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Q: Does footwear cause bunions?

A: The aetiology of hallux valgus (HV) is complex and still controversial with some specialist groups still holding parochial views as to the cause.

What is certain is that the cause is multi-factorial and that footwear certainly plays a role as an exacerbating factor and possibly serves to enhance the progression of the deformity.

HV occurs in unshod cultures although, in one study in Chinese Hong Kong, HV was 70 times more common among shoe-wearers compared with the unshod members of that community.

History taking among HV patients reveals the familial incidence to be in the range of 65-80 per cent with genetic predisposition being highly significant.

HV deformity is an autosomal dominant characteristic but with incomplete penetration, so successive generations won't always produce the deformity.

More obvious underlying pathology plays its part too, with generalised joint laxity (hypermobility) being more common in the HV patient. Conditions such as Marfan's and Ehlers-Danlos syndrome can produce remarkable joint laxity resulting in unstable and marked hallux valgus.

This 'splay foot' type is also seen in the more elderly patient where weak intrinsic muscles cause lateral instability of the digits at the metatarsal-phalangeal joint level, as does rheumatoid disease.

The chicken and egg question may remain unresolved as to whether the HV (lateral) deviation occurs prior to metatarsus primus varus (medial) deviation or vice versa as both can occur independently, but in reality they are rarely seen in isolation.

Mr Jason Hargrave, Consultant Podiatric Surgeon,

Charing Cross Hospital

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