Foot Facts: Bunions

Have you ever been in a shoe store, seen a great new style of shoes, and really wanted to purchase them, but knew that they would hurt your feet because of your "bunions"? Many individuals suffer with this common foot deformity known as hallux abducto valgus or "bunion deformity". A bunion can cause severe foot pain affecting an individual's activity level, footwear choices, and self-esteem. A person with bunion deformity is usually very self-conscious about his/her feet.

The term "bunion" is commonly used to refer to a large "bump" or outward protrusion on the inside of the foot along the big toe joint. The "bunion" or bump is caused by the spreading of two foot bones that cause this large prominence on the inside of the foot. It is this protrusion of bone and skin that receives pressure from footwear that causes swelling, redness, irritation, and pain along the side of the joint. In severe cases, the big toe is pushed so far over that it pushes the second toe up onto it and the joint is effectively dislocated.

What causes this deformity to occur?
There are several opinions as to the actual cause of bunion formation. While there are many factors that may or may not lead to development of this deformity, the main cause is thought to be an instability in the mechanics of the first metatarsal (foot bone) phalangeal (toe bone) joint; in lay terms, the joint at the base of the great toe. There is a normal balance of forces exerted on the bones, muscles, ligaments and tendons of our feet that allows our joints to function in a certain way when we walk. If there is a disruption in this balance, it can lead to instability at the joint causing the bones to move into abnormal positions. This instability may come from the way we walk, the foot type we have inherited, the shoes we wear, or from other sources.

We all inherit a certain foot type or developmental pattern of our foot bones. If this inherited bone structure causes an improper alignment of the bones, when we walk, body weight and certain muscular forces may exert abnormal stresses on the bones and their joints. It is over time with the many thousands of steps we take that these stresses ultimately lead to instability and joint displacement in some individuals. There is great debate as to whether improper shoes can actually cause instability in this joint, worsen the progression, or simply aggravate the symptoms. Other causes may include: neuromuscular disorders, laxity in the ligaments, congenital birth defects, trauma, or rheumatoid arthritis. In one way or another, they all may lead to a disruption in the balance of forces at the joint leading to a bunion formation.

Evaluation:
A proper examination is important in evaluating a bunion. The bunion may be classified as mild, moderate, or severe depending on the amount of displacement of the big toe joint and the amount of spreading of the key foot bones. The physician will focus his examination on symptoms that you may be experiencing, how long you have had them, and what makes the pain dissipate or increase. Other areas that are important for the evaluation of the bunion problems are past medical history and family medical history. Do relatives have bunion problems or related joint abnormalities? These are just a few of the questions that your doctor may ask you. They are all important in deciding which type of treatment may best help you. X-rays are an essential part of the evaluation process. Radiographs reveal the position of the metatarsal/phalangeal bones and the joint. With the x-rays, the physician is also able to determine the severity of the deformity and evaluate the joint for possible arthritis. Your doctor will examine how you walk, since the instability that occurs at the metatarsal phalangeal joint leading to bunion development occurs while the foot is in motion.

Treatment:
Treatment options should be geared to each person individually. The first step in relieving pain that is associated with bunions is to wear wider shoes. Conversely, it is imperative to avoid those new fashionable pointed shoes. For women, this may mean switching to a dress flat and eliminating the traditional high-heeled pump. Most patients have already tried changing shoes before ever seeking care from a doctor. Sneakers or other supportive walking shoes may allow extra toe room. Proper fitting shoes may help to control the deforming forces that can lead to instability in the joint. Bunion guards or pads can sometimes be helpful in eliminating pressure over the bump. These can be purchased over the counter at many pharmacies or markets. They can range from simple felt or foam pads to the new silicone versions. Bunion splints can be worn at night or in shoes, however, these are usually employed after surgery in an effort to prevent recurrence. Orthotics, or over-the-counter insoles can help reduce biomechanical stresses on the joint and help relieve pain. Currently studies are being performed to determine if prescription insoles will impede the progression of a bunion. Many physicians also use orthotics after surgery to help better align the foot and again possibly help prevent recurrence. Anti-inflammatory medications or the short-term use of steroid and local anesthetic injections may relieve severe joint pain. It is always recommended that these conservative treatment options be attempted before considering any surgical intervention.

Surgery:
The surgical treatment of hallux abducto valgus will vary depending upon the severity of the deformity and what the patient's expectations and goals happen to be. X-rays are important in determining which surgical procedure is to be performed. There are over 30 different types of bunion procedures that can be performed. The type of surgery chosen will depend on the causes and deforming factors that are present. The surgical recommendation should also be taken into consideration along with the patient's age, body type, medical history, activity level or occupational requirements. Most surgical options focus on repositioning the bones and realigning the joint. By repositioning the metatarsal phalangeal joint, the prominence or bump of bone will be eliminated. This usually relieves any ongoing joint pain. A cut is made in the bone, the bone is shifted, and then held in place either with a pin, wire, or screw. The position of the cuts in the first metatarsal bone varies depending on the severity of the deformity. Along with the repositioning of the bones, there is the release of specific tendons or ligaments that, if left untreated, would add to the continued instability of the joint. In cases where a person has a very severe and painful joint, a joint replacement procedure may be done. This is usually seen in patients with associated arthritis in the joint. A simple removal or "bone shaving" of the bump may be performed. However, it does not correct or address the cause of the deformity and usually leads to a high probability of reoccurrence.

Summary:
A simple evaluation or examination by a Podiatrist can determine if you have a bunion deformity. The Podiatrist can inform you of specific treatment options that best suit your situation. All conservative treatment options should be exhausted before pursuing a surgical recommendation.