What to Do about a Bunion?

In the front of the foot, the joint at the base of the great toe is the most complex. Here the bones, tendons and ligaments work together to transmit and distribute the body's weight, especially during movement. Should this joint become abnormally stressed over an extended period of time, a bunion deformity may result.

A bunion (from the Latin "bunio," meaning enlargement) is a protuberance of bone or tissue around the joint. The enlargement occurs either at the base of the great toe or on the outside of the foot, at the base of the little toe where it is called a "bunionette" or "tailor's bunion."

Bunions at the base of the great toe usually begin when the big toe starts moving toward the smaller toes when tight, pointed shoes are worn. This crowding puts pressure on the joint, pushing it outward. The movement of the joint in this outward direction starts the formation of a bunion.

A common deformity of the big toe joint, a bunion occurs mostly among people who wear shoes. Women are more frequently affected with bunions because of tight, pointed, confining or high-heeled shoes. Wearing high heels is especially stressful on the joints of the foot because all of the body's weight rests there. The foot is then forced into a narrow, pointed "toe box", compounding the problem. Older people are also vulnerable to bunions because of the higher incidence of arthritis affecting the big toe joint.

What Causes a Bunion?

A bunion is most often a symptom of faulty mechanics of the foot. The deformity runs in families, but it is the foot type that is hereditary, not the bunion. People with flat feet or low arches are more prone to develop the problem than those with higher arches. Bunions also may be associated with various forms of arthritis. Arthritis can cause the joint's protective covering of cartilage to deteriorate, leaving the joint damaged and with a decreased range of motion.

Parents who have bunions should know that there is a strong hereditary predisposition to bunion development, and should have children evaluated if early signs of deformity and/or discomfort are evident. If the child has the same foot type, there is a possibility that a bunion will eventually develop.

Symptoms

Pain from a bunion can be mild, moderate or severe, making it difficult to walk in normal shoes, especially high-heeled shoes. The skin and deeper tissues around the bunion also may be swollen or inflamed.

The other toes can be affected by a bunion, as a result of pressure from the great toe pushing inward toward the lesser toes. Toenails may begin to grow into the sides of the nail bed; the smaller toes can develop corns and become bent (hammertoes); or calluses may form on the bottom of the foot.

Can I Have any Alternative Treatments?

Treatments vary depending on the severity of pain and deformity. Left untreated, bunions tend to get larger and usually more painful. Evaluation by a podiatric surgeon should be sought at the first sign of pain or discomfort, so that severe deformity can be avoided.

Padding the bunion is an important first step, as is wearing shoes that are large enough to comfortably accommodate the bunion (such as sandals, athletic shoes or shoes made from soft leather). Stiff leather shoes may be stretched slightly for greater comfort. Tight, confining or high-heeled shoes should be avoided.

Medications, such as non-steroidal anti-inflammatory drugs or cortisone injections, may be prescribed to ease pain and inflammation caused by joint deformities.

Physical therapy, ultrasound treatment, or other techniques can also provide temporary relief.

Orthoses (shoe inserts) may be useful in controlling abnormal foot movement, and may reduce symptoms for those with a painful bunion that has not yet caused a significant bony abnormality at the joint. If a systemic disease like rheumatoid arthritis or gouty arthritis is related to the bunion, appropriate medical treatment may be recommended.

Surgical Treatment

When conservative treatment does not provide satisfactory relief from symptoms, or when the condition interferes with your activities, surgery may be necessary.

Pain and deformity are significantly reduced in the great majority of patients who undergo bunion surgery. In addition to easing pain, the purpose of bunion surgery is to remove the enlargement and realign the joint to restore normal function. This means that after surgery, the foot can carry the body's weight properly, and that special shoes are no longer needed. Postoperative orthoses or supportive devices may be recommended to improve foot function.

Surgery may be performed at a hospital, surgical center. Depending on the procedure, the facility at which it is performed and the patient's medical status, the surgeon may choose a local, spinal or general anesthetic. In many cases, the procedure can be performed under local anesthesia.

Types of Surgery

Many surgical procedures are used to correct bunions. The decision to employ a procedure is based on the severity of the deformity, the patient's age, the general health of the patient, their activity level, and the general health of the bones and connective tissue. Other factors may influence the choice of a procedure used.

For a mild bunion, the podiatric surgeon may remove the enlarged portion of bone and realign the muscles, tendons and ligaments surrounding the joint.

For a moderate bunion, the podiatric surgeon may cut the bone and shift it to its proper position. Whether or not the bone is cut depends on the severity and location of the deformity. In addition, the surrounding tendons and ligaments may need to be repositioned.

For a severe bunion, a combination of the following procedures may be necessary: removal of the enlarged portion of the bone; cutting and realignment of the bone; and correction of the tendons and ligaments. If the joint is destroyed beyond repair (commonly seen in arthritis), it may need to be reconstructed or replaced with an artificial joint. Joint replacement implants may be used in the reconstruction of the big toe joint.

If the bone was cut, as in surgery for a moderate to severe bunion, it may be held in place with an internal pin, screw or rod. In many cases, a slipper or short leg cast is worn for four to six weeks, and crutches assist walking.

Movement of the toe joint is important after any type of bunion surgery. Specific instructions for exercising the joint will be provided by the podiatric surgeon.

The operation is performed under local anaesthetic, usually put in around the ankle; most patients find this more comfortable than a dental injection. The operation takes about an hour, although you should expect to be in the clinic for around two hours.

Eating Before and After Surgery

You can eat as normal on the day of the operation as you will receive a local anaesthetic. You will not be staying overnight in hospital so have something prepared for your return and food already organised for the next two weeks if possible. For the first fourteen days after your operation you must rest with your feet elevated as much as possible. Failure to rest could result in complications and a delay in healing

The first Days After The Surgery

You will be able to stand and move around carefully, but you must rest, with your feet above the level of your hip. You should restrict your walking to going to the bathroom we will provide crutches and special shoes; we will instruct you on how to use these.

You will be seen 7 & 14 days after the surgery for redressing. The wound will be examined, cleaned, and redressed, you may receive instructions to slowly increase you activity. You must contact the clinic immediately if you have any problems.

When Will My Stitches Be Removed?

Patients commonly ask when they can have their stitches removed or trimmed (if absorbable). Stitches are usually removed 7-21 days after the operation depending upon how quickly the operation site has healed. Postoperative X-rays may be taken to check that all is well. Unless a cast has been applied you should be able to walk without crutches although you will not be able to return back to normal footwear just yet. You will be advised on how to increase activity and shown how to look after and exercise the foot.

When Can I return to Work?

The questions of returning to work and revert back to normal activities are another important factor for patients. Over the next 4-6 weeks the foot will return slowly to normal and most patients will go back to normal footwear. Patients may return back to work (depending upon the type of work and the type of footwear in which you are allowed to return to work). If a cast is applied this is removed and the foot X-rayed to check for adequate bone healing.

For a heavy job, return to work in less than six weeks would be an unrealistic expectation. Obviously other factors such as the severity of the deformity, tissue quality, circulation, and general health all make a difference. Although the foot should now be comfortable and returning to normal, there may be some swelling, especially at day end. This is normal and to be expected as feet and legs are prone to swelling anyway.