Website Bunions

We've divided this topic into three sections. This page discusses what bunions are and how you get them. Another page discusses how we how we evaluate bunions on X-ray. A third page discusses common surgical treatments for bunions. We recommend you start here.

What is a bunion?

The original definition of a bunion was a bursa (a fluid-filled sac) on the side of the foot near the base of the big toe. The bursa was caused by a chronic friction of the patient's first metatarsal bone (the bone to which the big toe attaches) and the shoe.

Few people go by this definition any longer. Today most people consider a bunion to be the enlarged bone on the side of the foot that typically caused the bursa. (See the illustration to the left.) Along with this bump, there is usually an associated mis-alignment of the big toe, with it leaning in towards the second toe.

In medical jargon, the term for a bunion is "Hallux Abducto Valgus," or "HAV" for short. Though the condition is really slightly different, it may also be known as "Hallux Valgus."

Bunions are usually a progressive problem, and can make it difficult to find shoes that fit. The condition is often quite uncomfortable, not only because of the pressure the shoes exert on the bump, but because of the other factors associated with bunions, which we shall discuss shortly. This is usually a progressive problem, and can make it difficult to find shoes that fit. The condition is often quite uncomfortable, not only because of the pressure the shoes exert on the bump, but because of the other factors associated with bunions, which we shall discuss shortly.

Bunions are among the most common problems of the foot. They are several possible reasons a bunion may develop, though a biomechanical abnormality (improper function of the foot) is the most common cause. In an unstable flat foot, for example, a muscular imbalance often develops that, over time, causes bunions.

Bunions tend to run in families, and most podiatrists believe that genetic factors play a role in predisposing some people to develop bunions. Poor shoes--like high heels and pointed toe boxes--exacerbate the condition by speeding up the development of bunions, and by making bunions more painful. Poor shoe choices is at least one of the reasons bunions are much more common in women than men.

Bunions typically start out as a mild bump or outward bending of the big toe. Bunions at this stage are usually only a concern of appearance at this stage, and at this point they often don't hurt much.

Over time, the ligaments that connect the bones of the toe stretch out, and the tendons attaching to the big toe gradually pull it farther and farther towards the second toe. Sometimes patients will find their first and second toes begin to press together too much, and they'll often get a painful corn between those toes. As the bunion progresses, the big toe may begin to ride on top of the second toe, or vice versa, creating a second deformity.

Others will develop bump pain at the site of the bony enlargement on the side of the foot. A painful bursa may develop at that site. This is particularly true in tight shoes. Many patients also develop a painful callus beneath the foot. Capsulitis and other types of metatarsalgia may develop in the joints beneath these calluses, particularly in the second and third metatarsophalangeal joints (the joints in the ball of the foot).

Over time, with the toe held in a crooked position for enough time, arthritis develops in the big toe joint. This will usually result in decreased range of motion of that joint (a condition known as "Hallux Limitis"), which as a result, often causes the patient to gait abnormalities, or changes in the way a patient walks. Often the patient walks in an "out-toed", or duck-like, fashion, which very frequently causes secondary pain in the legs, knee, hip, and low back.

Bunions are progressive problems, meaning they tend to get worse over time. Sometimes severe-looking bunions don't hurt much, and sometimes relatively modest-looking bunions hurt a great deal. Thus, treatment varies depending upon a patient's symptoms.

You can often improve the discomfort of bump pain by a change to more proper shoes. Alternatively, alterations to existing shoes may improve pain associated with bunions.

Accommodative padding, shields and various over-the-counter and custom-made orthopaedic appliances can also alleviate bunion pain.

Anti-inflammatory medications, steroid injections, physiotherapy, massage, stretching, acupuncture and other conservative treatment options may be recommended by your podiatric physician to calm down an acutely painful bunion.

Long term, orthoses (orthotics) can address many of the mechanical causes of a bunion. Thus, while orthoses don't actually correct a bunion deformity, if properly designed and made, they can slow the progression of bunions. They can also be made to redistribute weight away from pain in the ball of the foot, which often accompanies bunion development.

Padding, latex moulds and other accommodative devices may also be effective. While they don't correct the misalignment in the bones, they may alleviate pain.

Often, though, when conservative measures fail to alleviate pain associated with the bunion, when you start to limit the types of activities you perform, when it's difficult to find comfortable shoes, and when arthritis changes how you walk, surgery may be the best alternative.

There are dozens and dozens of types of surgery designed to address bunion deformities, and each have different indications. We review some of the factors that must be considered when choosing a bunion surgery on a second web page. And we review some of the most common bunion surgeries on a third web page.

But in short, some procedures simply address an enlarged bump. Some simply address a crooked big toe. But in order to slow the return of the bunion deformity, most procedures aim to realign the big toe with the bone behind it--the "first metatarsal." This would also realign the joint surfaces between those two bones.

But even if the surgery is designed to realign the big toe, there are still many choices to consider. Some procedures are meant for a short first metatarsal and others for a long first metatarsal. Some are best when the foot is very unstable, others are based on the severity of the arthritis present. In fact, there are many, many factors to consider when designing a procedure to address a particular patient's foot, to the extent that what's involved in a bunion surgery not only varies from patient to patient--the procedures often vary even from a patient's right foot to the left foot!

Sometimes a screw is placed in the foot to hold a bone in a corrected position, other times a pin, wire or plate is chosen. There are even absorbable pins and screws, which are used for some patients.

In British Columbia, pins seem to be used most frequently, as they're easier to insert and less expensive. They are typically--but not always--removed at some point in the healing process. But as a general rule, Dr. Schumacher prefers to use screws whenever possible, as they offer some advantages over pins. First, using screws allows you to close over the wound completely, without leaving a pin sticking out of the foot. That allows for a lower infection rate, it allows you to get your foot wet more quickly following the surgery, and it usually allows for a quicker return to normal shoes. Second, they're more stable than pins and wires. Stability allows for faster, more uneventful, bone healing. Third, they usually don't need to be removed down the road, so there's one less procedure involved.

It used to be that casts were almost always used, but over the years, many procedures have been designed to provide inherent bone stability and get patients back to normal as quickly as possible. We discuss this in our page on bunion surgeries. So casts are used much less frequently than years ago. When casts are used these days, it is usually because an procedure was chosen for one reason or another that puts the bones in a particularly unstable position for part of the healing process.

Not typically, no. Years ago patients were hospitalized for the procedure, but today, as a general rule, patients can have the procedure done in a surgical center and go home two or three hours later.

In most cases we try to use local anesthesia whenever possible.

General anaesthesia has been used historically, but there are problems inherent with using general anaesthesia, and it is more likely to cause post-operative pain and general medical problems than other forms of anesthesia, so we use general anaesthesia less and less. I.V. sedation, spinal anesthesia and other methods also exist. Each has indications and contraindications.

If you use local anaesthesia, can I feel what's going on?

You can't see what's going on, as there are blinds covering the operative site. Most patients watch TV, listen to music, read a book or even sleep during the procedure. Obviously, this is a big difference with how bunion surgery used to be done.

In 90% of procedures performed, you'd be able walk to a modest degree immediately after the procedure. You would not be walking completely normally, or certainly to the extent you may have walked the day before the surgery, but you usually can get around.

However, there are still occasions where non-weight bearing is required after a procedure, so this decision is made on a case-by-case basis.

This is our job as the surgeon to decide. Because of the number of variables in foot type and the vast number of procedures available to choose from, the only way to assess what procedure you may need is to examine the patient and x-rays very carefully beforehand and tailor the procedure to fit the patient's treatment goals and lifestyle.

Choosing the proper bunion surgical procedure is a very in-depth process, and decisions are made on a careful, individual, patient-by-patient, foot-by-foot basis. This is why it is recommended that patients considering a bunion surgery--or any foot surgery--choose an experienced surgeon who specializes in foot surgery.

Foot surgery is, in fact, one of Dr. Schumacher's specialties. He is board-certified by the American Board of Podiatric Surgery, (the gold standard in foot surgery certification), and he is a Fellow in the American College of Foot and Ankle Surgeons.