Bunions

What are Bunions?

Even though bunions are a common foot deformity, there are misconceptions about them. Many people may unnecessarily suffer the pain of bunions for years before seeking treatment.

A bunion (also referred to as hallux valgus or hallux abducto valgus) is often described as a bump on the side of the big toe. But a bunion is more than that. The visible bump actually reflects changes in the bony framework of the front part of the foot. The big toe leans toward the second toe, rather than pointing straight ahead. This throws the bones out of alignment – producing the bunion’s “bump.”

Bunions are a progressive disorder. They begin with a leaning of the big toe, gradually changing the angle of the bones over the years and slowly producing the characteristic bump, which becomes increasingly prominent. Symptoms usually appear at later stages, although some people never have symptoms.

Bunions are most often caused by an inherited faulty mechanical structure of the foot. It is not the bunion itself that is inherited, but certain foot types that make a person prone to developing a bunion.

Although wearing shoes that crowd the toes won’t actually cause bunions, it sometimes makes the deformity get progressively worse. Symptoms may therefore appear sooner.

Symptoms of Bunions

Symptoms, which occur at the site of the bunion, may include:

• Pain or soreness
• Inflammation and redness
• A burning sensation
• Possible numbness

Symptoms occur most often when wearing shoes that crowd the toes, such as shoes with a tight toe box or high heels. This may explain why women are more likely to have symptoms than men. In addition, spending long periods of time on your feet can aggravate the symptoms of bunions.

Diagnosis of Bunions

Bunions are readily apparent – the prominence is visible at the base of the big toe or side of the foot. However, to fully evaluate the condition, the foot and ankle surgeon may take x-rays to determine the degree of the deformity and assess the changes that have occurred.

Because bunions are progressive, they don’t go away, and will usually get worse over time. But not all cases are alike – some bunions progress more rapidly than others. Once your surgeon has evaluated your bunion, a treatment plan can be developed that is suited to your needs.

Treating Bunions

Sometimes observation of the bunion is all that’s needed. To reduce the chance of damage to the joint, periodic evaluation and x-rays by your surgeon are advised.

In many other cases, however, some type of treatment is needed. Early treatments are aimed at easing the pain of bunions, but they won’t reverse the deformity itself. These include:

• Changes in shoewear. Wearing the right kind of shoes is very important. Choose shoes that have a wide toe box and forgo those with pointed toes or high heels which may aggravate the condition.
• Padding. Pads placed over the area of the bunion can help minimize pain. These can be obtained from your surgeon or purchased at a drug store.
• Activity modifications. Avoid activity that causes bunion pain, including standing for long periods of time.
• Medications. Oral nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may be recommended to reduce pain and inflammation.
• Icing. Applying an ice pack several times a day helps reduce inflammation and pain.
• Injection therapy. Although rarely used in bunion treatment, injections of corticosteroids may be useful in treating the inflamed bursa (fluid-filled sac located around a joint) sometimes seen with bunions.
• Orthotic devices. In some cases, custom orthotic devices may be provided by the foot and ankle surgeon.

If non-surgical treatments fail to relieve bunion pain and when the pain of a bunion interferes with daily activities, it’s time to discuss surgical options with a foot and ankle surgeon. Together you can decide if surgery is best for you.

A variety of surgical procedures is available to treat bunions. The procedures are designed to remove the “bump” of bone, correct the changes in the bony structure of the foot, and correct soft tissue changes that may also have occurred. The goal of surgery is the reduction of pain.

In selecting the procedure or combination of procedures for your particular case, the foot and ankle surgeon will take into consideration the extent of your deformity based on the x-ray findings, your age, your activity level, and other factors. The length of the recovery period will vary, depending on the procedure or procedures performed.

After Bunion Removal

After surgery, you’ll be in a post-operative shoe (a big sandal) and crutches and will have pain medication. You will be able to put weight on the heel and outside portion of the foot immediately after surgery. Your foot will be quite sore for the first week or so. You will need to elevate your foot almost continuously for one week to minimize swelling. This will help reduce infection and increase range of motion.

You will return to the office at one week for a dressing change and x-rays and then at 10-14 day intervals for 6 weeks for dressing changes. At 6 to 8 weeks, another set of x-rays will be needed to assess healing. If the bone is healed, you’ll be in tennis shoes for a few months with a toe spacer. Most patients are back in normal shoes by 4 to 5 months. Swelling may recur with activity for the first 6 months. Dress shoes should be avoided for the first 6 months. A toe spacer or night splint may be used in certain cases for 6 months to maintain correction.

Specific operations:

• Distal chevron osteotomy (Austin) or Akin bunionectomy. This operation is usually done through a single incision and use absorbable pins or small screws to hold the bones together in the corrected position. This is done for mild and moderate bunions and recovery is relatively quick. But you still will be in a postop shoe for 6 weeks and be on crutches for 3 to 4 weeks.
• Proximal Osteotomy/shaft osteotomy. This operation is a big deal! We cut the metatarsal bone and put it in a corrected position. It requires 2 or 3 incisions and it is used for severe bunions. The recovery is longer and you will be on crutches for 6 weeks or more. The swelling after surgery will also be a factor and you need to elevate your foot for the first week (toes above the nose). The osteotomy is held with screws and wires in some combination. You’ll be in a postoperative shoe for 8 to 10 weeks and then you will go into a sneaker. Most patients are back in normal shoes by 4 to 5 months. Swelling may recur with activity for the first 6 months. Dress shoes should be avoided for the first 6 months. A toe spacer or night splint may be used in certain cases for 6 months to maintain correction.
• 1st TMT Fusion. This surgery is a bigger deal! Some patients may need a fusion of the 1st tarsometatarsal joint. With this surgery, the patient will be in a cast for 6 weeks and minimal weight bearing during that period. After the cast comes off, the postoperative course will be similar to the above procedures.
• Other associated procedures. Patients may get other related procedures at the same time, i.e. hammertoes, neuroma, callous surgery that will increase recovery time and change above plan.

Frequently Asked Questions:

• Shoewear: Before surgery, one-third of the patients with a bunion can wear any shoes they want. After surgery, studies have shown that two-thirds of patients can wear any shoes they want. This is an improvement, but still leaves one-third of patients with some limitations of shoewear.
• Back to Work: This depends on your age, job, and commute. If you are young, work at a desk, and live close to work, you can probably return to work in approximately 2 weeks. If you have to take public transportation or have to drive to work, you’ll need to be out longer.
• Back to Sports: Patients may return to sports at about 5 to 6 months following surgery. This means running, tennis, etc. Exercise such as bicycling, stairmaster, etc., you can return within 2-3 months. Occasionally, running at a reduced paced may be allowed at earlier intervals.
• Both bunions at one time: Technically, this can be done, but patients are quite limited for 3-4 weeks after surgery. For patients with the proximal osteotomy, you’ll need to be in a wheelchair for a few weeks because of the pain.
• Driving: If you have an automatic transmission and only have surgery done on your left foot, you could probably return to driving after you are no longer taking narcotic pain medications (percocet, vicodin, demerol, etc.). If you have a standard transmission or are having your right foot operated upon, you may not be able to drive for 2 months or longer.