By Asma Khan, DPM
June 26, 2013
Category: Uncategorized
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May Blog:  Bunions

                One of the most common complaints foot and ankle surgeons see is bunions.  A bunion is a bony prominence on the inside (medial) aspect of the big toe joint that can protrude against the inside of a person’s shoe, causing significant pain and discomfort.  Bunions can be small or large, however, treatment is based on a combination of factors that are specific to individual patients.  Therefore, treatment for bunions is not always the same from patient to patient, and not always based on the apparent size of the bunion.

Figure One:  A picture of a bunion

                As this picture makes clear, the bunion is not only a bony prominence at the big toe that makes shoe gear fitting problematic, but it is actually a malalignment of the underlying joint at the base of the big toe.  This malalignment is progressive over time, with the deformity creating a greater deforming force at the joint, and can be described as a “vicious cycle.”  Joint malalignment is a harbinger for arthritic changes.  Because the big toe joint is one of the most important joints in the foot for normal walking and ambulatory activities, arthritis at the big toe joint can be very debilitating for active patients.  Arthritis makes motion at the big toe joint painful, causing many patients to shift weight to the lesser joints of the forefoot.  This increases the pressure at the base of the lesser toes, causing calluses and increasing the chances of stress fractures of bones that are not designed for absorbing these increased pressures.

                Bunions are referred to as hallux abductovalgus deformity in the medical literature.  As this technical name suggests, bunions are a complex deformity with deviation of the big toe towards the lesser toes.  This shift in position to the lateral aspect is accompanied by a retrograde force causing the first metatarsal to shift further medially, causing an increasingly large medial bony prominence that is the actual bunion itself. 

                Furthermore, bunions occur in combination with other joint derangements, including but not limited to congenital flatfeet, hammertoes, and rheumatoid arthritis.  For a patient who elects to have surgical correction performed for his or her bunion, a successful outcome will depend on whether these or other concomitant issues are addressed sufficiently at the same time.

                The most common question a patient with a bunion asks me when they come in for an evaluation is “Do I need surgery to fix my bunion?”   Even though a bunion is a structural problem that can only be corrected surgically, the timing and necessity for surgical intervention is a complex issue that can only be decided after a thorough discussion between the patient and his or her physician.  The decision to proceed with surgical correction is usually based on whether the deformity is limiting the patient’s ability to perform his or her daily activities due to severe and ongoing pain that is not relieved by conservative measures, such as orthotics or changing one’s shoe gear.  Another telltale sign pointing to the need for surgical correction is when the deformity hinders a patient’s ability to participate in sports or other favorite pastimes.  The goals of surgery should be thoroughly outlined between the patient and surgeon.  This will prevent any disappointments with the final outcome of the surgical correction of the bunion.  For example, the surgeon may explain that while surgery will improve the patient’s tolerance of most shoes for daily activities, very pointy or fashionable shoes may still continue to create some discomfort.  

Many people think they must suffer with painful bunions quietly for the rest of their lives.   With well-defined goals and expectations, bunion surgery can provide lasting relief for a problem that is easily corrected in an out-patient setting.

Figure Two:  Clinical appearance of a bunion before and after surgical correction.