March 2011

Bunion research focuses on patient quality of life

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Lower extremity practitioners know the effect of hallux valgus on a patient’s quality of life starts with a frustrating inability to find fashionable shoes that fit—but evidence suggests it doesn’t end there. Pain, function, and self-image all play significant roles.

By Larry Hand

Recent studies have concluded that increasing severity of hallux valgus (HV) leads to a series of conditions or behaviors—increasing pain, decreasing functional ability, withdrawal from normal daily activities—that contribute directly to a progressive decline in health-related quality of life.

The chain reaction applies to men and women, but studies have shown that women are much more likely than men to develop HV and more likely to experience a drop in quality of life. And practitioners interviewed for this article said more and more younger people are being seen with juvenile-onset HV, a disorder that is most often inherited.

It’s logical to think that eliminating the deformity would necessarily reverse any downward quality of life trends. And recently published research does conclude that some surgical procedures are effective for correcting HV. What happens after surgery, however, can vary greatly, depending on the procedure done, the patient’s own tendency to stiffen after surgery, whether patients get physical therapy, and whether they comply with surgeons’ recovery instructions.

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“The most common quality of life issue is they just can’t put on the kind of shoes they want to wear,” said Lowell Weil, Jr., DPM, of the Weil Foot and Ankle Institute in Des Plaines, IL. “A typical patient is a woman in her mid- to late-40s who has seen her bunion progressively get worse and she’s tried wider shoes, deeper shoes, and less-high-heeled shoes. While that works for a time, the shoes are becoming less and less comfortable because of the progressive pain. She could probably find an ugly orthopedic shoe that she could get into, but that just doesn’t work for her professionally or socially.”

As the bunion progresses, Weil continued, women start to become embarrassed by their feet.

“They don’t want to go barefooted. They don’t want to wear sandals or flip flops. It’s an ugly deformity to them, and some people even have concerns that the opposite sex find it unappealing,” he added.

Mounting evidence

In a study e-published ahead of print in November by Arthritis Care & Research, researchers at the Musculoskeletal Research Centre at LaTrobe University in Australia and Keele University in the U.K. concluded that a progressive reduction in both general and foot-specific health-related quality of life occurred in people with increasing severity of hallux valgus deformity, or greater HV angle. They analyzed the records of people aged 56 and older in a six-year follow-up of the North Staffordshire Osteoarthritis Project in the United Kingdom.

More than 36% of the study’s participants were affected by HV, which was more prevalent in females and older patients. However, after adjusting for age, sex, education, and body mass index, Medical Outcomes Study Short Form 36 (SF-36) quality of life scores decreased as HV severity increased. After the same adjustments, increasing HV severity also was linked to greater impairment on the pain and function subscales of the Manchester Foot Pain and Disability Index (MFPDI). The same type of association existed for bodily pain, general health, social function, reduced physical function, and mental health subscale scores after adjusting for pain in the back, hip, knee, and foot.

The researchers used survey questionnaires to obtain their self-reported data, and they used five validated line drawings that showed various degrees of HV, with angles ranging from 0° to 60°. They started with a population of more than 11,300 people registered with three general practices from the North Staffordshire Primary Care Research Consortium. The researchers reasoned that, since more than 95% of people are registered with a general practice in the UK, the registers provided a valid sampling population.

Photos courtesy of Vincent Marino, DPM

Almost 3600 people completed the first of two surveys three years after recruitment into the trial, and the second survey three years later returned about 2800 responses, for an adjusted 83.9% response rate. Those reporting HV were most likely to be female and older than others, and they generally had a lower body mass index and shorter stature. Just over 40% had unilateral HV and just under 60% had bilateral HV. Of the 2681 respondents who could be considered for foot deformity severity, just over 33% characterized their worst foot severity as a 30° angle or higher, while most (almost 45%) characterized their foot angle as at least 15°. Only 57 people said their angle was more than 60°.

An earlier study, published earlier in 2010 in Osteoarthritis & Cartilage, was the first study to assess quality of life’s association with HV and big toe pain in a general community population. (An association had previously been reported in small hospital-based studies.) Researchers at the University of Nottingham in the UK analyzed results of almost 3100 responses received from more than 13,600 questionnaires mailed to individuals registered with two general practices  in Nottingham. They used the short version of the World Health Organization Quality of Life assessment instrument (WHOQOL-BREF).

They concluded that concurrent HV and big toe pain—but not HV alone—is associated with overall dissatisfaction with health and low scores on the WHOQOL-BREF physical, psychological, and social domains. They also compared the significance of the association to that of patients with severe knee and hip osteoarthritis who are in line to have joint replacement surgery.

Research involving such large numbers of people relates well to individual patients being seen by practitioners in the United States.

“Much of it has to do with the types of shoes people have to wear and their activity levels,” said Vincent Marino, DPM, a podiatrist who practices in San Francisco, Novato, and Sacramento, CA. “Many of our professional women [patients] who have to wear fashionable shoe types during the day usually suffer more and at an earlier stage than someone who can wear more comfortable shoes. It becomes frustrating because they are in pain a great deal and it becomes an issue with work requirements.”

Often, the pain causes a person to forego activities that, under normal circumstances, they would be doing on a daily basis.

“A lot of times patients will say they’re not able to do the things they normally do, or they have to curtail it; if they usually go out for an hour or two, now it’s just a half hour,” said Althea Powell, CPed, LPed, OST, who operates Powell Shoes in Vero Beach, FL. “We’ve had patients who said they were just unable to exercise. They can’t go for a walk even though the doctor says they need to walk for exercise.”

And the effects go well beyond middle-aged and older women. In an article published last year in the Journal of Foot and Ankle Research, researchers from the University of Queensland reported HV prevalence of 36% in elderly women and 16% in elderly men, 26.3% in adult women and 8.5% in adult men, and 15% in juvenile (under age 18) girls and 5.7% in juvenile boys.

“The unsightliness of the deformity has an effect on many teenage girls and young women. They’re hesitant to wear open-toed shoes because they perceive their foot as being ugly,” Marino said. “They come in because they want to wear some open-toed sandals without having people stare, and it has an effect on their psyche. It also affects the ability of men and women to exercise. They lose the ability to run comfortably and do some of the activities that they put in their everyday lifestyle to help control their stress levels. They stop running. They stop using the elliptical. They stop doing aerobic activities. Every time they put a shoe on, they’re in pain.”

Just getting into a properly sized shoe makes a big difference for even minor bunions, said Chad Brown, CPed, of Brown’s Enterprises, a specialty shoe retailer in St. Louis.

“But in more severe cases, hallux valgus deformity can be just as debilitating as someone who suffers from migraines,” he said. “You’re going through excruciating pain, and it affects everything from going to the grocery store to taking vacations with your family.”

Even professional basketball players are susceptible.

“One player who was a patient of mine probably wore a size 20 or 21 shoe and he had two different-sized feet,” said Dennis Janisse, CPed, president and CEO of National Pedorthic Services and a clinical assistant professor of physical medicine and rehabilitation at the Medical College of Wisconsin in Milwaukee. “I actually had to cast his feet for a high-end dress shoe company so that they could make a shoe over the cast. Because he had such a big-sized shoe, it was so hard for him to get footwear anyway. He was cramming that bigger foot into a smaller shoe, and he ended up with a significant deformity on the one foot and the other foot was fine.”

Wide range of treatments

Treatment for HV, most often a hereditary disorder, ranges from just trying to control the symptoms with proper shoes and orthotics to surgery, often considered a last resort.

“Unfortunately there’s not a lot that really works,” Weil said. “For somebody who is developing a bunion, there’s nothing you can do to arrest the progression. No mechanical device or change of shoe gear is going to prevent the progression of the problem. Basically you treat it with finding wider and deeper shoes that are more amenable to the deformity. You change activities to make it more comfortable. Shoes and orthotics may make it less painful—until it gets bad enough to have surgery.”

More than 130 procedures have been described for HV as far back as the early 1900s, but in the last 20 years, techniques have improved and have been refined based on technological advances in surgery in general, Weil said.

In 2000, a Cochrane Database Systematic Reviews article cited a consistently high (25% to 33%) rate of dissatisfaction among osteotomy patients postoperatively. However, recent publications have pointed to different, highly positive results. A June 2007 paper published in Quality of Life Research concluded that surgery improves the quality of life for HV patients in terms of bodily pain, vitality, and mental health. A study to be published in the March 2011 issue of Clinical Orthopaedics & Related Research cites improvements in AOFAS pain and function scores from 61.5 to 90.3 in patients who underwent a unilateral scarf osteotomy combined with distal soft tissue alignment at the Hospital for Special Surgery in New York City.

Still, opinions vary as to the effectiveness of surgical procedures, depending on who you ask. Some pedorthists and physical therapists still see patients postoperatively who may be predisposed to stiffness in joints or otherwise have not fared well after surgery for various reasons, including not complying with surgeons’ instructions. Marino, however, said noncompliance is not a significant problem in his San Francisco practice.

“I personally drill into their heads that I won’t operate unless they know what they have to do afterward. I tell them, ‘If you don’t listen, then we’ll just end up doing this again,’ ” he said.

Some results depend on the reason for the surgery in the beginning, and the expectations of the patients, particularly with regard to wearing stylish shoes.

“In our neighborhood, people have surgery based on what they can’t wear and the amount of deformity, which is a lousy reason to do it, quite frankly,” said Stephen Paulseth, PT, DPT, SCS, ATC, in private practice in Los Angeles, near Beverly Hills.

He recommends the use of orthotics before and after surgery, as needed.

“We always try to get the patient in before they consider surgery, to see if we can get them a little bit more mobility, get them in some calf/soleus exercises and calf stretching, and to use their flexor hallucis during push-off. They tend to allow their foot to deviate at push-off, which drives their first-toe into abduction,” he said.

Most of the patients seen by RobRoy Martin, PT, PhD, assistant professor of physical therapy at Duquesne University in Pittsburgh, PA, are postoperative patients.

“A lot of them have inappropriate preoperative expectations, thinking they can go back to the shoes they wore before they had surgery,” he said. “The really fashionable shoes are just so bad. I’ll trace their foot and then put the shoe on top of the trace and ask the patients, ‘how can you possibly jam your foot back into that?’ ”

Other people, he added, are simply prone to stiffness after surgery. He tries to counter that with aggressive joint stretching and mobilization exercises, and he recommends a good cross-training shoe that is sturdier and stiffer than a running shoe to maintain forefoot stability.

If a person’s job requires a higher fashion, therein lies the rub. Although most shoes that are wide enough and deep enough to accommodate HV are functional, Powell said, “They’re not pretty. It does not matter the age group, whether someone is in their 30s or 80s, they are looking for function as well as aesthetic.”

That said, the footwear options available for patients with HV today are much better than in the past, Janisse said.

“You’re not going to find a three-inch spike heel or anything like that that’s going to accommodate something like a significant deformity. But a lot of the footwear out there today is much more accommodating and is acceptable, unlike it was years ago,” he said.

Still, shoe manufacturers “definitely need to keep their efforts strong in making shoes that are more fashionable, even though they have made a lot of progress in the past 10 years,” said Brown in St. Louis.

And the shoes need to accommodate all ages, he added.

“The younger people don’t want to look like they’re wearing the same pair of shoes their mom or grandmother wore,” Brown said.

Larry Hand is a writer based in Massachusetts.

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