A bunion is a bump found on the inside of the foot at the base of the great toe. The deformity usually involves the first metatarsophalangeal joint (MTP). This joint is made up of the phalanx bone inside the toe and the metatarsal bone in the forefoot. If you bend your toes up you can feel the ends of the metatarsals on the bottom of the foot. This is called the ball of the foot.
The deformity occurs because the end of the metatarsal bone(head) becomes prominent. This is secondary to the bone growing in this area or the great toe deforming toward the second toe. The most common cause of this deformity is related to shoe wear that presses on the great toe or first metatarsal head. One can also be born with this deformity. An injury can cause the deformity to occur, but it is uncommon.
Patients usually present to the doctor with symptoms of pain caused by shoe wear rubbing on the bunion. If the great toe deforms significantly, it can push on the second toe causing it to hurt or deform into a hammertoe which can also rub on the shoe and cause pain. Sometimes the patient’s bunion won’t hurt, but the second toe pain/deformity will bring them to the doctor.
Upon evaluation, we need to determine what is causing the bunion deformity. Besides taking a patient’s history, we will need to examine the foot and get x-rays. Upon examination we will be determining what is causing the bump/deformity. We will see if it is passively correctible. We will check range of motion of the toe. We check for arthritis of the joints as well as instability.
We will have the patient stand to determine arch alignment and how the bunion deformity looks upon using the foot. We also want to see the influence of the great toe on the other toes to see if any deformity in the other toes exists. We also check to see if the foot has adequate blood supply. X-rays are taken standing so that we see how bad the deformity is and what is causing it. We can evaluate the arch, the other toes, and see if any arthritis is involved in this deformity.
Treatment can be surgical or non-surgical. Non-surgical treatment will not correct the bunion deformity or any lesser toe deformities that have occurred secondarily to the bunion deformity. Non-surgical treatment is an attempt to make the patient comfortable. Wider and deeper shoes are available that can take pressure off the bunion and/or toe deformities. Soft leather is helpful in that it can be stretched where the bump(s) are. A toe spacer can be used in between the first and second toes to keep them apart. A Budin splint or taping can be used to help the second toe lay flatter/straighter. Corn pads or cushion over the bump/deformity doesn’t usually help unless the shoe is bigger. Orthotics or arch supports are rarely helpful by themselves. They often make you wear a bigger shoe, though, and it is the bigger shoe that relieves the pain, not the orthotic. The orthotic may help someone with a significantly flattened arch by not allowing the foot to roll onto the bunion deformity when walking, thus lessening the stress/pain in this area.
The indications for surgery are pain despite trying shoe wear that is wider/bigger, worsening of the deformity with or without pain, second toe deformity caused by the great toe pushing on it, pain in the bunion area when using the foot without shoe wear on.
There are many procedures to correct the bunion deformity. The procedure selected will be based on the result of your examination and standing x-rays. Bunion surgery can involve removing the bone bump, releasing and tightening ligaments, lengthening tendons, cutting the bone and putting it back together in correct alignment and/or fusing joints together, thus, making that joint not move any longer. Fusion is used for extremely severe deformities, recurrent deformity, hallux varus or for significantly arthritic joints.
Some of the complications that can occur are an infection, stiffening of the metatarsophalangeal joint, recurrence of the bunion deformity, hallux varus(the great toe deforming away from the second toe), numbness/tingling secondary to moving nerves aside to perform the operation, pain in other areas of the foot secondary to altered pressure on that part of the foot by realigning the bones or by abnormally walking on the foot after the operation, swelling, loss of correction or blood clot (DVT).
Postoperatively, a cast or special shoe is worn. The repaired ligaments, tendon, cut bone(s) need time to heal. Crutches/walker is commonly used to keep pressure off the foot until healing is enough to allow weight bearing. Weight bearing on the foot is usually allowed at four weeks after the operation. Weight bearing for exercise usually starts at eight weeks post-op. At twelve weeks post-op, usually there is no restriction on activity. If you walk or weight bear on your foot too soon, you can damage your operation.
Range-of-motion(ROM) exercises of the first MTP joint are commonly started 7-10 days post-op. These have to be done to prevent stiffness of the joint. We will instruct you on how to do this. Physical therapy is seldom needed. When we do use it, it is to help those that can’t get back their ROM of the first MTP joint themselves.
Swelling will occur. The amount of swelling is dependent on the extent of your surgery and how much you keep your foot elevated above your heart prior to your first post-op visit. Swelling lasts six months.
Wearing a post-op shoe with the foot wrapped properly is important to getting and keeping a good bunion correction. We will change the flexibility of your post-op shoe during your recovery period. We will advise you on how to wrap your foot.
When a fusion is needed, you will wear a cast for three months. Walking usually is allowed after one month post-op. Range-of-motion exercises are not usually needed.. After three months, you may need physical therapy. Casting causes an increased risk of developing a blood clot in your leg or a deep venous thrombosis (DVT).
While the bunion correction usually allows the foot to be placed in many different types of shoes without pain, it is important not to wear the shoe wear that causes the deformity. Loafer shoe wear is more prone to causing the deformity than tie-up shoes. Also, shoe wear that narrows in the toe area, i.e. comes to a point will usually cause recurrence of the bunion deformity.
Dr. David J. Pochatko, MD, is a fellowship trained Foot and Ankle Orthopedic Surgeon for Northtowns Orthopedics. With the help of his physician assistants, he specializes in the surgical and non-surgical treatment of the foot and ankle problems, injuries, and deformities. He also sees many people who have had failed previous surgery and need revision of that surgery.
Northtowns Orthopedics – where your first surgery is your best chance to get better.
