Bunion Treatment and Management

There are 3-4 things that are predicable in life. I bet that no one would put bunions on that list. This may not be true for all 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?

A Bunion refers to the prominent lump of bone at the base of the great. ( ….not an average joint) —known as the metatarsophalangeal joint or MPJ. Two things will occur when you have a 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.

Stage 1

Toes are intended to be straight. In a Bunion, the 1st Metatarsal begins to tilt outward from the mid foot joint, the big toe begins to tilt inward like a gate hinge. There are 2 circular looking bones underneath the metatarsal head act like a pedestal or foot stool. They are hidden on x ray when they on 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 comfortable shoes).  Fashion and comfort are polar opposites. If shoes are important then surgery will provide be the solution.

Stage 2

An easy way to spot this is there are at least 2 deformities. The big toe drifts far enough to start pushing the 2nd toe over. In addition to the hammertoe deformity it is common to have pain under the lesser metatarsals, usually the 2nd (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 from a bursa that will inflate not because the bone will change in a day.

Getting dress shoes off at the end of the day will bring a gasp of 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 will involve protection or correction. When it comes down to protection, men have a definite advantage of women with shoe selection. The surgical options are gender neutral. It is goal is to return the 1st 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.

Stage 3

The key element is the joint hurts with movement. There may be a “crunchy” feeling with the 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 is that the 2nd toe is rubbing the top of the shoe. When the deformity has reached this stage we are using my “Hail Mary “treatments. Conservative management is a shoe that is as wide as the foot and this may be a challenge. Normal shoes are not 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 but will accelerate the progression of an existing bunion and often aggravate a painful response. It’s perhaps not surprising, then, that the majority of bunion patients are women.

That said, the fundamental cause of most bunions are 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 1st 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 to blame at the next family reunion!

 

Opportunities for Conservative Care

It’s important to realize that bunions are a progressive deformity. It will not get better on its own, and will get worse over time until steps are taken to correct it. 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.

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, preventing or at least delaying the need for surgery for some period of time. On the other side of the coin, the longer the bunion is present, the more 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 version that presents very early in life (during the pre-teen years). There is typically no distress since this age group uses athletic shoes. Bone growth plates are still active and it is recommended that surgery be delayed until growth has completed (13-14 years of age). Orthotics are used to control the biomechanical forces at his stage

The most convenient measure may simply be to find a comfortable pair of shoes that provide 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.

Bunionettes

A bunionette is a similar condition to a bunion, only it’s located on the outer edge of the foot by the little toe.  Another name for this is a Tailor’s bunion. This term comes from the turn of the previous century when tailors/seamstresses that would sit cross-legged on the ground to do their work. The outside of their feet would be irritated and swollen.

In this condition, the little toe begins to rotate and drift inward toward the other four toes. As this happens, the corresponding metatarsal bone starts to angle outwards. The result is that the metatarsophalangeal (MTP) joint—where the toe connects to the foot—is pushed out to the side.

The reason the shifting happens and a bunionette forms can be attributed to an uneven distribution of the pressures that accompany weight bearing on the tendons and joints in the feet. An imbalance in this distribution ultimately makes the MTP joint unstable and the components of the joint protrude out to the side.

There is some debate in the medical community as to whether or not tight shoes, particularly high heels, can cause bunions or bunionettes. These deformities are a result of the foot mechanics, hereditary factors (choice your parents wisely), or trauma. With that being said, footwear choices can exacerbate an existing problem and cause a bunionette to become more severe.

The primary symptom observed with a bunionette is the bulging bump found on the outside of the foot right at the little toe’s MTP joint. The body will create a bursa (similar to an air bag) that can change size on a daily basis. Additional symptoms include:

  • Soreness, swelling, or redness around the MTP joint
  • Thickening of skin in the affected area
  • Increased incidents of calluses, especially where the little toe overlaps with the next one over
  • Intermittent or persistent pain that is aggravated by shoes

Considering Corrective Surgery

In most cases where pain and disfigurement are significant—and conservative approaches have proven insufficient—we provide surgical procdures for more extreme cases. However, we will always take the time to discuss all options with you and give you the final say

The specific procedure will be selected by Dr. Leibovitz based on the severity of your condition and a discussion with you about all your options. Typical procedures may include (but are not necessarily limited to):

  • Exostectomy / bunionectomy. Removal of the bony bump. Usually performed in combination with other techniques, as the bunion is likely to reoccur if the joint is not properly realigned.
  • Osteotomy. The affected bones are cut, realigned, and held together with hardware during the healing process.
  • Arthrodesis. A more common choice for patients with more severe bunions and/or arthritis. The arthritic joint surfaces are removed and the bones are fused together.

Don’t Live with Pain!

Surgery is performed on an outpatient basis so you can go home the same day—no hospitalization required. The length of recovery varies based on the type of surgery performed as well as the patient’s ability to follow post-operative care directions. Dr. Leibovitz will be frank with you and establish an expected timeline when you can return to activities like walking, driving, or working. We will make sure you fully understand all post-surgical care instructions. An educated patient is the best way to ensure a full recovery as quickly as possible!

Don’t suffer through a painful bunion until symptoms become unbearable and you’re no longer able to maintain a healthy, active lifestyle. Let Jeffrie C. Leibovitz, D.P.M. and his team help you as soon as you recognize an issue—you may be able to avoid surgery, or qualify for a less extensive one, by being proactive. To schedule an appointment, please fill out our online contact form or call the office at 317-545-0505.    

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