Bunions Reduce Quality of Life; More Prevalent in Women, Elderly

Emma Hitt, PhD

February 28, 2011

February 28, 2011 — General and foot-specific health-related quality of life (HRQOL) decreases progressively with the increasing severity of hallux valgus (bunion) deformity independent of age, sex, body mass index, and pain in other regions, according to a population study.

Associate Professor Hylton Menz, PhD, from La Trobe University in Melbourne, Australia, and colleagues reported their findings in the March issue of Arthritis Care and Research.

"The study had a large, representative sample and examined the association between hallux valgus severity and HRQOL," Dr. Menz told Medscape Medical News. "Previous studies used relatively small samples, considered hallux valgus as simply present or absent, and generally did not adjust for confounders. We also used both general and foot-specific measures of [HRQOL]," he said.

The study was designed to explore the prevalence of and factors associated with hallux valgus. In addition, the study assessed the effect of hallux valgus severity on general quality of life and HRQOL in older people.

A total of 2831 participants aged 56 years or older participated in the 6-year follow-up of the North Staffordshire Osteoarthritis Project. Study subjects were asked to complete the Medical Outcomes Study Short Form 36 (SF-36) health survey and the Manchester Foot Pain and Disability Index (FPDI).

SF-36 and FPDI scores were compared across 5 severity grades of hallux valgus established by the researchers. The severity grades corresponded to the angle of deformity of 0, 15, 30, 45, and 60 degrees, with a score of 1 representing no angle and 5 indicating the most severe deformity.

Hallux valgus was present in 36.3% of the study population and was associated with female sex, older age, and pain in other bodily regions. SF-36 survey scores decreased progressively as the severity of hallux valgus increased (P < .001). This association was independent of age, sex, body mass index, education, and pain in certain body regions.

The association diminished after adjusting for pain in the back, hip, knee, and foot in the SF-36 survey. However, among participants with foot pain, increasing hallux valgus severity was significantly associated with greater impairment on the pain (P < .001) and function (P < .001) subscales of the FPDI, after adjusting for age, sex, and body mass index.

Hallux Valgus: More Than a Cosmetic Concern

The effect of hallux valgus was not limited to pain and reduced physical function. The condition also had a detrimental effect on additional aspects of the HRQOL, with a significant downward trend in general health, social function, and mental health with increasing severity.

"The clinical implication is that as hallux valgus progresses, its impact on [HRQOL] correspondingly increases. Therefore, interventions aimed at preventing further deformity may have a significant beneficial impact on patients beyond mere pain relief," Dr. Menz explained.

"Hallux valgus is clearly not only of cosmetic concern, particularly in older people. Rather, it is a progressive and potentially disabling condition that has a broad impact on physical function, vitality, social function, and mental health," he said. "The cause of hallux valgus is still poorly understood. Long-term prospective risk factor studies are required to adequately address this," he adds.

According to independent commentator Smita Rao, PhD, assistant professor of physical therapy at New York University, New York City, "this study adds to the existing body of literature by specifically showing that 1) increasing severity of hallux valgus is accompanied by decreased general and foot-specific quality of life, and 2) the effect of hallux valgus on quality of life persisted after adjusting for lower extremity and back pain. Previous studies have been cross-sectional in design and have compared quality of life in individuals with and without hallux valgus. The information related to severity is new," she told Medscape Medical News.

"The findings of this study provide strong support to existing literature showing that individuals with hallux valgus not only experience foot pain but also have problems with gait, balance, footwear choices, activity participation and social function," she added.

Dr. Rao noted that the effect of footwear choices and previous or current intervention remains unanswered because the current study did not include questions related to footwear in the questionnaires that were mailed out to participants. Secondly, she said that it would be interesting to see whether there is evidence for subgroups (epidemiological phenotypes) of individuals with more aggressive forms of foot pain and strategies for clinicians to identify the patients who are most likely to deteriorate. "Along the same lines, it would be interesting to see if there are subgroups demonstrating different coping strategies.

"As a clinician, I would want to assess general and foot-specific [HRQOL], in addition to gait, balance, and foot pain in an individual with hallux valgus," Dr. Rao said. "Additionally, interventions geared towards reducing foot pain in individuals with hallux valgus should be monitored for their ability to positively affect gait, balance, and quality of life."

This study was supported by 2 Program Grants awarded by the Medical Research Council, United Kingdom, and by funding secured from the North Staffordshire Primary Care R&D Consortium for National Health Service support costs. The authors and commentators have disclosed no relevant financial relationships.

Arthritis Care Res. 2011;63:396-404.