Bunions: A Pain in the Toe

One of the most common foot conditions that podiatrists treat surgically is a bunion. Many people mistakenly think that their bunion is a bump that grew on the toe, so they treat it by padding it, or they assume that the bump needs to be "shaved off" when it's being treated by surgery. One thing that isn't intuitive, and takes x-rays to see, is that the bone has shifted.

**a long explanation is about to begin. If you're just here for the home treatments you can try, you can skip to the bottom, but at least you can get a little more knowledge if you are curious.

Hallux abductovalgus (the scientific name for a bunion) is when the hallux--latin for big toe--has shifted into a "valgus" position. Going back to my brief foray into medical lingo a few weeks ago, valgus and varus are descriptions of how a body part is positioned in relation to the rest of the body (twisted one way or the other). Likewise, "abducto" refers to another position change meaning the body part is taken farther from the body (as though the part was abducted away from the rest of its nearby body parts). The opposite term of abducted is adducted (confusing sometimes early on, believe me), meaning that the body part is brought closer to the rest of the nearby body parts.

The diagram below shows how the heads of the bones in the ball of your foot should line up, roughly speaking. I've also added a line down the middle of the head of the main bone we're talking about. (The two tiny little bones in the diagram are called sesamoid bones. They give extra leverage to the tendon that pulls your big toe downward. They're supposed to be straight under the big bone. More on that another time). Just take a look at the x-ray below and see that the angle between the big bone and the one next to it is pretty small. Maybe 5 degrees difference between them and those little sesamoid bones are right beneath the head of the bigger bone, right where they're supposed to be.


What happens with a bunion is that the toe is both twisted out of its natural position and shifted farther away from the rest of the foot bones. That is because the joint at the base of the long bone is less stable than it's supposed to be, allowing the bone to shift over time when all the competing forces in the foot get sorted out. You can see in this x-ray that the angle between the bones is much greater, probably over 20 deg in this case. The distance between the heads of the bones has also increased. In order to fix this, you have to correct the deformity where it began: back at the base of the bone.

Why Did I Get My Bunions?

Unfortunately, the vast majority of patients with bunions developed them because of genetics. Yep, that's right, they're inherited. Why? For the same reasons that hair and eye color, near-sightedness, and body type are inherited. There are genes that tell your developing body how to form, and in the case of a patient with bunions, they got the genes that made the joint responsible for bunions shallower and less stable--actually, it looks very similar to an opposable thumb in primates. This means the joint naturally wants to rotate out of position, causing the bunion. I can't think of the last time a bunion patient of mine didn't have a close family member (usually a parent) who had bunions.

How Do I Fix Them?

My generally recommended procedure to fix a bunion is called the Lapidus procedure--named after a Dr. Lapidus from about a hundred years ago (you'll find that lots of things in medicine are named after doctors--shocking, I know). Anyway, this procedure involves correction of the angle between the bones by fusing the unstable joint, so the two bones grow together to become one bone. Most surgeons who do this include rotating the bones back into proper alignment prior to fusing this, so that the whole deformity is corrected. Below is typically what the bunion looks like after it has been corrected using this procedure. You can see that the angle between the bones is corrected and also that the bone is properly aligned vertically once again. This is my preferred procedure for most bunions, especially ones that developed early in life (teenage to late 20s). This is because it has by far the highest success rate (meaning the bunion doesn't come back) of any procedure we do.

There are procedures we will do that don't have higher success rates, but that doesn't mean they are without use. The most common bunion procedure performed today is called the Austin bunionectomy (You guessed it, named after a Dr. Austin who first started doing this). It involves making a bone cut in the head of the bone and shifting it back into a better position, so the weight bearing surface is more in line as it should be. 

This isn't a perfect procedure, but it is better than nothing, and the painful bump is usually gone. I typically use this for patients who can't be off their feet (or can't be trusted to stay off their feet) long enough to heal. I also will do this if there is any development of arthritis from having the joint out of alignment for a long time.

There are two dozen other procedures that have been used for bunion correction, but I'll save you the lecture. You didn't click on this link to learn how to do bunion surgery, after all. You're probably wondering what conservative things you can do for yours.

What Can I Try At Home For My Bunions?

Many people with bunions actually only have pain when their bump rubs against their shoes. The simplest solutions for this are to buy shoes that have more room in the toes or to get some sort of padding to cover the bony bump. A quick Google Search will show there are a number of devices that are sold to try and straighten the toe. I've never used them because I believe they're insignificant compared to the forces in the foot that are pulling the toes out of alignment, but hey, if it works for you I can't argue with results.

If you're developing bunions, or your parents have them and you want to try to avoid them, custom supportive inserts can help sometimes, by controlling the motion of your foot so there's less chance of the bunions developing. This isn't 100% effective, but it is better than nothing.

Ultimately, these are conditions that often require surgery. That being said, I often tell my patients "If it ain't broke, don't fix it." If your crooked toes don't bother you, nobody's gonna twist your arm and make you fix it--although usually painless bunions eventually become painful ones. Either way, trained foot and ankle surgeons are happy to help you sort out your options!

Note, as usual, the links I've provided today are not my websites. I simply performed a quick Google search to find an example

The illustrations are all mine, for either glory or embarrassment. Not flashy, but adequate.