Bunion deformity or hallux valgus, the technical term, is a common foot disorder affecting 30% of the population with women being affected more often.
Women are generally affected by bunion deformity for many reasons I will discuss later on in the blog.
There are many misconceptions regarding bunions, who develops a bunion, and what causes a bunion. I have watched popular talk show hosts tell women bunions are caused from wearing high heels. This logic fails when we start to discuss bunions in men as rarely do high heels come into play. Analyzing the historical record of the deformity the Greeks were the first stone masons to sculpt stone statues of realistic human form. In many of these statues a bunion was sculpted on the subject.
This tells us that the condition has been around for at least thousands of years and perhaps much longer.
Marsupials and great apes have a flexible opposing great toe used for grasping and gripping which looks very much like a bunion deformity. Modern bunion formation could perhaps be a reversion back to these atavistic foot types.
There can be many underlying causes for bunion deformity. I believe there is a strong genetic component. It is common for patients to relate a parent or grandparent had a bunion.
I have operated on three generations of patients for bunion deformity in my practice and seen the correlation over 20 years. The development, progression, and clinical symptoms are highly variable between patients, even within the same family.
In general, the size of the bunion and the associated symptoms tend to get worse with age. Pregnancy can also cause worsening pain and deformity.
During pregnancy, a hormone is produced called relaxin which relaxes the ligaments in the pelvis among other beneficial effects. Relaxin also relaxes other ligaments including those in the feet. This additional ligament laxity combined with the weight of carrying a child can have a marked impact on progression of bunion deformity as well as other structural problems.
It is common to consult with young women with progressive bunion pain after childbirth and even more so after each subsequent child.
In addition, collagen disorders such as Ehlors Danlos Syndrome which cause generalized ligament laxity and a predisposition for development and progression of bunion deformity.
Additionally, there are a myriad of biomechanical reasons patients develop bunions.
Bunion Pain
The cause of bunion pain can be the result of various factors. Inflammation around the joint involving the capsule (lining of the joint), ligaments, nerves, and skin can all become inflamed and painful. Arthritis can also cause pain. Arthritis usually involves loss of cartilage, stiffness, and bone spur formation around the joint.
The average active human walks approximately 25,000 miles in a lifetime, which is about the circumference of the earth. It is remarkable we are not all crippled from arthritis much earlier in life. Injuries and trauma can contribute to developing early joint pain and arthritis.
Certain sports can also predispose to developing premature wear and arthritis. Basketball, football, and soccer are the top three due to the mechanical requirements of the sport. Racquet sports such as tennis and racquet ball also can aggravate bunions due to the physical demands of playing on the forefoot.
In situations of a long standing bunion deformity which has not been treated or ignored the joint has been in a misaligned position for many years. The misaligned joint and abnormal function of the joint can cause degenerative changes to the joint and cartilage over time.
Oftentimes as bunions progress the shape of the foot and stability of the arch will change. The instability and misalignment can impact walking and impair normal function of the foot.
The instability and misalignment can cause other associated problems such as lesser toe pain, stress fractures and arch fatigue.
Shoes and Bunions
Contrary to popular belief shoes do not cause bunions.
Poor fitting shoes however do make bunions more symptomatic. If we understand bunion deformity likely predates written history based on observing Greek stonemasons and sculptors and prevalence of bunions around the world.
When we examine cultures of Sub-Saharan Africa where closed toed shoes are not often worn and the prevalence of bunions is the same as North America. What is true is that tight fitting shoes create pressure and irritation over the bunion causing inflammation.
As the early symptoms arise the first thing to do is have the foot measured when you are standing. It is likely your foot has gotten wider and may require a wider shoe. Knowing a skilled shoe repairman can also be beneficial.
I recommend patients spot stretch the shoe over the bunion as a first line treatment. This is simply done to gently stretch the shoe without ruining the look of the shoe. Inexpensive shoe stretchers can be purchased on Amazon. Even a couple millimeters of additional space can be very beneficial. Try with an old shoe first, and not your new Red Bottoms.
Non Surgical Treatment
The primary source of pain is caused from inflammation in the soft tissues around the joint.
Non- steroidal anti-inflammatory medications (NSAIDS) can be very helpful as a first line treatment in addition to shoe modifications. Topical NSAIDS such as Aspercream OTC, are readily available over the counter and are applied to the painful area 3 times daily.
Prescription topical medications are available but don’t offer much additional benefit and can be expensive. Oral NSAIDS are also helpful when taken properly. To ensure a proper anti-inflammatory level in the blood the NSAID must be taken in the proper dose and on schedule. For example, Ibuprofen (Motrin) can be dosed 600mg three times daily and continued for a week minimum. Two prescription NSAIDS I prefer in my practice are Meloxicam and Celebrex (I’m not a pharma consultant).
I like Meloxicam as it is inexpensive and only needs to be dosed daily. I take this myself for various joint pains. Celebrex (Cox 2 inhibitor) is the other NSAID that is dosed twice a day and has a strong anti-inflammatory effect and fewer gastrointestinal side effects.
A word of caution with NSAIDS. They can have several negative side effects for a small number of people. Consult with your doctor to make sure the NSAID will not interact with current medications or medical conditions.
In some cases of a painful symptomatic bunion an arch support or orthotic can be helpful. The orthotic is a device that is placed in the shoe to support the arch and reduce mechanical stress on the bunion.
The arch support may not be appropriate for all situations. In certain cases it can be very helpful to relieve mechanical stress on the great toe joint. However in some cases the added volume in the shoe
Surgical Care for Bunions
Surgical treatment for a bunion deformity is generally recommended for patients with progressive pain and deformity that has not been helped with non surgical care. A surgical evaluation includes an exam and radiographs to evaluate the joint and skeletal alignment.
There are several options for surgical correction of a bunion deformity. Most procedures require cutting the bone (osteotomy) to realign the bunion and repair of the ligaments around the joint. Titanium hardware such as small plates and screws are placed to maintain alignment during the healing of the bone.
The specific recommendation on surgery is best done on an individual basis as conditions can be highly variable. Generally, there is realignment of the bone and repair of the ligaments. Rarely removal of the titanium hardware is required.
What happens with surgery
Bunion surgery is most often done in an outpatient surgery center. Anesthesia can be performed using a monitored anesthesia (MAC) which allows for a painless experience but no need for a breathing tube. The procedure usually takes less than an hour. Patients generally emerge from anesthesia quickly and are given instructions and discharged to home.
Aftercare requires rest and elevation of the foot (above heart level). With a combination of the local anesthetics used today the post operative pain can be minimized. Every patient recovers at a different pace based on health status, age, and specific procedure performed. In general, bone takes 5-8 weeks to heal in healthy individuals.
I recommend all post op patients take Vit D supplements (5000 IU daily) to facilitate healing. If you have been previously diagnosed with Vit D deficiency make your Surgeon aware as a repeat blood test may be recommended.
Ice is also important after surgery. Cold therapy units are too cold for bunion surgery. A bag of ice or commercially available ice pack over the top of the bandages, ankle or behind the knee can be helpful. Ice is applied for 15 minutes and removed. Allow the skin to return to normal body temperature and then reapply.
Pain medication is important and should be taken as recommended. If you are not having pain then pain medication is not necessary.
When the local anesthetic starts to wear off I recommend taking one dose and reassess hour pain in 1 hour. If you need another pill in an hour then take another. Based on this determination you can base future dosing on a schedule as recommended.
For some patients you may want to set the alarm in the night to take a dose. Waking up in pain is hard to remedy quickly and can take a day in some cases to recapture a comfort level. In the instance where you take a first and second dose of pain medication and the pain is still unbearable or severe, call your Surgeon.
As swelling occurs the bandages can become too tight and your Surgeon should be aware immediately.
Mobility after bunion surgery can be accomplished many ways and depends on many patient factors and the procedure performed. Certain operations require less weight bearing on the foot to ensure proper bone healing. In these cases a cast boot is recommended and various devices to keep the weight off the foot.
Crutches, knee scooters, i-Walker, or wheelchair may be recommended.
Bleeding and blood loss with bunion surgery is minimal. The most common bleeding is seen around the incision and can sometimes stain the outer bandages which looks concerning. If this occurs take note of the amount and call your surgeon to discuss. A small amount of bleeding is expected and rarely a problem. However, your Surgeon may have you come in for a clean sterile bandage change.
Postoperative timelines generally have the first postoperative appointment at 10-12 days. The sutures are removed and the toe is re-splinted. Usually early and gentle motion and stretching the joint is instructed. This should be done as directed. It is very important to work on motion and prevent stiffness of the joint during healing. This is likely to be uncomfortable but is necessary. Ice after each session as instructed.
Radiographs are taken at 5-6 weeks and based on the healing you may be progressed to a comfort shoe and full weight bearing. Based on progress, physical therapy may be instituted.
Complications can occur
Complications can occur with any operation. Infection is rare and statistically occurs in less than 1% of cases. Swelling, bruising, and pain are expected in the first 2-3 weeks. Wound healing problems and scarring can occur and can lead to stiffness.
The joint can also develop a small degree of stiffness after surgery. This occurs more with joints which have arthritis or large bunion deformity. Slow or incomplete healing of the bone can occur. There are many reasons for this including premature weight bearing, Vit D deficiency, diabetes, vascular disease (poor circulation), smoking, vaping, and some medications (steroids, NSAIDS).
Blood clots (DVT) can develop in the legs after any surgery and are very rare. Unless there is a significant risk factor for developing blood clots, blood thinning medications are not necessary. However, if there is a family history of blood clots, you smoke or vape, take birth control pills, or have a history of previous blood clots your Surgeon may recommend blood thinners as a precaution.
How to Prepare for Bunion Surgery
Preoperative planning includes an updated exam from your primary care physician. Additional testing may include blood work and EKG. If there is any question about poor circulation or a history of poor healing after previous surgery a test of the circulation may be ordered by your Surgeon. The test is done in a non-invasive fashion and is not painful.
Any anesthesia requires you to be NPO (nothing in your mouth) for 8 hours prior to surgery. This includes no gum or mints. Certain medications are permitted with a sip of water. Ask your Surgeon to review your medications and determine which can be taken and which should be held until after surgery.
Knee Scooter Knee Walker (iWalk)
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