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Bunions

Bunions are a common problem that most people experience as a bony protuberance at the base of the big toe. A bunion, however, is more complicated than simply a bump on the foot.

When a patient has a bunion, the big toe angles in towards the other toes, a condition called hallux valgus. Bunions are most common in women, and the cause is almost always due to unsuitable footwear. The word 'bunion' is derived from the Latin word bunio, which means turnip.

What causes a bunion?
Tight fitting shoes are thought to be the cause of bunions in about 90% of patients. Shoes such as high heels are particularly damaging to the toes. These shoes have a sloping foot piece and a narrow toe box. The slope causes the front of the foot to be pushed with force into the narrow toe box. The narrow toe box causes the toes to become squeezed together. Depending on factors such as duration of wearing constraining footwear, skeletal maturity, and individual factors, the toes can become permanently adapted to the new position and lead to the formation of a bunion.

Bunions occur in about 3% of the population in countries where people wear non-Western style shoes. They occur in about 33% of the population in Western countries.

Once a bunion has formed, the mechanics of the feet and toes are altered. Tendons begin to pull the toe into an abnormal position, and the problem tends to progress over time.

Patients who develop bunions often seem to have a genetic tendency to do so. As stated earlier, even in countries without Western-style shoes, about 3% of the population will develop a bunion. Therefore, it's not only the footwear that's the problem--it's just that it's mostly footwear that is the issue.


Why is a bunion so painful?

Patients with bunions generally have one of two problems that can cause pain:
  • Pain over the bunion
    As the big toe becomes more and more angulated (pointing towards the other toes), the base of the toe becomes more and more prominent, thus forming the bunion. The bunion forms in part because of the new angulations of the toe, and in part due to inflammatory changes over the bunion surface. As the inflammation worsens, people can experience pain with shoe wear and walking.

     

    Development of a hammer toe
    The big toe may eventually come to lie over, or more commonly under, the second toe. This may cause more irritation and pain while wearing shoes. The second toe of patients who have bunions commonly forms a hammer toe.
Treatment of bunions is usually conservative at first, and usually means wearing more appropriate footwear. This does not necessarily imply wearing bulky orthopedic shoes, but it does require that you find comfortable shoes with a wider toe box. If your symptoms are only present when wearing shoes, adaptive footwear will be the key to treatment.

 

    • Tip: If you think some shoes may be too snug through the toe box, take them to a shoe store or shoe repairman. There are devices that will stretch the leather of the shoe over the bunion to allow you to wear the same shoes, but provide some extra room where the bunion is irritated.

For the most part, all patients with bunions can be treated with adaptive footwear. Surgery is only necessary if other treatments are not sufficient to relieve symptoms.

Isn't surgery easier for treatment of bunions?
There is a common misconception that surgical treatments for a bunion are better and quicker than non-surgical treatments. Unfortunately, patients often have unrealistic expectations, and may be unsatisfied with surgery.

In general patients should understand the following about surgical treatments of bunions:

  • Bunion surgery is not cosmetic surgery. Bunions may not be pretty, but cosmetic deformity is not a good reason to perform surgery. There are too many potential complications to perform a bunion surgery simply for cosmetic reasons. While improved cosmesis is an effect of surgical treatment, the procedure should be done because of pain and difficulty with footwear.

     

  • Patients must have realistic expectations. Bunion surgery can be helpful at relieving pain, but patients should not expect to have "normal" feet after surgery. In one study, a leading researcher on foot problems such as bunions, found that 1/3 of his patients could not wear the type of shoe they desired prior to surgery. Following surgery, 2/3 of his patients were able to achieve the goal of wearing their desired footwear. This left 1/3 of the patients unsatisfied with footwear even after their surgery.

     

  • Bunion surgery decreases the width of the forefoot by about 1/8 of an inch. That's not much! That is the reason why even after surgery, most patients will not be wearing slender shoes. In the average patient, removing the bunion only narrows the foot a tiny amount. The toes are straighter, and the pressure may be relieved, but the foot will still be about the same size.
Surgery can be an excellent treatment option for patients with problems from their bunions. Patients must understand this is a procedure that has potential complications and a lengthy rehabilitation period.

The patients who tend to be unsatisfied with bunion surgery are those patients who are having surgery done to allow them to have normal looking feet or allow them to wear slim shoes. If you fall into these categories, think long and hard about surgery. Surgery should be reserved for those patients who have significant pain, and are unable to correct the problem with adaptive footwear.

Surgical bunion treatment may be needed if conservative measures are not adequate to relieve the patient's symptoms. Surgical treatment is aimed at accomplishing a few goals:

  • Restoring the normal alignment and mechanics of the foot

     

  • Removing painful prominences and preventing their recurrence
How is bunion surgery performed?
Rarely, the bunion can simply be shaved off, but usually the surgical treatment of a bunion is more extensive-otherwise the bunion will simply return over time.

Bunion surgery involves breaking the toe bone (metatarsal) to correct the alignment. There is also a tightening of the ligaments on the outside of the toe, and a release of the ligaments on the inside, so the tension on the ligaments points the toe in the proper direction.

The major drawback to bunion surgery is that you will have pain in the foot, and probably not be completely healed for about three months. The most common complication of bunion surgery is a recurrence of the bunion months or years later. That said, if bunions are causing you problems in walking, it is certainly reasonable to consider surgical bunion treatment.

Other potential complications of surgery include:

  • Inadequate correction

     

  • Overcorrection of the deformity (hallux varus -- the big toe points inward)

     

  • Nerve injury, can cause numbness of the toes

     

  • Infection
What is the rehabilitation from bunion surgery?
The rehabilitation is relatively simple to understand, but it can be difficult to comply with. Patients must wear a special post-operative shoe to prevent pressure and forces to push on the healing bone. Most people will be on crutches, at least until the initial pain has subsided. Bunion surgery can be quite uncomfortable, and may require about 3 months or more to completely heal.

 

Sources:

About.com

Mann, R. Disorders of the First Metatarsophalangeal Joint J. Amer Acad Orthop Surg; Vol 3, No 1 1995; p 34-43.

Kato, T. & Watanabe, S. The etiology of hallux valgus in Japan. Clin Orthop. Vol 157, 1981; p 78-81.