Bunion

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.

1st metatarsal phalangeal joint - the big toe joint. Made up by the 1st metatarsal bone on the proximal side of the joint and the proximal phalanx of the hallux on the distal side of the joint.

Bunion - an enlargement of bone at the medial aspect of the 1st metatarsal phalangeal joint

Distal phalanx - the most distal phalange (bone) of a toe or finger. Most toes and fingers consist of three phalanges.

Hallux - refers to the great toe.

Hallux limitus - limitation of the motion of the 1st metatarsal phalangeal joint (big toe joint)

Hallux rigidus - complete limitation of motion of the 1st metatarsal phalangeal joint. h. rigidus is a step beyond h. limitus.

Metatarsus primus elevatus - a fixed elevated position of the 1st metatarsal bone.

Middle phalanx - the middle phalange of a toe or finger. Most toes and fingers consist of three phalanges.

Proximal phalanx - the most proximal phalange (singular) of a toe or finger. Most toes and fingers consist of three phalanges.

The 1st metatarsal bone, one of the five metatarsal bones, is located on the medial (inside) of the arch and is about the size of your index finger. The 1st metatarsal forms the proximal aspect of the 1st metatarsal phalangeal joint. The distal portion of the joint is compromised of the base of the proximal phalanx of the hallux.

As a bunion develops, the 1st metatarsal progressively moves out, away (medially) from the foot to form a prominence. The hallux (big toe) also changes in position and drifts towards the second toe. As a result, the joint subluxes, or buckles, and forms the bump that we know as a bunion.

Inheritance plays a powerful role in the formation of a bunion. It's not that you inherit a bunion, but more that you inherit the bones, joints, ligaments and related musculoskeletal structures that will form a bunion just like your mother and your grandmother did. These biomechanical characteristics are as unique to you as your facial characteristics or your hair color.

Several biomechanical factors have been identified as factors that contribute to the formation of a bunion. First is equinus, or a tightness in the calf muscle. Second is forefoot valgus. Forefoot valgus is a term used by podiatrists to describe the position of the bones in the forefoot in relationship to the heel. Valgus means that the 1st metatarsal is lower than the 5th metatarsal.

With every step that we take, these biomechanical forces recreate themselves. Over time, what we see is the progressive drift of the 1st metatarsal medially, or away from the foot resulting in a gap between the 1st and second metatarsals. The prominence we know as a bunion is actually the head of the 1st metatarsal as it drifts medially. Equinus and forefoot valgus place the 1st metatarsal un a position where it must increase it's normal range of motion. The increased range of motion and load applied to the 1st metatarsal results in a tendency for early formation of a bunion.

The formation of a bunion is due to medial drift of the 1st metatarsal.  As the 1st metatarsal drifts, the soft tissue structures that cross from the foot to the hallux remain in place, particularly the tendons that govern the function of the toe. As the first metatarsal drifts, the tendons will 'drag' the hallux (big toe) toward the second toe. This change in the position of the joint, between the 1st metatarsal and the toe, creates a subluxation of the great toe joint.  Subluxation is the term used to describe a joint that is function outside of its normal position.

The symptoms of a bunion can be described in as two categories of pain; intra-articular (within the joint) and extra-articular (outside/shoe) pain.

Intra-articular pain is due to jamming or subluxation of the joint. This may cause motion in and area where there is no cartilage or may crush the soft bone beneath the joint. Intra-articular pain is pain that is deep within the joint and described as an ache that continues even after the shoes are removed.

Extra-articular pain comes from direct pressure on the bump itself from shoes. Remove the shoes and the pain goes away.

The differential diagnosis for a bunion should include;

Arthritis

Gout

Hallux limitus

Hallux rigidus

Pseudogout

Psoriatic arthritis

Septic arthritis

• Gout

• Pseudogout

• Hallux Rigidus

• Hallux Limitus

• Arthritis Of The Foot and Ankle

This article was written by Jeffrey A. Oster, DPM last updated 2/5/13. Additional references include;

Drago, J.J., Olaf, L., Jacobs, E.M., A comprehensive review of hallux limitus. J. of Foot Surgery. 23:213-220, 1984

Hanft, J.R., Mason, E.T., Landsman, A.S., Kashuk, K.B., A new radiographic classification of hallux limitus. J. of Foot and Ankle Surgery, 32(4):397-404, 1993

Shereff, M.J., Baumhauer, J.F., Hallux rigidus and osteoarthrosis of the first metatarsalphalangeal joint. J. of Bone and Joint Surg. 80-A(6):898-908, 1998

Laporta, G., Melillo, T., Olinsky, D. X-ray evaluation of hallux abducto valgus deformity, J. Am. Podiatry Assoc. 64:544-566, 1974

Camasta, C. A., Hallux limitus and hallux rigidus. Clinical examination, radiographic findings, and natural history. Clin. Podiatr. Med Surg. 13:428-448, 1996

Ronconi, P., Monachino, P., Baleanu, P.M., Favilli, G. Distal Oblique Osteotomy of the first metatarsal for the correction of hallux limitus and rigidus deformity J. of Foot and Ankle Surg. 39:3 154-160 2000

Lundeen, R.O., Rose, J.M. Sliding oblique osteotomy for the treatment of hallux valgus associated with functional hallux limitus, J. Foot and Ankle Surg. 39:3 161-167