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Bunions - causes, treatment, surgery, prevention

 
A bunion is a bony lump that forms at the base of the big toe.  It occurs when the bones of the big toe get pulled towards the smaller toes, forcing the joint at the base of the big toe to stick out. This causes ligaments and tendons around the big toe joint to stretch, there may be additional bone formation 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 osteoarthritis

Signs and symptoms

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.
Bunions 1

 

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 shoes can be painful because most shoes do not allow room for the bunion and put pressure on the joint of the big toe.

Causes

It is thought that the primary cause of bunions is problems with bone structures in the feet. There are a number of different reasons 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.  That's because some foot types, eg: flat feet and feet worth low arches and/or loose tendons and joints, are more prone to developing bunions than other types of feet.

Factors that are known to increase the risk of bunions include: 

  • Wearing improperly fitting shoes (particularly narrow pointed toe and/or high-heeled shoes)
  • Certain arthritic conditions (eg: rheumatoid arthritis) 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. Bunions are also more common in people who routinely wear shoes and whose jobs involve a lot of standing and walking, eg: nurses and teachers.

Diagnosis

People will visit their doctor when the pain and deformity of a bunion interfere with daily tasks and physical activity. The doctor will 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 will also allow any other conditions that may be affecting the joint, such as osteoarthritis, to be seen.

Treatment

Bunions will not go away on their own and if left untreated can led to disability and physical inactivity.  

Non-surgical (conservative) 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 (a health professional that specialises in foot care) 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, such as ibuprofen can help to ease pain in the short term. Corticosteroid 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 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 osteoarthritis is present in the joint. 

What to expect after surgery

During the initial recovery following surgery compression dressings and a splint boot or short cast may be used to support the foot. Stitches are usually removed about two weeks after the operation.
 
Following removal of the stitches, dressings or a splint may 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.
 
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.
 
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 could be planned for 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.

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 (2016). Bunion surgery (Web Page). Rosemont, IL: American Academy of Orthopaedic Surgeons (AAOS). https://orthoinfo.aaos.org/en/treatment/bunion-surgery/ [Accessed: 14/01/20]
Harvard Health Publishing (2018). What to do about bunions (Web Page). Boston, MA: Harvard Medical School of Harvard University. https://www.health.harvard.edu/diseases-and-conditions/what-to-do-about-bunions [Accessed 14/01/20]O’Toole, M.T. (Ed.) (2017). Bunion. Mosby’s Dictionary of Medicine, Nursing & Health Professions (10th ed.). St Louis, MI: Elsevier.
MedicineNet (2018). Bunions (Hallux valgus) [Web Page]. New York, NY: WebMD LLC. http://www.medicinenet.com/bunions/article.htm [Accessed: 14/01/19]

Reviewed – January 2020

 

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