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Please see foot & ankle anatomy for more information about foot anatomy.
A bunionette is also known as a Tailor’s bunion.
The deformity results in a swelling along the outer border of the foot at the level of the 5th toe, also known as the 5th metatarsophalangeal (MTP) joint.
Clinical photograph of bilateral bunionette deformities
A bunionette deformity can be mild in the early stages, but with time can become progressively more severe and painful.
Please see foot & ankle anatomy for more information about the big toe anatomy.
A bunion is also known as a hallux valgus deformity.
Contrary to what most people believe, it is not a growth of bone, but actually when the two bones that make up the big toe joint point the wrong way. This is something that typically occurs slowly over several months to years.
The deformity is quite complex and involves not just the big toe but often the lesser toes as well. As well as the obvious bony abnormality there is soft tissue imbalance as well.
A bunion deformity can be mild in the early stages, but with time can become progressively more severe and painful.
Clinical picture of a patient with a severe bunion (hallux valgus) deformity. The 1st metatarsal bone moves medially (yellow arrow), the big toe (hallux) moves laterally (white arrow) pushing the second toe out of position, the big toe also rotates so that it rests on its side (red arrow). The blue lines indicate where the metatarsal (foot) bones are positioned. The bump or “bunion” is a result of an angular deformity as well as localised bone and soft tissue swelling which is very apparent in this case.
X-ray demonstrating the changes associated with a bunion compared to a normal foot. 1 – the big toe (hallux) turns on to its side, 2 – the sesamoid bones are no longer covered by the 1st metatarsal head, 3 – the 1st MTP joint is no longer congruent (when the two joint surfaces are properly aligned), 4 – prominent bump (medial eminence), A – the big toe (hallux) deviates laterally towards the lesser toes and displaces them, B – the 1st metatarsal deviates medially
X-rays demonstrating how the sesamoid bones are no longer in their correct anatomical position. In a patient with a bunion the sesamoids no longer lies in their groove and the resulting abnormal biomechanics can cause pain (yellow and amp; red). Note the straight lesser toes in the normal x-ray
Several factors can contribute to the formation of bunions although often there is no identifiable underlying cause.
Bunions can be associated with the following issues:
Patients with bunions can experience a significant amount of pain. The pain maybe felt at the site of the bump, the big toe joint, the second toe joint or elsewhere in the foot.
The prominent bump can get inflamed and irritated by rubbing against shoes (often those that are too small) and occasionally the skin can break down, split open and get infected.
Clinical picture of a patient with a hallux valgus deformity who has a painful medial eminence
The foot widens as a result of the deformity, this makes finding suitable and comfortable shoes a challenging shopping experience. Unfortunately, the longer you have a bunion, the more likely you are to develop arthritis in the big toe joint.
Many patients develop painful corns and callosities due to the abnormal pressure areas that result because of the bunion. This can be directly over the medial eminence of the big toe joint or as a result of the 2nd toe deformity.
A callosity results at the site of abnormal pressure, the thickened skin is the normal compensatory response. Unfortunately callosities can be quite painful. If you try and remove a callosity it will always come back as long as the abnormal pressure and load is still being applied.
Clinical picture demonstrating a severe bunion resulting in a crossover 2nd toe deformity with a painful callosity over the PIP joint
The big toe is big for a reason, it takes almost half of the weight transmitted through the toes when walking and standing. A bunion stops the big toe from working properly. Patients with bunions end up transferring the load first onto the second toe and then the other lesser toes. This is called transfer metatarsalgia. Not surprisingly the second and other lesser toes are not designed to bear the extra load, and as a result, several complications can occur:
Radiograph demonstrating transfer metatarsalgia
Clinical picture of a patient with a painful bunion who is off loading the big toe and as a result, develops transfer metatarsalgia
The big toe will also force the second toe out of its normal position, which may eventually have a domino effect on all the other toes.
Clinical picture a foot with lateral deviation of the lesser toes in a patient with a large bunion deformity
The bunion deformity will never improve on its own and will most likely continue to deteriorate if left untreated.
Typical symptoms of a bunion (Hallux valgus) include:
Not all patients with bunions complain of pain at the site of the bunion. This patient has painful 2nd TMT joint arthritis which developed as a result of her bunion (hallux valgus) deformity.
Investigations help confirm the diagnosis, grade the severity of the condition and where applicable, aid in pre operative planning.
Plain radiographs are a quick and effective way of confirming bunion (hallux valgus) deformity in a foot. In the early stages of the condition, the deformity can be quite subtle. Most people however present when there is an obvious clinical and radiological deformity, often with additional complications such as lesser toe deformity.
Plain radiographs (x-rays) provide the following information:
Foot x-ray of a patient with a severe bunion and associated complications
Bunion deformities are classified by the degree of deformity as assessed by weight-bearing radiographs (x-rays).
Many people have bunions that are not symptomatic. The degree of deformity does not necessarily correlate with the degree of pain or symptoms. However, generally longstanding and severe bunion deformities tend to be painful.
Untreated, bunion deformities tend to get worse. This may happen quite rapidly but may also take many years to occur.
Patients with longstanding bunions can develop problems in adjacent bones, joints and soft tissues such as:
Radiograph (x-ray) of the feet demonstrating arthritis in the big (1st MTP) joint on the left in a patient with an associated bunion deformity (note the prominent medial eminence)
Radiograph (x-ray) of the foot in a patient with a severe bunion deformity and arthritis in the midfoot
Radiograph (x-ray) of the foot, of a patient with a severe bunion deformity and 2nd MTP joint arthritis (note also has midfoot arthritis)
Clinical picture of a foot in a patient with a bunion (hallux valgus) deformity with associated crossover toe deformity
A – AP, B – oblique and C – lateral radiographs (x-rays) of the foot demonstrating dislocation and crossover deformity of the 2nd toe
Serial radiographs (x-rays) of the foot demonstrating a 2nd metatarsal stress fracture in a patient with a hallux valgus deformity A – at initial presentation B – 6 weeks C – 3 months (healed)
Patients with secondary complications of a bunion (hallux valgus) deformity tend to have poorer surgical outcomes than in patients with an uncomplicated mild to moderate bunions.
Patients with 2nd toe involvement (hammer toe, crossover toe, 2nd MTP joint instability and 2nd MTP joint arthritis) have a higher re-operation rate and poorer outcome than patients with an isolated bunion.
Non-operative management for bunion (hallux valgus) deformity aims at relieving pain and return to full activity including sports whenever possible. It is likely to be most effective in the early stages of the condition.
It should always be the first line of treatment. Options include:
A period of rest from sports and exercise that bring on symptoms. Avoiding high impact activities and sports that involve lots of turning, twisting and bending of the toes such as running, dancing, basket ball etc.
A shoe with a stiff sole that prevents motion at the big toe joint will ease symptoms. A shoe with a wide and deep toe box that can accommodate any deformity and avoid any painful rubbing against shoes. A shoe with a rocker bottom can also ease symptoms. Avoid or minimise the time spent wearing high heels if not already doing so.
Custom orthotic may help by correcting associating conditions such as pes planus, flexible flatfoot deformity.
Some patients experience symptomatic relief from bunion (hallux valgus) splints, pads and toe spacers.
The use of non-steroidal anti-inflammatory drugs (NSAIDs) can decrease discomfort in patients with a bunion who have associated big toe arthritis by reducing inflammation in the joint.
The use of paracetamol and other painkillers to help reduce pain levels.
Surgical management is reserved for patients who have failed to respond to non operative treatment.
Patients should understand that the decision to undergo surgery should not be taken lightly.
Any intervention is considered in a step wise manner, with the least invasive procedure carried out first.
Regardless of the degree of deformity, or the operative intervention chosen, a frank discussion of the risks and benefits of surgery will always be undertaken prior to surgery.
It is also important to appreciate the amount of time it takes for full recovery. Although recovery and rehabilitation varies from patient to patient, on average patients take up to 1 year to be fully recovered.
Patients who have this expectation set before surgery, find that the postoperative experience is more likely to match their expectations.
A variety of surgical options exist which need to be tailored to the individual and the stage of the disease:
The aim of surgery is to correct the underlying deformity and restore normal big toe (1st MTP) joint biomechanics. Restoration of the sesamoid – metatarsal articulation is also important for a good outcome.
Before and 6 weeks post operation x-rays demonstrating correction of a severe bunion deformity at The London Foot and Ankle Clinic
Sesamoid radiographic views A – in a patient with a bunion B – in a patient post surgical correction of their bunion (halux valgus) deformity – note normal position of both sesamoid bones in their grooves under the metatarsal head, and the screw used to fix the scarf osteotomy
Scarf and Akin osteotomy involves the following:
This operation has a success rate of roughly 95%. Success defined as a pain free joint with a good range of motion and good to excellent deformity correction.
The operation can in the correct patient be done using a minimally invasive surgical (MIS) technique or a mini open procedure. The operation is undertaken under a general anaesthetic and as a daycase procedure.
The operation is usually done one foot at a time. If both feet are operated on there is no “good” foot to weight bear on. Recovery and complications may be greater in bilateral surgery.
Radiographs of the foot A – pre operative mild bunion (hallux valgus) deformity B – post operative bunion correction with a Scarf and Akin osteotomy (note the smaller medial bump, covering of the sesamoids, restoration of the congruency of the joint and straightening of the toe)
Clinical photograph of a foot, before and 2 weeks after bunion correction surgery
As for Scarf and Akin osteotomy when there is minimal arthritis in the big (1st MTP) joint. Patients should be aware that there may be persistent pain in the big toe joint despite correcting the bunion due to persistent arthritis in the 1st MTP joint.
Radiographs (x-rays) of the foot in a patient with a moderate bunion (hallux valgus) deformity A – pre operative B – post operative (note excellent surgical correction and persistent arthritic change in the 1st MTP joint)
A 1st MTP joint fusion is performed in the presence of severe bunion (hallux valgus) deformity and arthritis in the big (1st MTP) toe joint. Painful movement is sacrificed for a pain free but stiff and straight toe. Patients have excellent function following this operation.
Radiographs before and after of the foot in a patient with a longstanding bunion and arthritis in the 1st MTP joint treated with a 1st MTP joint fusion at The London Foot and Ankle Clinic
The most common lesser toe deformity is 2nd hammer toe deformity.
For details of the treatment of the associated lesser toe deformity please go to the relevant pages:
Patients with lesser toe deformities tend to have slightly poorer outcomes than patients with only an isolated bunion deformity. This is because patients with lesser toe and associated foot complications have had symptoms for longer and by default are more severe.
It should be borne in mind that complications can result from a condition with or without surgery.
Complications can occur as with any type of surgery. Please see Complications for more detailed explanation of post surgical complications.
A – Before and B – After x-rays of the foot in a patient who has undergone bunion surgery, note the darker areas in the bone after surgery indicating disuse osteopenia
Note – this list is not exhaustive and is meant as a guide.
Please read the information regarding what to expect post surgery on this website.
Remember that below is a guide to recovery and that everyone heals at different rates and some people do take longer. Use this information to help you understand your condition, possible treatment and recovery. The timeframes given below are a minimum, it is important that you appreciate this when considering surgery as your healing and recovery may take longer.
Almost all surgical procedures for bunion (hallux valgus) deformity correction will be undertaken as a day case.
You will have a bandage applied similar to this during the operation.
Post operative bandage of the foot
Please do not remove your bandages until you are seen by your surgeon Mr Malik at the two week post operative clinic appointment. You will also be provided with a stiff soled black post operative shoe. Please ensure you wear this whenever you are weight bearing.
Post operative stiff soled shoe
For the first 48 hours you will be allowed to touch weight bear using two crutches. After 48hrs you can weight bear as tolerate. The physiotherapist will guide you after your operation and before your discharge from hospital with the use of crutches and mobilising.
For the first two weeks following your surgery please keep your foot elevated to the level of your heart for 95% of the time. It is recommended you stay at home during this period.
High elevation of the foot and ankle
Naturally most people do not have a hospital bed at home. The same effect can be achieved by lying in a bed or lengthways on a sofa, with pillows behind your back and under your foot. You cannot have your leg elevated sitting in a chair. It is strongly advised that during the first two weeks you are house bound.
To minimise risk of infection keep the foot dry and cool. Avoid humid and hot environments. Keep the foot dry and when showering wear a Limbo bag.
To minimise the risk of blood clots please move your foot and ankle at regular intervals. Please ensure you are well hydrated. If you have a risk of blood clots please notify Mr Malik who may organise for you to have blood thinning injections as a precaution.
You will be reviewed at the clinic and your dressings removed. Your wound will be checked.
Clinical photograph of a typical bunion wound 2 weeks post op. This patient adhered to the strict post-operative instructions and as a result has a dry wound with minimal swelling at 2 weeks.
The wound should be dry, minimal redness if any, slight bruising and with mild to moderate swelling. The foot will be more swollen and less well healed if it has not been kept elevated.
At this stage if the swelling has subsided sufficiently you will be advised to keep your foot in an elevated horizontal position 75% of the time during the day. At night keep one pillow under the foot. It is also advisable not to walk or stand for more than 15 minutes at a time as the foot will swell and start to hurt. You will require to wear the special post operative shoe for another 4 weeks. Short trips can be made outside, within limits of pain and swelling.
Driving will be permitted for short trips if the left foot has been operated on and you drive an automatic. If the right foot has been operated on it will be at least 7 to 8 weeks before any driving is advisable. This is because the right foot is your braking foot and you need to feel safe to do an emergency stop.
Scar desensitisation should start as soon as the wound has completely healed. You can do this by massaging cream (E45 for example) into the scar and around the wound area.
Commence exercises of the lesser toes 3 weeks after surgery and continue for 3 months. These exercises included active resistive and passive toe flexion and extension. They also include intrinsic foot muscle strengthening exercises.
You will have radiographs taken just before you are seen in clinic. You will go over these with Mr Malik and compare the before and after operation images. For a fusion it will generally take at least 6 weeks to show evidence of fusion, sometimes it can take as long as 3 months particularly if you are a smoker.
At this stage if your healing is progressing satisfactorily swelling and bruising should have subsided considerably, although expect some degree of swelling for at least 3 to 4 months.
You will be able to start wearing normal footwear (swelling permitted) around 8 weeks post surgery, although stiff soled shoes are advisable.
Clinical photograph of a foot, before and after bunion correction surgery
Final clinical examination. Discharge if satisfactory.
Please see guidance above and information here. Ultimately it is the responsibility of the patient to decide if they are safe to drive. A good way of knowing is if you can stamp your right foot heavily on the ground to mimic an emergency brake. If you have any hesitation or pain then it should suggest you are not safe to drive. Remember prolonged driving involves keeping your feet in a dependant position. This will worsen the post operative swelling.
This really depends on you and your job. If you have a job that involves a lot of standing, walking and is manual it may be 8 to 12 weeks. If you have a sedentary job, for example in an office and you have a reasonable commute you may be able to go back to work at 2 weeks, although this would be exceptional and not the norm.
Excellent pain relief and deformity correction. Ability to participate in sports by 6 months. Sometimes up to a year before the foot feels “normal” and fully healed.
Yes you should be able to participate in most sports. Certain activities that require the big toe to bend significantly may be difficult, for example certain Yoga positions.
I had found my foot increasingly painful in every day situations and foot wear was becoming a problem regarding fitting and comfort.
I think I was most concerned about how I would manage having my foot raised 95% of the time for 2 weeks. In fact it was easy, due mainly to having a very supportive husband and family and planning ahead with meals etc.
I was told by friends who had this operation that it would be painful but I didn’t experience any pain at all and only some low level discomfort which lasted about 2 hours.
I woke from my anaesthetic feeling absolutely fine. I had no drowsiness or nausea and no pain and went home a few hours later.
I may be one of the lucky ones having experienced no pain whatsoever and only minimal short term discomfort.
Without a doubt making sure I didn’t use my foot too much and ensuring I kept it elevated 95% of the time. Walking with crutches was easy, as was the stairs.
Don’t put off the operation. Plan for when you are going to be incapacitated with meals and things to do to keep you occupied.
Follow Mr Malik’s instructions to the letter. I kept my foot cool, dry and elevated, above my heart day and night for the first two weeks. After that I was still careful to make sure my foot was elevated most of the time, which I’m sure helped me heal quickly.
I decided to have my bunion treated because it caused me pain in my foot and leg and it was hard to find shoes that fitted.
My only concern before the operation was the recovery time.
The operation went very well, no problems at all. I was relieved not to have my foot in plaster like when my right foot bunion was removed 13 years ago. At that time the recovery was very long (the procedure was not done by Mr Malik), but not this time.
The most challenging part of having my bunion operated on was laying flat with my foot up for the first weeks but pre-planning what to do in that period helped: reading, listening to podcasts, doing crosswords, sorting out the family photos and creating albums and watching a bit of t.v.
The days went quickly as I settled into a routine and just knew I couldn’t do anything else.
Be patient and don’t try to do too much too quickly. Increase your walking week by week at your own pace, if your foot swells up rest and cool it down with ice if necessary.
I am 23 and have had bunions for as long as I can remember. I thought I was lucky as they didn’t cause me much pain during my daily routine, only causing pain when I exercised, however when I was 21 I qualified as a nurse. The work hours involve being on my feet for 12.5hrs and made standing or walking for too long extremely painful; I couldn’t ignore the general discomfort in my feet anymore as they had become continuously painful.
My biggest concern was being in pain afterwards. Unfortunately, this was inevitable as I had bilateral bunions; this means that less pain block can be given to each ankle as it needs to be evenly split between the two deformities. It was painful for the first few days, but after that I did not take any pain relief for the duration of my recovery. The pain was not anything worse than I expected; if I kept up with pain relief I found that even during the night initial post-operative pain was bearable.
I’ve read many blog posts over the last few months and I’ve begun to realise I had a good and straight forward recovery. Dr Malik is a brilliant and very calm surgeon; he fully prepared me for what to expect from the operation and recovery and provided advice on a number of occasions, during my post-operative recovery, at times when I was uncertain as to the best way for me to assist my body in it’s recovery. The operation went as expected. After the initial few days of pain and being very immobile/relying on others, I got into a routine.
The most challenging part was relying on other people for a long time and being immobile. I was expecting to heal quickly as I am young, however this wasn’t the case. The first piece of advice I would give anyone deciding to have this surgery would be that you must not be impatient with your body; by having an operation which involves you to be so immobile, and in my case weight-bearing on the operated areas due to having both feet done, the recovery can take a lot longer than expected. You’ve got to be flexible and relaxed about what the recovery period will be, as rushing your recovery can have long-term implications. I needed longer off work than I’d expected so if you mentally prepare yourself for this you will have a much easier time.
Don’t put it off; it might sound like I had the operation at an early stage in my life, however I had known it had to be done for years. I was just putting it off until “the right time”, but by doing so I made my feet much worse. The result of my decision to put off the surgery caused the bunion on my left foot to be so badly impacted that it made it very hard for Dr Malik to get it back to it’s natural angle. The worse the bunion, the harder they are to correct. Timing is a huge factor and it is so important to have support and people around in the first few weeks and so you must plan ahead. I would strongly advise that you get a wheelchair where you can raise your leg up. I got one in the last month of recovery and it means you can take trips outside without your feet swelling; this helps with the sanity as much as the recovery! See the recovery as a positive and take the opportunity to take up some new hobbies which you would have otherwise not started to keep your mind busy… I’ve started knitting!
I had my first bunion operated on in November 2016. It was so successful that in 2019 when I started to get pain in my other foot, I decided to see Mr Malik again immediately.
I had carried out my research before my first operation, viewed various surgeon’s websites and read different testimonials. Based on my findings I decided to go head with Mr Malik. Now, after my experiences with him, I realise what a wise choice I made. I didn’t really have any concerns before the operation as I knew that the recovery time was quite long, about 8 weeks and that the swelling would take some time to go down. With this in mind, patience is very much needed with this op!
I had heard that bunion operations can be very pain but this was not my experience at all. I took the painkillers that were prescribed for the first 2 days, after that I took just Paracetamol for a further 2 days and then stopped completely. I had no pain whatsoever. However, I did follow Mr Malik’s recovery instructions exactly. I sat with my foot up high for 2 weeks and then continued with my foot up for a further 4 weeks. Having had both feet operated on now, I do think that this is vital for a good recovery.
After my first op, I did imagine that maybe the recovery time would be quicker than 8 weeks. It isn’t! By 8 weeks I could walk normally, although my toe was still not ready for high heels or yoga!
If you are thinking of having this op, firstly, I would say emphatically, “yes do”! But… you must follow the instructions about resting and also do the exercises that are given to you. The swelling does take a long time to go down completely.
I am so, so pleased that I had my bunions removed and I really cannot thank and praise Mr Malik and his team highly enough.
“Mr Malik and his team provide first class care, for which I am very grateful. Mr Malik is an excellent consultant, he was caring, thoughtful and understanding. I was very worried about having complex surgery to correct a bunion and 3 toe deformities on my right foot. He is a great surgeon and person, I am now well on the way to recovery and would recommend him to anyone.”
Angela Sturgess 5/10/2016
“I can honestly say I would recommend Mr Malik to anyone. He is so kind and put me at ease from the off. He operated in October on my left foot and has corrected the deformity well, excellent Surgeon and as long as you follow his post op advice you will have great results. Waiting for the right foot to be operated on now with no worries at all. Thank you Mr Malik and your team.”
Suzie Best 28/4/2016
“I am delighted with the results achieved by Mr Malik. He put me at ease from the first appointment, explained everything in plain English and displayed a reassuring amount of confidence in what could be done. I wouldn’t hesitate to recommend Mr Malik to anyone. I have a straight foot after many years of pain and am delighted. Thank you Mr Malik and your team.”
Sophie Duffy 17/2/16
“The whole experience was good. Having healthy feet is so important and being able to walk pain free after a speedy recovery is great. I strongly recommend anyone with foot problems to see Mr Malik and get his expert advice on what to do.”
Mrs C Sidenius 8/2/16
“I am now the proud possessor of two new feet – all due to the skill, care and friendly attention Mr. Malik gave to the daunting task of straightening and repairing my toes for me.
My heartfelt thanks for making a much dreaded experience so much more endurable and pleasant than I had anticipated.”
Elizabeth Smith 13/12/15
“Nothing to worry about. Excellent surgeon, now happy to have the other foot done.”
Gay Titley 30/11/15
“My mum’s foot was in such a terrible state, as a family we were very concerned that the surgery would be too drastic to undertake, as she is a lady of advancing years. But Mr Malik took the time to explain to any member of the family who wished to know and did an amazing job. He removed a severe bunion and corrected, through surgery and pinning, the toes that had all headed off in a direction of their own, and to look at it now, you wouldn’t believe it was the same foot. Mum is still in the process of fully recovering but the future is so much brighter having been cloudy. THANK YOU VERY MUCH, Mr Malik!”
Patient’s daughter 4/11/15
“I had bunions on both feet which where very painful, I got referred to Mr Malik. Mr Malik knew exactly what needed to be done and explained it all in clear detail and plan of action, I came out my meeting with Mr Malik feeling relieved and confident that I’m finally going to be free of pain.
My first operation was in November 2013, I had 3 months off work due to having both feet done at the same time. My feet had to be elevated during the healing process. Even when I came out of hospital Mr Malik was very helpful, any questions I had I could contact Mr Malik and right away he would give me advice and insure I was comfortable. It wasn’t as painful as I thought it was going to be during and after the healing process.
After nearly 2 years, one of the screws started to loosen resulting in a lump at the top of my big toe which was also quite painful. I therefore contacted Mr Malik and a meeting and X-ray was booked in right away. 1 month later I had the operation to get the screw removed. I felt comfortable and welcomed before I had the procedure, I was also explained in detail about what Mr Malik was going to do. 2 weeks with my foot rested & elevated and I’m now back to normal.
As a teenager I would strongly recommend Mr Malik, If your suffering with similar symptoms from bunions. It has changed my life, my scars on the side of my toes are a bit tender but all is well no more pain or being uncomfortable. Outstanding results. Thank you Mr Malik and the team for everything, I will forever be grateful.”
Laura Hayes 4/9/15
“I was happy to follow all of the advice that Mr Malik gave me and I am very pleased with the result. It is wonderful to be free from pain.”
Mrs J Everil 29/4/15
Please see foot & ankle anatomy for more information about the big toe (1st MTP) joint.
Arthritis is disease (damage) of cartilage. Cartilage lines the surface of the bones where two or more bones form a joint. Cartilage allows smooth and frictionless movements. Disease of cartilage leads to roughened surfaces which causes friction and increased wear and tear in the joint. This in turn can cause inflammation, pain, and joint deformity.
Big toe arthritis (Hallux rigidus) is when arthritis involves the big toe (1st MTP) joint.
Hallux is the latin word for big toe. Rigidus is the latin word for stiff. Hallux rigidus therefore means stiff big toe which is how arthritis of the big toe typically presents.
Hallux rigidus is the second most common condition affecting the big toe after bunion (hallux valgus). It is also the most common arthritic condition in the foot.
Radiographs of the foot demonstrating A – normal 1st MTP joint B – mild arthritis in the 1st MTP joint (blue arrow) C – severe end stage 1st MTP joint arthritis with bone on bone changes
Any condition that damages the cartilage (joint surface) will cause big toe arthritis (Hallux rigidus) to develop.
The common conditions that cause big toe arthritis arthritis are:
Radiograph of both feet in a patient with a bunion deformity on the right foot. Note the normal 1st MTP joint (white circle) on the left and the arthritic joint (yellow circle) on the right
Typical symptoms of big toe arthritis (Hallux rigidus) include:
Typical site of big toe (1st MTP) joint arthritis – note the swelling in the joint
Clinical picture of a patient with big toe arthritis presenting with a painful prominent bump (dorsal osteophyte)
Grading a disease in medicine is used for the following reasons:
We use the following grading system at The London Foot & Ankle Clinic for big toe (1st MTP) joint arthritis:
In many patients with an arthritic 1st MTP joint, the body compensates for the stiff painful joint by offloading the big toe joint.
However the big toe joint is designed to withstand approximately 40 to 50% of body weight during normal gait and this increases substantially with running and jumping. If it is no longer working (defunctioned), then the load has to borne by something else.
This happens to be the other metatarsal bones and lesser MTP joints starting with the 2nd.
Radiograph demonstrating the load transfer in transfer metatarsalgia
Clinical picture demonstrating offloading of the left 1st MTP joint (white arrow) and increased load as a result on to the 2nd metatarsal (blue arrow)
Plain radiographs are a quick and effective way of confirming big toe (1st MTP) joint arthritis in a joint. In the early stages of the condition, when there is inflammation with no obvious damage to the joint, radiographs may be normal. Most people however present when there is some structural damage.
The following are features of arthritis on a plain radiograph:
Radiograph (x-ray) of an arthritic big toe (1st MTP) joint with a massive growth of bone on the top of the joint (dorsal osteophyte)
MRI is not generally required to make the diagnosis. Occasionally patients with early disease and minimal changes on an x-ray may benefit from an MRI as it will show damage to the cartilage and related changes of arthritis. An MRI provides excellent high definition static images.
MRI is particularly useful in assessing:
MRI of the big toe (1st MTP) joint demonstrating central area of damage to the cartilage
Ultrasound is a quick, painless and non invasive method of assessing soft tissue structures.
Ultrasound is particularly good at ascertaining:
The natural history of big toe (1st MTP) joint arthritis is very variable, some patients describe a rapid deterioration, while others take many years to get worse.
The changes associated with arthritis are irreversible, the joint will never return to its normal healthy state. That is not to say that all patients are symptomatic, some patients describe stiff joints with mild ache and are able to manage their symptoms with activity modification. However some patients describe significant pain and functional limitation.
You should see an Orthopaedic Foot & Ankle Surgeon if one or more of the following applies to you:
As the arthritis becomes more severe and any deformity becomes fixed, adjacent joints will also become involved and become arthritic.
Transfer metatarsalgia
Patients may present with no or little pain in the big toe joint because they are not putting any load on the big toe joint, and transferring it to the other toe bones in the foot (metatarsals). Symptoms may arise due to transfer metatarsalgia.
As discussed above this occurs due to offloading of weight from the big toe and transferring it to the other metatarsal bones starting with the 2nd.
Patients with transfer metatarsalgia may present with the following problems:
Sites of problems (pathology) as a result of transfer metatarsalgia A – 2nd MTP joint synovitis B – 2nd metatarsal stress lesion/stress fracture C – 2nd TMT joint arthritis D – intermetatarsal bursitis E – Morton’s neuroma F – toe deformity
A – 2nd metatarsal stress fracture due to transfer metatarsalgia as a result of 1st MTP joint arthritis B – healed 2nd metatarsal after 1st MTP joint fusion
Consequence of untreated 1st MTP joint arthritis A – 2nd MTP joint instability/synovitis, B – 2nd MTP joint arthritis, C – Midfoot arthritis
Non-operative management for 1st MTP joint arthritis aims at relieving pain and return to full activity including sports whenever possible. It is likely to be most effective in the early stages of the condition.
A period of rest from sports and exercise that bring on symptoms. Avoiding high impact activities with lots of turning, twisting and bending of the big toe.
A shoe with a stiff sole that prevents motion at the big toe joint will ease symptoms. A shoe with a wide and deep toe box that can accommodate any deformity and avoid any painful rubbing against shoes. A shoe with a rocker bottom can also ease symptoms. Avoid wearing high heels if not already doing so.
Custom orthotic with a stiff foot plate and big toe extension (Morton’s).
The use of non-steroidal anti-inflammatory drugs (NSAIDs) can decrease discomfort in patients with big toe arthritis by reducing inflammation in the joint.
The use of a walking stick or cane to reduce the forces going across the damaged joint.
Can relieve the pressure on painful damaged joints.
These are increasingly popular with people who have arthritis. The cartilage found in joints, normally contains glucosamine and chondroitin. It is thought that taking supplements of these natural ingredients may help to improve the health of damaged cartilage.
Research has provided mixed results but on the whole suggests that glucosamine sulphate is more likely to be helpful than glucosamine hydrochloride. If you are thinking of taking glucosamine, we suggest taking 1,500 mg per day of glucosamine sulphate. If you notice no improvement in your symptoms after 3 months then you should probably discontinue it. If you do find it improves your symptoms then you ned to continue taking the supplements. There is no extra benefit in taking glucosamine and chondroitin.
Remember that supplements also have side effects and it is advisable to discuss with your GP before starting any new treatment.
There is no one treatment that has a reliably successful, quick and easy cure for arthritis. Therefore researchers and doctors are constantly looking for new and better ways of treating arthritis.
Many treatments have come into fashion and then gone away over the years once results had shown that the initial promise was premature and misplaced.
At The London Foot & Ankle Clinic we do not promote or discourage new treatment options for arthritis. We would however advise a cautious approach to relatively untested treatment modalities with little or no evidence to back their use. Patients undergo these treatments at their own risk.
There are a number of treatments that involve an injection or series of injections for the treatment of big toe (1st MTP) joint arthritis.
This injection serves as both a therapeutic and diagnostic intervention. Steroids reduce inflammation and can ease painful symptoms. The local anaesthetic numbs an area of the body for roughly 12 to 48 hours.
The steroid is unpredictable in its success at easing painful symptoms but has very low risk of complications and therefore is an attractive therapeutic option prior to further more invasive surgical intervention. The local anaesthetic on the other hand is very predictable in its action. If there is an area of damage it will definitely ease symptoms for 12 to 48 hours. If symptoms do not ease during this period, one has to question whether the diagnosis is correct.
Steroids reduce inflammation and ease pain when injected directly into an arthritic joint. It is most likely to be effective in the early stages of arthritis.
We carry out almost all injections under a short general anaesthetic (1 minute) as injecting into a painful joint can be quite sore. While you are asleep and lying still a small needle is inserted into the joint and the position is confirmed using an x-ray in theatre. A small amount of dye is injected first to make sure the needle is in the correct spot and then a mixture of steroid and long lasting local anaesthetic is injected. Undertaking the injection in this manner ensures a pain free experience for the patient and the best outcome clinically as there is no doubt about the placement of the injection.
The local anaesthetic will cause numbness in the area injected for approximately 12 to 48 hours. This action is predictable. What is not predictable is the duration of action of the steroid. It may work for one month, several months or even more than a year.
A manipulation of the joint is also carried out, the aim of this is to stretch the joint capsule and improve the range of motion.
Injections are not repeated less than 6 monthly intervals.
Please read here for more information regarding injections and possible complications.
A – Placement of fine needle in the 1st MTP joint B – Radio-opaque dye confirms needle is in the joint
Normal joints have lubrication fluid called synovial fluid. A major constituent of synovial fluid is a substance called hyaluronic acid. This helps not only lubricate the joint but also act as a shock absorber easing the load across the joint.
It has been noted that people with arthritis tend to have lower concentrations of hyaluronic acid than normal.
Viscosupplementation involves injecting hyaluronic acid into arthritic joints. The procedure would be carried out as for a steroid injection under a short general anaesthetic and x-ray control.
In summary patients with pain from a large bump on the top of the big toe (dorsal osteophyte and stiffness with no mid range pain are suitable for joint preservation surgery such as cheilectomy or a Moberg procedure.
Patients with constant pain and mid range pain require a 1st MTP joint fusion or a hemiarthroplasty.
Cheilectomy can be thought of as a “tidy up” operation. It involves the following:
This operation has a success rate of roughly 85%. Success here is defined as a pain free joint with a good range of motion. 15% of patients have persistent or recurrent symptoms due to continued progression of arthritis in the joint and presence of damaged cartilage in the middle of the joint.
The operation can be done using a minimally invasive surgical (MIS) technique or a mini open procedure. Whenever possible we attempt to carry out the procedure using MIS.
The advantage of a cheilectomy is that it is:
The operation is undertaken under a general anaesthetic and as a daycase procedure.
An x-ray of the foot showing A – a large dorsal osteophyte B – the bone removed during a cheilectomy
The operation tends to be more successful in patients who only have damaged cartilage in the periphery of the joint which is removed during the surgery. Patients with central areas of damaged joint surface tend not to do so well as the disease will continue to spread and involve a larger area of the joint.
This surgical technique is done in conjunction with a cheilectomy. In some patients with central small areas of damaged cartilage, fusing the joint is not desirable, especially when there is a lot of healthy cartilage still present and good range of motion in the joint.
Microfracture is a surgical technique used in hip, knee, ankle and big toe joints. It involves removing the damaged (loose, friable and unstable) cartilage and drilling the underlying bone creating microfractures. This stimulates the bone marrow underneath and forms a blood clot rich in growth factors which in turn promotes new cartilage formation. The new cartilage is called fibrocartilage and can be thought of as the equivalent of scar tissue in the skin. Not as good as the original tissue but better than nothing. It has similar characteristics and properties as normal hyaline cartilage but is not as robust and durable.
Good to excellent results can be expected in around 75% of patients in the short to mid term. Longer term results are difficult to predict. For patients not keen on a fusion or a joint replacement procedure this is a good option.
The Moberg procedure is indicated in a select group of patients who require dorsiflexion of the big toe, for example runners and dancers. It may also be carried out in conjunction with or after a cheilectomy.
It involves removing a wedge of bone from the base of the big toe, which allows greater movement in dorsiflexion (lifting the big toe up), it does sacrifice movement in plantarflexion (pointing toe down).
In the Moberg osteotomy a wedge of bone is removed (yellow triangle), which allows greater movement in dorsiflexion
1st MTP joint fusion has excellent outcomes in terms of pain relief and return to activities of daily living.
It involves removing all remnants of the diseased joint (cartilage) and fusing the the bones so that no joint exists. With no more joint there will be no more movement and therefore no more pain. The aim is to sacrifice painful movement for pain relief.
The majority of patients when they first hear about this procedure are quite apprehensive. This is understandable, joints exist to allow movement. A fusion is the total opposite to this, and therefore most patients perceive it as unnatural. However contrary to what most people think, after a fusion you will be less likely to limp and be a lot more active. Please read this blog for more details.
The operation is usually carried out through one incision on the inside (medial) of the big toe joint. The operation is undertaken under a general anaesthetic and almost all cases are done as a daycase.
The main complication is non union (the bones not fusing together). This is reported in numerous studies to be around 5 to 10%. In the event of this complication, the operation is repeated with bone graft to stimulate the healing and given time most patients eventually heal.
Currently 1st MTP fusion remains the treatment of choice for end stage big toe (1st MTP) joint arthritis. There are 1st MTP total joint replacements but the indications and outcomes are controversial.
Patients who are only willing to undergo surgery once, should consider this procedure due to the higher failure rates and need for further surgery associated with 1st MTP hemiarthroplasty or total joint replacement.
After a 1st MTP joint fusion patients can wear a heel roughly 5 cm high.
A – Large bone growth (dorsal osteophyte) caused pain and difficulty wearing shoes B – removal of bone growth along with 1st MTP joint fusion
A – before and B – after radiographs (x-rays) of the foot after 1st MTP joint fusion (note one screw was removed as it was causing irritation)
A 1st MTP joint fusion can be carried out using 1 or 2 screws or 1 screw and a plate.
Advantage of using only screws:
Disadvantage of using only screws:
Advantage of using a 1st MTP joint plate:
Disadvantage of using a 1st MTP joint plate:
Mr Charnley popularised the total hip replacement in the 1960s for the treatment of hip arthritis. It allowed for pain free joint movement and significant improvement in quality of life. Over the last 50 years there has been incredible advances in technology and biomaterial science. Many changes have been and continue to be made to the total hip replacement. Total hip replacements now have a success rate of around 99% at 10 years and around 90% at 15 years. It is undeniably an orthopaedic success.
Orthopaedic surgeons wish to replicate the success of the total hip replacement by creating similar joint replacements for other arthritic and damaged joints around the body.
In the 1970’s the total knee replacement was introduced and while not as effective as the total hip replacement has a success rate of around 95% at 10 years.
Since the 1990’s orthopaedic foot and ankle surgeons have been testing and developing 1st MTP total joint replacements. Currently 1st MTP total joint replacements are still considered to be “work in progress”. Studies do indicate excellent short term benefits in terms of pain relief and function. However mid to long term results are not so good and a significant proportion of patients require further revision surgery.
Most 1st MTP total joint replacements that fail will require a bigger operation than a routine 1st MTP joint fusion. Once the metal and plastic artificial joint have been removed, there will be a defect. This is typically filled with donor bone graft. A plate is then used to secure the toe to the rest of the foot. Complications and healing are much greater than a primary 1st MTP joint fusion. Anyone considering a 1st MTP joint replacment needs to bear this in mind.
So why consider a 1st MTP joint replacement?
Who would be suitable for a 1st MTP total joint replacement?
Patients are not suitable for a 1st MTP joint replacement for the following reasons (contraindications):
Complications of 1st MTP total joint replacement:
The operation is usually carried out through one incision on the inside (medial) or the top (dorsum) of the big toe joint. The operation is undertaken under a general anaesthetic and almost all cases are done as a daycase.
Currently 1st MTP joint fusion and hemiarthroplasty are more predictable than a 1st MTP total joint replacement for alleviating symptoms and restoring function in patients with severe arthritis of the 1st MTP joint. Complications are also greater than with a 1st MTP joint fusion or a hemiarthroplasty.
This operation has the advantages of the 1st MTP total joint replacement without its major complications. The procedure involves replacing one half (proximal hallux) of the damaged 1st MTP joint surface. Minimal bone is removed. Range of motion is maintained with this procedure. Indications, contraindications and risks are similar to those for 1st MTP total joint replacement although the incidence of complications is probably lower and the outcome better.
Illustration demonstrating maintenance of range of motion at the 1st MTP joint following a hemiarthroplasty procedure (image courtesy of Arthrex)
So why consider a 1st MTP hemiarthroplasty?
Who would be suitable for a 1st MTP hemiarthroplasty?
Patients are not suitable for a 1st MTP hemiarthroplasty for the following reasons (contraindications):
Complications of 1st MTP hemiarthroplasty:
A – before and B – after x-rays of a patient who had a 1st MTP joint fusion elsewhere which developed non-union, revised successfully at The London Foot and Ankle Clinic
X-rays of both feet 8 weeks after successful left 1st MTP joint fusion – note the areas of disuse osteopenia (darker bone) – this is a temporary effect of non weight bearing and the bone will return to normal strength
Almost all surgical procedures for big toe (1st MTP) joint arthritis will be undertaken as a day case.
Post operative bandage around the foot
Cheilectomy, Moberg procedure, 1st MTP joint fusion with a plate, 1st MTP joint hemi and total joint replacement
High elevation of the foot and ankle following a surgical procedure
In addition for a 1st MTP hemiarthroplasty –
Early active and passive 1st MTP joint range of motion exercises are to commence at 48hrs post surgery. This is to ensure a good range of motion and prevent stiffening due to scar tissue. Patients are to keep their foot elevated for 95% of the time but can weight bear for short distances around the house for example when going to the bathroom.
In addition for a 1st MTP joint fusion with only screws –
You will require to be strictly non weight bearing for 6 weeks. This does not mean you can walk on your heel, it means strictly that the foot cannot touch the ground.
Typical appearance of a wound post surgery. This patient adhered to the strict post-operative instructions.
At this stage if the swelling has subsided sufficiently you will be advised to keep your foot in an elevated horizontal position (50-75% of the time). You will require to wear the special post operative shoe for another 4 weeks. Short trips can be made outside, within limits of pain and swelling.
I was experiencing pain in my feet. It was worse when playing golf/walking and when wearing most shoes. I didn’t want the pain for the rest of my life, knew the pain would only get worse and didn’t want to be in a position whereby I couldn’t do things I enjoy, like playing golf.
I spoke to a friend who has had a similar operation and recommended Mr Malik. I visited Mr Malik and I took confidence in his assessment. He advised me I should have the left foot operated first, as it was the worse foot.
The thought of having an operation, the recovery and whether the operation would be successful.
The operation wasn’t as dramatic as I had anticipated. I was surprised how quickly I recovered from the general anaesthetic and was able to go home late afternoon. Before leaving the hospital Mr Malik gave me guidance to ensure a speedy recovery. He gave me his contact details in case I had any concerns. Three days after the operation his Secretary called me to ask how I was doing, so she could feedback to Mr Malik, which I thought was a nice touch.
For the first two weeks I had to keep my foot elevated 95% of the time, took pain killers for six days and consequently didn’t experience any pain.
I purchased a small stool to put in the shower and used it beside the basin when cleaning my teeth. I purchased a limbo bag to avoid my foot getting wet when showering.
After two weeks I visited Mr Malik who removed the dressing from the foot and I was pleased how it was recovering. For the next four weeks I had to keep my foot elevated 75% of the time.
For the six weeks after the operation I have had to use crutches as I haven’t been able to put any weight on my foot.
The recovery at times has been frustrating as I’ve been unable to do things for myself and around the home. I put it into perspective telling myself it’s only for six weeks, which isn’t very long.
I am now booked in to have the right foot operated.
Not being able to put weight on my operated foot.
Don’t put off the treatment as your pain won’t improve.
Prepare yourself for the operation. My husband doesn’t cook so I prepared meals in advanced and put them in the freezer and ensured I had lots of reading material and my ipad close to hand.
Listen to exactly what Mr Malik tells you. Mr Malik is very passionate about his work which means patients benefit. I highly recommend him.
– Pauline Risk October 2016
I am a patient who has had rheumatoid arthritis (RA) for the last 30 years, over the years my joints have eroded away and my feet and toes have become very deformed and have caused a lot of pain, I was referred by my rheumatoid consultant to see Mr Malik.
All types of surgery require a general anaesthetic, which gives reason for concern. Due to having a past history of sickness during anaesthetics I was concerned this would be the case again.
Whilst I could still walk although in pain, I was worried the operation may not be a success and therefore reduce my ability to walk even more.
After my first consultation with Mr Malik I knew he was a dedicated surgeon passionate about his work, he made it clear that to achieve the most successful results you had to commit to his instructions. I liked his direct honest approach, giving me all the facts pro and cons allowing me to make a decision on whether to proceed with the operation.
After having numerous operations in the past due to RA, I knew that I had to have the operation to maintain my quality of life. I knew that due to my age I needed to proceed now while I am fully able to cope with the recovery.
The surgery was done as a day patient, I was treated excellently from the moment I arrived, I was put at ease by all staff concerned.
The anaesthetist assured me he would add an anti sickness drug to the anaesthetics , this proved to be very successful as I did not experience any sickness.
Following the guidance of Mr Malik I returned home and stayed with my foot elevated above my heart for 90% of the day, although this was hard to achieve I was determined to do as instructed by Mr Malik as I wanted the operation to give the best result possible.
I was surprised that a few days after the operation the pain was minimal and required only a small amount of pain relief.
After two weeks I returned to see Mr Malik who was very pleased and knew on first glance that I had followed his instruction perfectly, as my foot and toes had no swelling and were both healing well.
I then had 4 weeks at home where I was allowed to take short breaks, but 70 % of the day I had to have my foot elevated ie on a chair / stool.
On my final visit I had the pins removed and my foot re x-rayed and the results were amazing, I left the hospital feeling happy and confident that I will now have no fears about having the other foot operated on.
My advice to anyone that has RA and deformed feet like I have, is don’t put the operation off, I should have sought help earlier.
Basically don’t let any fears put you off as you are in very safe hands with Mr Malik.
I hurt my foot by falling off a step stool onto a very hard stone floor. Some weeks after the initial pain subsided I realised that the joint of my big toe was sore and maybe swollen. I didn’t think much more of it – I’m in my early/mid forties and have always thought of myself as pretty tough and too young to get joint problems. Over the next couple of months I noticed some pain and discomfort whilst walking. Eventually – mainly prompted by the fact that I could suddenly not wear heels without being in significant pain – I contacted my GP and then my medical insurers who referred me to a consultant at a different hospital – not Mr Malik – who diagnosed an arthritic toe joint and I had cortisone injections into the joint. These injections didn’t make any noticeable difference and so I thought that perhaps this was something I would just have to put up with. The surgeon (not Mr Malik) told me that the next step would be to have the 1st MTP (big toe) joint fused and I was a bit young for that.
I then happened to be chatting to my osteopath a couple of months later and mentioned my foot problem and she recommended Mr Malik who had successfully treated her. I went on to have a cheilectomy and microfracture on the toe to help remedy the problem.
I was apprehensive about having surgery for a number of reasons. Firstly I’m more of a ‘don’t make a fuss’ person and I thought if I can walk then maybe I’m just making a fuss. And after a while I just learnt to put up with it. I was also concerned that maybe it was an unnecessary operation, and of course operations come with risks so it you can avoid having one then that must be a good thing. I also worried that maybe it wouldn’t be a success.
I think also when you live a busy life like me with children, a full time busy job in London with a long commute and a hectic social life, there are just too many reasons why it isn’t convenient in the diary and you can’t find time to recuperate.
After the first consultation with Mr Malik I realised that there was an operation – the cheilectomy – that I hadn’t previously been told about. We discussed the potential success rate and risks and the unknown nature of the outcome and I went away to think about it.
It was also at this consultation that I was told why the joint on my fourth toe was hurting as well, due to transfer metatarsalgia and I realised that the damage being done to my foot was probably more than I had considered.
I took some time to think about it and I had a busy year with holidays and some big diary commitments at work so I delayed really thinking more about the surgery. However I began to realise that my foot was steadily getting more uncomfortable and was definitely not getting better.
I decided to go back for a second consultation at which I decided to have surgery. The decision was really prompted by the realisation that the condition was getting worse, even wearing sensible shoes and it was more likely to continue to deteriorate. I felt that an operation was now my best chance of slowing down the deterioration and possibly reversing it, and at worst it may not improve it at all.
I decided I didn’t want to regret not having it later on when perhaps the only option would be a big toe (1st MTP) joint fusion.
The surgery was very straightforward. A day case, so home the same day. And my recovery has been good, the swelling has gone down, and I only took pain relief for a few days and although I had a couple of early days when it was sore, it is a pretty bearable experience. But I did underestimate how much care I would need to take in the early days post op. I had thought that I’d be able to get into work (with my 90 min commute) maybe 2 or 3 weeks post op. That 4/6 weeks mainly off your foot, really is off your foot. And that to get the best outcome you need to really listen and follow the instructions of Mr Malik. It’s an investment to try and protect the joint and although it’s been frustrating watching people go out for long walks and grab that blue sky and sunshine whilst I sit at home with the foot elevated, the surgery would be a waste of time if I didn’t take the after care seriously. And after waiting all this time to have the operation, I’m going to do everything I can to ensure it’s a success. So 2.5 weeks post op, all good so far.
Have the surgery much sooner and don’t delay. Listen to your feet and don’t think ‘maybe I’m making a fuss’ or ‘maybe it’s not that bad’ and as my foot didn’t really look much different to the other one I thought it can’t really be that bad. I left it too long – and that was only a few months delay – and I should have opted to have it straight away after my first consultation.
As a result my cartilage continued to wear away and loose cartilage aggravated the rest of the joint. So my long term prognosis is less positive that it might have been if I had acted earlier. The other thing I’d say is, talk to other patients who have been through it – people like me – who can reassure you that what you think your foot is telling you, is right. Listen to your joints.
A medial ankle ligament injury is a serious and uncommon injury. It involves an injury to the ligament on the inside of the ankle.
Ligaments are a specific type of tissue in the body that connects bone to bone. A joint is when at least one bone articulates with another allowing movement to occur. Ligaments provide stability to the joints. The medial ankle ligament is also called the deltoid ligament.
The deltoid ligament is the primary ligamentous stabiliser of the ankle joint. It is composed of a superficial and deep part. The superficial deltoid ligament resists eversion of the hindfoot while the deep deltoid component resists external rotation and lateral displacement of the talus (one of the bones forming the ankle joint).
Please read more about the anatomy of the foot and ankle here.
Medial aspect of foot and ankle illustrating the site of the deltoid ligament
A medial ankle ligament injury (ankle sprain) occurs when the foot and ankle are stressed beyond their normal range of motion and the ligament fibres are stretched or torn. The deltoid is a very large ligament and to injure it requires a high energy force. For that reason it is not commonly injured, unlike the lateral ankle ligaments.
The mechanism of injury is typically an eversion of the ankle (turning/rolling out) with or without an element of twisting.
Deltoid ligament injuries typically occur in association with another injury such as an ankle fracture , high ankle sprain (syndesmotic injury) and spring ligament injury, but occasionally can occur in isolation.
A medial ligament ankle sprain typically presents with pain and swelling of the whole ankle, but worse on the inner (medial) aspect. Bruising may also be present depending on the severity of injury.
Patients often describe difficulty weight bearing immediately after the injury and often have a limp.
Symptoms following an ankle sprain:
On clinical examination your foot and ankle surgeon will look for signs of bruising and swelling. Your surgeon will also grade the severity of the injury.
In addition other conditions that can be often associated with or confused for an ankle sprain will be looked for such as:
With the ankle in neutral the eversion test assesses the superficial deltoid ligament. The external rotation stress test evaluates the deep deltoid ligament and the syndesmosis.
Radiographs are always requested in the acute setting of a suspected medial ligament injury. The following maybe evident on a plain radiograph:
MRI provides excellent high definition static images. It is generally not necessary in the investigation and treatment of routine low grade sprains. In severe injuries it may be necessary to exclude any other pathology in the hindfoot. It is also useful in monitoring healing.
In the setting of a severe ankle sprain an MRI is particularly useful in assessing:
MRI of the ankle revealing a torn ATFL
An ankle lateral ligament injury is another term for an ankle sprain.
Ankle sprains are the commonest sports injury.
A lateral ligament injury involves damage to one or more ligaments around the outer aspect of the ankle. Ligaments are a specific type of tissue in the body that connects bone to bone allowing movement to occur. A joint is when at least one bone articulates with another. Ligaments provide stability to the joints.
On the outer (lateral) aspect of the ankle there are 3 ligaments: ATFL, CFL and PTFL. The ATFL is the most commonly injured ligament in an ankle sprain followed by CFL.
Please read more about the ligaments of the foot and ankle here.
Lateral aspect of foot and ankle illustrating the 3 lateral ligaments, ATFL is the most commonly injured ligament in the foot and ankle
A lateral ankle ligament injury (ankle sprain) occurs when the foot and ankle are stressed beyond their normal range of motion and the ligaments are stretched or torn.
The mechanism of injury is typically an inversion of the ankle (rolling in, turning in) with or without an element of twisting.
The injury can occur when walking on uneven surfaces or while running and playing sports.
Stability to the joints is derived by two mechanisms:
Dynamic stability is the most important of the two during normal function and activities of daily living. It is only when dynamic stability fails, do the ligaments then come under tension. Poor dynamic control – weakness in core stability, gluteus medius, quadriceps, hamstring and peroneal muscle can predispose to ankle instability. Ankle proprioception: sense position, location, orientation and movement of the ankle is also vital for ankle stability.
Patients with hypermobility of their ligaments are also at risk of developing ankle sprains. In hypermobile patients the ligaments are more lax allowing for greater motion in the joint than usual.
Patients with a certain foot shape are also predisposed to lateral ligament ligament injury. If the hindfoot is in varus (turned in) such as in a cavus foot, the ligaments on the outer aspect of the foot are chronically stretched and can weaken over time.
In summary risk factors for ankle lateral ligament injury include:
Clinical picture illustrating a varus hindfoot deformity which predisposes the patient to a lateral ligament injury
An ankle sprain typically presents with pain and swelling on the outer aspect of the ankle. Bruising may also be present depending on the severity of injury.
We grade the severity of the injury using the following classification system:
Grade 1 – No ligament disruption, minimal swelling and bruising, weight bear normally
Grade 2 – Ligament stretched, moderate swelling and bruising, mild pain on weight bearing
Grade 3 – Ligament torn, severe swelling and bruising, severe pain on weight bearing
On clinical examination your foot and ankle surgeon will look for signs of bruising and swelling. Your surgeon will grade the severity of the injury.
In addition other conditions that can be often confused for an ankle sprain will be looked for such as:
Your surgeon will also examine you for associated injuries such as:
Clinical picture of the foot and ankle in a patient with a severe lateral ligament injury demonstrating significant bruising and swelling
In the acute setting no investigations are required if the history and clinical examination findings are consistent with a low grade uncomplicated ankle sprain.
Radiographs (x-rays) are requested if there is:
Radiograph of a sprained ankle demonstrating extensive soft tissue swelling on the lateral side (arrows), note normal soft tissue margin medially (blue line)
Yes, although the majority of ankle sprains (lateral ligament) recover without any long term complication.
Patients who have been misdiagnosed, have lacked proper rehabilitation post injury, and if the ligaments have failed to heal properly, may develop a chronic ankle sprain and instability.
Non operative management is the mainstay of treatment for the acute lateral ankle ligament injury. Managed appropriately the vast majority of injuries, even severe ankle sprains, will recover by 4 to 6 weeks.
We recommend the PRICE regime:
Non steroidal anti inflammatories (NSAIDs) help reduce inflammation and swelling but there also is a risk that this will have an adverse effect on ligament healing. We advise patients that if there continues to be considerable pain and swelling several days after the injury they should reflect on how much they are truly resting the ankle, rather than take more painkillers.
Your surgeon will guide you according to the grade of your ligament injury.
Effective rehabilitation is critical to ensuring full recovery: resolution of painful symptoms, swelling and restoration of stability. It is also important as it will prevent the risk of chronic ankle instability. Using an experienced physiotherapist can help with your recovery and rehabilitation.
The different stages of rehabilitation include:
Proprioception based exercises work on sense position, location, orientation and movement of the ankle.
Surgical repair of an acute lateral ligament injury is recommended in instances where a rapid return return to sports is required. Surgery can aid rehabilitation and return to full function in the case of a severe ligament injury to the ankle. The success rate following this surgery is 90%.
Patients who fail to recover following non operative treatment and develop chronic ankle instability may benefit from surgical intervention. Please read chronic ankle sprain for further information.
Please see guidance above and information here. Ultimately it is the responsibility of the patient to decide if they are safe to drive. A good way of knowing is if you can stamp your right foot heavily on the ground to mimic an emergency brake. If you have any hesitation or pain then it should suggest you are not safe to drive. Remember prolonged driving involves keeping your feet in a dependant position. This will worsen any swelling present and potentially result in chronic symptoms.
This really depends on you and your job. If you have a job that involves a lot of standing, walking and is manual it may be 4 to 6 weeks. If you have a sedentary job, for example in an office and you have a reasonable commute you may be able to go back to work at 1 to 2 weeks.
This really depends on the grade of injury. It may be 6 weeks to several months.
Excellent pain relief and return to full activities of daily living in the majority of patients.
This can result if you return to work, sports or other activities without letting the ankle heal properly and become rehabilitated.
I went to the doctors around 6 weeks after my initial incident as I was still experiencing issues, at first I thought it was a sprain but soon realised it was worse than that. Once meeting with the consultant following an MRI scan it was clear that operating was the best outcome for myself as I want to get back to playing football, running, gym and more…
My fears and concerns were that my ankle would never be the same again. I had also never been under general anaesthetic and was nervous regarding what to expect.
A very positive experience with excellent staff on hand for assistance and keeping me up to date with what was going on.
Not to be nervous or anxious. Don’t do any strenuous activity (prior to surgery) on the ankle and also buy an ankle support for the time leading up to the operation.
Patience and rest is key, do not rush or try anything silly. Follow the doctor’s advice and once you have seen the physiotherapist to make sure you do all the exercises daily.
Our 15 year old daughter tore an ankle ligament playing competitive netball. Despite months of rest and physio, it was not healing so we arranged an MRI scan, X rays and consultation with Mr Malik. We found his details on the websites for The Chiltern Hospital and The London Foot and Ankle clinic as well as local recommendation. He has immense experience in his field and a first-rate track record.
The MRI scans showed that the ligament was completely torn. Mr Malik carefully outlined all options to us and we discussed them in detail. We decided to proceed with surgery as this seemed to offer the best chance of a recovery which would enable our daughter to continue playing netball and other sport. We had absolute trust in his opinion and were very impressed with his approach.
The day of the operation came and we all felt a little nervous but there was no need as Mr Malik and his team were outstanding. The pre-operation process, anaesthetic and operation went really smoothly. We were kept fully informed of progress throughout which was incredibly reassuring to me as a mum!
As Mr Malik had briefed us so comprehensively, we knew what to expect for the period post op. I cannot emphasise enough the importance of following his instructions to the letter to maximise the chances of a strong recovery – there are no shortcuts.
In the weeks following the op, we worked as a team and our daughter’s recovery went like clockwork with very few blips. I often texted or sent photos/videos to Mr Malik at all hours of day and night for reassurance.
Our daughter was 100% committed to the recommended post op advice and physio exercises. She was nervous of coming off painkillers and walking without her boot/crutches. However, Mr Malik was calm, clear and reassuring which worked perfectly for her. As well as her regular physio, we also engaged a specialist sports rehab trainer to maximise her recovery.
Six months later, she made a complete recovery and is now able to resume all of her sports including competitive netball.
Our top three recommendations would be:-
1. Seek consultant advice and MRI scans at the first sign of an issue. Don’t leave it too long!
2. Choose a consultant surgeon whose approach works with your aims and objective.
3. Follow their advice and instructions to the letter, especially in the post op period
I cannot recommend Mr Malik highly enough and have shared his contact details with many others.
Orthopaedic Outpatient Department 30 Devonshire Street, London, W1G 6PU
tel: +44 (0) 203 7956053
Mon - Fri (8am-8pm) Sat (9am - 5pm)
info@lfaclinic.co.uk
