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Dr. Thomas F. Bembynista
Bunions
A bunion is a bump that develops on the inner side of the foot, near the base of the first toe. It is caused by poor alignment of the metatarsal-phalangeal joint of the big toe (hallux). Physicians call this deformity "hallux abducto valgus" (HAV), a term that refers to the hallux abducting (going away) from the midline of the body. It also refers to twisting of the toe so the inside edge touches the ground and the outside edge turns upward. Essentially, it describes the deviation of the toe toward the outside of the foot. The condition worsens over time leading to discomfort and skin problems, such as corns and lesions, and difficulty walking.
Bunions are one of the most common foot problems. They tend to run in families, suggesting that genetic factors associated with the inherited shape of the foot may predispose people to bunions. Pronated (flat) feet are unstable and often cause bunions. Body weight is repeatedly transferred to the hallux while walking, and in unstable, flat feet, this transfer of weight allows certain muscles to become stronger than others. This overpowering of muscles causes the toe to bend and deform. Bunions may be caused by excessively tight, pointy-toed, or high-heeled shoes, and shoes that are too small. Women get bunions much more often than men do. Improper shoes exacerbate the underlying cause of flat, unstable feet. Typically, bunions begin as a mild bump or outward bending of the big toe that is only a cosmetic concern at first. However, beneath the surface, strong forces are at work. The forces imparted by the misaligned, outward-bending toe stretch the ligaments that connect the foot bones, pulling against the tendons, gradually drawing the big toe farther out of line. Over time, the big toe continues to twist out of its original position until it no longer lines up properly with its corresponding metatarsal. The end of the metatarsal may become enlarged. Pressure from the first toe can lead to deformity of the metatarsal-phalangeal joint in the second toe, pushing it toward the third toe. In some cases, the second toe may ride up and over, or down and under, the big toe. At this point, the range of motion in the big toe is decreased, a condition called hallux limitus. The condition becomes painful at this stage. The bunion changes the shape of the foot and the biomechanics of walking become altered. Normally, the big toe can bend at least 65 degrees, enabling it to be the last part of the foot to leave the ground during walking. However, with hallux limitus, the big toe cannot function properly and the body weight is transferred to the bunion. A person with uncomfortable bunions gradually begins to compensate by walking in an exaggerated toe-turned-out manner, so the painful hallux does not have to bend as far. This is detrimental because walking with the feet turned out steadily forces the hallux even farther out, causing the bunion to worsen. Without treatment, the deformity eventually becomes disabling. Patients who have bunions must be thoroughly evaluated by a podiatrist. The only way to eliminate a bunion is by surgical removal surgical removal. There are a number of treatment options available. The first is to apply ice to the feet for approximately 15 minutes, three or four times a day to reduce pain and swelling. Taking a nonsteroidal antiinflammatory drug (NSAID) such as ibuprophen can also help. Comfortably fitting shoes are the next step. High heels and narrow toes should be discarded in favor of sandals or wider shoes and lower, padded heels. Padding is another option, particularly if the bunion is small. Different types of pads and toe spacers are available to prevent the big toe from angling outward and relieve pressure against the bunion while wearing shoes. Most patients can benefit from a custom-molded orthotic, which keeps the feet properly aligned and stable, preventing the progression of the bunion. Unfortunately, bunions worsen over time unless the problem that produces them is eliminated. If a bunion causes severe discomfort, a surgical procedure called a bunionectomy may be necessary. A variety of different surgical techniques can be used, depending on the angle of the bones in the bunion and the extent of the deformity. The simplest procedure involves shaving the bump and repairing the soft tissue in the big toe joint. Most patients who pursue surgery, do so because their bunion requires more correction than this procedure offers. Another procedure removes a wedge-shaped piece of bone from the metatarsal, decreasing the toe's angle of deviation. The bones are repositioned and stabilized with screws. Surgery is usually outpatient under an IV sedation. The foot is numbed and the procedure is performed once the patient is sedated. The patient is given postoperative instructions and pain medications. The patient is asked to start taking the pain medication before the numbing medication wears off, breaking the pain cycle. When surgery is done outpatient, Dr. Bembynista usually calls that evening to make sure you're doing well and answer any question you may have. The patient will call the day after surgery to make an appointment for postoperative care. Dr. Bembynista will change the bandage at which time you then can get the foot wet and start exercises to get good range of motion of the bunion area. Sutures are normally removed after approximately two weeks. Patients with bunions in both feet must decide whether to go through the bunionectomy and recovery process twice or have both feet repaired at the same time and endure 6 to 8 weeks of immobility. Most patients choose the former because it offers them a degree of mobility and selfsufficiency. After surgery and recovery, the patient is fitted with orthotics to maintain stable, properly aligned feet. Without this treatment, the underlying cause of the bunion continues to cause problems and the bunion can recur.
Overview
This is a condensed version of an original article on bunions from podiatrychannel.
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Dr. Thomas F. Bembynista
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