Bunions (Hallux Valgus) & Lesser-Toe Deformities

New page (2026): this common topic had no dedicated note — written from the AJGP 2020 review and established knowledge; flagged for verification.

Progressive deformity of the great-toe MTP joint: the great toe deviates laterally, the first metatarsal medially, producing a painful dorsomedial prominence. Adult prevalence ~23%; of Australian GP presentations, ~82% are female and ~80% aged ≥45. Bilateral deformity is common. The natural history is progression — long-term resolution with conservative care is unlikely.

Aetiology and assessment

• Exact cause unclear; strong heritable component (positive family history common). A causative link with footwear/high heels has not been shown. Pes planus and ligamentous laxity may contribute to the rare juvenile bunion (open growth plate, mostly girls).
• Pain is usually from the dorsomedial eminence; also transfer metatarsalgia (pain under the lesser MTP joints from loss of first-ray weight-bearing), associated hammer toes and plantar keratosis.
• Severe deformity alters gait and increases falls risk in the elderly.
• Examine the lower limb, foot and gait; check skin over the prominence (breakdown risk in diabetes/PVD). Weight-bearing AP, oblique and lateral X-rays before referral.

Non-operative management (first-line)

• Accommodative footwear — wide, deep toe box, low heel; podiatry for shoe stretching/modification (especially diabetes/PVD)
• Bunion cushion/padding over the medial eminence
• Orthotics (medial arch support; metatarsal dome for transfer metatarsalgia), toe spacers, splints/braces — may relieve symptoms but do not correct the deformity, and benefit may not last
• NSAIDs for pain (beware comorbidities in the elderly); avoid opioids.

A trial of non-operative care is advised, though a Cochrane review found limited overall benefit versus no treatment — set expectations accordingly.

Referral and surgery

• Refer to orthopaedics when there is a painful prominence, exhausted non-operative management and a suitable operative candidate — or urgently if impending skin breakdown/ulceration.
• Cosmesis alone is not an indication for surgery; pain relief is the goal, and footwear/cosmetic concerns can persist postoperatively.
• Smoking is a relative contraindication (wound complications, delayed union) — encourage cessation.
• Most patients get a corrective osteotomy (chevron/scarf ± soft-tissue procedure); severe deformity may need proximal osteotomy or TMT fusion; severe arthritis (hallux rigidus) may need MTP fusion. Simple bunionectomy has a high recurrence rate. Post-op: stiff-soled shoe, weight-bearing, ~6 weeks; no driving until back in normal footwear.
• Juvenile bunion: delay surgery until skeletal maturity where possible (recurrence and growth-plate risk).

Claw/hammer/mallet toe

Lesser-toe deformities, often associated with bunions/hallux valgus (above) and transfer metatarsalgia — distinguished by joint position:

	Claw Toe	Hammer Toe	Mallet Toe
MTP	hyperextension	normal (slight extension)	normal
PIP	flexion	flexion	normal
DIP	flexion	extension	flexion

• Hammer toe — the most common; usually the 2nd toe; typically older women; painful corns form over the prominent PIP joint. Good footwear helps less than expected, though a high toe box does; podiatry for foam/gel inserts; surgery if failing conservative care (common) — responds well.
• Claw toe — may follow neurological disease (classically polio; also consider peripheral neuropathy). Podiatry first, then surgical referral.
• Mallet toe — as above: podiatry, then surgery if refractory.