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.

The images below show the basic steps used in a bunion surgery called a Modified Austin Procedure. An Austin procedure is the most commonly performed bunionectomy today. Image 1 shows the dissection down through the skin and joint capsule, exposing the head of the first metatarsal. Image 2 shows the V cut (osteotomy) through the distal first metatarsal. The distal fragment is then physically shifted towards the second toe and fixated with screws (Image 3 and 4). Image 5 shows placement of a pain pump catheter in the wound site. The final image shows placement of the pain pump reservoir and final bandage.

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.

• 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.

But before we go any further, we need to understand that the terms turf toe and hallux limitus are indeed related but aren’t really 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.

Think of turf toe (hallux limitus) as an isolated case of osteoarthritis limited to the great toe joint. As the injury progresses, a series of micro fractures will develop in the subchondral bone. The typical soft spongy character of the metaphyseal bone (supporting bone beneath the joint surface) changes to become brittle and hard. The result is that the articular cartilage looses its’ underlying support and becomes susceptible to damage.  What you see on x-ray is the slow progressive destruction of the joint.

Turf toe (hallux limitus) 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. The joint 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.

Treatment of turf toe

Treatment of turf toe varies and may include rest, shoe modifications, orthotics, steroid injections and surgery. The success of non-surgical care will vary with the stage of injury, the rate at which the injury is healing and how much osteoarthritis has occurred (see our pages on hallux limitus for staging). 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 motin of the great toe joint.

Should a patient not respond to conservative care of turf toe in a reasonable time period, we are not reluctant to suggest surgical revision to address the problem whether it be revisions of the joint defect, shortening of a long first metatarsal or structural revision of metatarsus primus elevatus. As mentioned before, the clinical appearance of dorsal lipping or visible radiographic changes are suggestive of moderately advanced osteoarthritis, a condition that can only be repaired by joint revision or replacement.

Remember, turf toe is just one form of hallux limitus.  Be sure to visit our page on hallux limitus for a thorough discussion of this condition.

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.

Forefoot conditions specific to the 1st mpj.

1. Bunion
2. Gout
3. Hallux limitus
4. Hallux rigidus
5. Pseudogout
6. Sesamoiditis and sesamoid fractures
7. Turf toe

Forefoot conditions specific to the lesser mpj's (2-5).

1. Bursitis
2. Capsulitis
3. Freiberg's Infraction
4. Metatarsalgia
5. Morton's Neuroma
6. Metatarsal stress fractures
7. Tailor's bunion

Anterior tarsal tunnel syndrome.

Austin bunionectomy with screw fixation.

Baxter's nerve dissection for Baxter's nerve entrapment.

  Brostrom lateral ankle stabilization.

Charcot joint reconstruction.

Common peroneal nerve release.

Endoscopic decompression of Morton's neuroma (EDIN).

Endoscopic gastrocnemius recession.

Endoscopic plantar fasciotomy.

Ganglionic cyst excision.

Glomus tumor excision.

Hallux rigidus correction with implant.

Metatarsal osteotomy (Jacoby).

Modified Kidner procedure.

Mucoid cyst excision

ORIF Jones fracture, 5th metatarsal.

ORIF spiral oblique fracture, 5th metatarsal.

The most common cause of 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 evaluated 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 images show a tailor's bunionectomy with 5th metatarsal osteotomy. Image 1 shows the approach marked on the dorso-lateral aspect of the distal 5th metatarsal. Image 2 shows the 5th metatarsal head free of soft tissue and a bone saw being used to resect the tailor's bunion. Image 3 shows a saw being used to create the 5th metatarsal osteotomy. Image 4 shows fixation with a Kirschner wire and image 5 shows final skin closure.

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.