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
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
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
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.
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.
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
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.
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
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
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
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,
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
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