Joel D. Stewart, MD
One of the most commonly seen issues with the feet are bunions. Even if you aren’t a physician, you probably can recognize a bunion when you see one. The main characteristics of a bunion are 1) a large, knobby looking bump on the inside of the big toe, which may be red and painful; 2) the big toe typically slants towards the smaller toes and may even have gone under or over the second toe in severe cases; 3) corns and calluses may develop where the toe rubs on the second toe or one of the other toes where they push on each other. About one in three Americans have a bunion or bunions.
A bunion (clinically known as hallux valgus) doesn’t start as an area of boney growth (bone spurs or osteophytes) on the big toe joint. Bone spurs usually present on the top of the great toe and this is called hallux limitus or rigidus.
Some people have bunions as a child or “juvenile” bunion. These are often due to the joint being lined up incorrectly. As an adult, it begins as a subluxated or misaligned metatarsophalangeal (MTP) joint that develops which can be due to poor foot mechanics, pressure from walking and standing.
Bunions are more common in women than men and it is thought that they can be hereditary, caused by a foot deformity, such as flat footedness, or that patients with certain types of arthritis, such as rheumatoid arthritis, may be more prone to them. Experts are divided as to whether wearing pointy, tight, high-heeled shoes are a factor, but as they happen much more often to women than men, it is a theory worth considering. Personally, I don’t think pointy shoes “cause” bunions, but they certainly can make them hurt more. You can even have one on the outside of the foot at the small toe, called a bunionette. (Sounds cute unless you have one!)
The symptoms of a bunion are intermittent pain, swelling, redness, stiffening and later, difficulty in bending and moving the big toe, as well as numbness. Walking and balance may also become an issue as pain and foot deformity increase. Patients will also have increased difficulty finding shoes that fit without causing pain as their bunion continues to get larger.
When a patient comes to see me for a diagnosis, I order x-rays to determine if there is any joint damage or bone misalignment. I also do a thorough physical exam and ask the patient to walk and move their foot and big toe for me to observe. Bunions are classified in stages that range from mild to severe and I formulate a treatment plan based on the stage in which my patient presents. I want to try conservative treatment first, as bunion surgery is major, and the recovery period is lengthy.
While some bunions are progressive and cannot be reversed without surgery, there are treatment options available that can slow their progress and ease the discomfort. These conservative treatments can be used in combination or separately as best serves the patient’s needs and depending on the stage of severity of their bunion. They include but are certainly not only limited to:
- Splinting/toe separators/night splints – these orthotic devices are all meant to keep the bones in better alignment and to retard further inward shifting of the big toe. They can be worn during the day or only at night.
- Physical Therapy – A qualified Physical Therapist can help to keep the MTP joint mobile and functioning through exercise, manual manipulation and can help break up adhesions and decrease inflammation in the joint.
- Footwear – Buying footwear specifically with larger toe boxes to accommodate bunions and to prevent them is extremely important.
- Bunion, corns and callus padding – these pads can make wearing shoes less painful and can help prevent or retard the further growth of corns and calluses.
- Pain relief – The use of NSAIDS, such as naproxen sodium or ibuprofen can help to relieve pain and inflammation, as well as intermittent icing, for 20 minutes on and 20 minutes off, several times a day. Never put ice directly on your skin, but instead use a protective barrier between you and the icepack.
- Oral and injectable steroids – Injectables are typically used for more severe cases as a last resort before surgery, especially as they can cause joint weakening if used too often.
In my next article, I will discuss what happens when conservation treatment of bunions is not successful, and we must look at surgical options.