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Bunions - causes, treatment, surgery, prevention

A bunion is the enlargement of the joint at the base of the big toe.  It occurs as a result of the misalignment of the bones of the big toe. This leads to stretching of the ligaments and tendons around the big toe joint and causes soft tissue over the joint to become inflamed and painful. There may be additional bone formation (exostosis) in the joint and the skin around the joint may become red and tender. Over time the cartilage in the joint can break down, leading to arthritis. 
 
 

Signs and symptoms  

With an advanced bunion, the big toe joint can be significantly deformed.  The big toe can crowd the other toes and may lie over or under the second toe.  The larger the bunion gets, the more it hurts to walk. Wearing any type of shoe can be painful.
 
 
Symptoms of bunions tend to increase over time as the condition worsens. Typical symptoms include:
 
  • Deformity of the big toe joint
  • Growth of a bony lump (exostosis) at the side of the big toe joint
  • Pain, redness and tissue swelling (bursitis) over the big toe joint, with thickening of overlying skin
  • Pain when walking (particularly during the "push off" phase)
  • Overlapping of the big toe above or below the second toe in severe cases.

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Causes

It is thought that the primary cause of bunions is a mechanical instability in the big toe joint. There are a number of different reasons as to why this may happen. Bunions tend to run in families so a person with a family history of bunions has an increased risk of developing them.  Factors that are known to increase the risk of bunions include:
 
  • Wearing improperly fitting shoes (particularly narrow and/or high-heeled shoes)
  • Certain arthritic conditions and ligament disorders
  • Age (the incidence of bunions increases with age)
  • Being flatfooted with feet that roll inwards (over pronation)
  • Past injury (trauma) to the foot
  • Nerve conditions affecting the foot.
Bunions most commonly affect women (approximately 90% of cases) and are less common in people who do not regularly wear shoes.
 
 

Diagnosis  

People with bunions may be concerned about the changing appearance of their feet, but it is usually the pain caused by the condition that leads them to consult their doctor.  The doctor will evaluate any symptoms experienced and examine the affected foot for joint enlargement, tissue swelling and/or tenderness. They will also assess any risk factors for the condition and will ask about family history.
 
An x-ray of the foot is usually recommended so that the alignment of big toe joint can be assessed. This would also allow any other conditions that may be affecting the joint, such as arthritis, to be seen.
 
 

Treatment  

Non-Surgical Treatment
 
In most cases the symptoms of bunions can be reduced or relieved without surgery. Reducing pressure on the bunion is the first step in reducing the pain associated with the condition. Wearing correctly fitting shoes is important in achieving this.
 
A referral to a podiatrist may be made in order to assess the need for special orthotic devices, such as custom-made arch supports and shoe inserts (eg: metatarsal pad or bar). These can help to relieve tension on the base of the big toe and help prevent flat-footedness. Specific exercises and bunion pads available over-the-counter at pharmacies may also be of benefit.
 
Anti-inflammatory medicines can help to ease pain in the short term. Steroid injections may be used to relieve severe pain.  If a sufficient reduction in symptoms is not achieved by non-surgical treatment, then surgery may be recommended.
 
Surgery
 
The main goal of surgery is to realign the big toe joint in order to relieve symptoms, correct deformity and restore function. Surgery to remove a bunion is known as a bunionectomy. There are many variations of this operation and the type of surgery performed will vary depending on factors such as the degree of deformity, the strength of the bones, the person's age and the surgeon’s preferred approach.
 
Most surgery involves the removal of the bony outgrowth (exostosis) and the realignment of the bones of the joint. Soft tissue structures such as the ligaments and tendons may be repositioned and the bursa may be removed. The insertion of screws and pins may be required to stabilise the bones in their new, realigned position.
 
In cases where joint pain and deformity are severe, joint replacement surgery may be recommended. This may particularly be recommended when arthritis is present in the joint.
 
Surgery may be carried out under a local, regional or general anaesthetic. Most cases are performed as a day stay procedure.  However, an overnight stay in hospital may be required if the surgery is more extensive.  The type of surgery to be performed, the type of anaesthetic to be used and the expected hospital stay should be discussed with your surgeon prior to surgery.
 
 

What to expect after surgery

During the initial recovery following surgery the foot may be supported by compression dressings and a splint boot or short cast. Stitches are usually removed about two weeks after the operation. Following removal of the stitches, dressings or a splint may still need to be worn for some weeks to provide support and protection for the foot. Once the dressings and splints have been removed, shoes may need to be modified so that the foot fits comfortably, or it may be necessary to wear open shoes. Special orthotic shoes may also be suggested.
 
Clear activity and recovery guidelines should be given by the surgeon prior to discharge from hospital. It is important to follow these carefully. Excessive activity during recovery can disrupt healing and slow down the overall recovery time.
 
Some pain and discomfort is to be expected after bunionectomy surgery. Immediately following surgery, pain relief medication may be given by injection into a muscle or through a drip in the arm (intravenously). After discharge from hospital, anti-inflammatory and pain relieving medications, as well as cold packs and rest, usually provide adequate relief of pain.
 
Swelling is usual for about a month after the operation. A small amount of painless residual swelling may be present for another couple of months, making shoe fitting difficult. It is therefore important to elevate the foot and rest as much as possible, particularly in the early weeks. Bruising may be noticed around the operation site following the operation. This will gradually resolve.
 
Changes in sensation, such as numbness or “pins and needles” may be experienced following surgery. This is as the result of damage to small nerves during surgery and usually settles as the nerve endings re-grow. Normal sensation should return within a few weeks following surgery.
 
Any signs of infection should be reported to the surgeon immediately. These include fluid or pus discharge from the wound, throbbing pain, increased redness and swelling and raised temperature. Antibiotics may need to be prescribed to treat the infection.
 
 

Things to consider when planning surgery

A full recovery may take three months or more. Therefore surgery should be planned when it would be least inconvenient eg: during work holidays or in the warmer months when open shoes can be worn with comfort.
 
A person who does a less physical job, such as office work, will have a quicker return to work than a person who does heavy physical work or a lot of walking. The surgeon will give guidelines as to when a return to work and other activities can be achieved. When both feet are affected, the decision to have the bunions corrected together or individually will depend on the person’s circumstances and the advice of the surgeon. Possible risks of surgery include excessive bleeding, infection, non-union and/or non-alignment of the bones and failure to relieve pain. There are also risks with any operation that uses general anaesthesia. These risks should be explained by the anaesthetist or surgeon before the operation.
 
 

Prevention  

Choosing footwear that fits correctly, especially low heeled shoes with plenty of space for the toes, is one of the main ways that bunions can be prevented.   Always stand when trying on shoes to ensure they still fit comfortably when the foot expands under your body weight. Try shoes on both feet, and select the size appropriate for your larger foot. Use an extra insole if one shoe is looser than the other. Do not cramp the larger foot.
 
People prone to flat-footedness should consider the use of arch supports, orthotic shoe inserts or special orthotic shoes to prevent or delay the development of bunions.
 
 

References

American Academy of Orthopaedic Surgeons (2012) Bunion Surgery. American Academy of Orthopaedic Surgeons (AAOS). Illinois. http://orthoinfo.aaos.org/topic.cfm?topic=a00140
 
Anderson, K.N., Anderson, l. E & Glanze, W.D (eds). (2006) Mosby's medical, nursing, & allied health dictionary (6th ed.) St. Louis: Mosby-Year Book, Inc.
 
Shiel, W. C. (2006) Bunions. In MedicineNet.com. Foothill Ranch: MedicineNet Inc- http://www.medicinenet.com/bunions/article.htm
 
Last Reviewed – 1 March 2013
 
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