Bunions
BUNION (Hallux Valgus)
Synonyms and Keywords
Bunion, hallux valgus, hallux abducto-valgus
What is a bunion?
A bunion (from the Latin "bunio," meaning enlargement) is a protuberance of bone or tissue around the joint. A bunion is one of the most common foot problems. Your big toe does far more work than the lesser toes. Every time you take a step, the big toe supports most of your body's weight. It is indispensable to foot movement, and problems with it can make walking or even standing painful.
A deformity of the big toe joint, bunions are usually visible as a “bump” on the inside of the foot just behind the big toe, ranging in size from hardly visible to the size of a quarter or half-dollar. The bony bump can be accompanied with bursitis which is a “cushion” created by the body to protect the affected area from excessive pressure or friction.
This deformity can cause a deviation of the big toe as it moves toward the second toe, sometimes underlapping the second toe. The big toe leans toward the second toe, rather than pointing straight ahead. This throws the bones out of alignment, producing the bunion’s “bump.”
Bunions are a progressive disorder and can be degenerative, most often caused by an inherited faulty mechanical structure of the foot.
They begin with a leaning of the big toe, gradually changing the angle of the bones over the years and slowly producing the characteristic bump, which becomes increasingly prominent.
In addition to causing pain and discomfort, the changes bunions make to the shape of your foot, can make it harder to find shoes to wear, and in severe cases can make walking extremely difficult.
What causes a bunion ?
Bunions are a common problem usually affecting women. The deformity can develop from an abnormality in foot function, or arthritis, but is more commonly caused by improper fitting shoes. Tight, narrow dress shoes with a constrictive toe box can cause the foot to begin to take the shape of the shoe, leading to the formation of a bunion. Women who have bunions normally wear dress shoes that are too small for their feet. Their toes are squeezed together in their shoes causing the first metatarsal bone to protrude on the side of the foot.
Bunion pathology is also related to foot structure and function both of which are inherited features.
Feet that have a tendency to excessively pronate cause an over-flattening of the foot. This excessive flattening causes tension on the extensor hallucis tendon (the tendon on the top of the foot that enables you to bend your big toe upwards). This causes the tendon to "bowstring" and in doing so forces the big toe to be pulled laterally, toward the second toe. This is what causes the initial deviation.
Over time, there is a retrograde (or backward) force placed on the first metatarsal bone by the big toe and the first metatarsal bone begins to move medially (or away from the second metatarsal bone). Due to these changes there is now more pressure on the side of first metatarsal bone from shoe pressure and this causes a hyperostosis or thickening of bone and this results in the formation of a bunion deformity.
Excessive rubbing of the bunion against the top of the shoe can lead to pain and the development of a corn. The tip of the toe is often turned down against the shoe causing pressure and discomfort.
Arthritis can also lead to deformities including bunions. Bunions can cause extreme discomfort, and can be aggravated if restrictive or improperly fitting footwear is worn for a prolonged period of time.
Who gets a bunion?
Women who spend a lot of time wearing tight or ill-fitting shoes are most often susceptible to bunion. Tight fitting shoes cause muscles to lose their function for straightening the toes. Wearing tight shoes for long periods of time can also shorten the tendons and over time the muscles will not be able to fully straighten on their own, forming bunions.
Bunion deformities are also often caused by the biomechanical functions of the foot and hereditary conditions such as flat foot, high arch and pronation, which can put excessive stress on the joints causing the buckling.
Are there different types of bunions?
If your big toe bends up to fifteen degrees toward your second toe, it is considered normal. Once the angle is more than fifteen degrees then it is considered hallux valgus. Bunions can start out mild and progress to severe. Unfortunately there is no way of predicting how rapidly a bunion will progress or worsen. The severity of the symptoms will vary. You and your podiatrist must determine what treatment is best for you.
There are three types of bunions:
- Mild: New bone growth stretches and stresses the joints, pushing the big to towards the lesser toes. The inside tendons tighten, pulling the big toe farther out of alignment. Mild or beginning bunion deformities should be observed to determine the rate of progression of the deformity. It is beneficial to perform corrective surgery early on before the deformity becomes severe. This will avoid a more involved surgery with a longer recovery necessary for the severe deformity.
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Moderate: Most bunions fall into this category. At this stage of deformity, it is difficult to find shoes that fit comfortably, due to the difference in the width of the forefoot compared to the width of the heel. If the shoe fits in the forefoot, the heel of the shoe will typically slip up and down. If the heel is fitted properly, the forefoot is cramped.
- Severe: When the angle between the bones of the first and second toes is greater than normal (more than fifteen degrees), the big toe slants toward the lesser toes. In severe cases, this may also cause the second and third toes to buckle. Severe bunion deformities require surgery at the base of the metatarsal. Because of the severity of the deformity, the location of the osteotomy (cut in the bone), patients are not allowed to walk on the operated foot for several weeks. Crutches, cast, and sometimes a wheel chair are needed during the recovery period.
What are the symptoms of bunions?
- Deformed shape: Bunions exhibit a deformed bumped curve at the joint of the big toe, pushing the toe towards the lesser toes.
- Redness: Redness and tenderness at site location or inside of the foot at the big toe joint are also usually present.
- Pain and tenderness: There will commonly be pain in the toe joint and difficulty wearing shoes, sometimes causing difficulty walking, cramping in toe, foot and leg. The bursa (fluid-filled sac) on the inside of your foot at the big toe joint may also become painful and tender to the touch.
- Swelling: Inflammation may be present on the inside of the foot at the big toe joint.
- Numbness: Tingling, burning or total numbness in the big toe (hallux).
- Immobility: Decreased motion at the big toe joint.
- Corn: A corn can develop in between the big toe and second toe from the pressure caused by the bunion moving the toes.
- Callous: formation on the side or bottom of the big toe or big toe joint Callous under the second toe joint
How do you diagnose bunions?
To diagnose bunions, the foot and ankle surgeon will examine the patient’s foot and look for signs and symptoms of a bunion.
- Pathological exam : Direct observation of the bunions, typically makes the diagnosis. Your doctor will ask you questions about the symptoms you are having while examining your foot. You may also be asked to stand and walk barefoot to further assess your foot function. Bunions are usually termed mild, moderate or severe.
- X-rays: May often be necessary to get a better understanding of the deformity and what the best type of treatment is. The podiatrist will measure angles between the bones to help determine the stage of the bunion.
How do you treat bunions?
Foot problems causing pain should be given prompt attention. Ignoring the symptoms can aggravate the condition and lead to a breakdown of tissue, or possibly even infection.
Conservative Treatments
- Padding: A doctor may fit your foot and show you how to properly pad it to reduce friction and minimize pain.
- Corticosteroids: Injections of cortisone steroids may be administered at an office visit if the bursa sac is excessively inflamed. Corticosteroids can suppress inflammation, reducing pain and easing discomfort.
- Functional orthotics: prescribed and cast by your doctor are designed to relieve pressure within the big toe joint.
- Shoe Therapy: including supportive shoes or modifications for your foot type and activities.
- Activity modifications: By avoiding strenuous foot activity, you may be able to slow the development of bunions and bring relief to those already formed.
- Injection therapy: Corticosteroids may help in treating an inflamed bursa, but because of the risks of further damaging the foot, injections are not most commonly recommended.
Self-Care at Home
- High Toe Box Shoes: To prevent further irritation to the toe, shoes with a high and broad toe box (toe area) are recommended. Shoes such as Crocs, clogs or Birkenstocks may be enough of a change to allow pain free walking.
- Icing: Treat the affected area with ice packs daily by raising the feet above the heart, resting them comfortably and gently massaging with an ice pack or even a bag of frozen vegetables can work. It is best to ice 15 minutes at a time with a 15-minute break in-between.
- NSAIDS: Take over the counter medications such as ibuprofin or acetaminophen to reduce inflammation and manage pain.
- Foot Spacer: The doctor may recommend you use toe/foot spacers to prevent underlapping.
Surgical Treatments
Who should have bunion surgery?
- If a deforming or potentially deforming bunion has been determined by your podiatrist (by clinical exam /x-rays).
- You have a bunion but your podiatrist feels conservative care is not working.
- Bunions prevent normal daily activity. Shoes no longer fit properly or excessive pain is involved.
Types of bunion surgery
Different people will respond to different types of surgeries. Some procedures allow you to walk much sooner and avoid crutches, but run an increased risk of the bunions returning. Other procedures may require crutches for a few weeks, but may offer longer lasting results.
- Head osteotomy procedures (around the great toe joint): the bone is cut and the head of the metatarsal moved over to correct the bunion. Various types of bone cuts can be performed depending on the necessary correction. Some cases of flexible bunions will respond to a release of the flexor tendon. This procedure releases the tight tendon allowing increased range of motion. The procedure may be performed in office or as an outpatient procedure. Head procedures are usually performed for mild to moderate bunions, or for patients who cannot be off their feet for any length of time. Typical healing time can vary from several days to several weeks. Return to a loose fitting shoe such as a tennis shoe would begin approximately 3-4 weeks.
- Base osteotomy procedures (near or at the joint behind the great toe joint): Base procedures are commonly indicated for a moderate to severe bunion. They are performed around the base of the bone behind great toe (the 1st metatarsal). Base procedures can involve cutting a wedge shape out of the bone, a crescentic osteotomy, which involves making a semi-circle cut and rotating the bone, and Lapidus bunionectomy—fusing the joint behind the big toe joint. Once realigned, the bone is held in place with surgical pins.
Prior to Surgery
You are about to have surgery. As you may already know, nutrition plays a very important role in proper healing. One of the most important benefits of proper nutrition is maintaining a right pH balance in your body. pH is the measurement of acidity and alkalinity. pH ranges are from one to fourteen with fourteen representing most alkaline. Seven is neutral. The most optimal pH level for humans is slightly more alkaline than acidic at around 7.36.
Undergoing surgery can increase acid levels in the body. Emotional and physical stress from both the surgery and recovery time changes your metabolism, which increases acid production. The use of both general and local anesthesia, pain medication, anti-inflammatory medications and other medications such as antibiotics will also introduce more acid to your system, lowering the alkalinity. This will delay healing and prolong recovery time.
To maintain your body's proper pH, keep yourself well hydrated prior to and after surgery. Water helps to dilute the acid build up in your body and release it through urination. Eating alkaline rich foods such as dark, leafy green vegetables will add alkalinity. Avoid acidic foods such as meats, fried foods, coffee (and other caffeinated drinks), carbonated beverages, cigarettes and alcohol.
Other pre-operative considerations:
- Many people may need medical clearance through their Primary Care Physician, especially if taking medications such as Coumadin.
- Stop using anti-inflammatory medication 5 - 7 days before surgery. These include: aspirin, ibuprofen, Advil and Aleve.
- Arrange for a ride home from surgery and for someone to look after you for at least the first 24 hours.
- Avoid long trips for at least two weeks after surgery.
- Avoid eating and drinking anything after midnight the night before surgery.
Day of Surgery
Most foot and ankle surgeries are day surgeries, which means you will go home the day of surgery. You will generally be given a local anesthetic and anesthesia. After surgery you will receive pain medication and care instructions.
Post-op Recovery
The best results and quickest healing is achieved when patients follow after surgery instructions.
- Keep your foot elevated as much as possible for the first week after surgery.
- Keep your foot dry for at least 2 weeks after surgery.
- One week after surgery you will have your dressing changed by coming to see your attending physician.
- The sutures will be removed after the second week.
- Your doctor will advise you when you can increase weight and activities on the foot.
- Take pain and anti-inflammatory medications as prescribed by your physician.
- Vitamin C is important to heal scar tissue. It is vital in aiding in collagen formation. Take 4,000 mg spread out over each day in 500 mg doses taken for several days to several weeks after surgery.
- Omega 3 fatty acids, such as flax or fish oil, vitamin A and beta-carotene aid in the skin healing and lessen the appearance of scars.
How to prevent a bunion?
- Wear comfortable, wide shoes to prevent uneven or excessive pressure on the foot.
- Avoid wearing tight-fitting, pointed toe shoes, such as women's high heels or pumps as these will cause your foot to stay in an unnatural shape for too long, which can increase the risk of developing bunions.
- Treat and prevent bunions at the onset to reduce the risk of them causing deformity. This is key to your foot health. See a podiatrist right away and make any necessary changes to your footwear and activity.
- Treat foot irregularities such as flat feet or high arches as they may also contribute to the development of bunions by affecting how shoes wear on your feet.
- Regularly visit your podiatrist to manage your foot health.
