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[If the bump is on your little toe, that’s a Bunionette. Click here to head to that section!]
[If the bump is directly on top of the base of your toe, instead of to the side, that may be Hallux Limitus!]
There are 3-4 things that are predicable in life and I bet that no one would put bunions on that list. This may not be true for everyone, but there are families where this will be a very predicable problem. There is a strong family trait for the mechanics that will create this deformity. (Notice we haven’t mentioned shoes at all yet.)
Bunions are one of the most common foot deformities in the United States, particularly among women. By some accounts, up to 50% of women may develop one at some point. There is also a kid’s version of this…because adults can’t have all the fun. Men appear to be lucky and are less likely to have bunions.
I hear people call every type of foot deformity a ”bunion,” from bumps on the second toe to bulges on the bottom of the foot. So what actually is the definition of a bunion?
Let’s start with the most common type of bunion, Hallux Abducto Valgus deformity. This refers to the prominent lump of bone at the base of the great (not an average) joint—known as the metatarsophalangeal joint or MTPJ.
Two things will occur when you have this bunion. First, the big toe begins to tilt or drift inward, pushing into (or crossing over) the second toe. Second, an obvious enlargement of bone forms on the inside of the foot at the MTPJ. This is not a bone that has grown larger but one that has been pushed outward. This will be important to remember. (When the little toe does something similar on the opposite side, it’s called a tailor’s bunion or bunionette.)
At first there is a feeling of pressure or minor discomfort, but over time bunions become more and more severe, leading to swelling, pain, difficulty wearing shoes, formation of calluses, and transfer pressure. These symptoms can keep you sidelined from work and activities you cherish. Unfortunately, your symptoms won’t go away unless you do something about the tilting toes.
Toes are intended to be straight. In a bunion, the first metatarsal begins to tilt outward from the midfoot joint, the big toe begins to tilt inward like a gate hinge.
There are two circular-looking bones underneath the metatarsal head that act like a pedestal or foot stool. They are hidden on x-rays when they are in the correct position but will come out of hiding when the metatarsal begins to drift outward (like stepping sideways off a stool.) Make sure you look at these when you see your x-ray.
Since the foot is slowly becoming wider, shoes will seem narrower and there will be tenderness on the side of the joint over the bump. Wider shoes will make the foot feel a lot better.
This is the stage when the treatment is the easiest, but not the prettiest (as in “you need to stop wearing cute, high-heeled shoes and start wearing comfortable-but-perhaps-not-as-stylish ones”). Fashion and comfort are polar opposites, so if shoes are important to you, surgery will probably be the solution.
An easy way to spot this is there are at least two deformities:
The big toe drifts far enough to start pushing the second toe over. In addition to the hammertoe deformity, it is common to have pain under the lesser metatarsals, usually the second (called a capsulitis). The big toe should normally move straight up and down, but now it will begin to arc inward as it moves upward.
The bump may become larger after a long day. This is caused by a bursa that inflates; a sudden change in size is not because of the bone.
Getting dress shoes off at the end of the day will bring sweet relief. Some people believe that using running shoes for daily wear is a sign of old age, but it is really the universal sign for bunions.
Treatment options in this stage will involve protection or correction. When it comes down to protection, men have a definite advantage over women with wider, deeper, and softer shoe selection.
The surgical options, though, are gender neutral. Our goal here is to return the first metatarsal over the sesamoids (remember those pedestal bones?). Just removing the “bump” is so 1990 and will lead to a re-occurrence when the metatarsal continues to tilt.
The key element here is that the joint hurts with movement. There may be a “crunchy” feeling accompanying decreased range-of-motion. This is because of joint damage.
The big toe is now in the parking spot of the second toe, which is sitting on top of the Hallux. If the joint pain is not the problem, it’s that the second toe is rubbing the top of the shoe.
When the deformity has reached this stage, we are typically using my “Hail Mary shoe“ treatments. Conservative management is a shoe that’s as wide as the foot, and this may be a challenge. Normal shoes are no longer in the equation. If the joint has been extensively damaged, joint fusion may be required.
Where Bunions Come From—Nature vs. Nurture
Bunions have been associated with certain lifestyle choices—for example, wearing high-heeled shoes or footwear with tight, constricting toe boxes. Contrary to popular belief, these choices do not create the deformity. Rather, they will accelerate the progression of an existing bunion and often aggravate the painful condition. It’s perhaps unsurprising, then, that the majority of bunion patients are women.
That said, the fundamental cause of most bunions is related to heredity.
Most people don’t have perfect feet—in fact, up to 60% of the population inherited some kind of mechanical flaw in their foot structure, and certain flaws predispose a person to developing bunions because the foot is unstable and bones slowly change position (like the first metatarsal tilting inward).
Parents or grandparents who developed bunions usually pass on an elevated risk to their descendants. You can tell which side of your family is to blame at the next family reunion!
Opportunities for Conservative Care
It’s important to realize that
Once the bump has formed and the toe begins drifting, surgery is the only way to correct the bone deformity. You may have seen advertising for bunion splints in the back of magazines or late-night TV. They will be happy to take your money, but don’t hold your breath waiting for results!
If the bunion remains relatively small and mild, and your pain is still minimal, taking immediate conservative measures may help you slow the rate of progression. This can prevent, or at least delay, the need for surgery for some period of time.
On the other side of the procrastination coin, the longer the bunion is present, the more likely additional procedures may be required to fix other problems (such as hammertoes and transferred pressure on the adjacent bones).
It may take 3-4 decades for a bunion to reveal itself. There is a juvenile bunion that presents very early in life (during the preteen years) and typically doesn’t cause distress, since this age group often uses athletic shoes. Bone growth plates are still active and it is recommended that surgery
The most convenient measure may simply be to find a comfortable pair of shoes that provides adequate room for your deformity. We can also help you with padding or taping (if the joint remains sufficiently flexible) or provide custom orthotics to accommodate an underlying structural issue.