The term bunion, as it is popularly used, describes a variety of deformities involving a painful bump and swelling at the base of the big toe. Orthopedists use additional terms to describe the different individual deformities. A condition in which the big toe deviates from the normal position and angles inward toward the second toe is referred to as hallux valgus.
Technically speaking, the word bunion refers specifically to an enlarged bump made of bone and sometimes including an inflamed bursa. This inflammation is caused by the bony prominence (bump) and develops on the bursa of the first metatarsal head at the base of the big toe. Although a bunion can develop without hallux valgus, this article discusses only bunions that include hallux valgus. (Dorsal bunions are a completely different variety, in which the bump appears on the top of the base of the toe. These are often the result of arthritis in the toe joint.)
Doctors and scientists have not been able to identify a single cause or set of causes for bunions. However, heredity and gender each play a role. Bunions tend to run in families, and women develop bunions more frequently than men. In addition, the foot gradually widens with age as the ligaments that connect the bones in the forefoot become more lax. Contrary to what many people believe, poorly fitting shoes do not cause bunions. In fact, bunions are found in populations all over the world, including among those who never wear shoes. Shoes that are too tight can, however, contribute to the progression of the condition. Bunions are often bilateral, that is, appearing in both feet. Although bunions are usually seen in people who are middle-aged or older, even teenagers sometimes develop them, usually as a result of a congenital condition.
Orthopedic surgeons diagnose bunions on the basis of a physical examination and X-rays taken while the person is weightbearing (standing). Two angles are assessed:
Although some people feel that their bunion is unattractive, the condition is not always painful. If you have only minor discomfort due to a bunion, your pain may be eased by wearing wider shoes made of soft leather and/or with the aid of spacers – padding placed between the toes to correct alignment. You may need no additional treatment.
More serious cases may require one or both of the following:
Orthopedic foot and ankle specialists at HSS perform more than 400 bunion surgeries a year. Cosmetic concerns alone are not a sufficient reason to have bunion surgery.
"There are different reasons to consider bunion surgery," says Jonathan T. Deland, MD, founder of the Foot and Ankle Service at HSS. "If the patient has pain in reasonable shoes, has tried wearing wider shoes with no relief and pain been a long-term problem or is worsening, surgery should be considered. Also, if the big toe is pushing against or overlapping the second toe and causing pain in that toe, the bunion must be addressed in order to take care of the painful second toe."
Another symptom that may require surgery is instability in the first ray (a combination of the medial cuneiform bone and first metatarsal bones, which nestle together and connect to the bones of the big toe) with pain on the ball of the foot (the portion of the foot at the base of the toes under the metatarsals from the tip of the toe, back up to the midfoot).
Surgical treatment for bunion deformities usually involves an osteotomy to restore proper alignment. Different techniques are used, depending on the type of deformity. The technique your foot surgeon will select is guided by considering the:
Some of the more common bunion surgery procedures are:
Patients undergoing bunion surgery are given a regional anesthesia ankle block, which anesthetizes the foot from the ankle down. Depending on individual preference, a sedative may be given as well and the patient can be as sedated as they wish. The ankle block administered as anesthesia provides pain relief for up to 12 hours following surgery. Strong pain relievers are provided and anti-inflammatories can be used as well. "Bunion surgery has a reputation for being painful," says Dr. Deland. "But with appropriate pain management and elevation of the foot, this can be minimized."
All bunion surgeries can be done on an ambulatory (same-day) basis, eliminating the need for hospitalization.
Length of recovery from bunion surgery varies according to the nature of the procedure.
Formal physical therapy is most often not necessary. Patients are given range of motion exercises for the toe. Therapy is used only if progress with the motion is slow.
Overall, outcomes for bunion surgeries are quite good. However, orthopedic surgeons on the Foot and Ankle Service at HSS often treat patients who have had unsatisfactory outcomes from surgery at other institutions. While the problems resulting from these surgeries can be addressed, the success rates are better when the proper procedure is expertly done the first time.
If you are considering surgery to correct a bunion, Dr. Deland and members of the Foot and Ankle Service advise you consult an orthopedic surgeon who is experienced in a wide range of surgical techniques – the simpler procedures as well as those that are complex. You should feel confident that you are getting the right surgery for your condition, and that the recovery and rehabilitation process will be appropriate and effective.
In addition, Dr. Deland cautions against committing to any procedure in which the bunion is simply "shaved down" rather than correctly addressing the metatarsal deformity. Shaving a bunion may only provide a temporary solution. A shaved bunion may come back in the future.
Summary prepared by Nancy Novick • Diagnostic imaging examinations provided by HSS Radiologists