PARDEE FOOT CLINIC
In general it takes a few years for the great toe to move towards the small toes. (In some cases of trauma, this can happen much more quickly). Most people notice the bump on their foot or notice that their big toe has moved before they notice any pain. The typical complaint of pain is a deep, dull, "in-the-joint" pain. Some experience pain on the top or the side of the toe from shoe pressure. Others experience dull, achy pain after walking, or sharp pain with walking in certain shoes. There can be a grinding pain and stiffness is fairly common. The type of pain depends on the person, what stage the bunion is in, the activity level and the shoe type. Some individuals never develop pain, despite having severe bunion deformities. In the X-rays pictured above, the bunion on the right looks like it would be much more painful. But, the individual on the left was actually experiencing more pain at the time of the X-ray. (The X-ray on the right shows a toe ring on the 2nd toe).
There are no effective measures which will prevent bunion development, but they are a few conservative treatments which may help slow the progression of a bunion and some treatments which can minimize the pain. Custom made orthotics can place the foot in the appropriate position and help remove abnormal tendon pull on the bunion, slowing progression. Custom orthotics tend to be the most effective in individuals with flexible feet and abnormal pronation. Wider shoes, particularly with a wide toe box, will decrease the pressure on the great toe and may eliminate pain and slow progression. Rigid shoes with a rocker type sole can eliminate pressure on the forefoot and the great toe joint, minimizing pain when walking. Bunion night splints will not slow progression nor change the structure or shape of the bunion, but may help eliminate pressure type pain while sleeping or walking.
Surgery is only recommended when there is pain which limits daily activities. This means that the pain limits your ability to do your job, your house work, your hobbies or your exercise routine. If the pain is rare or there is no pain, surgery is generally not recommended.
There are exceptions of course, and when the bunion deformity is severe and causing open sores or a patient is diabetic and there is concern for ulcer development, surgery may be recommended, even if there is no pain. Another instance may be when the great toe has moved under the 2nd toe and is causing the 2nd to pop up into a hammertoe. If the hammertoe is causing pain or problems, then the bunion must also be addressed. Cosmetic bunion surgery is not recommended.
The most common type of bunion surgery is surgery at the great toe. This involves breaking the metatarsal bone (called an osteotomy), moving it and stabilizing it with a screw. Not all surgeons use a screw, some use staples or wires. The goal is to move the head of the metatarsal bone over (laterally) in the direction of the small toes. A tendon is cut in between the great toe and the 2nd toe, to release the great toe and allow it to align with the metatarsal. Other ligaments and some of the joint capsule might also be released to allow the great toe to come back into alignment.
A tailor's bunion is also a structural change in the foot. The result is a bony deformity at the 5th metatarsal phalangeal joint. The 5th metatarsal moves laterally and the 5th toe moves medially, as seen below. The movement results in a structural change and causes a bump to form on the outside of the foot. The bump may be due to an enlarged bone or bone spur, as seen to the right. Like bunions, tailor’s bunions may take a few years to develop. Generally the pain is deep, dull and achy, but the pain can be sharp with walking. The pain is usually worsened with shoe pressure. Another name for a tailor's bunion is a bunionette.
The treatments are very similar to bunion treatments. Addressing the cause of the tailor’s bunion development is important. Faulty foot mechanics may have contributed to the devlopment and orthotics may be necessary as part of the treatment. If the bump is from a bone spur and/or bursa, simple padding or shoe modifications may help. But, surgery to remove the spur may be necessary. It is much more common to remove part of the bone on the outside of the metatarsal (exostectomy) on tailor's bunions, than it is to do this procedure on the 1st metatarsal, for a bunion. If the 5th metatarsal has moved out enough, a chevron type osteotomy can be performed to move the head of the metatarsal bone back into place
A bunion is a structural change in the foot, resulting in a bone deformity at the great toe joint. The 1st metatarsal (seen in the picture below) moves medially, towards the center line of the body and the great toe moves laterally, or abducts, towards the small toes. This movement causes a bump to form at the great toe joint. The great toe joint is also called the metatarsal phalangeal joint or 1st MPJ. The great toe, also known as the hallux, has two bones in it, the proximal phalanx, closer to the metatarsal bone and the distal phalanx, near the toenail. In most bunion cases there is also rotation (valgus rotation) occuring, hence the long medical name hallux abducto valgus. There may be some bone growth at the big toe, but the bump is mostly from the movement of the metatarsal bone. The movement of the bones occurs gradually over time in response to abnormal motion of the foot, abnormal position of the foot, abnormal tendon pull or tight, narrow shoes. Below is a diagram of a bunion and X-rays of two bunions.