Hallux Valgus

hallux-intro

What is hallux valgus?

A bump on the side of the big toe joint is commonly known as a hallux valgus or bunion. The visible lump represents a complex deformity of the forefoot, with the big toe getting out of alignment and moving towards the second toe over time.

How can it occur?

Dancing places a heavy load on the foot and may lead to degenerative changes over time. A hallux valgus, though, is not usually caused by dancing; there are actually certain inherited foot types that make a dancer prone to developing a hallux valgus. It may, however, be aggravated or accelerated by tight fitting dancing shoes and repetitive irritation to the big toe joint. Muscle dysfunction can seriously affect leg alignment and foot stabilization and thus cause acute pain in hallux valgus. Muscle overuse often occurs when the body fails to compensate for existing muscle dysbalance. Muscle dysbalances are very common and naturally occur as the body adapts to specific training demands over time. As long as compensation is effective – or, in other words, as long as the dysbalance is well managed by the body – this need not cause any problems. However, with high training loads, insufficient rest or after a minor injury, the body may struggle to compensate, leading to muscle dysfunction in the various muscle groups involved in the compensation. This is why symptoms may simultaneously occur in different parts of the body in an overuse situation.
The psoas muscle is probably the most important muscle involved with dance injuries and overuse. Psoas dysfunction leads to tightness of the rectus femoris muscle (a part of the quadriceps) and deactivation of the piriformis (one of the smaller pelvic muscles inserting on the sacrum). This causes pelvic torsion and functional leg length discrepancy. The increased amount of stabilization work needed to compensate for leg length discrepancy will overcharge different groups of muscles. The peroneals – a group of two active foot stabilizers on the lower leg – are often affected. With impaired function of the peroneals, both active leg and foot stabilization will be affected and overuse symptoms can arise in the foot.

What are the typical symptoms of hallux valgus?

Symptoms of acute Hallux valgus include pain and soreness at the base of the big toe and an inflammation or redness around the bunion. A burning sensation or numbness may be present in some cases. Symptoms occur most often when wearing shoes that crowd the toes. Spending long periods of time in point shoes can aggravate the symptoms of hallux valgus.

How can hallux valgus be diagnosed?

Your doctor will examine your foot and may find a typical bony bump at the base of the big toe. He will check your foot statics and test the active stabilization of the foot. Correct diagnosis of this issue demands a thorough functional clinical examination, including specific tests to identify joint and muscle dysfunction. Finding out the exact causes of actute foot pain is often challenging and your doctor may ask a specialist in manual medicine for his opinion. To fully evaluate the condition, he may order X-rays to determine the degree of deformity and to assess the changes that have already occurred.

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This X-ray shows the typical aspect of a hallux valgus. You can see how the first metatarsal bone is deviated to the side allowing to see the two sesamoid bones that are usually located directly underneath the toe joint.

What treatment options are there?

If you have severe or constant foot pain, you should take a break from your ballet training immediately. Ignoring the pain can have serious consequences, as the situation will become increasingly complicated the longer you train with pain.
The RICE concept (rest, ice, compression and elevation) is an easy guideline that can be used to initially treat acute as well as overuse injuries. Please read my “First Aid” post to obtain some background information that you will need to adapt this concept successfully and learn about the use of painkillers. Wearing the right kind of shoes is very important during rehabilitation. Outside the ballet studio, choose comfortable shoes that have a wide toe box. High heels may make the condition worse. Custom orthotics (shoe inserts) may be helpful in some cases to support the foot.
In order to handle a given overuse situation successfully, its underlying causes – namely muscle dysfunction and muscle dysbalance – have to be addressed specifically in the rehabilitation process. Muscle dysfunction can appear as muscle tightness (contraction) or weakness (inhibition) and the muscles affected have to be treated accordingly in the rehabilitation process. Some muscles will have to be stretched whereas others will rather have to be strengthened. A well-suited training program including corrective exercises as well as a general strengthening and endurance routine is the most effective way to deal with most overuse situations.
Manual medicine and especially deep myofascial release treatment is recommended to address present joint and myofascial dysfunction. Restriction of the fascia plays a key role in all overuse issues and can be addressed effectively with manual medicine. Ensure that you follow your specific training routine after the rehabilitation is finished. Myofascial rollers (Blackroll, Triggerpoint Roll, etc.) as well as Lacrosse balls and resistance bands are easy to use in the studio and will help you remain balanced in the long run.
Non-operative treatment is aimed at easing the pain and stabilizing the situation, but it won’t reverse the present deformity of the foot. If the deformity progresses and treatments fail to relieve bunion pain, you may want to discuss surgical options with a foot and ankle surgeon.

Next steps

Do you have acute pain or progressive deformation of your big toe and want to have it sorted out? These are the next steps:

  • See a doctor

Dancers seek help from various different kinds of therapists, many of whom may employ treatments that are outside of mainstream medicine. Before considering the use of such alternative medicine, you should see a doctor for an evaluation and diagnosis.
Finding a doctor who is familiar with the specific medical issues faced by dancers is often challenging and you may need to see several different specialists in order to get a full picture of your diagnosis. A good place to start is to ask your friends and fellow dancers for the names of their favorite doctors.

  • Find a specialist in manual medicine

Doctors who specialize in manual medicine practice a whole-body approach. They will try to identify and specifically treat the underlying causes of your problem, rather than just the localized symptoms. This approach is important in addressing all aspects of the often very complex overuse problems that dancers experience. A specialist in manual medicine will perform a functional examination on every part of your body and will treat you according to these thorough findings.
To find a physician who specializes in this field, search for “Manual Medicine”, “Osteopathic Manipulative Medicine” or “Osteopathic Physician” on the internet.

  • Start working on your problem

There is a lot that you can do to work on your problem after a proper diagnosis has been set. Ultimately, it often comes down to addressing the same fundamental issues. Here are some useful exercises that I recommend to my patients:

Flexibility training: Foot release, Professional calf and foot release, Deep back release, Rectus femoris release, Psoas release, Piriformis release, Compex “DECONTRACTURE” program (peroneal muscles)

Strength training: Compex “DISUSE ATROPHY” program (peroneal muscles), “The clamshell” – Piriformis training,“The monster walk” – Piriformis training

Please refer to your doctor to confirm that the exercises you choose to do are suited to your individual problem, and obtain supervision from a professional trainer to ensure that you are performing them correctly.

  • Talk to your ballet master or dance teacher

Technical issues and faulty dance technique are important predisposing factors of overuse and injury in dancers. Amending dance techniques often plays a crucial role in the treatment and prevention of overuse and injury and you should not hesitate to address any issues, if necessary.


 

 


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