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Introduction

"My bunions are killing me," is a common complaint heard by foot and ankle specialists. To date, no one has died from the sheer presence of bunions, but they can be aggravating and painful nonetheless. You may wonder how you got them - especially if you wear comfortable shoes. What really causes them? Is there any hope to alleviate the pain? We'll explore these questions and provide answers that you may have concerning your bunions.

What is a Bunion?

A bunion is a progressive deformity seen as a bump at the base of the big toe. As simple as this may seem, it is actually more complicated. There are many factors involved in a bunion and its development. In order to understand these, we need to discuss the anatomy of the big toe and its associated structures.

Anatomy

The structures involved in a bunion consist primarily of five bones (figure 1). There are two bones in the big toe called phalanges. The next bone in line with the phalanges is the first metatarsal. The metatarsal and its closest phalanx together with ligament and tendon attachments make up the first metatarsal phalangeal joint-it is at this joint that the bunion forms. Underneath the first metatarsal lie two small bones called sesamoids (not visible in figure 1). When in proper alignment, these sesamoids provide stability to the first metatarsal phalangeal joint via their attachments to various tendons and ligaments.

As a bunion begins to form, the big toe drifts towards the smaller toes. Consequently, the joint and base of the big toe are pushed outward beyond the normal contour of the foot, forming a mild bony prominence at the arch side (medial aspect) of the foot. As the bunion worsens, the first and second metatarsals spread farther apart. The prominence of bone on the side of the first metatarsal becomes even more impressive. In severe cases, the metatarsal phalangeal joint can be partially or, even worse, totally dislocated. The big toe may eventually end up underlapping or overlapping the second toe. Stiffness in the big toe joint may be associated as the deformity progresses. Occasionally, a fluid filled cyst or bursa may develop between the skin and medial bony prominence of the first metatarsal. Therefore, the bunion that you see may be bone, bursa, or both.

What Causes a Bunion?

Bunions are relatively common foot problems that can affect anyone. They seem to be more common in females and usually occur in both feet [1,2]. The symptoms vary from one person to the next. Some people find it difficult to walk all the time, while others only experience pain in certain shoes. These symptoms may vary depending on the cause of the bunion.

Sometimes the cause of the bunion is due to genetics. A person's foot structure is passed down from one generation to the next. We inherit the shape of our foot from our parents [3]. Certain foot types often lead to problems in the way a person walks. Therefore, although the bunion deformity does seem to run in families, it is actually the foot type that is hereditary and it is the foot type that can lead to the development of a bunion. That is why it often seems that the bunion worsens as we age. If your genes predetermine you to develop a bunion, nothing can prevent them, but you may be able to slow their progression.

Those who have flat feet (low arches) seem more prone to develop bunions than people with higher arches. That is not to say all people with flat feet acquire bunions or those who have high arches will not be afflicted. Another cause of bunions can be increased flexibility of the feet. This can be a result of many factors including genetics, foot type (flat feet), or pregnancy. During pregnancy, hormones are released that allow the ligaments in the body to become relaxed. It is not uncommon for the arches in the feet to become flattened and influence the development of bunions.

In addition, improper fitting shoes or shoes with narrow toes may push your big toe outward toward the second toe (figure 2). After years of this pressure, the deformity may accelerate by gradually and permanently pushing the big toe toward the second toe.

Finally, injury to the joint can hasten the progression of a bunion. Different types of arthritis can also predispose a bunion formation. Gout and rheumatoid arthritis are two examples of arthritis that may lead to a painful bunion.

Treatment for Bunions

The treatment for bunions depends on the location and severity of the pain. There are two main types of treatments for bunions - surgical and non-surgical. Although the bunion deformity cannot be removed without surgery, there are many simple ways to relieve the associated pain and slow the progression of deformity.

Conservative Therapies (Non-Surgical)

The pain associated with bunion deformity has two primary sources: those outside the foot and those within the foot itself. The pain caused by bunions may be due to pressure from tight shoe gear. High heeled shoes or dress shoes (especially those with stiff, narrow toe regions) will cause irritation at the bump. Typically, wearing the proper shoe gear, shoes with plenty of room to accommodate the bunion in both depth and width, will relieve this pain. Furthermore, proper shoes should have a soft, flexible upper or covering.

Arch supports in the shoes can also be helpful in both decreasing the amount of pain and helping slow the progression of the deformity. Abnormal foot motions that contribute to the development of the bunion can be decreased by arch supports. Many athletic shoes come with good arch supports in them. Special supports or shoe inserts (orthoses) are also available both pre-made at many stores or can be specifically made for your foot by your doctor. Often these supports, in conjunction with proper footwear, can slow the development of a bunion by maintaining the proper alignment of the foot.

While improved shoegear, with or without orthoses, will almost always help with "bump" pain, other modalities can be used when the pain is caused by degenerative arthritis in the joint. Ice, anti-inflammatory medications like aspirin, and steroid injections can help with the inflammation and discomfort. Physical therapy treatments may also be used to help alleviate the arthritis symptoms.

Surgical Therapies

When the pain from a bunion is not relieved by these therapies, surgical intervention may be warranted. There are many surgical procedures available depending on the location and severity of the deformity. Severity of deformity is generally classified as mild, moderate, and severe. The severity of deformity can dictate where on the bone the deformity needs to be corrected. The surgical procedures to correct the bunion deformity are more complex with severe cases.

When the bunion is mild and there is no significant malalignment of the joint. The simplest surgical procedures for a bunion involve freeing the soft tissue around the joint and removing the bump behind the big toe. More severe deformities are treated by removing the prominent bump and cutting the bone to realign the joint. The bone is then held in place with screws or pins (figure 3). There are many types of surgeries that are used in order to correct the misalignment of the joint and bones. You and your doctor can discuss these procedures and decide which one is appropriate for you.

When the bone is too severely deformed for the above treatments, or the arthritis has destroyed the cartilage in the joint, it is sometimes necessary to remove the joint, fuse it, or replace the joint with an artificial implant.

The bunion surgery itself is painless because appropriate anesthesia is provided throughout. Rest is crucial after the surgery and your doctor will prescribe pain medication. Most patients experience only mild discomfort. Depending on the type of bunion procedure, many patients can walk the same day of surgery. More severe bunions generally require a more complex procedure and can require a longer time to heal. A special surgical shoe is worn during the initial recovery period. Several days of rest and inactivity are required for the foot to heal correctly. Physical therapy may help with post-operative pain and joint stiffness. Many patients are allowed to return to work within one to two weeks, depending on the patient's surgery and occupation. Those with desk jobs, may be able to return to work within one week. Complete recovery typically takes between 6 and 8 weeks, depending on the type of procedure necessary. Once you are back to regular activities, supportive and comfortable shoes should be worn to help prevent recurrence of the deformity. Orthoses are often recommended to maintain the correct alignment of the foot. These often help prevent recurrences by treating what originally caused the bunion. The chance of the bunion returning is kept low by the appropriate surgical procedure, the severity of the bunion before surgery, and patient compliance.

Conclusion

Since we walk on our feet every day, foot comfort is essential. Foot deformities and pain can usually be treated with either surgical or non-surgical therapies. Appropriate shoes and many over the counter remedies are readily available and are a great place to start. Not everyone with a bunion has the same symptoms. Left untreated, bunions will generally worsen with time. To determine the best treatment, make an appointment with a podiatrist to have your feet evaluated.

References

1. Thompson, G: Bunions and Deformities of the Toes in Children and Adolescents. JBJS 77A(12): 1924, 1995.
2. Helal, B: Surgery for Adolescent Hallux Valgus. Clin Orthop 157: 50, 1981.
3. Coughlin, M: Hallux Valgus. JBJS 78A(6): 932, 1999.
4. Keeping your feet healthy. Cleveland Clinic Journal of Medicine 67(1): 57, 2000.
5. Bunions: Don't crowd your toes. Mayo Clinic Health Letter 18(3): 7, 2000.
6. Robbins, JM: Recognizing, treating, and preventing common foot problems. Clev Clin J Med 67(1): 45-56, 2000.

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