The classic bunion is a bump on the side of the great toe joint. This bump represents an actual deviation of the 1st metatarsal. In addition, there is also deviation of the great toe toward the second toe. In severe cases, the great toe can either lie above or below the second toe.
What causes bunions? This question is often answered by blaming shoes. But in fact, shoes only play a small role in developing bunions. Yes, shoes, especially high heels cause abnormal squeezing of your forefoot. This in turn to help promote a bunion. But if everyone who wore high heels shoes had a bunion, there would be a lot more then the 15% prevalence we see in the general population. As you can see from the flow chart, genetics plays the major role in development of bunion deformities.
Genetics determines the way your foot functions. Are you flatfooted? Are your joints flexible or stiff? Do you have a high arch? Do you have tight muscles? These traits are determined by your genetic code. These characteristics then govern how your bones and joints move when you walk. As an example, if your joints are very flexible, this can cause an abnormal amount of instability in your forefoot when you walk. Over time, this abnormal motion will cause the a bunion to develop by allowing your first metatarsal to "drift" towards the mid-line of your body.
The fundamental driving force behind developing bunions as a result of faulty foot mechanics is genetics. Issues such as loose ligaments and flat feet, are inherited. The traits then act as the foundation for abnormal foot mechanics and lead to formation of bunions.
The most common symptoms associated with this condition are pain on the side of the foot just behind the great toe. A red painful bump is usually present. Pain is usually brought on with walking or sports. Shoes don't cause bunions but will typically aggravate them. Stiff leather shoes or shoes with a tapered toe box are the prime offenders. This is why bunion pain is most common in women whose shoes have a pointed toe box. The bunion site will often be slightly swollen and red from the constant rubbing and irritation of a shoe. Occasionally, corns can develop between the 1st and 2nd toe from the pressure the toes rubbing against each other.
Normal bisection of metatarsal bones
Red line: Abnormal bisection of first metatarsal
Green line: Correct bisection if bone where not splayed out
Treatment falls into two broad categories, conservative and surgical. From a conservative standpoint, efforts are directed at correcting faulty foot mechanics with custom molded insoles and relief of symptoms. These include:
- Custom Orthosis to stabilize the abnormal motion of the hind and fore foot.
- Shoe gear modification: Using shoes with larger toe boxed and more supple materials.
- Changes in activities: Try to avoid those things which cause symptoms.
- Anti-inflammatory medication for periodic relief this includes cortisone injections into the joint as well as oral medication.
The primary goal of bunion surgery is to relieve the pain associated with the deformity. This is accomplished by:
- correcting the underlying abnormal metatarsal position by realigning it toward the second toe.
- Removing excessive bone formation on the bunion "bump"
- releasing the soft tissue tightness which is pulling the big toe towards the second toe.
- Tightening the soft tissues which are overly stretched on the bump side of the joint.
- Reestablish the correct alignment of the cartilage surfaces.
- Move the sesamoid bones into correct alignment.
- Realign the great toe.
Bunion surgery procedures are based on many factors, including health, age and lifestyle of the patient. However, a critical factor in procedure choice is the grading of the bunion deformity.
Bunions are grade by the severity into three broad categories:
- Mild: Patient's symptoms may include pain and throbbing with activities. There is a slight bump. There is no arthritis of the joint.
- Moderate: Patient's symptoms may include pain and throbbing most days regardless of activity level. Patient has difficulty wearing most styles of shoes without pain. There is a moderate bump. Some arthritis maybe present in the joint. The big toe is pressing firmly against the second toe.
- Severe: Patient's has pain daily. Large bump which is red and irritated from shoes and may deform shoes. Inability to wear all styles of closed shoes without pain. Arthritis is present within the joint. The big toe and second toe may overlap. The big toe cannot be straightened manually.
This is the term used to describe surgery which is performed exclusively around the great toe joint. There are several proximal procedures, including "Austin" or chevron procedure and "distal L" or Reverdin-Laird procedure. Indication for a proximal surgery include:
- Mild to moderate bunion deformity;
- Inability to tolerate proximal procedure;
- Minimal to no arthritis within the joint.
- Performed under a local anesthetic. You are, however, sedated by an anesthesiologist prior to injection of the numbing agent to your foot.
- Incisions are located around the great toe joint only.
- Weight bearing is started right after surgery unless instructed otherwise.
- Return to work in 1 to 2 weeks if you primarily work in an office setting, sitting most of the day. If you work on your feet throughout the day, such as in heavy industry (wearing steel toed boots, no light duty) you may require 4 to 6 weeks off of work.
- Return to low impact cardio (walking, elliptical trainer) in 4-5 weeks.
- Return to high impact activities (running, soccer, softball, etc) in 10-15 weeks.
- Return to athletic shoes in 1 month, dress shoes without a heel in 2 months, high heels in 3 months.
- Before and After Pictures of Bunion Surgery
Moderate bunion deformity
Example of moderate bunion surgery correction
via a distal bunionectomy
This is the term used to describe surgery which is performed in the around the big toe joint and in the middle part of the foot. Procedures we perform include Lapidus bunionectomy and crecentic bunionectomy. Indications include:
- Moderate to severe deformity;
- Hypermobility (excessive motion) of the metatarsal;
- Rapidly progressing deformity.
Details of a proximal bunion surgery:
- General anesthesia or local anesthesia
- Incisions are located around the great toe joint and the midfoot.
- No weight is allowed on the foot until healing of the fusion site is seen on x-ray (usually 6 weeks);
- Return to work in 2 to 3 weeks if you primarily work in an office setting, sitting most of the day. If you work on your feet throughout the day, such as in heavy industry (wearing steel toed boots, no light duty) you may require 10 to 12 weeks off of work.
- Return to low impact cardio (walking, elliptical trainer) in 8 to 10 weeks.
- Return to high impact activities (running, soccer, softball, etc) in 4 to 6 months
- Return to athletic shoes in 8 to 10 weeks, other style of shoes will depend on extent of pre-operative joint damage.
- Before and After Pictures of Bunion Surgery
X-ray of a moderate bunion deformity with hypermobility
Lapidus proximal bunion surgery