Hallux Valgus: The bunion as the most common foot deformity

Hallux valgus or bunion – two terms that cause many people grief. But what exactly is that? Where does it come from? And how do you get rid of it? You’ll learn that and more in this article!

What is this hallux valgus or bunion?

There is one part of the body to which we pay very little attention. This part of our body is just too far away from our attention. Often we only pay heed to it when it is time to cut our toenails. I’m talking about our feet.

Usually we only take care of our feet when they cause problems. Like when they hurt. Or when our feet are heavy after a long working day.

But what if we look down and notice that the big toe is crooked? It points outwards and not forward like the other toes. Suddenly we ask ourselves what this is all about. What’s this?

It’s called a bunion or hallux valgus in medical terms. Hallux in Latin means big toe and valgus means crooked. Most people just say hallux as a synonym for hallux valgus.

When you look down at your feet you ideally see your toes. That’s the forefoot. At the point where the toes merge into the foot are the metatarsophalangeal joints. That’s where the metatarsals start.

The metatarsal of the big toe points inwards at the ball of the foot. The big toe points outwards. Unfortunately, the base joint thickens and appears clearly on the ball. Therefore also bunion.

Definition according to the German Society for Orthopaedics and Orthopaedic Surgery:
“Hallux valgus is a malposition of the big toe with an axial deviation to fibular (valgus) and a simultaneous axial deviation of metatarsal I to tibial (varus).”
(Source: Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e.V.)

What are the causes?

Why should our body allow our big toe to stand crooked? And even more painful. The whole thing will then perhaps still be led so far that the big toe can no longer fulfil its task.

Wrong shoes are often mentioned, soft connective tissue, weak muscles and arthritis. In most cases, the ball toe does not come from a single cause. It is rather the case that different reasons intertwine and cause an obliquity of the big toe. I will go into all possible causes in more detail below.

Shoes as a cause

For several hundred years, shoes have not only fulfilled their actual function. They no longer simply protect the feet from the environment. Shoes have become a fashion accessory. And in most cases, the more beautiful the shoe, the more uncomfortable it is. If the shoe is uncomfortable, it is also usually unhealthy.

Shoes are often cited as the cause of a big toe. But is that so? I can definitely answer yes. Bad shoes can lead to a hallux valgus.

Let us first look at “normal” shoes.

Most shoes have to look good, ergonomics are not taken into account. As a result, many people buy shoes that are too small. This compresses the toes at the front. And so they come permanently into a position that shortens the forefoot.

Who once had to wear a cast for several weeks, knows what happens to the muscles during this time. When the cast is removed, the muscles underneath are gone. Same thing happens in our foot.

Small shoes pack our feet tightly. Our foot muscles will then no longer need to work. If there is still a proper footbed in the shoe, our arch no longer has to be held by the muscles. That’s why we lose our muscles in our feet. And as a result, a flat foot and splayfoot develops. This in turn favours the development of a hallux.

Now let’s look at shoes with heels.

What does heel height have to do with a hallux valgus? There have been many studies on this over the years. And they came to similar conclusions.

When we stand barefoot on a smooth surface, our body weight is mostly on the heel and a little on the forefoot. If we wear shoes with a heel, the weight distribution looks different. Now there’s more strain on the forefoot.

The larger the heel, the more weight is placed on the ball of the foot. However, most of the strain goes more and more into the ball of the big toe.

The rolling movement in the foot no longer goes over the whole foot, but more over the ball of the foot. This means that our foot cannot absorb the load, but transmits it across the bale into the width. So we step through our feet over time and provide for a splayfoot. And thus for a bunion.

My apple at this point. Just leave the fancy kicks in the cupboard and walk more barefoot. But more about this later. Katja’s doubts

Source: Christian Sommer (ed.) “Fußchirurgie – Ein praktischer Leitfaden” (Foot surgery – A practical guide)

Genetics as the cause

Do our parents pass the bunion on to us? Is it hereditary? There are some studies that have dealt with this topic. They all came to the same conclusion.

Yes, the hallux valgus has a genetic component!

Genetic component, that sounds very spongy at first. This is because there is a family history of this disease. If the parents had it, the probability of suffering is the same.

Source and more detailed information on genetics as the cause of hallux valgus:
“Genetic Influences on Hallux Valgus in Koreans:
The Healthy Twin Study”

Connective tissue weakness as a cause

Our muscles are nothing without connective tissue. A small heap of cell mass that can contract. Only the cover of connective tissue gives the muscle its shape and transfers the strength to the tendons. And the tendons transfer the strength of the muscle to the bones and joints.

Ligaments also belong to the family of connective tissue. They passively support our body by lying very firmly around different structures of the body. No muscle power is needed.

If we have connective tissue weakness, our tendons and ligaments are softer than they should be. This prevents them from doing their job so well. Our joints aren’t as well supported as they need to be.

Because of this weakness, our feet are also poorly stabilized. This widens the forefoot and creates the bunion.

A weakness of the connective tissue can have many causes. It can be congenital or acquired through medication, hormonal changes or diet.

Be a woman as the cause?

I beg your pardon? Being a woman is a possible cause of the bunion? Women are statistically more affected than men. And it also has a very simple explanation.

The female sex has a different anatomy than the male counterpart. Women naturally have a wide pelvis. That’s why the hip joints are further apart. This in turn causes the thigh bones to slant. The result is a knock knees.

The X-leg position also changes the load on the feet. As a result, women tend to have flat or flat feet. This results in the splayfoot. In the end, the hallux valgus comes out.

Furthermore, women have a different hormone distribution than men. This softens the connective tissue. During pregnancy the whole thing is intensified. This leads to a weakness of the connective tissue. The consequences of this are further up.

Source: Manual Therapy and Complex Rehabilitation Volume 2 by Uwe Streeck, Jürgen Focke, Lothar Klimpel, Dietmar-Walter Noack

A congenital deformity as a cause

Let me say right away that congenital foot deformities are a very complex issue. Each deformity is a disease in itself, which itself can have causes. That’s why I can’t go into much detail. Otherwise I’d have to write a book, not an article.

Here is a list of diseases that can cause a hallux valgus from birth or in the course of life:

  • Flat foot: A flattening of the longitudinal arch in the foot. This results in a widening of the forefoot.
  • Hollow foot: The arch of the foot is too pronounced. As a result, the load on the ball of the foot is greater.
  • Extended first metatarsal bone: Extremely rare. Due to the forward displacement of the metatarsophalangeal joint, the main load when rolling on the big toe. In order to bring all metatarsals to one height, the first metatarsal bone moves away from the others.
  • Articulated flat foot: Here the situation is similar to that of the flat foot.
  • Equinus: The heel cannot be placed on the ground. The affected person always remains on the bale.

Injuries as a cause

It’s very rare to go through life unharmed. At some point you have an accident, overlook a step or fold over. Some things are serious and some without further consequences. But which one is so serious that it leads to consequences.

A patient came to me a few days ago for physiotherapy. She had pain in her ankle joint with radiations towards the big toe and a piece of her tibia high. Medical diagnosis, metatarsalgia or foot pain in English. I was uneasy. Visually she already showed a flat foot and a slight hallux valgus. This became worse from treatment to treatment. I sent her back to the doctor for further clarification. MRI showed a torn ligament on the tibial ligament posterior.

In such cases you can sometimes practically watch the big toe get sloping. Within a few weeks.

In my girlfriend’s case, a horse stepped on her foot. Nothing was broken, but it hurt a lot. After the event, the area was also always very sensitive. And with time, this foot became a hallux. The disease is not common in her family and she has never worn unhealthy shoes.

That’s just two injuries out of many. There are of course many more, but that would go beyond the scope of this article.

The splayfoot as the cause

In most books and articles, the splayfoot is cited as the main cause at all. And it may have been noticed that the causes described above often lead to a splayfoot. But is that really the case?

Yes, it is!

Most bunion toes develop from a widened forefoot. Basically, a hallux valgus without splayfoot anatomically is hardly possible.

The splayfoot lacks a transverse arch in the forefoot area. One can also say that the foot has kicked through. As a result, the metatarsals are further apart and the foot is very wide at the front.

What happens then exactly in the foot, you read further down! But first a little excursion into the anatomy!

Anatomy of the foot

Of course, we do not need a profound knowledge of the anatomy of the human body. This is just necessary to get an idea of what our feet look like inside. Then it will be easier to understand later why certain treatment methods are necessary.

On the first picture we see a scheme of our foot skeleton. The yellow and green bones are relevant for the bunion.
The yellow bone on the far left is the first metatarsal bone and the green bone on top is already part of the big toe.
In the bunion, the first metatarsal bone moves away from the others and the big toe tilts towards the other toes. The big toe can exert pressure on its neighbors and also deform them ( hammer toe).

Why does a hallux valgus develop?

I won’t go into too much detail here. Because you don’t necessarily need to know all the names of muscles, tendons and bones to understand them. You only need one picture to imagine the whole thing.

When you look at the pictures with the muscles, you can see how they go. The first metatarsal bone is held bad, the big toe all the better. And the pulling direction of most large tehmuscles is in the direction of the other toes or straight to the hock.

Now the first metatarsal moves away from the others. The distance becomes larger and so does the tension on the muscles. These muscles now pull the big toe towards them. So all he can do is give in and get into trouble.

Course of this disease

When you looked at the feet of older ladies with hallux, you might have seen that the big toe was bent almost 90°. That was not the case with them from the beginning. It gets worse over time.

Unfortunately, the hallux valgus is a self worsening disease. Because the first metatarsal bone has moved to the side and the big toe is crooked, there is a lack of mobility. Due to this lack of mobility, the muscles shorten further and pull even more strongly.

One also has little desire to move the feet more because it can hurt. This is why the supporting muscles of the feet continue to degrade. This makes the splayfoot even wider and the muscle tension on the big toe stronger.

Who tends to the bunion?

There is a group of people who are more prone to this disease. Depending on the source and study, up to 90% of those affected are women. From personal experience I must also say that I have seen more women with the problem in practice than men.

Statistically, the bunion is most common among women over 50. However, I often notice this disease in my patients at a very young age. I often see women at 30 with this “problem”. I write this in quotation marks, because the patients did not give it much thought. At an early stage, it’s not a problem. They say they’ve had it for a few years in most cases.

I can only speculate now that the statistics should be corrected downwards. After all, people only go to the doctor when they have a “real” problem. So if it hurts and disturbs everyday life.

Are there the first signs?

Can you see a hallux valgus before you have it? Then you could start with exercises before it’s too late. Then no operations would be necessary. Or aids such as orthopaedic insoles and night splints. That would be too good to be true.

I haven’t found a source that clearly proves it. Therefore I have only tried to add 1 and 1 from my searches together. Here are my thoughts on possible early signs:

  1. a symptom of the splayfoot is the formation of corneas in the middle of football. This indicates that the foot has stepped through and the transverse arch is flattened. The consequence of a splayfoot can be a hallux. So check your feet for unusual corneal formation.
  2. actively move your big toe in flexion and extension. Is the big toe moving straight up? Or is he moving towards the other toes? When the second happens you either have poor control over the movement or you have shortened muscles in your foot that pull your big toe into the valgus position.
  3. How are your feet? People with flat feet or flat feet tend to hallux. So check your feet on it. Do you have a good arch or is it flattened? And what about foot stability in motion? Walk barefoot towards a mirror and check if your hocks remain stable or bend inwards.

Those were some thoughts of mine. I would be very happy about some ideas from you, would like to comment on it.

What are the symptoms?

Apart from the misalignment at the beginning, a bunion usually does not cause any problems. But with time it can happen that more and more problems are added and the pressure of suffering increases. There are more symptoms than what you can already see.

First metatarsal in valgus position: In English this means that the metatarsal of the big toe is spread. This is also a symptom of the splayfoot and one of the main causes of hallux.

Load and movement pain in the big toe: Due to the displacement of the toe, the movement no longer runs straight in its sliding bearing ( joint). This can irritate many structures in the foot, such as tendons and muscles. But also the displacement of the sesame bones under the big toe joint leads to irritation. For these reasons it comes to pain when we strain the toe or simply move.

Pain in the metatarsus: This is also caused by misalignment. On the one hand, the widened forefoot overburdens the tendons, muscles and also the metatarsals of the other toes. On the other hand, the big toe shifts over or under its neighbours. This also deforms over time. This also causes an overloading of the tendons of the second toe.

Bursitis over metatarsals: By sticking out the bale, the shoes feel tighter. Usually they then press on the ball of the big toe from above in movement and rub against the skin. At this point, however, there is a bursa under the skin which can become inflamed by the constant pressure. That hurts too.

Movement restricted metatarsophalangeal joint: Due to the malalignment, the big toe is no longer able to move in its full range.

Big toe twisted around itself: Because the tendons of the big toe lie as close as they do, they pull the toe not only to the other toes. No, they make the big toe twist a few degrees.

Protruding bale: This is probably the most noticeable symptom which also gives the disease the name Ballenzeh. It is not ossification or thickening at the site. So it’s just the shape of the joint that comes out.

Cornea on the ball: The cornea forms only because of friction in the shoe. Over time it can become very thick and cracked.

Inflamed reddened skin: This too is caused by constant friction on the skin. This symptom improves quickly if you haven’t worn shoes for a while.

Changed gait pattern: Due to the pain and limited movement, we tend to adopt a gentle posture either unconsciously or consciously. This also includes walking in a different way. Firstly, we take shorter steps to compensate for the lack of mobility in the toe. Or we turn our feet to the outside to roll off at an angle with our feet and not to strain our toes at all.

Aesthetic problems

A hallux valgus is not just a sign of foot health that needs improvement. He can get really ugly. While many men can often overlook this and simply wear closed shoes, it can become a problem for the ladies.

It always looks good when a woman wears fancy shoes. But if the foot is too wide and the ball of the foot still protrudes, it is quickly over with beautiful shoes. Orthopaedic shoes must now be used. But most of them are anything but beautiful.

It gets even worse in summer. Beautiful open-toed shoes like to present the big toe. Many women are ashamed of their feet and crooked toes. If the bale is reddened with a thick layer of cornea, the sight is even worse.

We probably all know what it’s like to be dissatisfied with sharing your body. It can exert strong internal pressure and take a share of the quality of life. So it is all the more important to do something about it. Because you don’t have to live with a bunion.


Not every bunion is like the next. As so often in medicine, there is a division into severity and stage. Messrs Mann and Coughlin ( 1999 ) proposed a classification of the hallux valgus stage or the severity according to the most important angles in the forefoot. No great emphasis is placed on other symptoms. Many bunion toes do not hurt at all, even at the last stage. That’s why you only go by the angle.

Normal condition: Normal is when the big toe deviates less than 15° and the first metatarsal bone deviates less than 9°.

Stage 1, mild severity: At this stage, the big toe deviates by less than 20° and the angle between the first and second metatarsal bone is less than 11°.

Stage 2, moderate severity: The big toe deviates by 20-40° and the angle between the first two metatarsals is 11-16°.

Stage 3, severe severity (double moupled): The deviation of the big toe is therefore more than 40° and the angle between the first two metatarsals accordingly more than 16°.

Treatment without surgery

Surgery certainly has its advantages. It is done quickly and promises an immediate solution. But there are also risks to consider. And an operation is no guarantee that you won’t have any problems afterwards.

Sometimes it can happen that the toes are straight after the operation, but the feet still hurt. Or your toes got stiffened and you can’t move them anymore. Then that’s not exactly the yellow of the egg either.

But even the thought of being cut open is not tingling. Considering they may have sawn out another piece of bone. This is a strong intervention in the own body. There’s gotta be something other than an operation.

Conservative Therapy

This term refers to non-surgical therapy. So measures that work without cutting the foot. Sounds pretty good to me.

This area includes painkillers, physiotherapy, insoles….. etc. The range of treatment options is very wide. Some work better than others, which is different from person to person. Here you just have to try what’s better for you.

A distinction is always made between active and passive therapies. With the active ones you have to work yourself. That means they are exercises to do yourself. Passive therapies are possible without own use. You will be treated and do not have to use any strength.

My experience has shown that a combination of different approaches produces the best results.

Immediate help to do it yourself ( passive )

If you have acute and chronic problems, this is the right thing for you. It’s not fun to do any exercises with pain. Therefore, you can try these immediate measures. But of course only after consultation with your doctor. And you listen to your body, please. If you realize something’s wrong with you, stop it.

Cold: Especially if your bunion is reddened or the pain is new, you can try it with cold. Either cold water or an ice bag (in a towel, not on naked skin) put directly on the aching spot. The cold relieves pain and reduces inflammation. In addition, blood circulation increases after application. 15 minutes is enough. You are welcome to repeat this after a few hours.

Warmth: A warm cherry stone cushion, a hot-water bottle or a warm footbath. This relaxes tendons and muscles. But also the blood circulation is increased and depending on the bath additive and if one believes the theory, one can detoxify the feet. 15 minutes is enough to start. Attention: In case of acute inflammation, heat is not recommended as it can promote inflammation.

Chilli: An ointment with chillie extract also warms. It increases blood circulation and relieves pain. But the nice thing is that you can wear shoes and move while warming your feet. But also be careful when applying. Do not rub between the toes, the skin is particularly sensitive.

Mobilization: Grab your big toe and pull it lightly. Then make gentle circular movements with a slight pull. Next, grasp your index and middle fingers between big fingers and the other toes with the remaining fingers. Now you gently circle your toes together. In the next step you put a tennis ball or something similar on the ground and step slightly on it with the middle of the bale and stretch your transverse arch.

Kinesiotape: Try a very simple and uncomplicated Kinesiotape system. Simply cut off a strip of tape 10cm long. Place a part of 3cm without tension on the side of the big toe and place the rest along the foot in the direction of the heel with a slight pull.

Pain gel: You may also use pain gel or pain ointment in serious cases. But not for long.

LaShoe ( passive)

One of the causes of hallux valgus is tight shoes. Therefore, you should immediately stop wearing shoes that squeeze your toes. But you don’t have to change all your pedals with orthopaedic shoes. They don’t look pretty at all. The LaShoe brand can help here.

LaShoe is a manufacturer that advertises fashionable health shoes. Their secret are padded expansion zones for the toes and ball of the foot. Nevertheless, the shoe retains its beautiful shape from the outside. The leather of the shoe is also stretched at the critical points and should not exert any pressure on the toes.

It’s always worth a try. At least for the ladies.

Insoles ( passive / active )

Insoles that improve a bunion? Just put it in your shoes and the problem is solved? It’s not that simple for now. You have to be careful what insoles you take.

There are “ordinary” insoles with footbed. I can’t recommend them at all. They ensure that the foot is passively pressed into a mould. So our foot muscles can’t work properly. The arch of the foot is also not sustainably supported. But which insoles are suitable?

Sensomotoric insoles…..

They are offered by orthopaedic shoe technicians and specialist shops for running. Usually they are individually adapted. It’s probably better that way, because one shape doesn’t necessarily fit your foot for everyone.

These insoles stimulate your propioceptors in the foot. These are sensors in our tendons, muscles and joints that provide reactive muscle tension. This means they provide muscle activation without us having to pay conscious attention to it. Or even easier said: Training with autopilot.

With these insoles the gait changes a little, the foot occurs differently and does not roll off as before. Different activation zones press on the sole of the foot from below and ensure that the muscles are tensed.

Unfortunately, these soles will not simply heal the foot. More has to happen. But they are an excellent complement to further action towards strong and healthy feet.

Hallux wonder or toe spreader ( passive)

When you enter hallux valgus at Amazon, these little helpers come first. These toe spreaders are usually pulled over the big toe and press the first two toes apart. The Hallux Wonder is one of the best known of them. But are they really helpful in the fight against the bunion toes?

To be honest, toe spreaders are not the first thing I recommend to my patients. On the one hand, a crooked toe cannot simply be bent straight again. On the other hand, the padding between the toes is quite large and presses on the second toe. This may allow you to create a second construction site.

Moreover, the silicone spreaders are usually only available in one size. And one for all does not always fit your individual problem.

But there are also so-called night splints. They are strapped around the metatarsus and press only on the big toe. A supposedly better solution. However, they can be used to quickly overload the joint.

But there is a more elegant solution that can also be worn loosely in a shoe.

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