BUNIONS

If the joint that connects your big toe to your foot has a swollen, sore bump, you may have a bunion.

Definition
A bunion is an abnormal, bony enlargement of the joint at the base of the big toe (metatarsophalangeal joint).  As the bunion progresses the big toe may angle toward the second toe.  The “bump” is painful and may become red and stiff.  An advanced bunion may make your foot look grotesque and arthritis may develop. 

Cause
Bunions can occur for a number of reasons but most commonly develop due to poor foot mechanics.  While bunions are not inherited, if there is a history of bunions in the family the development is much more likely.  Bunions form when the normal balance of forces that are exerted on the joints and tendons of the foot becomes disrupted.  This causes instability of the joint leading to deformity.  Over years of walking with these imbalances in the foot structure, the bunion slowly develops.  While shoes aren’t a direct cause of bunions, tight shoes may cause pain by putting pressure on the “bump”.  Pointed toe shoes can cause someone already predisposed to develop a bunion faster.  To minimize your chances of developing a bunion, never force your foot into a shoe that doesn’t fit.  Shoes that conform to the shape of your foot are always best.  Look for shoes with a good arch, broad toes and soft soles.  Avoid shoes that are short, tight or have pointed toes and those with heels higher than 2 ¼ inches.  If you are already developing a bunion, wear shoes that are roomy enough to not put pressure on it.  This should help relieve most of your pain. Other causes include injury, gout, and neuromuscular disorders.

Signs/Symptoms
The most common symptom is a painful bulging bump on the inside of the base of the big toe.  Surprisingly, the degree of deformity may be quite out of sync with the pain level.  Some patients have a severe bunion deformity with very little pain while others have an almost normal appearing foot with a lot of pain.  X-rays will generally reveal a prominent bony bump at the base of the big toe with an increased angulation between the first and second metatarsal--  the long bones in the forefoot that connect each toe with the rest of the foot.  If the bunion has been present for many years, patients often experience arthritis at the big toe joint.  Redness may occur on the bunion at the point of maximum tenderness.  Occasionally a “bursa” may develop at the site.  With severe bunions the big toe may crowd the second toe causing it to elevate and rub on the top of the shoe.  The second toe ultimately develops into a hammertoe as a result.

Treatment
Conservative treatment includes physical therapy, padding, taping, wearing comfortable shoes and taking oral anti-inflammatories.  Unfortunately these conservative treatments are not always effective and surgery is frequently needed. 

Bunion Surgery
Bunion surgery is a same-day outpatient procedure.  The procedure is aimed at realigning the big toe joint and removing the painful bony bump.  There are over 50 different types of bunion surgeries but most include what is called an osteotomy.  An osteotomy is where the metatarsal bone is cut, realigned and fixated.  Fixation may involve a screw, pin, wire, or plate and is necessary in order to speed healing and prevent the cut bone from moving out of place.  Bunion surgery in which the bump is simply cut off is appropriate in only a very small number of bunions.  The entire operation is performed through one incision on the top of the foot.  The skin incision is closed with plastic surgery techniques to limit scarring and, after healing, is barely visible.  With excellent technique and proper procedure selection, bunion surgery can be both simple to recover from and highly successful--with little to no pain.

Bunion Surgery Rehabilitation
Patients are to remain non-weight bearing with bathroom privileges for three to five days.  The foot should remain elevated and iced.  Patients are not in a cast or wheelchair and, if they need to get up to use the bathroom or get to their bed, they can put weight on the foot.  Other than the bare essentials, the patient should try to stay off the foot.  After three to four days, the patient is able to get around in their post-op shoe. 

After one week, the patient returns to the office for a dressing change and x-ray.  After two weeks, stitches are removed, and after three weeks, patients can return to a comfortable shoe such as a tennis shoe.  It may take several months before fancier shoes such as pumps or high heels can be worn.  For the first two weeks while stitches are in, the foot should be kept dry and bandages not removed except by the doctor at the one-week appointment.  Some residual stiffness and swelling may linger for six months to a year after surgery but should not slow the patient down.  Reoccurrence of bunions after surgery is possible but very rare.  Complications are few and patients are almost always very pleased with the outcome.