Saturday, 25th of April
It’s time. Together with my daughters Lisa (15) and Roos (12), I’m leaving for Schiphol at five in the morning. Our destination is the Clinica San Román in Alicante, the only specialised foot clinic in Europe, where I’m going to have an operation on my gnarled toe. I like to wear elegant heels and fashionable boots. I’ve been wearing high heels for as long as I can remember, preferably with pointed fronts. But for the last few years I’ve been secretly hiding my pain when wearing them. The ugly swelling on the inside of my crooked big toe kept getting bigger and redder, and chafed against the leather of my elegant footwear. My doctor calls the problemhallus valgus, with a nasty case of bursitis in the joint of my toe. When I ask if anything can be done, he answers laconically: “Go to a podiatrist, have him give you shoe inserts and wear firm, flat shoes from now on.” So no operation? “As long as it’s not strictly necessary, I wouldn’t advise it.” He continues in a sinister tone: “It’s a painful operation, which could result in many unpleasant complications. There are methods with and without pins in your toe. Sometimes they saw through multiple bones and in severe cases they can permanently fix the joint in position. Nerves and veins are often damaged and usually you’d need to wear a cast for weeks. Then tissue damage can occur because your swollen foot doesn’t have enough room. Many people who have this operated on find themselves jumping from the frying pan into the fire. The result is more pain, which requires even more procedures.” After listening to his gruesome story I decided to keep suffering my embarrassing swelling, better know as a bunion. In the unpleasant knowledge that hallus valgus has a tendency to keep getting worse. The other toes start to grow crooked, the ball of the foot becomes too loaded with weight and starts to hurt. Eventually you can even develop arthritis, and then you’re really beyond help. The breakthrough was when a friend of mine, connected to the AMC in Amsterdam as a physiotherapist, gave me the advice I needed. “Go to Alicante,” she said. “Apparently there’s a very good clinic there, where they’ve exclusively performed foot surgery for thirty years.” Google found me the website of the Clinica San Román, where they treat not only hallus valgus, but also hammertoes and other problems to do with toes and feet and ankles. I contacted them, sent them an e-mail with a picture of my troublesome foot, and asked them for a temporary treatment plan with which I convinced my doctor and my insurance company to help me with my adventure. And now I am indeed flying to Alicante, armed with my blood test results and my daughters, who have solemnly promised to be my own Florence Nightingales for however long necessary.
Sunday, 26th of April
We couldn’t have had it better. Having been frightened away by the prices of the hotels often situated in ugly apartment complexes in Alicante, I had booked a small house twenty minutes from town on a guess. If I won’t be able to walk anyway, it won’t be of any use to stare at the sea from a balcony in the middle of town. So we arrived at a miniresort with small villas on the hills around Alicante, surrounded by a tropical garden and a brilliant swimming pool. Now I still can, I spend my time merrily sunbathing, swimming and strolling around with my exuberant children.
Monday, 27th of April
My operation is today. I’ve been tossing and turning all night. Is this clinic really that good? Maybe I’ll only be able to wear sneakers. What if they hit a nerve? What should we do if it all goes wrong? Isn’t the swelling quite bearable? What have I got myself into?! “It’ll be fine, mum,” my daughters keep telling me. But I can see in their faces that they’re also a bit scared. We ride to the centre of Alicante by taxi. We find my clinic on a respectable avenue lined with palm trees. I’m relieved to see that everything looks immaculate, modern and excellently organised. A friendly nurse puts me to work right away. I have to fill in a questionnaire and they take x-rays of my foot. The specialists, José San Román and his son Israel rapidly make an exact diagnosis with an additional inspection by computer (fluoroscopy* and Doppler*). Every foot is different and hallus valgus is a relatively complicated condition. Israel San Román clearly explains to me what will happen, pointing out everything on the x-rays. What it comes down to is that they’re going to remove my bunion in such a way that it will never come back, while the joint remains intact and flexible. He tells me it’s advisable to also correct the position of my big toe. Father and son, both members of the Foot and Ankle Academy in the United States, deliberate for a few more minutes, and then it’s time.
A nurse dresses me in a blue operating gown. In the sterile room my foot gets washed, rubbed with iodine, wrapped in sterile tissues and a rubber collar is wrapped around my ankle. Thankfully the nurse draws a curtain over my abdomen. So I can’t see my foot. The doctors don their lead aprons and sterile coats, and put on their scrub caps featuring small feet. While one of the specialists fires up the fluoroscope, the other anaesthetises my foot. I can see their faces above the curtain, frowning in concentration. It’s obvious that my doctors know exactly what they’re doing. They pay close attention to see if I feel anything despite of the anaesthesia. If I display any feeling in my foot, more anaesthesia will be administered. At a certain stage I feel a lot of force being used. Afterwards I learned that he was separating the soft tissue from the bone at that moment with highly sophisticated equipment, the type that is also used for neurosurgery. No nerves or blood vessels can be caught in the ‘empty’ space created then, so they can remove the bunion without damaging any surrounding tissue. I doze off a bit. Then, suddenly, after no more than an hour, the specialist solemnly declares: “The bunion is gone!” His son asks me if I want to see my foot. The curtain is pulled aside and I can hardly believe my eyes. There is my foot, not swollen or cut open, virtually without any blood or bruising. Right above and below where the ghastly lump recently dwelled, two small incisions are visible. A third cut, only a few millimetres long is situated above my middle toes. Unbelievable. The bunion is gone, my smaller toes are once again properly positioned and for the first time in years I have an elegant and ladylike foot! While wrapping my foot in bandages, Israel San Román explains to me how to handle my altered foot for the next week. I can start walking straight away(!), albeit in strange medical slippers. For five days I have to take antibiotics and anti-inflammatory drugs, with which I unfortunately can’t be in direct sunlight. They also give me painkillers and vitamins to quicken the healing process. The nurse asks me for my shoe size and retrieves the ugliest velcro shoes ever. A bit later I manage to ‘walk’ out of the clinic. I’m hardly bothered by pain.
Tuesday, 28th of April to Tuesday, 5th of May
I’ve never read so many books while lying in the shadow under an umbrella. With my sore foot up, eating tapas with a drink close by, I’m having an excellent time. In the mornings I shower with a plastic boot on my foot and once in a while I go for a stroll around the pool. Lisa and Roos sunbathe, swim, serve their mother and do shopping. My foot doesn’t swell up or throb. It’s pure pleasure.
Wednesday, 6th of May
Back to the clinic for a check-up. The nurse cuts of the bandages. What comes out into the light is impressive: a virtually unharmed foot, slightly blue and yellow around the incisions from the operation, with an almost undetectable accumulation of fluid where my bunion was situated until recently. The specialist examines my foot. He establishes that my foot is healing nicely, cut away the stitches and reapplies the bandages. I have to leave the bandages on for three weeks, and regrettably I need to keep wearing those slippers for that period. Then I need to have another x-ray taken of my foot, which my doctor will send to Alicante to be examined. Father and son San Román wish us a pleasant journey back home. At Schiphol we are driven to the luggage belt in a buggy. Being temporarily disabled does have advantages.
(How is Wenneke’s foot now? Go to santeonline.nl for the second part of her diary.)
How much does it cost?
Wenneke’s surgery consisted of two parts and cost €2850 (€1500 for the bunion, €1000 for the correction of the little toes, €350 for the examination, bandages, medicine etc). Some insurance companies (partially) pay for this treatment.
Foot diary Alicante
Thursday, 7th of May
Being lame in Amsterdam is quite difficult. I’m a bit embarrassed by those weird Chinese velcro shoes that I have to wear to protect my healing foot. I’m not supposed to ride my bicycle, but think I can handle it on the old cargo bike I used to transport the kids in. It can’t fall over anyway. And somebody needs to do the shopping. People look at my sympathetically, while I limp past the shelves in the supermarket. To top it off, my bicycle key breaks in the lock. With my shopping in the front, I push the bike home like a walking frame. That night I’m supposed to interview the Chinese piano star Lang Lang. In my vanity, I decide to wear a nice low-heeled boot on my good foot. When he sees my operation shoe, he says, “Made in China.” We both laugh, but I have felt more dignified in the Concertgebouw.
Friday, 8th of May
I wake up with a sore feeling. My recovering foot seems a bit swollen through the bandages, and one of the corrected middle toes seems to have moved a bit off centre. I feel guilty, apparently I did strain myself too much the previous day. Somewhat panicked, I take a couple of photos of my foot and send them to the Clinica San Román. A reassuring response soon arrives: I can adjust my middle toe a little with the Hypafix bandages they gave me. And once the bandages come off in three weeks, everything should be all right. I’m relieved, but I resolve to take it easier from now on. Not to pressure myself too much and to regularly poot my bad foot up. I immediately notice the difference. The swelling diminishes, the pain disappears completely.
Saturday, 9th of May to Saturday, 30th of May
Life goes on. The kids are back in school and writing is no problem with this damaged foot of mine. My toes have aligned themselves properly and the pain, which comes in occasional flashes, gets less every day. I’m growing accustomed to my temporary handicap, it’s as if I’ve always walked this way. But on Whit Monday/Pentecost, I’ve suddenly had enough of these horrible bandages on my foot. It’s beginning to itch and it smells. I realise it’s already been three weeks since I flew back from Alicante, and I decide to go to the first aid department of the hospital RIGHT NOW to have the bandages removed. They refuse to help me there, seeing as I was operated on in Spain and I might have been contaminated by bacteria that they don’t want to have in their hospital. It’s just standard procedure. Fine, I’ll do it myself then. I go back home and get a pair of scissors. After a moment’s hesitation, I cut of the bandages following the instructions given to me at the Clinica San Román. A flaky foot comes out, obviously longing for a lukewarm footbath with lavender soap. I don’t dare to have a proper look until I’ve dried my foot. The result is astonishing: my new foot has been transformed into an exact copy of my healthy one. The ugly bunion is gone and all my toes are perfectly aligned. I could almost cry.
Sunday, 31st of May to Thursday, 16th of June
To be safe, I’ve decided to wear the Chinese Velcro shoes for a little while longer. I protect thee place where my bunion used to be with gauze and ointments, which make the scabs from the incisions heal extremely fast. I have an x-ray at the hospital and send it to the Clinica San Roman. My foot feels more flexible every day, and before I know it I can walk around the house barefoot.
February 28, 2011 — General and foot-specific health-related quality of life (HRQOL) decreases progressively with the increasing severity of hallux valgus (bunion) deformity independent of age, sex, body mass index, and pain in other regions, according to a population study.
Associate Professor Hylton Menz, PhD, from La Trobe University in Melbourne, Australia, and colleagues reported their findings in the March issue of Arthritis Care and Research.
“The study had a large, representative sample and examined the association between hallux valgus severity and HRQOL,” Dr. Menz told Medscape Medical News. “Previous studies used relatively small samples, considered hallux valgus as simply present or absent, and generally did not adjust for confounders. We also used both general and foot-specific measures of [HRQOL],” he said.
The study was designed to explore the prevalence of and factors associated with hallux valgus. In addition, the study assessed the effect of hallux valgus severity on general quality of life and HRQOL in older people.
A total of 2831 participants aged 56 years or older participated in the 6-year follow-up of the North Staffordshire Osteoarthritis Project. Study subjects were asked to complete the Medical Outcomes Study Short Form 36 (SF-36) health survey and the Manchester Foot Pain and Disability Index (FPDI).
SF-36 and FPDI scores were compared across 5 severity grades of hallux valgus established by the researchers. The severity grades corresponded to the angle of deformity of 0, 15, 30, 45, and 60 degrees, with a score of 1 representing no angle and 5 indicating the most severe deformity.
Hallux valgus was present in 36.3% of the study population and was associated with female sex, older age, and pain in other bodily regions. SF-36 survey scores decreased progressively as the severity of hallux valgus increased (P < .001). This association was independent of age, sex, body mass index, education, and pain in certain body regions.
The association diminished after adjusting for pain in the back, hip, knee, and foot in the SF-36 survey. However, among participants with foot pain, increasing hallux valgus severity was significantly associated with greater impairment on the pain (P < .001) and function (P < .001) subscales of the FPDI, after adjusting for age, sex, and body mass index.
Hallux Valgus: More Than a Cosmetic Concern
The effect of hallux valgus was not limited to pain and reduced physical function. The condition also had a detrimental effect on additional aspects of the HRQOL, with a significant downward trend in general health, social function, and mental health with increasing severity.
“The clinical implication is that as hallux valgus progresses, its impact on [HRQOL] correspondingly increases. Therefore, interventions aimed at preventing further deformity may have a significant beneficial impact on patients beyond mere pain relief,” Dr. Menz explained.
“Hallux valgus is clearly not only of cosmetic concern, particularly in older people. Rather, it is a progressive and potentially disabling condition that has a broad impact on physical function, vitality, social function, and mental health,” he said. “The cause of hallux valgus is still poorly understood. Long-term prospective risk factor studies are required to adequately address this,” he adds.
According to independent commentator Smita Rao, PhD, assistant professor of physical therapy at New York University, New York City, “this study adds to the existing body of literature by specifically showing that 1) increasing severity of hallux valgus is accompanied by decreased general and foot-specific quality of life, and 2) the effect of hallux valgus on quality of life persisted after adjusting for lower extremity and back pain. Previous studies have been cross-sectional in design and have compared quality of life in individuals with and without hallux valgus. The information related to severity is new,” she told Medscape Medical News.
“The findings of this study provide strong support to existing literature showing that individuals with hallux valgus not only experience foot pain but also have problems with gait, balance, footwear choices, activity participation and social function,” she added.
Dr. Rao noted that the effect of footwear choices and previous or current intervention remains unanswered because the current study did not include questions related to footwear in the questionnaires that were mailed out to participants. Secondly, she said that it would be interesting to see whether there is evidence for subgroups (epidemiological phenotypes) of individuals with more aggressive forms of foot pain and strategies for clinicians to identify the patients who are most likely to deteriorate. “Along the same lines, it would be interesting to see if there are subgroups demonstrating different coping strategies.
“As a clinician, I would want to assess general and foot-specific [HRQOL], in addition to gait, balance, and foot pain in an individual with hallux valgus,” Dr. Rao said. “Additionally, interventions geared towards reducing foot pain in individuals with hallux valgus should be monitored for their ability to positively affect gait, balance, and quality of life.”
This study was supported by 2 Program Grants awarded by the Medical Research Council, United Kingdom, and by funding secured from the North Staffordshire Primary Care R&D Consortium for National Health Service support costs. The authors and commentators have disclosed no relevant financial relationships.
Arthritis Care Res. 2011;63:396-404.
Bunions (hallux valgus) and toe abnormalities such as hammer or claw toes become more prevalent with age but are strongly influenced by heredity, Marian Hannan, DSc, MPH, and colleagues report in an article published online May 20 inArthritis Care & Research. Dr. Hannan, who is editor-in-chief ofArthritis Care & Research, is senior scientist at Hebrew SeniorLife and associate professor of medicine at Harvard Medical School, Boston, Massachusetts.
“This is the first study in humans that addresses heritability of hallux valgus or bunions. It tells us the this common foot condition is indeed very heritable, and our paper notes that this is more so in women than men, and more so in women who show hallux valgus before age 65 (what we called early onset), where hallux valgus appears to be even more heritable than height, which is well appreciated as being inherited from one’s parents,” Dr. Hannan told Medscape Medical News.
Clinicians had suspected that hallux valgus ran in families, but this is the first study to document that heritability.
“I Immediately Looked At My Parents’ Feet!”
“The most surprising aspect to me is the extent of how heritable bunions are. I immediately looked at my parents’ feet!” Dr. Hannan said.
The study objective was to estimate the heritability of hallux valgus, lesser toe deformities, and plantar forefoot soft tissue atrophy. The researchers analyzed data from 2446 Caucasian adults, with a mean age of 66 years, from the Framingham Foot Study. Of those participants, family information was available for 1370. The authors used the Sequential Oligogenic Linkage Analysis Routines package, and heritability estimates were adjusted for age, sex, and body mass index.
Foot deformities were diagnosed by a clinical exam that did not include radiography.
Heritability refers to the proportion of variation between individuals that is attributable to genetics. The estimate ranges from 0 (not heritable) to 1 (highly heritable). Heritability was estimated for participants aged 60 years or younger, 61 to 70 years, and older than 70 years.
Hallux valgus heritability ranged from 0.29 to 0.89, depending on age and sex, and was 0.89 for women younger than 60 years. Toe deformity heritability was 0.56 (0.85 for women, 0.61 for men), peaking at 0.90 for men older than 70 years and at 0.80 for women older than 70 years. Plantar soft tissue atrophy heritability was 0.09 and was statistically significant only for participants older than 70 years.
For comparison, the authors noted that adult height heritability ranges from 0.68 to 0.93 (depending on sex, age, and other factors) and that the heritability for diabetes in white populations is 0.26.
“Increased prevalence of these three foot disorders was found in older age groups for both men and women. Almost half of the women aged 70+ years had hallux valgus, lesser toe deformity and/or plantar soft tissue atrophy,” the authors report.
Long Toes, Lax Ligaments, Bad Shoes Might Contribute
“Given that congenital hallux valgus is extremely rare, our finding that hallux valgus is heritable in adults raises questions as to which anatomical or functional characteristics are inherited that may predispose to the development of the condition in later life. Anatomical factors such as a large first-second inter-metatarsal angle, an excessively long first metatarsal and a round first metatarsal head have recently been shown to be associated with increased hallux valgus severity in older people, and it has been speculated that these foot structures may be more susceptible to lateral deviation of the hallux and subsequent hallux valgus deformity as a result of footwear compression. It is also possible that anomalous muscle insertions may predispose to hallux valgus,” the authors write.
The researchers speculate that the high heritability of lesser toe deformities might be associated with excessively long toes, which may be vulnerable to deformity resulting from footwear compression.
“I read the study and found it to be credible. I think anecdotally we have always believed hallux valgus/hammer toes were caused by a hereditary component. I personally believe the genes that are responsible for flexibility/ligamentous laxity play a role,” William D. Fishco, DPM, told Medscape Medical News. Dr. Fishco, who was not involved in the study, chairs the Podiatry Institute Board of Directors and is in private practice in Phoenix, Arizona.
“Congenital hallux valgus is rare; however, metatarsus adductus is not rare deformity, which clinically is a curved foot type. Patients with metatarsus adductus may have a clinical bunion deformity without an increase in intermetatarsal angle between the first and second. Therefore, without looking at an X-ray, one cannot be certain that the hallux valgus is not associated with a congenital deformity,” Dr. Fishco added.
Genetic Markers Might Enable Earlier Intervention
Earlier intervention is associated with better outcomes in hallux valgus, according to Dr. Hannan, and knowing that one’s family might be at risk might encourage patients to seek treatment.
“Education on proper shoe gear is the most important part of prevention. Anecdotally, we have recommended foot orthoses to prevent excessive motion/flexibility of the foot. No study has been done to my knowledge that has prospectively studied populations wearing orthoses…. [T]hat would be a great study,” Dr. Fishco said.
This study was supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases and the National Heart, Lung and Blood Institute’s Framingham Heart Study This work was derived from the Framingham Heart Study of the National Heart Lung and Blood Institute of the National Institutes of Health and Boston University School of Medicine. One coauthor was supported by an Australian-American Fulbright Commission Senior Scholarship at the time this work was undertaken. The other authors and Dr. Fishco have disclosed no relevant financial relationships.
Arthritis Care Res. Published online May 20, 2013.