophalangeal joint increases disproportionately, accelerating the deformity
• Connective tissue weakness — joint hypermobility, which is more common in women, contributes to widening of the forefoot
• Improper footwear — a narrow toe box compresses the toes, while high heels shift the center of gravity toward the forefoot, increasing pressure on the big toe; however, footwear is not the root cause but a contributing factor that accelerates the deformity in predisposed individuals
• Excess weight — increases the load on the feet
• Hormonal factors — estrogen affects connective tissue elasticity; the highest number of medical visits occurs around menopause
• Foot injuries — fractures, dislocations, and ligament damage can disrupt biomechanics and trigger the deformity
• Certain diseases — rheumatoid arthritis, gout, and neuromuscular disorders

Stages of the Deformity

The severity of the deformity is assessed by the hallux valgus angle (HVA):

• Mild (HVA 15–20°) — slight deviation of the toe, with the bunion barely visible; pain is minor and occurs during prolonged walking in tight footwear
• Moderate (HVA 20–40°) — noticeable deformity, with the toe overlapping the adjacent toe; pain while walking, difficulty finding suitable footwear, and the formation of corns and calluses
• Severe (HVA over 40°) — pronounced displacement; the big toe may tuck under or overlap the second toe; persistent pain, significantly limited walking, and deformity of the other toes

Symptoms and Progression

The deformity develops slowly, usually over years or decades. In the early stages, redness and slight swelling appear around the bunion, along with discomfort when wearing tight footwear. Over time, the pain intensifies and occurs even in comfortable shoes, the bump enlarges, and the skin over it becomes thickened. Bursitis—an inflammation of the joint capsule—may develop, causing swelling, redness, and persistent aching pain.

As the condition progresses, the big toe begins to press against the second toe, which becomes deformed and takes on a “hammer” shape (hammertoe). Painful calluses develop on the sole due to load redistribution, resulting in metatarsalgia. Gait is altered as the person instinctively avoids putting weight on the painful foot, creating compensatory strain on the knees, hip joints, and spine.

Effects on Gait and Posture

The feet are the foundation of the entire body. Deformity of the big toe disrupts the push-off phase of walking: instead of pushing off forcefully with the big toe, the person shifts weight onto the outer edge of the foot and the other toes. This leads to:

• Overloading of the small joints of the foot, causing pain in the metatarsal region (metatarsalgia)
• Callus formation on the sole beneath the heads of the middle metatarsal bones
• Changes in the alignment of the ankle and knee joints
• Compensatory pain in the knees, lower back, and even the neck
• Impaired balance and an increased risk of falls in older adults

Associated Conditions

• Hammertoe deformity — the second and third toes bend at the interphalangeal joints, making footwear difficult to wear and causing painful corns on the tops of the toes
• Metatarsalgia — pain in the front part of the sole caused by overloading the heads of the middle metatarsal bones
• Bursitis of the big toe — chronic inflammation of the joint capsule around the bunion
• Osteoarthritis of the first metatarsophalangeal joint — cartilage deterioration caused by abnormal biomechanics, which limits toe mobility and increases pain

Diagnosis

The diagnosis is made by an orthopedic specialist based on a physical examination and weight-bearing X-rays of the feet taken in the frontal projection while standing. Key angles are measured on the X-ray: HVA (hallux valgus angle) and IMA (the angle between the first and second metatarsal bones). These angles determine the stage of the deformity and influence the choice of treatment. The condition of the joint cartilage, the presence of osteoarthritis, and the position of the sesamoid bones are also assessed.

Conservative Correction Methods

The following methods are used in the early stages and to slow progression:

Orthopedic Insoles and Arch Supports

Custom-made insoles correct the foot arch, redistribute load, and relieve pressure on the first metatarsophalangeal joint. They are particularly effective when hallux valgus is combined with flat feet. Insoles are selected by an orthopedic specialist based on the results of plantoscopy, a computerized analysis of the foot’s imprint.

Toe Spacers and Correctors

Silicone separators placed between the first and second toes reduce pressure between them. Night splints (orthoses) hold the toe in the correct position during sleep. They do not correct the bone deformity, but they may slow progression in the early stages and relieve pain.

Therapeutic Exercises

Strengthening the foot muscles supports the arches and slows widening of the forefoot. Recommended exercises include:

• Picking up small objects from the floor with the toes (pencils, balls, or fabric)
• Actively spreading the toes and holding for 5–10 seconds
• Rolling a tennis ball or bottle under the foot
• Walking on tiptoes and heels for 30 seconds each
• Extending and flexing the toes, like “playing the piano” with the feet
• Rotating the feet at the ankle joints
• Walking barefoot on uneven surfaces such as grass, sand, or special exercise mats

Proper Footwear

Choosing the right footwear is critically important:

• A wide toe box that allows the toes to rest freely without compression
• A heel no higher than 3–4 cm, ideally 2–3 cm; completely flat soles are also undesirable because they do not provide arch support
• Soft material without rigid seams around the bunion
• Secure heel support—the shoe should not be loose
• Choose footwear in the afternoon, when the feet are slightly swollen
• An insole with arch support or enough space for an orthopedic insole

When Surgery Is Necessary

Surgical treatment is considered in cases of pronounced deformity (HVA over 30–40°), persistent pain, failure of conservative measures, and significant limitations in daily activities. There are more than 300 surgical techniques for the big toe; the choice depends on the severity of the deformity, the condition of the joint, and the patient’s age.

The main approaches include osteotomy (cutting and repositioning the bone, followed by fixation with screws), arthrodesis (joint fusion in severe osteoarthritis), and soft tissue procedures (correction of ligaments and tendons). Modern techniques allow patients to walk almost immediately after surgery in special footwear; full recovery takes 4–8 weeks.

Prevention From Childhood

The feet develop actively during the first 6–7 years of life. To prevent deformities in children, it is important to:

• Allow them to walk barefoot on different surfaces such as grass, sand, and pebbles, as this strengthens the foot muscles
• Choose correctly sized footwear with 0.5–1 cm of extra space, neither too tight nor too loose
• Avoid handing down footwear, as it has already molded to someone else’s foot
• Inspect the feet regularly; if the big toe begins to deviate or the arch flattens, consult an orthopedic specialist
• Encourage physical activity—running, jumping, and climbing help develop the foot’s muscular support system

Myths About Hallux Valgus and High Heels

• “Bunions are caused by high heels” — high heels contribute to and accelerate the deformity but are not the root cause; bunions can also occur in people who have never worn heels if they have a genetic predisposition
• “Bunions can be removed with ointments and compresses” — this is a bone deformity, not a growth; topical treatments may reduce inflammation and pain but cannot correct the position of the bone
• “You won’t be able to walk normally after surgery” — modern techniques provide good functional outcomes; most patients are satisfied and return to their usual activities
• “Hallux valgus only affects women” — it is less common in men, but it does occur, especially in those with flat feet or gout
• “If it doesn’t hurt, it doesn’t need treatment” — the deformity progresses, and correction is easier and more effective when started at an early stage

Hallux valgus is not a life sentence. Early prevention, proper footwear, orthopedic insoles, and foot exercises can significantly slow its progression. If symptoms are pronounced, consultation with an orthopedic specialist can help determine the best approach, from conservative measures to modern minimally invasive surgery. Do not postpone caring for your feet—they carry you through life every day.