Milton J. Stern, DPM

What is a Bunion?

A bunion is an enlargement of the bone at the base of the big toe. The medical term for this condition is Hallux Valgus, which means a turning outward of the great toe. Bunions are one of the most common forefoot deformities. These usually begin when the big toe starts moving toward the smaller toes because of the shoe gear. This shifting of the bones causes a bony prominence on the side of the patient’s foot (the bunion joint). Over a period of time the big toe may come to rest under (occasionally over) the 2nd toe. A bunion is more common in women then men due to the fact that women tend to wear tighter shoes. Wearing high heel shoes even further puts stress on the bunion because all the body’s weight rests there.This condition can cause a variety of different soft tissue and bone complaints, which may result in severe pain.

What causes a Bunion?

There is no one single cause of bunions. A bunion is commonly a symptom of faulty mechanics of the foot. The imbalance of the forces on the big toe causes the bunion deformity to start and increase progressively with time. Usually there is abnormal foot function, with excessive pronation. This is the excessive rolling in of the foot at the ankle joint while you are walking. The deformity seems to run in families so there is an inherited component. Those people with flat feet seem to develop the typical bunion whereas people with high arches develop the arthritic type bunion more frequently. No matter what type of foot you have inherited it is the type of shoes that make the progression of the bunion increase. The most important causative factor is poor fitting footwear. This accounts for a higher incidence among women than men. As the big toe is pushed toward the second toe by our shoes, it changes the structure of the joint. The skin and deeper tissues deform, become inflamed and swell. Some systemic problems such as rheumatoid or osteoarthritis can cause bunion development of bunions. If one leg is longer that the other then the longer leg is more inclined to develop a bunion. Trauma to the first joint can set an arthritic type bunion. People with very flexible feet tend to develop bunions.

What are the symptoms of a Bunion?

The patient’s feet may become too wide to fit into their normal size shoe. Redness, swelling and pain may be present along the inside margin of the foot. Moderate to severe discomfort may occur when the patient is wearing tight shoes. A hammertoe may occur of the 2nd toe. This is when the toe contracts and allows the toe to press on the shoe. Subsequently, this may cause a corn on top of the second toe. A painful callus may develop over the bunion or at the bottom of the foot. A callus usually occurs on the sole of the foot directly under the second toe. Painful corns may develop due to abnormal pressures being exerted on to the foot. These may occur in between the 1st and 2nd toes and on the 5th toe. There may be irritation caused by the overlapping of the 1st and 2nd toes. Stiffness may occur at the big toe due to secondary arthritis occurring, this is known as hallux rigidus. The bunion may have a fluid filled sack called a bursitis. This can be very painful and can become infected. An in growing toenail may occur on the 1st toe due the excessive pressures being applied to it. In some cases, due to the chronic pressure caused by the bunions, the corns, calluses or bursitis present can become ulcerated and infected.

What can you do for a Bunion?

Wear wide fitting shoes, preferably with a leather upper, which will allow a stretch. Make sure the shoe has a good support structure, which will control foot motion. Use an arch support also to control abnormal foot motion. Avoid high-heeled shoes. If your bunion becomes painful, red and swollen, try using ice on the joint and elevate the foot on a stool. Apply a commercial bunion pad, making sure it is not too rigid or medicated. A bunion shield can reduce the pain over the bunion. Apply a moisturizer twice daily to hard skin and use a pumice stone to reduce the thickness of the hard skin. Ignoring the condition hoping that it will go away on its own is not a good idea. Do not try to remove any painful build up of skin yourself. This includes picking at them or using a sharp razor blade to remove them (especially if you are diabetic).

What the podiatrist will do for a Bunion?

With most orthopedic conditions in the foot there are several different treatment plans available. The most important first line treatment is to adequately diagnose the condition. Once the condition is diagnosed there are usually three different approaches. The first is to do no active treatment but just to monitor the condition.
Have the patient follow the above steps in “What you can do for your bunion?” The second option is to accommodate the foot. By this we mean treat the pain. This might include injections, strapping of the foot, arch supports, physical therapy or oral medications. When we accommodate we don’t make the deformity go away, but try to make the pain decrease. The third option is to correct the condition. For bunions this always requires some sort of surgical intervention. There are two main reasons to consider surgery for your bunions. The first is if you are in pain and conservative care has not rendered you pain free. The second is if you have a deformity that progressively has gotten worse and waiting would require more extensive surgery at a later date.

Evaluation of the bunion is essential to the proper surgical approach. The most important consideration is the angle between the first and second metatarsal.This is called the IM angle.This stands for the inter-metatarsal angle. The picture on the right shows that angle. We have three different surgical approaches based on this angle. Of course the structure of the rest of your foot also adds to our decision. If your IM angle is 0-10 degrees we call this a simple bunion. We can just remove the bunion bump and do some soft tissue work around the bunion. Usually you can walk on this the same day as the surgery.

If your IM angle measures 11-14 degrees we call this a moderate bunion. If you just take off the bump as a simple bunion then the chances of the bunion reoccurring increases. We want to try to decrease this angle. We try to move the metatarsal head closer to the second metatarsal. This effectively reduces the IM angle by up to 4 degrees. There are sometimes additional corrections needed to straighten the big toe. By moving the head of the metatarsal over in a moderate bunion the recurrence rate goes down drastically. Usually this requires you not to walk on the foot for a period of 10-21 days.

If your IM angle is over 14 degrees we call this a severe bunion. This usually requires work to be done at the base of the metatarsal. We can reduce the IM angle to almost zero depending on the structure of the rest of the forefoot.This requires you not to walk on the foot for a period of 6-7 weeks. A combination of procedures may be necessary with severe bunions. We may need to do work at the head of the bunion also.

With all these bunions we evaluate how much the big toe is drifting towards the second toe and we also evaluate the joint itself. Each of these may require a little extra work. If the joint is totally arthritic and cannot be saved then it might have to be replaced with an artificial one. Many of the arthritic joints if caught early enough can be saved or at least not need artificial joints for a more prolonged period of time.

Bunion surgery has come along way over the last 30 years and the recurrence rate had dropped dramatically as long as you properly evaluate the IM angle on the weight bearing x-ray.