The term bunion refers to a bump of bone that becomes prominent at
the great toe joint. A bunion is actually normal anatomy that has shifted
to a position where the bump becomes more noticeable and prominent.
Bunions become more common as we age but are not uncommon in teenagers and young
adults. Bunions are found more often in women than in men. Not all bunions are
painful. When painful, bunion pain is caused by two factors. The
first is direct pressure from shoes on the bunion. And the second source
of pain is due to arthritis that develops within the great toe joint. Bunions
are also called HAV, hallux valgus or hallux abducto valgus.
Do high heels contribute to the onset of bunions? The
degree to which shoes contribute to the onset of a bunion is
questionable.
There's no hard science to say that any particular type of shoe contributes to
the formation of a bunion. We can say with certainty that bunions
are an inherited disorder. More
specifically, we don't actually inherit a bunion, but we inherit a set
of bones, joints and ligaments in our feet and lower extremity that are
very similar to that which we would see in our parent's and our
grandparent's feet. The
same biomechanical events that took place to cause the parent's bunion
problems are recreated with each step in each new
generation.
Why does a bunion hurt? Bunions increase the width
of the forefoot. As the forefoot becomes wider, it becomes
increasingly more difficult to fit into a shoe. Bunions also
change the position of the joint and force the great toe joint to
function in a manner that promotes arthritis of the great toe joint.
As the arthritis becomes increasingly evident, the great toe will ache
both with and without shoes.
Bunions become more common as we age. Bunions aren't
really a product of old age, but rather a combination of genetic factors
that given enough time will develop into a bunion. Bunions are not
uncommon in teenagers and young adult. There are some very specific
biomechanical characteristics that contribute to the early development
of bunions in children. These characteristics are somewhat
technical but your doctor should take these into account before
prescribing treatment such as surgery. Surgical procedures for
pediatric bunions tend to be somewhat more aggressive in nature merely due to
the fact that the child has a lifetime in which the bunion may recur.
Treatment of Bunions
Should you have your bunion
corrected? Has your foot pain
affected your job? Has your pain
limited the kinds of shoes you like to wear? There's a number of different factors that ultimately affect
a patient's decision to have their
bunion corrected, but the single most important issue is pain.
Surgery is the only way to correct a
bunion. In poor surgical candidates,
bunion pads are helpful to relieve shoe
pressure. We always recommend patients try wider shoes with
softer shoe materials such as leather. A good leather
shoe can be stretched to accommodate a bunion. Clogs are also a
remarkably good solution for patients with bunions. Clogs offer a wide toe
box that can accommodate bunions and hammer toes.
Bunion surgery has a long
and colorful history. There's probably more than 400 different
combinations of procedures that are named after this doctor or that
doctor. Most doctors use just a handful of these procedures.
Surgeons are no different than anyone else. Once a surgeon finds a technique
that works
they have a tendency to stick with it.
Foot surgeons classify bunions based upon three criteria; (1)
Size of the bump (medial eminence) (2) abduction of the great toe and
(3) the inter-metatarsal angle. Each of these issues become a part
of the treatment plan and guide your doctor to determine which procedure
would be best for you.
When
planning bunion surgery, foot surgeons use x-rays as a blueprint to
evaluate surgical choices. The age of the patient is an issue to be
considered when planning a bunion surgery. We are much more
aggressive with younger patients and less so with older patients.
The younger the bunion patient, the more chance that patient has for the
bunion to recur during their lifetime. So subsequently, additional
considerations must be made when planning for bunion surgery in
children. Other pre-operative considerations include the patient's
occupation and the patient's overall health status.
A bunion procedure is
normally performed on an out-patient basis. Most bunionectomies are
performed under local anesthesia with IV sedation at a surgery center or hospital.
This is the preferred setting because it's the safest and most comfortable
setting for patients. Patients are given a sedative through
their IV that makes them very sleepy while their foot is anesthetized prior
to the procedure. In the hands of a skilled anesthesiologist, most
patients remember very little of their procedure and are ready to return
home in just a short time after their procedure is completed.
Most surgeons use a
long acting anesthetic in surgery that will keep the foot numb for up to
8 hours. This allows patients to get home and situated
comfortably. The two most important tools
used post-operatively to control pain are ice
and elevation. Foot surgery is unique in the fact that we're going
to be walking on an area of the body that recently underwent
surgery. Obviously that presents with some challenges. When
the foot is placed down below the level of the heart it's going to
swell. When it swells it is going to hurt, particularly during the
first few days following surgery. Patients who plan ahead and
spend time with their foot elevated use very little pain medication following
surgery. Ice is a must. Ice will help to reduce swelling
thereby controlling any pain without the use of narcotics.
Recovery time following a bunionectomy will vary
with the choice of procedure, the patient's occupation and general
health status. Most post-op patients can bear weight immediately
following surgery for short periods of time. Patients will be
limited for several days in walking and will return to about 50% of
their normal activities at 3 weeks. Most post-op bunion patients
will return to regular shoes at about 5-6 weeks post surgery.
Postoperatively, many doctors use a removable walking cast called
a cam walker to protect the surgical site
during healing. Additional post-op care may include a
forefoot compression sleeve to control
swelling or a bunion regulator to wear
while sleeping.
Another important
consideration in any surgery is family, friends, bosses and co-workers. Bunionectomy patients need to establish a few designated support people
before they have their surgery. Widows, widowers and single
parents are special cases and need to be sure they have enough support
at home for meals, laundry etc. And lastly, bosses and co-workers
are counting on realistic expectations of when you return to work
and when you do, are you going to limited in any way? If so, how
long? It's pretty easy to
see that the technical component of completing a bunionectomy is just
one part of a successful outcome.
Can a bunion return after being surgically corrected?
Occasionally. As a rough estimate (non-scientific), many doctors will estimate
the percentage of chance of recurrence of a bunion to be 60 minus your age.
So for a 50 year old patient, the percentage of chance that a bunion would
reoccur would be about 10%.
Post operative complications can occur but are uncommon with
bunionectomies. With any surgery you need to consider the possibility of
infection, delay in healing or scar formation. These are problems that can
occur in any surgery, even to the best of surgeons using the latest techniques.
One complication specific to bunionectomies is overcorrection of the bunion
resulting in hallux varus. Hallux varus is uncommon and is usually
associated with removal of the fibular sesamoid in a Modified McBride procedure.
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Turf toe
is the term used in athletic circles to describe a jamming or impaction injury
of the great toe joint.
Turf toe caused by a direct injury
to the joint may or may not initially be obvious. Athletes may not remember an
incident of pain since they’re often distracted by the event or
game in which they’re involved. The onset of direct injury to the
joint may be abrupt, but also may be insidious becoming increasingly
more painful as the season progresses. Turf toe pain will subside
with rest only to recur with increased activity. It’s not unusual
to see symptoms of turf toe resolve in the off season only to recur
with renewed exercise.
Turf toe is also called
hallux
limitus or a dorsal bunion. Turf
toe represents just one of the four reasons that patients may develop hallux
limitus. Those four reasons include;
Direct physical injury to the great toe joint (turf toe) - injury
to the articular cartilage or subchondral bone. These injuries
may be due impaction injuries or hyperextension/flexion of the
first MPJ.
Functional hallux limitus -
biomechanical function that results in metatarsus primus
elevatus and subsequent repetitive jamming of the first MPJ.
Structural hallux limitus - limited range of motion caused by a long
first metatarsal.
Other conditions - synovitis,
crystal deposition diseases such as gout, systemic arthritis,
external physical influences such as Dupytren's contracture,
etc.
It's important to understand that the terms turf toe and hallux
limitus are indeed similar but aren’t synonymous. The
fundamental difference between the two terms is the patient population that they
affect. Turf toe is a term used in athletic circles that refers to an injury of
the great toe joint. On the
other hand, when we discuss hallux limitus, we’re actually
referring to a broader, ‘non-athletic’ patient population and
need to include all four causes of hallux limitus.
Turf toe is graded in severity ranging from grade 1 through grade
4. The following chart describes the clinical appearance,
x-ray findings and corresponding treatment for each of the four
stages of turf toe.
Treatment of turf toe may include rest, shoe modifications,
orthotics, steroid injections or surgery. The success of
non-surgical care will vary with the severity of the initial injury,
the current stage of injury, the rate at which the injury is healing
and the general health of the patient.
In stage 1 turf toe, use of a
dancer's pad can decrease pain by plantarflexing the first
metatarsal, thereby increasing the range of motion of the great toe
joint. A
turf
toe strap can help in stage 2 to limit motion of the joint. We see varying degrees of success with orthotics that
promote plantarflexion of the first ray, effectively treating
metatarsus primus elevatus and peroneus longus dysfunction. Simple
arch supports can make a significant difference in the symptoms of
turf toe. Most successful are
orthotics with a rigid Morton's extension beneath the great toe
joint. A Morton's extension is used to decrease the range of
motion of the joint. Alternatively, a full length, rigid,
carbon
graphite spring plate may also be used to limit range of motion
of the great toe joint.
If a patient
does not respond to conservative care
of turf toe in a reasonable time period, there are several choices
of surgical procedures that may be used to treat turf toe. The most common
surgical procedure addresses cases of turf toe in stages 2 &3. This
procedure is called a Youngswick modification of an Austin bunionectomy.
The Youngswick modification is used to shorten and plantarflex the 1st
metatarsal as seen in the image
to the left. This procedure is performed on an outpatient basis in either a
hospital or surgery center. The procedure is performed using either a
general or local anesthetic with sedation. Patients are able to bear
partial weight the day of surgery. Return to moderate athletic activities
is realized in approximately 6 weeks. The following images show a Youngswick
modification of an Austin bunionectomy for the treatment of stage 2 turf toe.
The post-operative x-ray to the right shows the shortening of the 1st metatarsal
following the procedure.
Stage 4 turf toe represents complete destruction of the joint surfaces.
Stage 4 turf toe can be treated by either implant arthroplasty or joint fusion.
The choice between implant arthroplasty or fusion for the correction of stage 4
turf toe is open to debate. The choice of procedure depends, in part upon
your doctor's training and philosophical approach to the
treatment of stage 4 turf toe. Patients considering these procedures should
discuss treatment options for stage 4 turf toe with their doctor pe-operatively.
The follow images show the steps necessary to complete implant arthroplasty
of the great toe joint for cases of stage 4 turf toe. This procedure is
completed in either a hospital or surgery center using a general anesthetic or
IV sedation with local anesthetic. The procedure takes approximately 45
minutes to complete. Patients are able to bear full weight the day of
surgery. Most patients return to an enclosed shoe at 3-4 weeks post-op.
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The
internal support and structure of the forefoot consists of five metatarsal bones that originate in the midfoot and
descend at an angle to meet the toes. Each of the five metatarsal bones
terminate at the metatarsal phalangeal joints (mpj's). The plantar, or
bottom aspect of the mpj is often called the ball of the foot. Due to the
amount of load bearing applied to the forefoot in walking and running, the
forefoot is prone to a number of different injuries.
The distal portion of the forefoot consists of the 1st mpj and the
lesser mpj's (2-5). The great toe joint (1st mpj) is a bit unique in that
the anatomy of the great toe joint is a bit different than that of the lesser
mpj's. To a degree, the lesser mpj's act independently of the 1st mpj.
Therefore , any discussion of forefoot conditions should be broken into those
problems specific to the 1st mpj and those problems specific to the lesser mpj's
(2-5).
The following is a list of common forefoot conditions. To
find more information about these conditions, follow the highlighted link.
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A
tailor's bunion is a prominence of the lateral aspect of the 5th metatarsal
head. The term tailor's bunion was coined in the age when a tailor would
sit cross legged on the floor putting up the hem on a coat or dress. The
constant pressure applied to the lateral aspect of the foot resulted in pain at
the 5th metatarsal head. Tailor's bunions also go by the name bunionette
or baby bunion.
The most common cause of pain with a tailor's bunion is direct pressure to the lateral
aspect of the 5th metatarsal head from tight shoes. Pressure from shoes
will initially present as a red spot or blister over the 5th metatarsal head.
If pressure persists, a bursa can form over the 5th
metatarsal
head. A bursa is a small
fluid filled sac that forms in response to chronic pressure against the bone.
Bursitis, or inflammation of the bursa is commonly found in conjunction with a
tailor's bunion.
The shape of the 5th metatarsal can also contribute to the presence of a
tailor's bunion. Lateral bowing of the 5th metatarsal can make the
forefoot much wider. This can make shoe fitting much more difficult.
Bowing is a significant issue to be considered when electing to perform surgery
for a tailor's bunion.
Treatment of Tailor's Bunions
Conservative care for a tailor's bunion includes
padding and the
use of wider, softer shoes. Shoes can be spot stretched with a ring and
ball stretcher to make the area of the shoe adjacent to the tailor's bunion a
bit wider (ask your local pedorthist or shoe repair shop for help on spot
stretching). Another important consideration is the shape of the toe box
of the shoe. When buying shoes, be sure to buy a shoe with a toe box that
is shaped like your foot. To be sure the toe box is shaped like your foot,
stand in your socks next to the new shoe and compare the shape of your foot and
the shape of the toe box. If the two don't seem to be the same shape, then
perhaps that's not the right pair of shoes for you.
Planing
for surgical treatment of a tailor's bunion depends upon the degree to which the
5th metatarsal is bowed. With minimal bowing, a simple partial metatarsal
head resection can be performed. A partial metatarsal head resection
removes the lateral head of the 5th metatarsal. In cases of mild to
moderate bowing, a distal metatarsal osteotomy is performed in conjunction with
the partial head resection. Severe cases of bowing require a mid-shaft
osteotomy with plating.
Another
procedure used to treat a tailor's bunion is a 5th metatarsal head resection.
This procedure will result in the shortening of the 5th toe but is great in the
patient population who cannot tolerate a period of non-weight bearing or
casting. Patients with co-morbidities that may effect the surgery may be
candidates for a 5th metatarsal head resection. Examples of these
co-morbidities include obesity, severe arthritis, propensity to DVT and gait
abnormalities. This is a population of patients that you want to keep as
ambulatory as possible to prevent post-op complications. Diabetic patients
also do quite well with 5th metatarsal head resections.
Another important consideration in planing tailor's bunion surgery is to be
sure that the surgery is consistent with the location of the problem. Pain
at the 5th metatarsal head can be due to pressure on the side of the metatarsal
head, the bottom of the metatarsal head or both. A partial metatarsal head
resection will only address pain on the lateral aspect of the 5th metatarsal
head. To treat pain found on both the lateral aspect of the 5th metatarsal
head and the bottom of the metatarsal head, a 5th metatarsal osteotomy or
metatarsal head resection must be performed.
The following video shows a tailor's bunionectomy with 5th metatarsal
osteotomy.
Tailor's bunion surgery can be performed on an out-patient basis at a
hospital or surgery center. The most common anesthesia used for this
procedure is a local anesthetic with sedation. General or spinal
anesthetics may also be used based upon the surgeon's preference. The
procedure takes approximately 20-30 minutes to perform. The post operative
course varies based upon the procedure performed. Patients who undergo a
partial head resection are able to bear weight on the foot the same day.
Partial head resections with an osteotomy may be able to partially bear weight
and are likely on crutches for several weeks. Plating for severe
deformities will require a hard cast and non-weight bearing for a period of at
least 6 weeks. Return to normal shoes and activities also depends upon the
choice of procedure.
