Bunions are one of the most common deformities we see in the office. I have found throughout my years in practice that most people have a conception about bunions that is either misinformed or has been passed on by accepted myth. And while bunions will not cause anyone to leave this earth earlier than expected, they can present with progressive deformity and pain which can impact one's ability to enjoy life in many ways.
I have always been an avid proponent of education. I believe that an educated patient is an informed patient and, as such, can make informed decisions regarding treatment for their bunion deformity once they understand more completely the nature of and treatment options for the issue. I hope the information below assists you in your education process. Please feel free to email me at [email protected] with any questions after reading this material.
What is a Bunion?
Simply put, a bunion can be described as a "bump" on the big toe area. At least this is what you see when you look at the foot. In actuality, a bunion is more than just a "bump". What is being seen and felt in shoes is more like the "tip of the iceberg" under which the real issue lies. The bump is a symptom of a much more complicated process in the foot which results in a bone protruding through the skin. Most people will notice the bunion progresses over time, i.e. it gets worse with the big toe shifting towards the outside of the foot and the second toe possibly sitting on top or underneath the big toe in extreme cases. Interestingly enough, some people will never have any problems or symptoms with the bunions, outside of some shoe fitting challenges. However, the age at which a bunion starts and how rapidly it progresses will play a significant role in how painful the bunion can become or how severe the deformity is in later stages.
Bunions are not gender or age-specific. While most people picture a woman in her 30's or 40's with a big bump on the side of her foot complaining about tight shoes, bunions can be seen in women AND men of all ages. I have seen children as young as five years old with bunions. Bunions in children nine to seventeen years old are more common than people think. And it is this specific population of individuals with bunions that are often overlooked and under treated. I address this particular age group in the Should You have Your Bunion Corrected? of this topic.
Another significant aspect is that there really two types of bunions. While most people understand a bunion to be a bump on the outside of the big toe joint, another presentation is with the bump on top of the big toe joint. In this scenario, there is usually no or little deviation of the big toe to the side. The importance of the distinction between the two bunion types relates to their origins and treatment. While there are similarities, significant consequences exist for an individual with a top bunion versus a side bunion; especially if the deformity goes untreated for an extended period of time. So as not to confuse the situation, I will talk about Side Bunions in this section and Top Bunions in the section entitled Hallux Limitus/Rigidus.
Clinically in someone with a Side Bunion the big toe (hallux) is seen angling towards the little toe and a bump (the bunion) is formed as a result. (PHOTO INSERTION OF NORMAL, MILD TO SEVERE BUNIONS CLINCIALLY). In the more severe cases, the big toe may ride over or under the second toe. What is important to understand is that the bunion is not just a "bump" of bone. It is actually the result of a dislocation of the joint with bones moving in the wrong direction. This poor alignment often results in arthritic degeneration of the cartilage of the joint with pain, swelling and redness.
Evaluating Your Bunion Deformity
When evaluating bunions, besides the clinical examination performed by the podiatrist, it is essential that x-rays are taken of your feet. It is also important these x-rays are obtained with you standing in your normal stance. Unless this is done, it is impossible to correctly and fully evaluate your bunion deformity. This is especially critical if surgery is to be performed.
As you can see in the x-rays below (INSERT PICS OF XRAYS NORMAL AND BUNIONS FROM MILD TO SEVERE), when comparing a foot without a bunion to one with, there are significant changes that are observed. The major difference noted is the relationship of a line drawn down the first metatarsal to one drawn down the second metatarsal. Because of the way your foot functions, the first metatarsal is actually moving away from the second metatarsal. There are some accepted normal angles in the podiatric literature and it is the deviation from these angles that are evaluated. The higher measured angle usually correlates with greater deformity. This serves as a guide in the decision process for the type of surgical procedure to be performed. There are several other factors that are important to be evaluated in the x-rays, but the relationship between the first and second is easily demonstrated for your general understanding.
As this movement of the first metatarsal occurs, the ligaments and tendons attached to the big toe and first metatarsal cannot accommodate the big toe to follow in the same direction. As a result, the big toe is pulled toward the outside of the foot. Now the big toe starts to push back against the first metatarsal pushing it even further into a deviated position. This sets up a vicious cycle that can progress rapidly creating a severe bunion and significant arthritic changes.
What Causes Bunions?
Let's get one myth out of the way...shoes do not cause bunions! Now I know you may be scratching your head at this because, after all, isn't that what everybody thinks? In the early years of the podiatric profession, it was thought this may be a factor. However, studies done on people in remote areas of the world that never wore shoes revealed an interesting finding. Many individuals in the population of these cultures exhibited severe bunions, hammertoes and other associated deformities. Of course, they had few complaints because they didn't wear shoes. Needless to say, this provoked the podiatry profession to look further and through study, cadaver dissection and clinical evaluations, a better understanding of foot function and biomechanics (how the bones and joints work together with tendons and ligaments), has elucidated the cause of bunions.
Bunions are most often caused by a faulty structure and thereby a mechanical function and of the foot. You do not inherit the bunion, but the foot type that is prone to developing the bunion. (Yes, you can blame mom or grandma for your bunions) Now, I mentioned above that shoes do not cause bunions. However, they serve as great promoters of bunions. Because of the shoe styles, there are very few shoes made with a toe box that properly accommodates our toes. We squeeze, cajole and otherwise do what is needed to fit into the shoe of our dreams. I know we are more conscious of the shoes we wear today, but shoe fashion has yet to submit to the recommendations of the podiatry profession; especially when it comes to women's footwear. Therefore, if there is a tendency for a bunion, wearing of certain shoes will aggravate the situation and contribute to a more rapid formation of the bunion (ergo, my investment in the stock of shoe companies!).
Now there may be other contributing factors to bunion formation. Such factors include:
- Neurological conditions
However, in the majority of instances, it is the alignment of the bones in the foot and the way your foot functions that promotes formation of a bunion. For this reason, the treatment of bunions can vary with a person's age, foot type, and foot function.
Conservative Treatment of Bunions
With all foot conditions, conservative treatment should always be considered. Symptoms from bunions include pain, redness, swelling over the bump in shoes, pain in the joint itself and of course significant deformity in severe cases.
Conservative treatment regimens for bunion symptoms include:
- Padding of the area
- Wearing shoes that have adequate toe room and a proper shoe box width
- Local injection therapy with cortisone and anesthetic
- Physical therapy
- Oral anti-inflammatory medication
- Custom molded arch supports
Treatments 1-5 are intended to treat the symptoms of bunions, but not the cause. It is important for patients to understand in any condition there are symptoms which always have an underlying cause. Treatment of the symptoms in most cases does not address the root cause of those symptoms. As I pointed out earlier, bunions result from poor foot function that leads to the big toe deviating abnormally toward the outside of the foot. So it makes sense that to resolve bunion symptoms on a permanent basis, foot function and structure need to be corrected.
When it comes to addressing foot function, custom arch supports (orthotics) are recommended. Orthotics work by holding the foot in a more proper position and controlling how the foot functions, thereby reducing the stress on the joints and hopefully reducing pain. In controlling such function, we hope to prevent the bones from further deviating and producing larger deformities. What must be understood is that orthotics, while controlling function, do not reduce current deformity or permanently correct poor alignment. They are a good pathway for reducing symptoms and helping to slow the progression of formation. However, symptoms may persist as time passes even with orthotics.
Considerations in the Surgical Treatment of Bunions
When bunion symptoms persist despite conservative care, or the deformity progresses to a more severe state, then surgical intervention should be considered. As I mentioned earlier, bunions are generally not a life threatening condition. However it should be understood that people with diabetes, poor circulation and certain other health conditions may be at risk for infection in the skin and bones from ulcer formation or irritations because of a severe bunion deformity. But for the most part, bunions are a structural problem that requires surgery to realign the bones and joints.
It is important when surgery is considered to evaluate many factors so that the optimum result can be achieved. Such factors can be categorized into:
|Medical Factors:||Social/Personal Factors:|
Many people do not realize the importance of social factors in any foot surgery. It has become an important part of my pre-operative workup to address these issues early in the pre-operative discussions with my patients. I have found it to be critical to the success of the surgery and sometimes important in selection of the procedure I may perform.
Medical factors are the more obvious of the two categories. For purposes of this discussion, I am going to assume that someone is healthy enough to undergo bunion surgery and has made the decision to move forward in this direction. Let's now look ways in which bunions can be surgically corrected. Also, we are going to limit our approaches to those feet that do not have a lot of arthritis or joint damage. The surgical approaches for these bunion types will be discussed in the section on Hallux Limitus/Rigidus.
Surgical Approaches for Bunion Correction
In order for a procedure to be selected, several factors in two areas must be considered and evaluated. The clinical exam of the foot e.g. foot function, foot type, range of motion of the joints and the x-ray exam of the foot, e.g. relationships of the bones to one another, the alignment of the cartilage, amount of joint dislocation. Once these are evaluated, a surgical procedure(s) can be chosen. Such procedures would more than likely entail cutting of the bone with insertion of pins and/or screws to hold the bones in position while they heal. Several approaches to cutting the bone are illustrated below along with actual cases I have performed (INSERT XRAY PICS) using these exact procedures. X-rays and clinical pictures of bunions before and after correction are shown. You will notice on the x-rays that different approaches have been used. While there are many more procedures than the two shown here, they all are used to achieve the same goal: Realignment of the bones and joints for correction of the bunion deformity and resolution of pain and/or preventing degeneration in the future.
What Else Does Bunion Surgery Entail?
While certain aspects surrounding your surgery may differ between surgeons, the following considerations are important points to discuss with your surgeon:
1. Anesthesia: Surgery is most often performed under local with sedation anesthesia. Some call it twilight sleep or monitored anesthesia care (MAC). In any case, this is a very comfortable method that does not require you to be put to sleep under general anesthesia. After you are sedated, the foot is numbed up with local anesthesia and the surgery performed. You experience no pain and have no recollection of the experience. It is the method I recommend to almost all of our patients.
2. Surgical Facility: In almost all cases, bunion surgery is performed in an out-patient setting. This can be accomplished in a hospital through their Same Day Surgery Department, a free-standing Ambulatory Surgical Center or an Office-Based Surgical Facility. In our practice, we have developed a state-of-the-art Office Based surgical environment called the Seven Bridges Surgical Facility. We perform most of our cases in this facility with an experienced and well-trained staff. Please tour our facility and read about our staff and credentials in the Seven Bridges Surgical Facility section.
3. Pre-Operative Testing: As with all surgical procedures, pre-operative testing may be required. This is arranged by our office with the facility where your procedure will be performed. Additionally, medical clearance by your family physician may be required depending upon your health status or the requirements of the specific facility.
What You Should Expect After Bunion Surgery
Post-op Immobilization and Weightbearing Restrictions
Following your surgery, there is a fairly predictable post-operative course that will be required. Depending upon the actual type of procedure performed, you may or may not be permitted to bear weight on your foot. This period of non-weightbearing may last from two weeks to six or even eight weeks. This is critical to allow the bones to heal in proper position. It takes bones three to four weeks to attain a state of "stickiness" in which the bones are adhered together adequately to bear weight. Additional time past the initial 3-4 weeks for weightbearing may be necessary depending on how x-rays look, how much swelling there is and your level of pain. Post-operative pain medication is often prescribed and is always tailored to a patient's past history of allergies, side effects and previous experiences with such medications. Pain medication is not always necessary, but is always offered for patient convenience.
Physical Therapy Rehabilitation
Another facet of your post-operative recovery is the use of physical therapy. In our practice, physical therapy is mandatory after surgery. Physical therapy plays an essential role in reducing swelling, increasing range of motion of the big toe joint, rehabilitating the leg muscles that become naturally weakened and decreasing pain. We have also found that it promotes a quicker return to life's activities like work, play and family time. The Foot and Ankle Centers are proud to be associated the Advanced Rehabilitation Centers, a premier physical therapy organization that specializes in foot and ankle rehabilitation and has been the exclusive provider of such services for our patients since our inception. If your surgeon is not using physical therapy after surgery, ask them, "Why not?" Considering what I just outlined above, it would be interesting to hear their answer.
Long Term Prognosis after Bunion Surgery
With any foot surgery there is a period where you will experience pain, swelling, stiffness and weakness. This is expected. However, the majority of pain, the level of which is variable from patient to patient, resolves within the first week. As tissues heal, you will experience swelling. Again, swelling, as with pain, is more severe in the early stages of healing, but may persist for months in some form. Most people will get into a sneaker-type shoe at about six to eight weeks post-op. In may be three months before a dress shoe is wearable. Stiffness of the big toe joint is an issue that also exists after surgery. The range of motion may take three to four months to return to normal. Most patients deal with these issues as a natural consequence of having bunion surgery, but respond it is worth it in the long run and return to most activities without pain or restriction.
Should you have Your Bunions Corrected?
Bunions are a progressive disorder
Obviously, no one will leave this good earth early because of bunions. However, when they begin to cause deformity and pain, a significant impact will be made on your ability to walk and enjoy life in many ways we sometimes take for granted. And as mentioned earlier in our discussion of what cause bunions, they are the result of poor alignment which can lead to arthritic degeneration of the cartilage of the joint causing pain, swelling and redness. Since bunions are a progressive disorder, then it makes sense that the earlier they are corrected and proper alignment is restored, the greater the chance further degeneration can be prevented.
Do all bunions need surgical correction?
Plain and simple, no. There are some things that need to be discussed between you and your surgeon to see if you are good candidate for surgery. I believe the earlier the problem is addressed, the less work needed to fix it and the less degenerative arthritis that develops in the future. Factors that determine your candidacy for bunion surgery include:
- Your clinical picture (how much pain, swelling, redness, deformity)
- How much does it impact your lifestyle
- What do your x-rays look like (how much dislocation, cartilage loss, and degeneration is present)
- Your age and health status
Should Bunion Surgery Be Performed in Children?
When indicated, absolutely. Let me state this up front. I have performed bunion surgery in children as young as eight years old. Why? At eight their foot looked like an adult who had bunions all their life with severe dislocation of the joint and poor alignment. What do you think the foot would have looked like, and more importantly, felt like even at 25 years old? It would be a painful, more arthritic foot. Even if reconstructive foot surgery was performed at the still tender age of 25 there would be future difficulties because he/she waited too long.
Another important point; that eight year old may present without any pain whatsoever. At eight years old, their feet are still flexible; they have a low body weight/mass and their feet are still growing and moldable. So when abnormal stress is placed on the bones and joints of the foot because of poor alignment, the foot will accommodate this abnormal stress very easily through the deforming of bones and joints which, as the child gets older, become more fixed and rigid. When this rigidity starts to set in, it is not as forgiving. As the child grows through the pre-teen and teen years, more weight is gained, more muscle mass is achieved and the foot soon slows down its growth and the growth plates start to mature and close. However, since the foot has not been corrected or realigned, the new abnormal structure of the joint becomes more permanent. The bunion continues to grow larger and now pain and degeneration start to occur in a young individual who has yet to enjoy life.
I need to dispel another myth. Performing surgery on a child does not stunt the growth of their foot. The key in performing pediatric foot surgery is to do so without interfering with the growth plates. This can be easily accomplished when correcting bunions or, for that matter, any deformity in children. I have been performing bunion correction in children for over twenty years and it has been a very satisfying part of my practice.