bunions

A bunion, or hallux valgus, is a deformity of the big toe joint. Bunion pathology is usually manifested as a “bump” on the inside of the foot just behind the big toe. The bump can be very small or reasonably large; the size of which is not necessarily proportional to the amount of pain one can experience. Along with this bony bump there can be an associated bursitis which is a “cushion” that the body originally creates to protect an area from pressure or friction, but after a while this cushion can also become inflamed and painful. The last component of this deformity is the deviation of the big toe as it moves toward the second toe, sometimes even underlapping the second toe.

Here is a picture of a bunion compared to a normal big toe.

Below is a bunion deformity with the big toe under lapping the second toe.

The short story is feet that have a tendency to excessively pronate cause an over-flattening of the foot. This excessive flattening causes excessive 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.

So, in theory, if you lived on a tropical island and never wore shoes your whole life you could still develop a bunion deformity.

Below is a video describing the formation of a bunion in technical detail.

Generally speaking, bunions are progressive deformities and in most people will worsen over time (if appropriate measures are not taken to remove the underlying cause). When evaluating this deformity we recognize two types of pain. One, the more common of which is the “bump” pain or pain on the inside of the foot from the bony enlargement. People will complain of pain in shoes, the more narrow the more painful. Generally, these same people will not experience pain when walking barefoot.

The other type of pain in this condition is what is known as joint pain. As the big toe starts to move closer to the second toe it creates an abnormal alignment in the big toe joint. This causes a premature erosion of cartilage and over time the joint will no longer move smoothly and the patient will start to experience pain and limitation of motion of the big toe. This type of pain can be experienced both in and out of shoes.

As previously mentioned, the best treatment is conservative treatment started when one first recognizes a bunion developing. Once the deformity worsens and begins to hurt, treatment becomes more aggressive and invasive. Use of anti-inflammatory medication is fine for short term use but should never be considered as a solution in that over the long haul the medication will lead to systemic problems in most individuals.

Conservative non-surgical bunion treatments include modification in shoe selection, such as shoes that are wider and take pressure off the deformity. Sometimes physical therapy can be helpful in relieving flare ups. If the pain is limited to the large bump and associated bursitis, a cortisone injection may be helpful. I am not big on cushions and braces that are sold for this condition because in most cases they just take up more space in the shoe and put more pressure on the bump. My only exception to this is in people who are experiencing "joint pain". Wearing a night splint may relieve some of the discomfort. I have also been known to use bunion splints after surgery, for a short time, in an effort to keep the joint properly aligned during the healing process.

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Having said that, keep in mind that bunion surgery is not without risks (as is any kind of surgery) and that the type of surgery your friend may have had, may not be the type you will require. The well trained podiatrist probably does at least a half dozen different types of procedures based primarily on the size of deformity. The type of procedure will usually determine the length of recuperation. The risks of bunion surgery include the following:

• infection (true in all types of surgery)
• loss of motion (joint stiffness); the big toe does not bend, although in some procedures this is expected and the joint will no longer hurt.
• delayed healing- because of the dependent nature of the foot there is usually more swelling than in other parts of the body so healing may take longer.
• surgical failure- whereby you are no better off after surgery than you were before the procedure.
• nonunion- in procedures where the metatarsal bone has to be broken and re-set in an effort to re-angulate the bone, there is always the possibility that the broken bone will not heal.
• implant failure- in the case of a joint implant there is always the possibility it may have to be removed due to infection or reaction to the materials of the implant.
• recurrence of the deformity.

Even worse, the hallux varus throws off the "architecture" of the foot. Because the big toe and to a lesser extent, the second toe are in a "varus" position she has developed a painful corn on the end of her third toe.

The type of anesthesia used in bunion surgery ranges anywhere from local anesthesia where just the foot is put to sleep, to intravenous sedation (twilight sedation) with local anesthesia, to general anesthesia. The vast majority of my patients are done under local anesthesia with intravenous sedation on an outpatient basis. I prefer this type of anesthesia because the patient feels no pain, is not having general anesthesia and all the potential risks associated with general anesthesia, and tends to be awake shortly after surgery with less chance of being "sick" from the anesthesia during the following 24 hours.

Bunion surgery has become very sophisticated surgery; it is not just a question of removing the bump. Most of the procedures done attempt to realign the joint.(joint pain vs. bump pain) Discuss your bunion surgery options with your doctor

Below is a short video of bunion surgery demonstrating an Austin bunionectomy. The metatarsal bone is surgically broken with precise cuts in an effort to realign the bone (osteotomy). With the great fixation procedures that we have today people can walk after a bunion osteotomy.

A new device called the TightRope fixation manufactured by Arthrex is a high tension wire that is placed through the first and second metatarsal bones in an effort to reduce the distance between the two bones. The beauty of this concept is that an osteotomy does not have to be performed. Since most bunion complications generally center around the osteotomy itself, having another option to reduce the intermetatarsal angle is very exciting.

If you look at the two x-rays below the one on the left is the preoperative x-ray. The goal of surgery as represented by the horizontal arrow is to move the first metatarsal bone closer to the second metatarsal. The x-ray on the right is the postoperative view and you can see the "tightrope" that has been drilled through both the first and second metatarsal bones and is held together by the black anchors.

I must caution you that the use of the TightRope for bunion correction is a relatively new concept but is very promising.

As a side note, many patients ask me if you can have laser surgery on bunions. The answer is no. Theoretically you could use a co2 laser to make the skin incision (which I have done) but it really affords no advantage over a regular scalpel incision. More importantly, lasers cannot remove bone, all they do is burn bone, so a laser could not be used to remove the large bump of a bunion deformity.

Recovery time after bunion surgery will vary depending on a number of factors. Probably the most important factor is the type of bunion surgery being performed. People will generally recover quicker with a more simpler procedure. The more complicated procedures take longer to heal, then there is the time period involved to rehabilitate the joint generally through physical therapy. This does not mean you are not walking after bunion surgery; in most cases the patient is walking immediately. By this I mean you can ambulate from day one (there are some bunion procedures where you have to be nonweightbearing for a period of time; discuss this with your doctor), meaning you will be able to get around and take care of yourself but by no means will you be on the golf course.

The goal in this day and age is to get our patients walking as soon as possible in an effort to keep the newly remodeled joint moving. Years ago the thinking was to keep the patient in bed so that the joint could heal; the problem with that line of logic was that the joint tended to get stiff and it would take even longer to rehabilitate.

Other factors that will affect the recovery time after bunion surgery include your age, younger people tend to heal quicker, your overall health, and maybe the most important factor is patient compliance. Follow your doctor's postoperative orders for home care and mobilization. Generally, when patients are noncompliant they will run into more postoperative problems.

Once your sutures have been removed and if not in a cast, you will be ready for a shoe. This does not mean your everyday shoes. Some doctors like to have their patients wear a daytime bunion splint to maintain their surgical correction. This plus the fact that your foot will be swollen (a normal part of healing) will make it impossible to wear the shoes you already own. I generally have my patients buy an inexpensive pair of sneakers large enough to accommodate the enlarged foot and splint; this seems to work out well. If you were given a surgical shoe to wear you want to get out of that for two reasons. One, it limits motion in the joint, which we do not want and secondly patients start complaining of back pain, plus, you cannot drive with a surgical shoe if it is on your right foot.

If after reading this page you are still "up in the air" as to what you should do about your bunion, may I suggest you visit the following web site for a personal account of one person's experience with a variety of non-surgical bunion treatments The bunion experiment.

While we are on the subject of bunions we should also discuss the condition known as tailors bunion. This is a bunion deformity on the outside of the foot.

In the picture below you will notice the location of a tailors bunion.

This condition can be an acquired problem such as the example above or a congenital problem where there is a flare laterally of the fifth metatarsal bone resulting in the head of the bone being very prominent.

In either case the foot now has trouble fitting into a conventional shoe, (it is too wide). If there is enough pressure on the bone a secondary bursitis may form which will make the pain even worse. In those with poor circulation the skin overlying the bone may breakdown from too much pressure.

A tailors bunion will generally only hurt in shoes and be fine barefoot, or in open shoes like a sandal.

So now that we know the major precipitating factor is shoes, the sensible move would be to avoid shoes that aggravate the condition. Shoes that are too narrow, or have too high a heel, or are made of very stiff material will all go a long way to aggravating the tailors bunion.

You can always try padding over the tailors bunion but I generally find that to be a waste of time. All the pad does is take up more room and cause the tailors bunion to hurt more.

If there is an inflamed bursal sac, a cortisone injection can be very helpful with the understanding that if you do not modify your shoe selection, the problem will eventually return.

Anti-inflammatory medication can be tried but I find it is rarely helpful by itself.

If all else fails there is always surgical intervention. A tailors bunion is different than the classic bunion in that in this type of bunion we do not really have to worry about biomechanical considerations.

Sometimes going in and removing the enlarged bone is all that is necessary, but in general, if there is a real lateral flare to the fifth metatarsal bone, an osteotomy (cutting and resetting of the bone to change its angulation) may be necessary.