Incidence of thyroid disease in patients with forefoot deformity

[helvella]

Another of those "Well I never…" papers.

I don't have Hallux valgus, but I do have somewhat unusual feet.

Many of us have little things that we do like snap our fingers. Or interlace the fingers of our hands. In some, these are very obvious traits.

Something has always compelled me to move my hallux (big toe) over the next toe - a bit like in the picture. Differences being lack of problem with the joint, and that the hallux wants to go above the next toe rather than push it out of the way. And I then snap my big toe down. (I simply can't wear a pair of shoes that prevent me from doing that! Just have to take them off immediately.)

Foot Ankle Surg. 2019 May 30. pii: S1268-7731(19)30076-1. doi: 10.1016/j.fas.2019.05.014. [Epub ahead of print]

Incidence of thyroid disease in patients with forefoot deformity.

Tran SK1, Carr JB1, Hall MJ1, Park JS1, Cooper MT2.

Author information

1 University of Virginia School of Medicine, Charlottesville, VA, USA.

2 University of Virginia School of Medicine, Charlottesville, VA, USA. Electronic address: [e-mail].

Abstract

BACKGROUND:

Hallux valgus and lesser toe deformities are common foot disorders with substantial functional consequences. While the exact etiologies are multi-factorial, it is unknown if certain endocrine abnormalities, such as thyroid dysfunction, may be associated with these pathologies. The current study sought to investigate the prevalence of thyroid disease in patients with hallux valgus or lesser toe deformities.

METHODS:

Every new patient who presented to our institution's foot and ankle clinic during a three-month time period was given a survey to determine the presence of a known thyroid disorder. The diagnosis for each visit was then recorded. Additionally, a national, publicly available database was queried for patients diagnosed with thyroid disease and concomitant hallux valgus or specific forefoot pathology. Odds ratios for the presence of thyroid dysfunction were then calculated for each patient group.

RESULTS:

Three-hundred and fifty initial visit patient surveys were collected, and 74 (21.1%) patients had a known diagnosis of thyroid disease. The most common diagnoses were primary hypothyroidism (n = 61, 17.4%), secondary hypothyroidism (n = 6, 1.7%), thyroiditis (n = 4, 1.1%), and hyperthyroidism (n = 3, 0.9%). Thyroid disease was present in 16 of 26 patients (61.5%) with a diagnosis of hallux valgus (OR 7.3, CI[3.16-16.99], p<0.0001). Lesser toe deformities, including hammertoes, mallet toes, bunionettes and crossover toes, were also significantly associated with thyroid disease (OR 5.45, CI[1.83-16.26], p<0.002). The national database revealed 905,924 patients with a diagnosis of a specific forefoot deformity, and 321,656 of these patients (35.5%) had a concomitant diagnosis of a thyroid condition (OR 2.11, CI[2.10-2.12], p<0.0001).

CONCLUSIONS:

The current study suggests a significant association between forefoot pathology and thyroid dysfunction, especially hallux valgus and lesser toe deformities. Increased understanding of these correlations may offer an important opportunity in population health management, both in diagnosis and treatment. While further studies with long-term outcomes are necessary, the early diagnosis of thyroid disease may provide an opportunity to predict and potentially alter the course of forefoot pathology.

Copyright © 2019 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.

KEYWORDS:

Forefoot pathology; Hallux valgus; Hyperthyroidism; Hypothyroidism; Lesser toe deformity; Thyroid disease

PMID: 31186135

DOI: 10.1016/j.fas.2019.05.014

ncbi.nlm.nih.gov/pubmed/311...

Image: By Malmstajn - Own work, CC BY 3.0, commons.wikimedia.org/w/ind...

[jgelliss]

WOW ! This is amazing . Thank You helvella for bringing Amazing and Interesting thyroid issues to this great forum .

Go figure that a bunions are connected to our thyroid issues ? My question is what came

first the bunions or thyroid issues ?

[Aurealis in reply to jgelliss]

In me, the thyroid

[jgelliss in reply to Aurealis]

Thank you for your response . It would be interesting if others can chime in and share their experiences with their findings as to having bunions first or thyroid issues first ? I think looking back now in my personal situation I had thyroid issues for a very long time before it was actually diagnosed . I consequently ended up having bunion surgery a few years after my TT . So I can not really say what came first for me ? But I can say that this topic hit home for me since I experienced both thyroid and bunion surgeries .

[HypoMorgan in reply to Aurealis]

I have a bunion on my left foot! So if I get this sorted will that help my thyroid?? Xx

[TSH110 in reply to jgelliss]

Thyroid in my case, bunions only just beginning to appear. All my foot problems started to appear after the thyroid problems started, but thinking about it arthritis started up before those in my early 20’s.

[BadHare]

Curious! I like to spread my toes out & hate constricting shoes.

Is there a known connection between thyroid disorders & hypermobile joints?

[Hillwoman in reply to BadHare]

I think it's fairly well known. As a child, I had a set of party tricks involving my hyper-mobile right shoulder and most of my fingers and toes, which other kids found fascinating - at least, the ones who didn't throw up.

[BadHare in reply to Hillwoman]

Not my fingers with regard to JHS, but I can always squidge my hands to get wristbands off.

[Angel_of_the_North in reply to BadHare]

Same here.

[Greekchick in reply to Hillwoman]

I would love to have seen those party tricks! 😂😂😂

[SilverAvocado in reply to Hillwoman]

That's interesting! One of my hypo friends is hypermobile, and a local forum member can still do the party tricks!

[Hillwoman in reply to SilverAvocado]

Advise her to beware: the over-use of hypermobile joints can cause pain and stiffness later in life. I stopped doing the tricks fairly early on, partly because one child's mother told me off for making him cry (!) and partly because of dire warnings from my aunt. She'd had a schoolfriend who could dislocate her shoulder, just like me, but she came to a sad end. I was sufficiently frightened to stop the shoulder thing, but the fingers-and-toes show had a long run.

[helvella in reply to BadHare]

Oh yes - spreading out my toes! 🦶

No - not hypermobile.

[TSH110 in reply to BadHare]

Not in my case i’m stiff as an old board!

[RockyPath in reply to TSH110]

I aspire to move like a jaguar, but I’m a sawhorse. Yet when evaluated by a physical therapist, I’m judged to have hyper mobile joints.

[radd in reply to BadHare]

BadHare,

Yes, if you read articles on Ehlers-Danlos, Hashi gets mentioned. I am hyper flexible.

[BadHare in reply to radd]

My son thinks we have EDS, though neither of us has Hashimoto's. I mentioned it to my GP, but he'd never heard of it.

[radd in reply to BadHare]

Badhare

That’s coz there’s no drugs to cure it. 😂

There is a known genetic polymorphism to the TNXB gene (tenascin-X) associated with hyper flexibility. T’is how we are born.

[Hillwoman in reply to radd]

I'll look that up in my 23andMe results.

[Hillwoman in reply to radd]

Well, having trawled through my reported SNPs on that gene (of course, not all are reported), I've found one polymorphism which is recorded in the NIH ClinVar database as having a pathogenic significance. It's associated with 'Ehlers-Danlos Syndrome, classic-like, 1'. The SNP is rs144556766.

[radd in reply to Hillwoman]

Hillwoman

And are you hyper flexible ? 🧘🏼‍♀️

[Hillwoman in reply to radd]

I was, but in childhood I over-used my abilities in the name of entertainment! Hypermobility leads to extra wear and tear, it would seem.

Skin healing is also very poor, and scar tissue (like the scar from my appendectomy) develops in abnormal ways. Plus, lots and lots of stretch marks that started in childhood.

[radd in reply to Hillwoman]

Oh dear. Poor you.

I have always practiced yoga so maybe less demanding than your entertaining antics 🤸‍♀️ .

I also have the slow healing. A small graze can take weeks even if I manage to keep it dry.

[Fruitandnutcase in reply to BadHare]

Ooh gosh I’ve got Graves and hyper mobile joints. My Pilates teacher who is a physiotherapist is always restricting what I do because of my hyper mobility and you could have knocked me down with a feather when my new podiatrist commented that I was hyper-mobile - she was examining me for the first time - I had hardly done anything for her. I began to wonder if I had a neon sign on my head saying ‘hyper-mobile’.

Funnily enough I’m stiff as an old board for a couple of hours after I first get up - I’ve got inflammatory arthritis. You wouldn’t think the two would go together but they seem to do.

[Hillwoman in reply to Fruitandnutcase]

During my worst years of Hashi's and severe hypo my joint and general movements were greatly reduced by mucin deposits. In recent years I've found I'm getting stiff even in the hypermobile joints, because the over-use has led to accelerated wear.

[SilverAvocado in reply to Fruitandnutcase]

I believe there are a few negative consequences to hyper mobile joints. In terms of things like pain and stiffness, but haven't looked into it.

[Fruitandnutcase in reply to SilverAvocado]

Judging by what my physio / Pilates teacher says it’s not good to be hyper mobile. She is always very careful that I don’t overextend and it seems like overextending is my natural default position so I get the impression that it’s not great to be hyper mobile and that there are lots of problems associated with it.

[Ell17 in reply to SilverAvocado]

I have hEDS. You're right about the negatives. Unstable, hypermobile joints can cause serious pain in all stages and areas of life, especially the dislocations. Arthritis starting at a very young age is the norm. The chiropractor and splints are your lifelong best friends. I have stiffened up quite a bit as I've gotten older, but the loose, painful joints are still there. As for the party tricks....In hindsight, I believe that engaging in them, even modestly, causes many more problems down the road.😊

[Hillwoman in reply to Ell17]

Your warnings have proven correct in my own case.

[BadHare in reply to SilverAvocado]

Injuries which don't heal.

[RockyPath in reply to BadHare]

Yes.

[Aurealis in reply to BadHare]

Yes, I have hypermobile joints too, but they aren’t as mobile now I’m older

[Aurealis]

It gets better ... or worse ... 🤣

Thanks for posting... who’d have thought that?

[MaisieGray]

So no connection was made between the greater incidence of women with thyroid dysfunction than men, and the incidence amongst women of feet becoming deformed due to wearing tightly fitting shoes and high heels, not to mention the incidence of foot problems in women arising from wearing flip-flop type footwear, flat ballerina pumps and poor quality Ugg-copycat boots none of which provide foot support and therefore also lead to the development of the conditions looked at in the study?

[helvella in reply to MaisieGray]

Needs careful consideration and analysis.

It seems quite possible that the effects of footwear are more likely to cause deformities and problems in those who are hypothyroid. That is, those who are not hypothyroid can better tolerate this footwear.

[MaisieGray in reply to helvella]

Yes possibly, so very much a chicken and egg unknown at the moment. The other question that comes to mind is, how much, if at all, is the population attending foot clinics skewed towards those who are more likely to be (more) frequent attenders for health care generally, because of their health conditions ie I'd guess (but don't know) that far more people don't seek professional help for bunions and such, than do.

[LindaC in reply to helvella]

I have worn pretty dreadful silly shoes when younger... kitten heels for school when 7 y/o - yet my feet are pretty perfect - says the podiatrist - and they look good too Suppose something has to go well, but I can't even wear sandals now due to 'veiny feet', lol x

[RockyPath in reply to helvella]

Dr. Lowe did note the hyper mobility of joints as an outcome of hypothyroidism, due to beta adrenogenic effects on connective tissues.

[stiltzski in reply to MaisieGray]

Maybe, but I only have it in one foot and was never a high-heel, flipflop, Uggs or pump fan...Thinking back I reckon the two started at about the same time ue 15 years ago.

[TSH110 in reply to stiltzski]

That makes two of us in the footwear front!

[Angel_of_the_North in reply to stiltzski]

I don't even know what an Ugg is!?

[helvella in reply to Angel_of_the_North]

This is a link to a picture of some Uggs!

commons.wikimedia.org/wiki/...

[Angel_of_the_North in reply to helvella]

Ah, a flat boot that gets soaking wet easily - OK

[TSH110 in reply to MaisieGray]

The connection was that these things are more prevalent in those with thyroid disorders. I suppose we may all be masochistic foot fetishists who enjoy wearing footwear that is bad for us, but it seems unlikely. I have rarely worn high heels or any heels and never flip flops, always sticking to sensible good quality flats what one might think is more ‘man’ footwear. My hypothyroid mother too and she had awful bunions. Hypothyroid sister - terrible hammer toes. My feet problems cannot be blamed on footwear or lifestyle. This paper suggests to me a quite compelling reason for my foot deformities and similarly afflicted relatives.

[Angel_of_the_North in reply to MaisieGray]

I get really cross when people try to blame my bad feet on ME for wearing bad shoes. I went to a posh school where we had to wear regulation shoes that were correctly fitted with plenty of toe room. Never worn heels (I once had a pair with 1.5 inch heels but I couldn't walk in them, so I gave them away). Never worn flip-flops, never worn pointy shoes, only wore ballet pumps in ballet class. Spent most of my time in sensible lace-ups, riding boots and wellies. It's just "blame the patient".

[MaisieGray in reply to Angel_of_the_North]

I can't see what relevance there is, in going to a posh school. My parents were hardworking but poor, and I first attended state infant and junior schools, followed by a Grammar Technical school having passed the 11-plus, but my parents nevertheless of their own volition, outwith any demand of my school, prioritised my being properly fitted for quality shoes and being retested frequently starting with my first pair of shoes, and onwards throughout the whole of my childhood. On the other hand, my youngest son attended a fee-paying private school in his early years, and they didn't give a jot about his feet or his footwear. But seriously, "blame the patient"??? My comments were intended simply and solely to point out possible limitations, flaws, or assumptions in the study, that may or may not be material, that may or may not prove to have a skewing or other effect; and to highlight that there can be other causal factors of distorted feet other than, or in combination with, medical conditions. And in any case, when did it become "patient blaming" to discuss and consider the impact of human behaviour on life and health outcomes? Are we supposed to not educate people about the effects of them smoking, or overeating or doing anything that can have an adverse effect on them, for fear of accusations about patient blaming? But in any case, my comments were in response to the study, and the result of my brief consideration of issues pertaining to its method and conclusions drawn.

[Angel_of_the_North in reply to MaisieGray]

Posh schools enforce the uniform code with approved suppliers and so on, while state schools are not allowed to as long as the colours and items are approximately correct. No state school would be allowed to purchase a pair of shoes for a child and charge the parents if the shoes the child had on were the wrong make, for example - a posh school would do that

[Aurealis]

I don’t suppose there’s any evidence that T3 is good for bunions... ???

[TSH110 in reply to Aurealis]

My thoughts exactly! But I did wonder about calcitonin too

[RockyPath in reply to Aurealis]

It could.

Dr. Lowe’s tome has entire chapters on bone metabolism and connective tissues with respect to T3 therapy.

You’d have to experiment on yourself.... 🤔

[TSH110]

Thanks for posting it is very interesting to see that correlation. I have annoying lumps between my toes (which are becoming increasingly deformed) that can be agony, rendering walking extremely painful. I had such beautiful feet when I was young they are hideous now all occurring since becoming hypothyroid. They don’t mention nails - mine are ghastly!

[Marymary7]

How strange. I have that. I think the feet problems probably came before diagnosis so I don't know which was first but it's a fascinating thing...my pal has both problems too. She says I blame everything on my thyroid so perhaps I won't mention this! It's also in my family, Mother, Grandmother, father. Thanks for the research. 😀

[WildDeer]

About 30 years ago sinovial fluid started balooning out of my big toe joints, and this has led to ongoing problems with finding comfortable footwear. Because of less sinovial lubrication my toe joints have become worn and swollen. The first signs of Hashimotos started 20 years before that.

[Fruitandnutcase]

That is really amazing. Who would have thought that. I’ve not got a bunion although I’ve got what a podiatrist said people call a ‘tailors bunion’. It’s on the outside at the little toe.

I’ve got weird feet though in spite of wearing horrid brown lace up shoes right into my teens. Can you imagine! Oh how I would have loved your kitten heels LindaC!

Perhaps all the xrays I used to get to get when I bought new shoes to be sure my tootsies had loads of room to move have mutated my feet in some weird way. The odd thing is my toes all lean in towards my big toe and look like I’ve worn pointed toe shoes since birth. Doesn’t make sense. I sometimes look at them and think that all of my poor mother’s care in trying to look after my feet has gone to waste.

[Treepie in reply to Fruitandnutcase]

Thats a bunionette. How tailors used to sit on the floor.

[Fruitandnutcase in reply to Treepie]

That’s it, I’d forgotten that. I don’t think it’s a bunion as such because it doesn’t affect the bone or I don’t think it does.

[Aurealis in reply to Treepie]

Ah, I have a bunionette too

[jgelliss in reply to Fruitandnutcase]

My surgeon called those a bunion net .Either way they are both not fun .

[Harebell60]

Ha! Always thought others were weird because they couldn't spread toes wide like me, or pick things up with their feet... but no, it's me!

[Hillwoman in reply to Harebell60]

I was actually encouraged to pick things up with my feet when a child. It was supposed to help strengthen my flat arches. It never made any difference to them, nor did the mortifyingly awful surgical shoes I had to wear into my teens.

[Harebell60 in reply to Hillwoman]

Me too, flat brown lace ups right into secondary school because I was born with pigeon feet... straightened my feet, but oh my, have suffered with my right knee for forty years !

[Angel_of_the_North in reply to Hillwoman]

Same here, and I could always do it. Didn't have flat feet though, but I do remember being told I had dropped metatarsal arches (the horizontal ones, I think) when I was 11. What you normally think of as arches have always been high

[Hillwoman in reply to Angel_of_the_North]

Do you mean the insteps? Because mine have always been high, despite the arch-free soles. Feet are v wide too.

[Angel_of_the_North in reply to Hillwoman]

Not exactly. I make a traditional "normal" footprint with a big gap at the inside and just a narrow band at the outside where the foot touches the ground, but apparently the bit behind the toes is flat - the primary transverse arch sportspodiatryinfo.wordpres... It might not actually exist, but it is a long time since I was 11

[Hillwoman in reply to Angel_of_the_North]

Thanks, I haven't come across this one before.

[helvella in reply to Hillwoman]

And mine are extremely wide, very high arches and very high insteps.

[Hillwoman in reply to helvella]

Do you have trouble finding footwear too?

[helvella in reply to Hillwoman]

Certainly do. Nothing in the high street fits.

[SilverAvocado in reply to Harebell60]

I've heard picking things up with the feet is still recommended! Strengthens the muscles.

[Fruitandnutcase in reply to SilverAvocado]

It does, we do that in Pilates. I used t be able to pick all sorts of things up with my feet wth no difficulty, now I find it really difficult and can barely manage it.

[DeeD123]

My grandmother had horrendous bunions on both feet. No thyroid problem though. My mother had beautiful feet and was graves. I have bunions and both hashies and graves. 🤷‍♀️

[Hidden]

Interesting. I am lucky in that my feet are wonderful, working and good to look at. My size 5 's are good for a 72 year old. I do, however, look after them. I think that's it's hereditary my best friend has very very bad feet, so did her mother they never had thyroid problems.

it may be connected to autoimmune things going on.

If the bottom half of me was as good as the top it would be wonderful, but little hearing, vision in one eye sight missing, no gallbladder or thyroid. Two major sinus ops too.

Everyone if different.

[Angel_of_the_North]

Well, well, I have that. But it was caused by a horse landing very hard on my foot and dislocating the joint (which never went back right and grew a lot of extra bone). But I have the equivalent on my thumbs! I also have hammer toes on both feet.

[Fruitandnutcase]

Just thinking- my youth may have been borderline misspent but there’s no chance of me having a misspent old age.

I don’t think I even have high heels. I have one pair of ‘dressy’ shoes, with a tiny little kitten type heel that I wear if I need to look a bit dressed up, rest of the time I live in either Merrill walking shoes or walking trainers, Ecco lace up shoes, Sketchers or ASICS trainers. Fortunately I’m not a shoe diva like my mother who used to smuggle shoes into the house when my father wasn’t around.

[Oracle39]

I was officially diagnosed about 6 months before presenting with this problem. How interesting, I had an operation on mine and a metal plate was inserted to keep big toe straight by the way. I’ve also had shoulder surgery and I believe it’s where my joints have been affected by dysfunctional thyroid. I wonder if those affected had Hashimotos like me.

[Fruitandnutcase]

That’s funny. I worked with someone who was completely mad about shoes - as someone who thinks a new pair of walking shoes / boots was exciting I was absolutely fascinated - I’d never have worn them but I loved seeing her in raptures over her latest purchase.

[Babette]

I'm hypermobile too.

No bunions but every so often have a painful lump on the top of the hallux joint that my GP said was arthritis. I'm not convinced.

I've had pain in the sole of one foot - the same one as the painful joint - for just over a year.

Thyroid problem came first.

[Marz]

I have a book somewhere called - Body in Action. Within there is good explanation of the cause of a bunion ... usually the second toe is longer and bumps up against the footwear. Over time the muscles on the outer part of the big toe are weakened as they are not being stimulated. Hence the big toe drifts inward creating the bunion. This is where being Hypo comes in as low thyroid seems connected to weaker muscles ....

[helvella in reply to Marz]

The Greek foot. As opposed to the Egyptian foot where the great toe is the longest.

Moderately interesting and fairly short (article, not foot):

en.wikipedia.org/wiki/Morto...

[Marz in reply to helvella]

Ooooh thanks !

[Unhole]

Ooh...interesting if a little baffling as to why the two are connected ...but....I have a ‘bunion’ on my right foot since a child ...it’s not a real bunion I don’t think..not one you get later in life...and...I’m hyper mobile which I have heard is connected to thyroid issues ....

[helvella]

I think my eye has been caught by the boots rather than the shoes:

dragshoes.co.uk/index.php

👠👢💋💄

[thyr01d]

This is so interesting Helvella, thank-you.

[Mistydeb01]

I have JHS in all joints including feet I scored 9 out of 9 in the tests they did. When I stand straight my knees hyper extend which I’ve been told off for by the rheumy but it’s a natural position for me otherwise it hurts when I stand or feels really uncomfortable. When I straighten my elbows they go in weird directions as well and if people notice it they always say ‘eww’, nice. I also have a hallux, which was diagnosed way before my thyroid, but that doesn’t mean a lot where thyroid is concerned as they seem to be of the opinion of letting it develop until you feel like utter shit and can’t function properly.

[Twopoint4]

This is interesting. I don’t have Hallux Valgus but Hallux Rigidus and this occurred a year before I was diagnosed with Hashimotos.

[wellness1]

YogaToes can help give the feet a lovely stretch. I don't claim they're curative for serious medical conditions, but as part of a treatment program, I have found them to help.

yogastudio.co.uk/yogatoes-t...

*off to find mine*

[helvella in reply to wellness1]

Quite expensive!

[wellness1 in reply to helvella]

Indeed. But then, so are drag shoes.

[Fruitandnutcase in reply to wellness1]

Touché 😉

[Neverending63]

I have Hypermobility and got arthritis fairly young resulting in knee replacements in my 40s. I now also have RD. Luckily I don’t currently have bunions but have always been able to pick things up with my feet. Can’t stand tight shoes and tend to live in my sketchers or barefoot if indoors. Maybe that’s why I haven’t developed bunions. However a very interesting article and would be interested to see how many people with hashis have bunions and which came first and by how long.

[Bookworm1961]

Hi Helvella

I have had bunions on both feet since I was in my my twenties. The worst big toe was my left which I had a very painful operation on it was never completely straight afterwards. My mum had always bought my self and my sister properly fitting shoes from Clarks up to we left school. I thought wearing wrongly fitting shoes from then on may have caused it. I was diagnosed borderline underactive thyroid of around 6 on routine healthcheck about age of 30 I didn't take medication as felt well. Fast forward to perI menopause around 47 years of age then I felt unwell and had to have Levothyroxine. My sister started Levothyroxine in her forties but didn't get foot problems until her fifties. Dad was born with hammer toes his mum had severe bunions don't know if she had thyroid issues and mum had bunions later diagnosed in life with thyroid issyes. Incidentally my friend has thyroid issues and wears high pointed shoes she has no bunions😅

[dreaton7]

Very interesting article. I have been hypothyroid since birth and have been on Armour Thyroid most of my life. My paternal grandmother’s cousin was a pioneer of thyroid many years ago. His name was Broda Barnes, MD. He claimed our whole family was hypothyroid and treated us accordingly with Armour Thyroid. Regarding foot deformities, my mother had hammertoes and I had a bunion on my right foot. I always thought our foot issues were caused by shoes that were too small. After reading your article, I am not so sure that’s true. I got my bunion probably in my 40s. Not sure at what age my mom got her hammertoes. At any rate, we were both hypothyroid prior to having foot deformity issues; however we were both being treated for our hypothyroidism at the time we had these issues. Not sure what this means 🤔