Hallux valgus (bunion) surgery in athletes

first of all, permit me to suggest you to make an appointment with an experienced Consultant Orthopaedic Surgeon (MD) who specializes in foot and ankle surgery. He will assess your clinical case and will explain to you the various treatment options and discuss them with you.

The management of bunions in an athlete is challenging and a different approach is required for successful outcomes.

Athletes put great demands on their feet, especially on the great toe for push-off and acceleration power. These increased demands make treatment of bunions especially more challenging and a different approach is required for a successful outcome.

Bunions occur commonly in middle-aged women and in non-athletes. The treatment of bunions in this population varies greatly from the treatment of a bunion in an athlete.

Athletes can develop hallux valgus just like the general population. A cause of hallux valgus unique to athletes is due to an acute injury, such as dislocation or hyperextension of the first MTP joint resulting in a plantar plate or medial capsular tear. The medial capsular tear allows the lateral muscles to pull the proximal phalanx laterally, thus creating an imbalance that ultimately can cause a bunion.

Because of the fixation and healing requirements of bone, recovery and return to sport can take six to nine months.

While hallux valgus correction is very successful when treating the non-athlete, surgical treatment must be considered with caution in the athlete. As surgery involves manipulating the structures around the MTP joint, there is a potential to develop stiffness in the joint. As athletes place high demands on their joints and require flexibility to function well, any loss of movement may be detrimental to their sport. Thus, non-operative treatment should be exhausted to alleviate symptoms before considering surgery in the athletic patient.

Initial treatment of hallux valgus for athletes should focus on their shoe wear. Shoe modification to larger or wider sizes or models will help to accommodate the foot with a bunion. Certain shoe manufacturers have addressed issues of variations in feet. Sports podiatrists or specialised athletic shoe stores can help in educating patients on appropriate brands of shoes for their bunions.

Some patients have hyperpronation that may put extra stress on the medial forefoot. This can be addressed by a medium or high-density polyurethane orthosis with medial longitudinal arch.

A podiatrist can be helpful in assessing alignment of the foot and addressing these issues for the athlete with hallux valgus.

In conclusion, bunions can occur in athletes and are occasionally symptomatic. Initial treatment should be tailored to the individual patient. Generally, non-operative measures should be attempted in the athlete to allow them to continue their sport. Surgery can be considered when symptoms hinder them from playing, or symptoms and the deformity worsen. Surgical correction of bunions requires a complete correction of the angular deformity and a lengthy recovery. The decision for surgery should always be made carefully in the athletic patient.

Patients should be made to realize that return to professional sports or dance cannot be guaranteed. They must fully understand that some residual stiffness, pain, or deformity may be inevitable. Following surgery, they may not be able to return to their previous level of activity. Therefore, until they can no longer perform in their chosen field, bunion surgery should probably be deferred.

Unless the athlete's career is seriously jeopardized by his or her hallux valgus deformity, surgical correction probably should not be undertaken, for fear that a less than perfect result may jeopardize the athlete's career.

Surgery is often best postponed until retirement, since it can lead to stiffness and inflexibility. Scar tissue can develop and not even the best surgeon can guarantee full range of motion. Unless bunions cause major trouble, surgery is not worth the long recovery process and possible loss of flexibility.

As for best football cleats for bunion sufferers, message me and I will send you a very helpful link to football shoes for bunion patients (as you know, links are not allowe in this forum)

All the best.

Emis Moderator comment:I removed the email address as we also do not publish these. Please use the Private Message facility to exchange links or other details.

http://patient.uservoice.com/knowledgebase/articles/398331-private-messages

Thanks,

Jackie

Hi Paul,

I just had surgery on my left foot (Aug 16th) 1st MTP joint fusion. I'm a tennis player and hoping to be able to play again. I am truly inspired by Lleyton Hewitt (former #1 tennis player) who also had a 1st MTP joint fusion in 2012 and after a speedy recovery returned to the tour and played 4 more years.

Here is the article from the Australian May 26, 2012:

WHEN Lleyton Hewitt walks on to a Roland Garros court for his opening match at the French Open next week, it will be with steps rarely taken by a professional tennis player.Hewitt has undergone radical surgery to prolong his career and remove the constant pain that has accompanied his every court appearance over the past two years, with two screws and a metal plate now locking permanently into place in the big toe on his left foot.

Hewitt's toe, chronically arthritic and misshapen after years of digging into hard courts to launch his service action, is now reconstructed and irreversibly fused. Whatever cartilage there was in the first metatarsophalangeal (MPT) joint has been removed and painful bone spurs shaved off. The toe no longer moves, but nor should it give Hewitt any more grief.

For the first time that he can remember, Hewitt is without pain when he begins each day. If his luck holds, he may even start finishing tennis matches the same way.

The dramatic change in outlook has prompted Hewitt to reset his remaining career sights on a full-time return to the tour this year, a competitive campaign next year, and perhaps beyond.

Hewitt's manager David Drysdale, although reluctant to discuss the medical procedure in detail, told The Weekend Australian: "The X-rays look like something out of Bunnings."

The toe fusion surgery, performed by Melbourne foot and ankle specialist Harvinder Bedi, is common enough as a remedy for degenerative arthritic conditions but extremely rare, if not unknown, for a tennis player still trying to earn a living on the professional tour.

When Hewitt was deciding whether to undergo the procedure, he was warned there was a significant chance he might not be able to play again. The biggest unknowns were whether having the toe set in place would allow Hewitt to push up into his serve or push off hard from his forehand in a baseline rally.

Hewitt opted to go under the knife anyway, reasoning he would need it at some stage for a pain-free retirement. Such was his frustration with the time he has been forced to spend off court in recent years, he calculated it was a risk worth taking.

The pay-off for Hewitt will begin in Paris, where he will return to the circuit two weeks earlier than he had planned. Although his expectations for Roland Garros are low - he has only been on the practice court for two weeks - the success of his rehabilitation has encouraged him to dedicate the rest of this year to restoring his lowly world ranking.

"The aim is certainly to play out the rest of this year and get his ranking up again and then have a good 12 months, hopefully injury free, where he can have another crack at it," Drysdale said.

"He has played spasmodically because he has had different injuries over the last three years so in some ways, it has actually protected his body. He has had time off. If anything he might be able to play a little bit longer."

At age 31, Hewitt has spent the past two weeks practising up to three times daily against former Davis Cup teammate Todd Woodbridge on a clay court at Kooyong.

As recently as four weeks ago, Hewitt had next month's grass tournament at Queen's locked in for his return to the tour, in preparation for Wimbledon and the Olympics, which are also being played at the All England Club. In a recent interview, he explained that his better-than-expected recovery from surgery and Australia's Davis Cup draw encouraged him to push hard towards Paris.

"Once I knew that the next Davis Cup tie was going to be most likely on clay in Germany. I probably pushed the boundaries a little bit more," he said.

It normally takes between six and 12 months to make a full recovery from toe fusion surgery.

Hewitt's speedy recovery will improve his chances of making inroads at Wimbledon, the tournament he won 10 years ago. It will also bolster Australia's chances of beating Germany and returning to the Davis Cup World Group.

Thanks for the info re Leyton Hewitt. I had read it, but also i have heard some more negative stories from other people. You mentioned in your original post that you had some exercises that appeared to work and ease the pain. Would it be possible to share these? Good luck with your own rehab

Hi, Susan: How is fusion doing these days? I have mine scheduled Jan. 3 and I'm still looking for feedback. Thanks! -- Monica

Hi Amparo,

and thank you for my interest in my post. I had bunion surgery on my left foot 2 years ago because all conservative measures had been exhausted. My father is a doctor and he contacted a very experienced orthopaedic surgeon (MD, not DPM) specialized in foot and ankle surgery. He choose a technique called "Distal soft tissue realignement + basal osteotomy of the first metatarsal". Surgery went fine. I had to wear a surgical shoe for about 2 months. After 6 months I was ninety nine percent back to normal mobility: I could play tennis, started jogging  and cycling. It took me 1 whole year to return to play soccer and, despite a minor loss of dorsiflexion of the big toe, my athletic performance was not significantly  impaired by the surgery. Everything considered, I am very pleased with the outcome. I asked the surgeon about conservative measures, and he answered that conservative management of the athlete with a hallux valgus deformity begins with specifically pinpointing the area of maximal pain because conservative management must be directed toward relieving that problem. Generally, pain is over the medial eminence and not infrequently where the dorsal medial cutaneous nerve crosses over the bony medial eminence. First, the size of the shoe must be evaluated carefully in relation to the foot. Next, the pattern of the seams that cross over the medial eminence must be evaluated, because,

although leather will give way to pressure from the medial eminence, the stitching will not. Sometimes just altering the seams that cross over the bony prominence will result in a great deal of relief. If it appears that the shoe is of adequate size, then the area over the painful spot can be relieved by having the shoe enlarged over

this area. This is particularly useful in the athlete who requires a rigid boot, such as a skier, hockey player, rollerblader, and so forth. Even the ballet slipper can be expanded to a certain extent to relieve the pressure over the medial eminence.

The shoe itself could be stiffened to decrease stress across the first metatarsophalangeal joint if the patient’s athletic performance would not be diminished. Obviously a lineman can tolerate a stiffer shoe than a ballerina or gymnast. As a general rule, an orthotic device per se will not do anything to relieve the problems associated with a hallux

valgus deformity unless there is sesamoid pain or a transfer lesion beneath the second metatarsophalangeal joint.

One must be careful when using an orthotic device because it will take up a certain amount of volume in the shoe and as a result may aggravate the patient’s problem rather than relieve it. An orthotic device will not prevent a bunion from occurring. If the hallux valgus deformity has progressed to the point at which a transfer lesion is occurring beneath the second metatarsal head, then some type of an

orthotic device to relieve the pressure will be useful.

One must keep in mind, however, that whenever something is added to a shoe it takes up volume; if the shoe is already small, this can aggravate the problem. A change in shoewear may be necessary if an orthotic device is to be used. Sometimes when an individual has a large medial eminence that is painful, there is tendency to place

a pad over the involved area, with the thought that this will relieve pressure, but in actuality doing this increases the pressure. The person should be advised to cut out an area in the pad so that pressure is taken off of the medial eminence rather than applied to it.

Best wishes and greetings from Robert !

Excuse me: I should have written "for your interest in my post". Needless to say, throughout the recovery process, physical therapy is all important !