Is This a Bunion?
By Jeffrey W. Watkins, DPM, AACFAS  

Often patients will present to the office asking the question, “Is this a bunion?” After my confirmation, the patient will instinctively ask, “What can I do about it?” In this article I will give a brief explanation of Hallux Valgus (bunion) deformities, including cause, conservative and surgical care and how we try to prevent recurrence.

Webster’s dictionary defines a bunion as “an inflamed swelling of the small sax on the first joint of the big toe.” Indeed, patients often come to the office stating that they have a bump on the inside of their foot. This “bump” is traditionally located at the base of their big toe. Initially it may or may not cause much pain. However, by the time care is sought the bump usually has become irritated and red; particularly with certain types of shoes. Patients will usually state that is has progressively gotten worse over the past several months to a year. These are the “classical” signs of a bunion.

The cause of a bunion is much more complex than Webster’s simplified definition. Although it is possible to develop an inflamed sax at the great toe, in actuality, this sac (called a bursa) has developed to protect the underlying bony prominence from rubbing against the shoe. It is the underlying prominence that is the true bunion deformity. The bursa may become inflamed due to the constant pressure from shoes. However, the true cause of a bunion is much more complex.

Hallux valgus (bunion) is an orthopaedic condition in which there is an increase in the angle between the first and second metatarsal bones of the foot. This can be caused by such conditions as neuromuscular disease, congenital abnormalities (limb length discrepancy, trauma, metabolic disease (rheumatoid arthritis) and structural deformities of the foot. However, the most common cuase of a bunion is a biomechanical condition called pronation.

Increased pronation or flattening of the foot places the foot in a very flexible position. This leads to increased range of motion of the first ray (great toe and first metatarsal) of the foot. With increased range of motion there is increased instability at the great toe joint, which leads to its drift toward the second toe. As the toe drifts, the joint becomes more prominent on the side of the foot, which, in time, will lead to shoe irritation, joint pain, degenerative changes, decreased great toe range of motion and possibly calluses.

It is at this point that people usually will seek treatment. On initial evaluation the physician will examine the patient not only to evaluate the foot, byt to evaluate for systemic diseases, progression of the foot deformity, family history or disease and foot deformity, current health status, activity level and prior treatment. Clinical examination should include evaluation of pulses, neurological sensation to the foot, range of motion of the foot and ankle, limb measurements and evaluation of callus formation. X-rays can also be evaluated for bone potion, joint alignment, joint integrity and bone quality.

Conservative care is usually recommended initially. This would include evaluation of shoes to assure that fit is proper. The widest part of the shoes should be at the widest part of the foot. Anti-inflammatory medications may be prescribed for acute pain or bursal inflammation. Debridement of calluses should be performed to relieve pressure points and patients should be instructed on debridement at home. Injections may be indicated for treatment of bursitis. Range of motion exercises may temporarily limit stiffness at the great toe joint. There have also been reports that arch support may help slow the progression of a bunion deformity by controlling the pronatory forces contributing to the deformity. If, however, conservative treatment fails and the deformity begins to alter a patient’s activity and quality of life, surgery is the only way to correct a bunion.

Once it has been decided by the patient and physician to proceed with surgery, a thorough evaluation of the patient’s x-rays, foot structures, expectations and activity level must be performed to choose the appropriate surgical procedure. Much of this decision will be based on the angle of the first and second metatarsals as measured on the x-ray. This will tell the physician at what level to perform the surgery to sufficiently reduce the angle to a more normal range. This in turn will dictate the post-operative course, in that mild bunions can usually be corrected at a level that will allow the patient to ambulate immediately following surgery. A moderate bunion may require a patient to be completely off the foot for up to four weeks. Severe bunions may necessitate at least six weeks of non-weight-bearing. Of course, these times can be altered depending on several factors including patient health status, bone density, use of screws or pins to hold the fixed bone, use of casts and patient compliance.

Clearly, a bunion is a much more complicated medical condition than Webster’s simple definition would indicate. However, with thorough evaluation, proper selection of surgical procedure, correction of the causing force and realistic goals and expectations, having a bunion should only be a temporary speed “bump” on the road of a happy, healthy and active life.

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