Hallux valgus, commonly known as a bunion, is a progressive deformity of the first metatarsophalangeal (MTP) joint, where the big toe drifts laterally toward the second toe while the first metatarsal bone deviates medially. This creates the characteristic bony bump on the inside of the foot. Although often perceived as a simple cosmetic issue, hallux valgus represents a complex, three-dimensional deformity involving bone alignment, joint surfaces, ligaments, and muscle balance.
How Common It Is and Who Gets It? (Epidemiology)
Hallux valgus is one of the most common forefoot deformities, affecting approximately 23–35% of adults worldwide. The condition is more prevalent in women, likely due to footwear and structural differences in the forefoot. It typically develops between the ages of 40 and 60, though adolescents and young adults can also be affected (juvenile hallux valgus). The incidence increases with age and is more common among individuals who wear narrow, pointed shoes or high heels.
Why It Happens – Causes (Etiology and Pathophysiology)
Hallux valgus arises from a combination of genetic predisposition and biomechanical imbalance. Factors that contribute to its development include:
- Genetics: A family history of bunions increases the likelihood of occurrence.
- Gender: Women are disproportionately affected, likely due to ligamentous laxity and footwear choices.
- Footwear: Tight, narrow, or high-heeled shoes crowd the toes, increasing lateral pressure.
- Foot biomechanics: Flat feet, hypermobility of the first ray, and tight calf muscles (equinus contracture) can destabilize the first metatarsal joint.
- Systemic factors: Conditions such as rheumatoid arthritis and neuromuscular disorders (e.g., cerebral palsy) may predispose to deformity.
Progression occurs as the soft tissues around the first MTP joint stretch and weaken, leading to imbalance between the adductor and abductor muscles of the great toe, causing further deviation.
How the Body Part Normally Works? (Relevant Anatomy)
The first MTP joint connects the first metatarsal bone and the proximal phalanx of the big toe. It enables flexion, extension, and stability during push-off in walking. Proper alignment allows even weight distribution. In hallux valgus, deviation of the first metatarsal and lateral drift of the toe alter joint congruity, leading to bursal inflammation, pain, and loss of stability.
What You Might Feel – Symptoms (Clinical Presentation)
- Pain and tenderness along the inside of the foot, especially over the bunion.
- Redness and swelling over the MTP joint.
- Visible deviation of the big toe toward the second toe.
- Difficulty fitting into shoes.
- Secondary deformities such as hammertoes or calluses under the lesser metatarsals (transfer metatarsalgia).
- Stiffness or reduced motion of the big toe joint.
Pain severity varies and does not always correlate with the visible size of the bunion.
How Doctors Find the Problem? (Diagnosis and Imaging)
Diagnosis begins with a clinical exam of the foot in both sitting and standing positions. Physicians assess joint alignment, skin irritation, callus formation, and range of motion.
Radiographs (X-rays) are essential for diagnosis and surgical planning. Key measurements include:
- Hallux Valgus Angle (HVA): Normal <15°.
- Intermetatarsal Angle (IMA): Normal <9°.
- Distal Metatarsal Articular Angle (DMAA): Assesses articular orientation.
- Hallux Valgus Interphalangeus (HVI): Indicates additional toe deformity requiring phalangeal correction (Akin osteotomy).
Weight-bearing CT scans may be used for complex or recurrent deformities to assess 3D rotational components.
Classification
Hallux valgus can be classified based on deformity severity using radiographic measurements:
- Mild: HVA <20°, IMA <11°
- Moderate: HVA 20–40°, IMA 11–16°
- Severe: HVA >40°, IMA >16°
It may also be described by cause (juvenile, adult, or arthritic) or associated conditions (e.g., rheumatoid arthritis).
Other Problems That Can Feel Similar (Differential Diagnosis)
- Hallux rigidus (arthritic stiffness of the big toe joint)
- Gout or inflammatory arthritis
- Sesamoiditis (inflammation under the first MTP joint)
- Bursitis or soft tissue swelling
- Stress fracture of the first metatarsal
Treatment Options
Non-Surgical Care
Conservative management focuses on relieving symptoms rather than correcting deformity.
- Footwear modification: Wide toe-box shoes to reduce pressure on the bunion.
- Padding and toe spacers: Cushion the area and prevent irritation.
- Orthotics: Custom inserts improve alignment and reduce stress on the forefoot.
- Physical therapy: Calf stretching and intrinsic muscle strengthening.
- Anti-inflammatory medications: Reduce pain and swelling.
Non-surgical treatment is suitable for mild cases or for patients who are not surgical candidates.
Surgical Care
Surgery is indicated when pain and functional limitations persist despite conservative measures. More than 100 surgical procedures exist, typically grouped into categories based on deformity severity and site of correction:
- Soft-Tissue Procedures
- Modified McBride Procedure: Balances soft tissues around the MTP joint, often combined with bone realignment.
- Distal Metatarsal Osteotomies
- Chevron (Austin) Osteotomy: V-shaped cut at the metatarsal head for mild to moderate deformities.
- Midshaft (Diaphyseal) Osteotomy
- Scarf Osteotomy: Allows correction of severe angular and rotational deformities.
- Proximal Osteotomies
- Proximal Chevron or Crescentic Osteotomy: For severe cases; adjusts the metatarsal base.
- Lapidus Procedure (First Tarsometatarsal Fusion):
- Best for hypermobility or recurrent deformity. Stabilizes the first ray by fusing the first metatarsal base to the medial cuneiform.
- First MTP Joint Fusion:
- Indicated for arthritic bunions or failed prior surgeries.
- Minimally Invasive Surgery (MIS):
- Modern percutaneous approaches (e.g., SERI, MIS Chevron + Akin) reduce incision size and recovery time.
Recovery and What to Expect After Treatment
- Distal osteotomies: Patients can often bear weight immediately in a surgical shoe for 4–6 weeks.
- Lapidus and proximal osteotomies: Require non-weight-bearing for 6–8 weeks.
- MTP fusion: Heals in 8–10 weeks, followed by gradual shoe transition.
Physical therapy and range-of-motion exercises aid recovery. Swelling may persist for several months.
Possible Risks or Side Effects (Complications)
- Recurrence of deformity (up to 30% in some series)
- Overcorrection (hallux varus)
- Nonunion or delayed bone healing
- Nerve irritation or numbness around the incision
- Persistent pain or stiffness
- Transfer metatarsalgia due to altered weight distribution
Long-Term Outlook (Prognosis)
With proper surgical planning and rehabilitation, most patients achieve excellent outcomes. Pain relief and improved function are expected, with patient satisfaction rates above 85%. Full recovery may take 3–5 months, depending on procedure type and activity level.
Out-of-Pocket Costs
Medicare
CPT Code 28292 – Soft-Tissue Procedure (e.g., Modified McBride Type): $159.49
CPT Code 28296 – Distal Metatarsal Osteotomy (e.g., Chevron/Austin or Minimally Invasive Chevron + Akin): $200.67
CPT Code 28306 – Midshaft (Diaphyseal) Osteotomy (e.g., Scarf Osteotomy-Type Correction): Cost not provided
CPT Code 28297 – Proximal Osteotomy (Proximal Metatarsal Correction): $231.14
CPT Code 28740 – Lapidus Procedure (First Tarsometatarsal Fusion): $189.82
CPT Code 28750 – First MTP Joint Fusion (Arthrodesis, Great Toe): $178.82
Medicare Part B covers 80% of the approved cost for these procedures after your annual deductible has been met, leaving you responsible for the remaining 20%. Supplemental Insurance plans such as Medigap, AARP, or Blue Cross Blue Shield typically cover that remaining 20%, minimizing or eliminating out-of-pocket expenses for Medicare-approved surgeries. These supplemental plans coordinate with Medicare to fill the coverage gap and reduce financial responsibility for patients.
If you have Secondary Insurance, such as TRICARE, an Employer-Based Plan, or Veterans Health Administration coverage, it acts as a secondary payer. These plans usually cover any remaining coinsurance or deductibles, which typically range between $100 and $300, depending on your coverage terms and provider network.
Workers’ Compensation
If your bunion deformity was caused or aggravated by a work-related condition, Workers’ Compensation will cover all treatment costs, including surgery, postoperative care, and rehabilitation. You will not have any out-of-pocket expenses, as the employer’s insurance carrier directly covers all approved medical expenses.
No-Fault Insurance
If your bunion deformity or related foot condition developed due to an automobile accident, No-Fault Insurance will typically cover the full cost of treatment, including surgical correction and postoperative care. The only possible out-of-pocket cost may be a small deductible or co-payment depending on your insurance policy.
Example
Karen Mitchell underwent a Chevron osteotomy (CPT 28296) and Akin correction as part of a minimally invasive bunion surgery. Her estimated Medicare out-of-pocket cost for the procedure was $200.67. Since Karen had supplemental insurance through AARP Medigap, her remaining 20% balance was fully covered, leaving her with no out-of-pocket expenses for the procedure.
Frequently Asked Questions (FAQ)
Q. What is hallux valgus?
A. Hallux valgus, commonly known as a bunion, is a deformity where the big toe deviates outward toward the second toe, often causing a bony bump on the side of the foot.
Q. What causes hallux valgus?
A. Hallux valgus can be caused by genetic factors, abnormal foot mechanics, wearing tight or ill-fitting shoes, and conditions like flat feet or arthritis.
Q. What are the symptoms of hallux valgus?
A. Symptoms include a visible bump on the side of the foot, pain, swelling, redness, and difficulty wearing shoes or walking.
Q. Can hallux valgus lead to other foot problems?
A. Yes, it can cause problems such as hammertoes, metatarsalgia, and skin irritation due to friction from shoes.
Q. How is hallux valgus diagnosed?
A. It is diagnosed based on physical examination and confirmed with weight-bearing X-rays that show the angle between the big toe and the first metatarsal bone.
Q. What non-surgical treatments are available for hallux valgus?
A. Non-surgical options include wearing wider shoes, using orthotic devices or bunion pads, applying ice, and taking anti-inflammatory medications.
Q. When is surgery considered for hallux valgus?
A. Surgery is considered when non-operative measures fail to relieve pain and the deformity interferes significantly with daily activities.
Q. What types of surgery are performed for hallux valgus?
A. Surgical procedures include bunionectomy, osteotomy, and soft tissue realignment, selected based on the severity of the deformity.
Q. How long is the recovery after bunion surgery?
A. Recovery varies but typically involves several weeks of limited weight-bearing followed by gradual return to normal activities over a few months.
Q. What are the risks of hallux valgus surgery?
A. Risks include infection, recurrence of the deformity, stiffness, nerve injury, and dissatisfaction with cosmetic outcome.
Q. Can hallux valgus recur after surgery?
A. Yes, recurrence is possible, especially if contributing factors such as improper footwear are not addressed.
Q. Is physical therapy needed after bunion surgery?
A. Physical therapy is often recommended to restore motion, strength, and proper gait after surgery.
Q. What kind of shoes should be worn after recovering from hallux valgus?
A. Supportive, wide-toe box shoes with proper arch support are recommended to prevent recurrence and maintain foot health.
Summary and Takeaway
Hallux valgus (bunion) is a common and often painful foot deformity caused by misalignment of the first metatarsal and big toe. While conservative management alleviates symptoms, surgery provides lasting correction and pain relief. The choice of procedure depends on deformity severity, joint mobility, and patient needs. Advances in imaging and minimally invasive techniques have improved accuracy, reduced recovery time, and enhanced patient satisfaction.
Clinical Insight & Recent Findings
A 2024 study from Foot & Ankle Specialist introduced a simple, low-cost postoperative dressing technique for hallux valgus correction that provides semirigid support without the need for frequent changes.
The method uses a wooden tongue depressor placed along the inside of the great toe to help maintain neutral alignment during healing. Dressings are changed only once at two weeks and kept until six weeks post-surgery, minimizing clinic visits while maintaining correction and avoiding complications.
The authors report no wound issues and emphasize that this approach offers a practical, easily replicable alternative to more restrictive or labor-intensive postoperative care routines. (“Study on a low-cost toe splint that helps maintain alignment after bunion surgery – see PubMed”)
Who Performs This Treatment? (Specialists and Team Involved)
Bunion correction is performed by orthopedic foot and ankle surgeons or podiatric surgeons. The care team often includes anesthesiologists, physical therapists, and orthotists.
When to See a Specialist?
Consult a foot and ankle specialist if you experience persistent pain, difficulty finding comfortable shoes, or progressive deformity despite conservative measures.
When to Go to the Emergency Room?
Immediate evaluation is needed if there is severe swelling, redness, or inability to bear weight after trauma to the bunion area, as these may indicate fracture or infection.
What Recovery Really Looks Like?
Recovery involves wound care, swelling management, and gradual weight-bearing. Mild stiffness and swelling are expected for several months. Long-term use of supportive footwear and orthotics helps maintain correction.
What Happens If You Ignore It?
Untreated bunions can worsen over time, leading to chronic pain, difficulty walking, hammertoe deformities, and degenerative arthritis of the MTP joint.
How to Prevent It?
- Wear wide, supportive shoes with adequate toe space.
- Maintain healthy body weight to reduce foot stress.
- Stretch and strengthen the calf and foot muscles.
- Address flatfoot or gait abnormalities early with orthotics.
Nutrition and Bone or Joint Health
A diet rich in calcium, vitamin D, and omega-3 fatty acids supports bone and joint health. Proper hydration and anti-inflammatory foods help reduce postoperative swelling and improve healing.
Activity and Lifestyle Modifications
After surgery or conservative treatment, avoid tight shoes and high heels. Gradual return to normal activity, regular stretching, and using orthotics can prevent recurrence and preserve foot alignment.
Dr. Mo Athar
