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.

Treatment of hallux rigidus

Conservative care of hallux rigidus focuses on the use of pads to limit the range of motion of the great toe or devices to stiffen the shoe.  Turf toe straps are a great short term aid for symptoms of hallux limitus and hallux rigidus.  Turf toe plates and carbon spring plates are two examples of inserts that can be used to stiffen the shoe.  Shoe modifications are also used to decrease bending of the forefoot.  The most common modification is called an anterior rocker sole, seen at right.

Surgical care of hallux rigidus may include a Keller bunionectomy, great toe fusion or implant arthroplasty.  A Keller bunionectomy is an old procedure that utilizes the capsule of the great toe joint to create a new joint.  The capsule, or lining of the joint is interposed in the position where the joint is resected.  The disadvantage of the Keller bunionectomy is that the great toe is usually much shorter and floppy post-op. 

Fusion of the great toe joint is accomplished by resection of the joint and fixation of the joint with crossed screws or a plate.  A bone graft is often used to supplement shortening created when the joint is resected.  The bone graft can be from bone bank bone or from the iliac crest (crest of the pelvis).  Fusion of the great toe joint requires a 6-8 week period of non-weight bearing for proper healing.

Implant arthroplasty involves resection of the joint and replacement of the joint with a flexible hinge.  The following pictures show the steps used to perform implant arthroplasty of the great toe joint.  Image 1 shows the pre-op planning and location of the incision.  Images 2 and 3 show dissection of the joint and removal of arthritic spurring surrounding the the joint.  Image 4 shows the trial implant sizers.  Images 5-8 show remodeling of the joint with preparation of the implant site.  Image 9-12 shoe placement of the implant and final closure.  This procedure is performed at a hospital or surgery center under general anesthesia or local anesthesia with sedation.  The procedure takes about and hour to complete.  Patients can bear full weight on the foot immediately following surgery.

For additional information regarding the onset and development of hallux rigidus, please refer to our pages on hallux limitus.

Hallux limitus is caused by four contributing factors. These factors include the following;

1. A long 1st metatarsal.
2. An elevated 1st metatarsal.
3. An impaction injury of the 1st mpj resulting in an osteochondral defect (OCD) of the joint.
4. Systemic diseases that cause injury to the joint such as rheumatoid arthritis, lupus or gout.

Hallux limitus is graded in four stages;

Treatment of Hallux Limitus

Evaluation of the range of motion of the 1st mpj can be performed in two positions; relaxed and functional. In a relaxed position, with no resistance exerted by the calf, the 1st mpj shows normal range of motion without pain. In a functional position, when resistance is applied by the calf, the range of motion of the 1st mpj changes and hallux limitus can be more appropriately assessed. The term functional hallux limitus is applied to cases that have normal range of motion in a relaxed position, but decreased range of motion in a functional position.

Assessment of hallux limitus requires evaluation of the 1st mpj in both a relaxed and functional position. Is there crepitus (grating or cracking) with range of motion? Does the joint catch or pop? Is there pain with range of motion? Each of these signs can indicate a certain stage of hallux limitus.

Conservative care of stage 1 hallux limitus may include the use of a dancer's pad or orthotic custom made with a sub 1 cut out pad. These two types of pads are used in an attempt to increase the plantarflexion of the 1st metatarsal to improve range of motion of the 1st mpj. As we progress into more advanced stages of hallux limitus (2-4), the dancer's pads will no longer be effective. At this stage, we change treatment to a stiff insert with a rigid extension called a Morton's extension. A Morton's extension is used to stiffen the shoe to decrease painful range of motion. Another short term solution for stage 2-4 is to use a turf toe strap to limit range of motion.

Injectable cortisone is often used to treat hallux limitus. There is some debate as to the merit of using cortisone for the treatment of hallux limitus. As noted above, the majority of cases of hallux limitus are due to aberrations in the biomechanical properties of the 1st mpj. Therefore, common sense would say that the most effective method of treatment for hallux limitus would be to change or alter the biomechanical property that is casing problems. For instance, if hallux limitus is due to a long first metatarsal, then shorten the metatarsal. Cortisone cannot treat these biomechanical factors and therefore must have only a minimal role in the treatment of hallux limitus.

There are a number of common surgical procedures used to correct hallux limitus. One method of care is a procedure called a cheilectomy. Cheil means lip and a cheilectomy is a procedure that focuses exclusively on resection of the dorsal exostosis (the lip) of the 1st metatarsal head. A second type of surgery for hallux limitus is a metatarsal osteotomy and cheilectomy. The metatarsal osteotomy, often called a Youngswick's modification of an Austin bunionectomy, creates an break in the bone that can either shorten or plantarflex the head of the metatarsal. The osteotomy is important because it addresses the primary reason for hallux limitus. It should be noted that there is not universal agreement among doctors as to which of these procedure is the best solution for hallux limitus.

Many surgeons believe that hallux limitus can be corrected with a simple cheilectomy. The advantage to performing just a cheilectomy is that a person will regain some range of motion and be back on their feet relatively quickly. The disadvantage to performing just the cheilectomy without osteotomy is that the primary biomechanical reason for hallux limitus will not be addressed. In time, the dorsal lip will return and arthritis within the joint will increase. The disadvantage of an osteotomy is that it increases the difficulty of the surgery and increases healing time.

Cheilectomy and osteotomies are procedures applicable to stage 2 and 3 hallux limitus. In addition to these procedures, revision of the joint may be performed to repair or induce regeneration of the cartilage. Transchondral drilling is a technique used by many doctors to resurface the joint during surgery. Transchondral drilling means that a fine drill is used to drill through the hard layer of bone (subchondral bone) just beneath the surface of the cartilage. Drilling provides access to bone cells in the marrow of the bone that can become cartilage cells. Another technique used to resurface the joint involves the use of a osteochondral graft often referred to as an OAT procedure or osteo-articular transfer. OAT grafts can be harvested from other joints (often the knee) to transfer to the damaged cartilage of the 1st mpj. Synthetic bone graft material can also be used for joint resurfacing.

Surgical repair of stage 4 hallux limitus again has disagreement among doctors as to the best choice of procedure. In stage 4, often referred to as hallux rigidus, the surface of the joint is so badly damaged that the joint is not salvageable. Implant arthroplasty is one choice. Implant arthroplasty involves resection of the joint and replacement of the joint with an implant. The advantage of implant arthroplasty is that the implant will maintain the normal length of the toe and preserve normal range of motion. Another technique used in stage 4 hallux limitus is fusion of the 1st mpj. Fusion of the joint requires a period of non-weight bearing for proper healing. The disadvantage of 1st mpj healing is that the toe may be shortened due to resection of the joint. A bone graft may be taken from the hip to supplement length. Another disadvantage of fusion is permanent stiffness of the 1st mpj. The last option for stage 4 hallux limitus is a Keller bunionectomy. A Keller bunionectomy is a procedure where the base of the great toe is resected and a new joint created using a flap of the joint capsule. This technique is called an interpositional arthroplasty; interposing the soft tissue to create a joint. The advantage of a Keller bunionectomy is that it is easy for patients to get back on their feet. The disadvantage is that the great toe becomes loose, short and floppy.

Surgical correction of hallux limitus is performed at a hospital or outpatient center. The procedure takes approximately 1 hours to complete. A local anesthetic with sedation or general anesthesia is used. Patients are able to bear weight on the foot immediately post-op for limited periods of time. A walking cast will be used for 6 weeks post-op. Variations in this procedure may include K wire fixation or absorbable pin fixation.

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