A bunion is a common condition that affects the foot and is also known as hallux valgus. A bunion is not an overgrowth of bone, the main reason for the prominence is that the ligaments that hold the big toe in position are lax and are no longer able to keep the toe in alignment. The most common reason for this to occur is shoewear, and unfortunately in modern society, fashionable closed toe shoes are a societal norm. In some patients, there is a congenital component to the bunion, with a the ligaments beings lax from a young age or the shape of the bones are such that a higher risk of a bunion exists. As we age, some patients will also develop arthritis and can be a reason why a bunion that hasn’t hurt before begin to cause pain. The treatment for a bunion with arthritis requires a fusion in most cases and very different than treating a bunion without arthritis.
Diagnosing a bunion on physical exam is clear as the patient can tell that there is a prominence on the inside of the foot. However, there are important physical examination findings that help to determine what the best surgical procedure would be if needed. Starting from the leg, the tightness of the calf muscle (gastrocnemius) is assessed. If there is more motion of the ankle with the knee flexed (bent) than with the knee extended (straight) this indicates that you have a tight calf muscle. In these cases, lengthening the calf muscle can be considered in addition to the work on the toe itself. The instability or looseness of the joint in the middle of the foot called the 1st tarsometatarsal joint is assessed. If there is a significant amount of instability in this joint, this may imply that the loose joint is allowing the bones to deviate causing the bunion and a special surgery called a Lapidus may be required. If the joint is stable and there is no pain within the big toe joint or limited range of motion, the bones can be broken and shifted to help realign the toe. Unfortunately, simply removing the prominence is not appropriate in most cases as the problem is an alignment of the bones not simply an overgrowth of bone. Xrays are taken to evaluate the alignment and presence of arthritis of the foot.
Treatment of bunions is initially focused on shoewear modification, which includes wider sole shoes and consideration to have fashionable shoes widened with a shoe cobbler. Over the counter devices to pad the bunion can help minimize the pain from pressure on the toe as well. In patients where the nerve is very irritated, these cushions can be very helpful. No over the counter device has proven to be successful in correcting the shape of the foot. Surgery can be considered in patients who have severe deformity or who have pain despite shoe modifications. Surgical treatment is individualized based on the physical exam and the xrays as there is no one surgery that works for all patients. The surgery requires either breaking the bones and realigning them, or a Lapidus, or a big toe fusion (arthritis) and does require the use of screws and/or plates and screws in addition to tightening the ligaments. A period of limited or protected weightbearing in surgical shoes or splints is needed.
