Learn more about how bunions develop and bunionectomy surgery in this three-minute video with Dr. Gottlieb, Medical Director at Chesapeake Research Group (directly below).
- To read more about bunion causes and symptoms click here
- What are the complications of an untreated bunions?
- Should I have bunion surgery?
- Do I qualify for a bunion clinical trial?
- If you would like to skip to our infographic, visit it here.
Bunion Causes and Symptoms
Many people have heard of bunions, know someone that has complained about them, or have them without knowing exactly what they are. A bunion (hallux valgus) is an extruding swelling on the side of the great toe that makes the toe bend or slant toward the other toes. It is actually a bony deformity on the side of the foot that is often painful and make shoes uncomfortable.
How do you get bunions?
The exact causes of bunions are not fully known. Genetics or heredity can play a role in the likelihood of developing a bunion. Some doctors believe that certain foot shapes are more prone to bunion formation. These include feet that have hypermobile (loose) joints and feet with little or no arch. An individual’s foot biomechanics (movement) can influence the condition of the feet and how they respond during different activities such as walking and running.
However, many doctors believe that the main bunion causes are certain types of commonly used footwear that cause dislocation of the great toes. This is more notable in women who wear tighter fitting shoes that narrow towards the toe area and may explain why bunions are much more common in women.
In addition to heredity and improperly fitted shoes, other bunion causes include the stresses placed on the toes. People who have occupations that require excess stress on the toes tend to develop bunions more than those of the general population. This includes occupations that require long periods of standing or walking. Ballet dancers have been noted as developing bunions at a much higher rate than people of other occupations. Other examples of occupations associated with bunion formation are factory and construction workers, healthcare personnel, mail carriers, and hairdressers.
Some people have foot defects present at birth that may increase the risk of bunion formation. Trauma to the foot, as can occur in athletes, is yet another risk factor for bunion development. It is also not uncommon to see bunions form in people who have rheumatoid arthritis. The inflammation of the joints can lead to a number of deformities that can increase the likelihood of bunions to form.
People often visit the doctor’s office with a complaint of pain and swelling in the base of the great toe in the inner foot area. The classic swelling and leaning of the great toes toward the other toes is a feature that the doctor can see during the physical exam. Therefore, visual inspection and examination is the primary means to a bunion diagnosis. During the examination, the doctor will look at the foot anatomy, movement of the foot, and the condition of the joints.
The doctor may manipulate the foot to determine the alignment of the bones and to get a good feel for the condition of the bone joints and the range of foot movement. To have a better view and understanding of the particular anatomy of the bunion and how to approach it, a bunion diagnosis may also include taking foot x-rays. This is also useful to rule out other causes of joint swelling in the foot (gout, arthritis).
Types of bunions
The most common type of bunion is the great toe bunion. The joint at the base of the great toe is affected, and the toe bone (metatarsal bone) spreads outward leading to the bony bulge that is responsible for the classic inner-foot swelling. These are notorious for causing pain with many types of shoes and activities that place pressure on the toes. The joint can also become inflamed and the bunion can progress over time to make shoe selection very difficult or impossible. Bunions can become severe enough to affect the range of foot movement and limit daily activities including walking.
A great toe bunion that is less common and due to arthritis is the arthritic bunion. It can develop as a bunion progresses or may be formed due to the inflammation that occurs with rheumatoid or osteoarthritis. The pain may be felt deeper into the bone, and the swelling due to arthritis can make a milder underlying bunion condition worse. With an arthritic bunion, there is joint swelling, redness, and stiffness that is primarily due to joint inflammation and not mechanical irritation occurring with nonarthritic bunion pain. As the arthritic condition progresses and swelling increases, the mechanical rubbing of the bunion against the shoe can also result.
Fifth toe tailor’s bunions, also called bunionettes, are the least common form of bunion. In this case, the swelling or bulge occurs at the base of the fifth or little toe. The causes of tailor’s bunions are similar to those for great toe bunions. The symptoms are also very similar and can become painful with constant rubbing of the bunion against the shoe.
One thing people can do to prevent hallux valgus or bunions from forming, or at least keep them from progressing to a more severe and painful form, is to select shoes that do not promote overpronation (excessively turning inward) of the foot. Also important is to wear shoes that allow room for some toe movement. These types of shoes have rounded toe boxes with heels that are lower than two inches high (to prevent the toes from being pushed forward and forced together). When the foot slides forward, this leads to repeated foot trauma that can make bunion problems worse.
Shoes that are designed to prevent the foot from sliding forward while walking should have a strap or laces over the instep. Another consideration are shoes or sandals with a molded footbed because these may help to relieve pressure on the great toe joint. For athletes, choosing training shoes that support the foot and minimize trauma during sport activities can help to reduce the types of pressure and trauma that increases the risk of bunion formation or progression.
Many people, particularly those whose feet tend to overpronate, find that the use of orthotics (footpads or shoe inserts) significantly helps to stabilize the foot. Orthotics are ideally made from a cast of the foot while placed in the proper position; however, some over-the-counter orthotics can be very helpful. They should touch or support the arch of the foot and promote better alignment of the great toe.
Splints that keep the great toe straight and stabilized can also limit bunion progression. Even exercises recommended by a physical therapist can help lower risk of bunion formation or severity. The options discussed can help prevent hallux valgus in people who overpronate if applied early enough or to treat less severe forms of this foot deformity. Early consultation with a podiatrist can allow proper diagnosis and the opportunity for the doctor to recommend the best approach for those who have foot anatomy and mechanics that make them more prone to bunion formation.
What Are the Complications of an Untreated Bunion?
Bunions that are left untreated can get larger and more painful over time. The long-term effects of an inflamed great toe bunion include arthritis of the great toe joint, hammertoe formation, and other foot problems.
When arthritis in the great toe joint develops, people can feel tenderness and pain in the joint. In these cases, removal of tight shoes and other remedies often do not relieve the pain that can persist while at rest. Another type of inflammation that can occur with untreated bunions is bursitis. This is inflammation of the fluid-filled sac (bursa) that functions as a cushion for the bone and other tissues surrounding a joint. Bursitis resulting from untreated bunions can lead to painful inflammation of the great toe bursa.
A common result of untreated bunions is the formation of hammertoes. A hammertoe is an abnormal bending of the toe located next to the great toe. The slant that the bunion-affected great toe makes towards the other toes can cause hammertoe formation in the adjacent second toe. This is mainly due to the second toe becoming longer relative to the slanted great toe (even if the second toe it is not actually anatomically longer). This leads to cramping of the second and/or other toes inside the shoes. Over time, this cramping leads to the abnormal bending that leads to a hammertoe. Much like a bunion, a hammertoe can rub against the inside of the shoe leading to pain and inflammation.
As bunions become more severe, they can cause other toe deformities leading to significant changes in the overall shape of the foot. The great toe is very important for balance, and major changes occurring due to bunions can make walking painful. Calluses are not uncommon consequences of bunion-induced toe deformities such as the crossing or overlapping of the great and second toes.
Inflammation and pain in the ball of the foot, metatarsalgia, is a symptom that can occur in people who have bunions. Trapped or irritated nerves are often the cause of the pain and can result from hammertoe and other toe deformities that result from bunions. The increased stress on the ball of the foot resulting from bunions can also result in metatarsalgia.
Should I have Bunion Surgery?
A Bunionectomy is a surgical procedure performed to correct the bunion bone deformity. When nonsurgical measures do not help to relieve bunion pain that affects daily life, a bunionectomy may be a viable option. Those who may be recommended surgery are people who have substantial foot pain that is difficult to control and that affect common activities such as wearing comfortable shoes or even walking. People who have toe deformities such as hammertoe and crossing of the toes may benefit from a bunionectomy.
There are many different ways to perform bunionectomies, but the main idea is to put the great toe back in a correct position. Below are examples of the types of bunionectomies that doctors perform in patients.
- Realignment with a distal bone cut: Distal osteotomy is the most common approach and involves cutting the metatarsal bone at the far end of the bone (the part located toward the tip of the toe). Cutting the bone in the distal region reduces the abnormal spacing between the first and second metatarsal bones. After the bone is cut and realigned, pins or screws are placed in the bone to hold the bone in place. Cutting the bone at the distal location leads to fewer post-surgical complications.
- Realignment with a proximal bone cut: Proximal osteotomy is a less common approach and involves cutting the first metatarsal at the near end of the bone (in the opposite direction, the part near the ball of the foot). A greater chance for post-surgical complications is associated with using this approach.
- Fusion procedures: Also called arthrodesis, a fusion procedure involves the permanent locking of the joint. Arthrodesis may be necessary in people who have severe bunions and/or arthritis of the joint. The procedure may also be needed in a person that has had poor response after a previous bunion surgery. Fusion procedures lower risk of returning bunions by reducing excess movement of the joint.
- Joint replacement procedures: Total joint replacement for the great toe (total toe arthroplasty) involves the removal of destroyed bone and placement of an implant. There are still some challenges with finding the best implant material that can provide long-term positive outcomes.
All surgical procedures including bunionectomies have risks of complications. These don’t occur often, but it is still good to know what complications can occur after surgery. An infection can occur at the surgical site and measures are taken to help prevent this. Nerve injury is possible but uncommon. Some may not get the expected pain relief intended with a bunionectomy. A few people have experienced delayed or difficult bone healing and joint stiffness. Bunions may also return some time after surgery.
Alternative Help to Reduce Symptoms
Nonsurgical means to get relief from bunion symptoms are often tried before surgery is considered. This is particularly important for those with milder types of bunions. Shoe selection is very important, and a shoe that does not cause undue pressure on the foot can help ease bunion pain. Shoes that allow some toe movement can help many who have bunions. The use of patches to protect the bunion from friction with the shoe can prevent increased inflammation and pressure on the bunion. Icing down the bunion is an easy way to help reduce bunion inflammation.
Additional bunion relief can include using custom-made orthotics and specially made shoes for bunions. As mentioned previously, splints can help keep the great toe straight and in a stable position. It may also be necessary to cut down on long-term standing and other activities that worsen bunion inflammation. Other nonsurgical bunion treatment such as taking anti-inflammatory agents can help some people get relief from pain due to bunion inflammation. Many people find that taking nonsteroidal anti-inflammatory agents can sometimes provide relief, while others get more benefit from cortisone injections. These are not permanent fixes, but can provide relief form some of the pain and swelling symptoms of bunions.
Do I qualify for a bunion clinical trial?
Medical Studies for Bunion Research
There are a number of ongoing clinical trials involving the treatment of bunions. There are currently over 50 different bunion-related clinical trials registered on ClinicalTrials.gov, a database of clinical studies in humans. A few studies address the outcomes of implant surgery and specific bunion surgical approaches. The vast majority study the safety and efficacy of new forms of post-operative pain relief.
What are the risks?
As with known and approved drugs and medical remedies, those that are part of clinical trials can have a risk of side effects. You will not know if you receive the actual treatment or a placebo (a control treatment with no medical effect). In addition, the patient in a clinical trial has a time and effort commitment that is essential so that the medical team can get sufficient results needed to decide if the studied treatment is safe and effective. After taking part in a trial, it may be found that the treatment may not be any better than those that already exist.
What are the benefits?
On the positive side, there are benefits to participating in a clinical trial. Most importantly, you may contribute to the discovery of a new treatment that will benefit the masses. You may get health benefits if you are in trial’s treatment group. Participants also receive medical care and attention during a trial.
What happens during a clinical study?
Those who are potential participants in clinical trials receive thorough medical examinations by a complete medical team. Clinical research scientists determine who is or isn’t eligible to participate in the trial. This is based on specific conditions that must be met. Those that are included in the trial will receive detailed instructions on how to take or apply the test treatment. During this period, participants’ health and treatment use is monitored by the medical team. For a period after the trial, additional monitoring is performed and more information is collected by the medical team.
What is Informed Consent?
Before participating in a clinical trial, a potential participant must understand what the trial is for, as well as the risks and benefits of participating. Giving permission to be included in a clinical trial after having and understanding this information is informed consent. A special review team (Institutional Review Board) has the duty to protect the rights of clinical trial participants and to make sure the trial is ethical.