A bunion, also called hallux valgus, is a bump at the big toe joint. The bump is actually bone and in some cases inflamed tissue called capsulitis or bursitis. The bony prominence forms from the subluxation or change in the position of the bones of the big toe joint. The origin of the word bunion comes from the French word for onion. Those who coined the word felt that a bunion was a many layered object much like an onion.

A bunion has an insidious onset, growing slowly over a number of months to years. Doctors tend to think of a bunion as an inherited disorder and really not due to any one pair of shoe that you may have worn during your life. More specifically, we don't actually inherit a bunion, but we inherit a set of bones, joints and ligaments in our feet and lower extremity that are very similar to that which we would see in our parents feet. The same biomechanical events that took place to cause the parent's bunion problems are recreated with each step in each new generation.

Consider a simple analogy; a square peg and a round hole. The foot is the square peg and the shoe is the round hole. The larger the bunion, the larger the degree of incompatibility between the foot and the shoe. That's an issue. How does a 30 year old female with a large bunion fit into dress shoes to go to work in an office environment? If you like to wear heels and your feet don't hurt, enjoy yourself and forget all the guilt that's supposed to go hand in hand with high heels. Now on the other hand, if your feet hurt you need to make some concessions with the type of shoes you wear.

There are two additional problems of the big toe joint that we should discuss called hallux limitus, hallux rigidus, both of which are collectively called a dorsal bunion. Hallux limitus and hallux rigidus are two cousins of hallux valgus, or what we've described already as a bunion. Hallux limitus and hallux rigidus are the same condition at different stages of development. Hallux refers to the big toe. Limitus and rigidus describe the limitation or lack of motion of the big toe joint. The name dorsal bunion came about because, in cases of hallux limitus and hallux rigidus, the bump on the big toe joint forms on the top of the joint rather than on the medial side.

The symptoms of hallux limitus and rigidus are insidious, slowly developing over a period of months. Patients will notice transient pain in the big toe joint that increases with the amount of time they spend on their feet. The joint may swell as it becomes painful.

Occasionally we will see bunions in children. We tend to find bunions more so in patients ranging from 35 to 75 years old. Bunions really aren't a function of old age. As already mentioned, the more we walk and recreate the biomechanical properties that contribute to the formation of a bunion, the more we'll see them occur. Therefore, some of us are more genetically programed to develop a bunion than others.

Treatment of bunions, hallux valgus, hallux limitus and hallux rigidus

Should you have your bunion corrected?

Only if it hurts. Think of what activities you're missing out on because your foot hurts. Have you stopped exercising or has your foot pain affected your job? Has your pain limited the kinds of shoes you like to wear? There may be a lot of different factors that ultimately affect your choice to have their bunion corrected, but the single most important issue is pain.

Surgery is the only way to correct a bunion. In poor surgical candidates, pads are helpful to relieve shoe pressure. We always recommend patients try wider shoes and softer shoe materials such as leather. Sometimes a good leather shoe can even be stretched to accommodate a bunion. We recommend a lot of eurocomfort shoes to our patients as a conservative method of care. Clogs are a great choice for bunion patients due to the fact that to fit a clog you need to only fit the forefoot and not worry about the heel.

Bunion surgery has a long and colorful history. There's probably more than 400 different combinations of procedures that are named after this doctor or that doctor. Most doctors use just a handful of these procedures. Surgeons are no different than anyone else. Once you've found what works you have a tendency to stick with it.

Doctors will classify bunions in four different stages ranging from 1 through 4. Stage one bunions are somewhat uncommon merely by virtue of the fact that they don't hurt. Most of the patients we treat present with stages 2 and 3. Stage 4 are the tough cases; those folks who really held out not wanting to seek care.

Every builder needs a blue print. For foot surgeons, x-rays are the blue prints that help to evaluate the bunion and determine the best choice of procedure for that patient. Other pre-operative considerations include age, the patient's occupation and the patient's overall health status. We've already discussed bunion surgery in children and the fact that we tend to be fairly aggressive in our choice of procedures with kids. But on the other end of the spectrum, let's think of the 82 year old active grandma. She's not so concerned about long term solutions. She merely wants to get back on her feet comfortably in as short a period of time as possible. In her case, our choice of procedure will be much less aggressive.

Occupations are also a consideration when choosing a procedure. Let's look at two cases. Judy is an accountant and spends most of her work time at a desk. Sharon, on the other hand, is a waitress and single mom. She's the sole (foot joke) provider for her family. Obviously, the return to work is going to be much more challenging for Sharon than Judy.

The procedure itself is performed on an out-patient basis. Most bunionectomies are performed under local anesthesia with IV sedation at a surgery center or hospital. This is the preferred setting because it's the safest and most comfortable setting for patients. Patients are given a sedative through their IV that makes them very sleepy while their foot is numbed and during the course of the procedure. In the hands of a skilled anesthesiologist, most patients remember very little of their procedure and are ready to return home in just a short time after their procedure is completed.

Most doctors use a long acting anesthetic in surgery that will keep the foot numb for up to 8 hours. This allows patients to get home and situated comfortably. Believe it or not, the most important post-operative tools used to control pain and swelling are ice and elevation. Foot surgery is unique in the fact that we're going to be walking on an area of the body that recently underwent surgery. Obviously that presents with some challenges. When the foot is placed down below the level of the heart it's going to swell. When it swells it is going to hurt, particularly during the first few days following surgery. Patients that plan ahead and spend time with their foot elevated use very little pain medication following surgery. Ice is a must. Ice will help to reduce swelling thereby controlling any pain without the use of narcotics.

Recovery time will vary with the choice of procedure and the patient's occupation and general health status. Remember Sharon and Judy? Judy could look forward to a couple of days off where as Sharon should plan on several weeks off. I think you can understand how important it would be to Sharon, and her family, to develop realistic post-op expectation with her doctor even before her surgery.

Another important consideration is family, friends, bosses and co-workers. Bunionectomy patients need to establish a few designated support people before they have their surgery. Widows, widowers and single parents are special cases and need to be sure they have enough support at home for meals, laundry etc. And lastly, bosses and co-workers are counting on realistic expectation such as when do you return to work and when you do, are you going to limited in any way? If so, how long? It's pretty easy to see that the technical component of completing a bunionectomy is just one part of a successful outcome.

Treatment of hallux limitus and hallux rigidus differs from treating hallux valgus (bunion) in several ways. It's important to treat hallux limitus quickly and thoroughly. The pain of hallux limitus is due to the slow degenerative change taking place in the big toe joint. If treated early, the joint can be preserved and last a lifetime. If a patient waits to seek care, limitus progresses to rigidus which can only be corrected by placing an implant in the joint or fusing it. Early treatment of hallux limitus needs to focus on making a permanent mechanical change in the function of the joint with a prescription orthotic.

If you understand this one point you can save yourself a lot of time money and effort. Anti-inflammatory medications and injections only help following trauma to the big toe joint and not in cases of metatarsus primus elevatus. Metatarsus primus elevatus recurs with every step that we take. It can only be changed with a prescription arch support or surgery. Postponing treatment leads to hallux rigidus and loss of the joint.

Can a bunion return after being surgically corrected?

Occasionally. We've discussed age and choice of procedure as some of the issues we deal with pre-operatively. The biggest factors are age and current activity levels. How many years will the patient be active following their procedure? The longer the period, the greater the chance for recurrence.

Nomenclature:

• 1st metatarsal phangeal joint - the big toe joint. Made up by the 1st metatarsal bone on the proximal side of the joint and the proximal phalanx of the hallux on the distal side of the joint.
• Bunion - an enlargement of bone at the medial aspect of the 1st metatarsal phalangeal joint
• Distal phalanx - the most distal phalange (bone) of a toe or finger. Most toes and fingers consist of three phalanges.
• Hallux - Refers to the great toe.
• Hallux limitus - limitation of the motion of the 1st metatarsal phalangeal joint (big toe joint)
• Hallux rigidus - complete limitation of motion of the 1st metatarsal phalangeal joint. h. rigidus is a step beyond h. limitus.
• Metatarsus primus elevatus - a fixed elevated position of the 1st metatarsal bone.
• Middle phalanx - the middle phalange of a toe or finger. Most toes and fingers consist of three phalanges.
• Proximal phalanx - the most proximal phalange (singular) of a toe or finger. Most toes and fingers consist of three phalanges.

Anatomy:

The 1st metatarsal bone, one of the five metatarsal bones, is located on the medial (inside) of the arch and is about the size of your index finger. The 1st metatarsal forms the proximal aspect of the 1st metatarsal phalangeal joint. The distal portion of the joint is compromised of the base of the proximal phalanx of the hallux.

As a bunion develops, the 1st metatarsal progressively moves out away from the foot to form a prominence. The hallux (big toe) also changes in position and drifts towards the second toe. As a result, the joint subluxes, or buckles, and forms the bump that we know as a bunion.

Biomechanics:

Biomechanical factors contributing to the development of hallux valgus are somewhat different from the development of hallux limitus or hallux rigidus. Subsequently, the two conditions will be discussed separately.

Hallux valgus - As mentioned earlier, inheritance plays a powerful role in the formation of a bunion. It's not that you inherit a bunion, but more that you inherit the bones, joints, ligaments and related musculoskeletal structures that will form a bunion just like your mother and your grandmother did. These biomechanical characteristics are as unique to you as your facial characteristics or your hair color.

Several biomechanical factors have been identified as factors that contribute to the formation of a bunion. First is equinus, or a tightness in the calf muscle. Second is forefoot valgus. Forefoot valgus is a term used by podiatrists to describe the position of the bones in the forefoot in relationship to the heel. Valgus means that the 1st metatarsal is lower than the 5th metatarsal.

With every step that we take, these biomechanical forces recreate themselves. Over time, what we see is the progressive drift of the 1st metatarsal medially, or away from the foot resulting in a gap between the 1st and second metatarsals. The prominence we know as a bunion is actually the head of the 1st metatarsal as it drifts medially.

As the 1st metatarsal drifts, all of the soft tissue structures that cross from the foot to the toe remain in place, particularly the tendons that govern the function of the toe. The tendons will 'drag' the hallux (big toe) toward the second toe. This change in the position of the joint, between the 1st metatarsal and the toe, creates a subluxation of the great toe joint.

Hallux limitus and hallux rigidus develop in a somewhat different manner and are summarized as follows;

• 1. Trauma to the big toe joint- we'll see this a lot in athletes such as soccer players. This type of injury is often referred to as turf toe. The joint is jammed resulting in physical damage to the joint or underlying bone.
• 2. Arthritis- gout, rheumatoid and osteoarthritis are common are the three most common forms of arthritis seen in as factors that contribute to hallux limitus and hallux rigidus.
• 3. Metatarsus primus elevatus- (see below) abnormal elevation of the first metatarsal bone leading to chronic jamming of the joint. This is the most common cause of hallux limitus and hallux rigidus.

I mentioned metatarsus primus elevatus. I know it's a big word but it is the most common cause of hallux limitus and needs to be discussed. The bone in the foot that comes from the arch to the big toe joint is called the first metatarsal bone, hence the term metatarsus. Primus, yup, you guessed it. It means first. And elevatus refers to the bone being elevated and unable to drop into its' normal range of motion.

With each step that we take, it's important that the first metatarsal moves in a way to promote free range of motion of the toe. In cases of hallux limitus that are caused by metatarsus primus elevatus, the first metatarsal bone is elevated, therefore inhibiting the normal range of motion of the toe. This begins a process of jamming and subsequent loss of surface cartilage in the big to joint. As hallux limitus progresses, the pain patients feel is from the loss of cartilage and bone rubbing on bone. That hurts. As the joint progressively becomes more and more stiff, we call this condition hallux rigidus.

About the author: Jeffrey A. Oster, DPM, C.Ped is a board certified foot and ankle surgeon. Dr. Oster is also board certified in pedorthics. Dr. Oster is medical director of Myfootshop.com and is in active practice in Granville, Ohio.