One of the most common complaints of the forefoot presented by patients to the primary care physician and orthopaedic foot and ankle surgeon is a painful bunion or hallux valgus. Although these two terms are commonly used by the lay person interchangeably, hallux valgus and bunions are distinct clinical entities. Hallux valgus represents a deformity that involves subluxation of the first metatarsophalangeal joint (MTPJ) resulting in medial deviation of the first metatarsal and a corresponding lateral deviation of the great toe. The term bunion refers merely to an enlargement of the medial eminence at the first MTPJ, where the bursa overlying it can become inflamed and erythematous (Figure 26-1).

Hallux valgus is considered mostly to be an adult problem. The most common age it is first noticed varies significantly, ranging from the third to fifth decade, although it can occur at younger ages.^1,2 The overwhelming majority of patients who seek medical attention and subsequent surgical consultation are female, often in excess of 90%.^3,4 The deformity may in fact be more prevalent in females, but it is more likely that these numbers are influenced by many factors, including gender-related perceptions regarding the unsightliness of the deformity.

As demonstrated by Sim-Fook and Hodgson, there is a trend for hallux valgus to occur in those who wear shoes (33%) versus those who do not (2%). Similar reviews have subsequently confirmed these findings, and thus footwear has become the leading extrinsic cause of symptomatic hallux valgus. The deformity has long been thought to be associated with narrow shoe wear, such as high heels, although it is clearly not a necessary means. Additionally, the occurrence of juvenile hallux valgus does not appear to be related to a history of wearing constricting footwear.^4,5,6

The heritability of hallux valgus has been debated by many investigators. Numerous papers have demonstrated a trend toward a genetic predisposition, reporting a positive family history in up to 88% and with one author reporting a maternal history in 94% of patients.^4,5,7,8,9,10 Despite an unknown mode of inheritance, these numbers make it hard not to consider this as a potential contributor.

As with any patient encounter, a thorough history, physical examination, and focused workup needs to be conducted as hallux valgus can present in isolation or as a result of, for instance, underlying rheumatoid arthritis, a connective tissue disorder, or a neurologic disorder.