Bunions are bumps on the joints in the ball of the foot, either on the inside (big toe) or the outside, where they are also called tailor’s bunions. The most common type is a bunion on the big toe joint. The bunion deformity is far more than a bony bump. There is an underlying biomechanical dysfunction that leads to the bump. This dysfunction is described by the condition known as hallux abducto valgus deformity. This simply means that the hallux (big toe) is abducted (tilted towards the second toe) and in valgus (rotated around clockwise on the big toe joint). The hallux abducto valgus (HAV) deformity is caused by a number of factors. The bunion (bump on the big toe joint – actually on the side of the 1st metatarsal) is what people usually notice first. Bunions are almost always associated with HAV. Shaving off the bump does not usually solve the problem in the long term. The reason is that underlying the bump is a biomechanical dysfunction that must be addressed.
What is the biomechanical dysfunction that leads to bunions and HAV?
Many people with bunions and HAV have what is called a hypermobile 1st MPJ (big toe joint). This means that the 1st MPJ has too much motion and is not able to stabilize properly in gait (leading to excess pronation). Over years and years of walking on an unstable joint, it eventually pulls itself out of position and ends up creating the bump and joint deformity. If it has been present for many years, there is eventually damage caused to the joint which results in narrowing of the joint (osteoarthritis) and usually pain. Some people who develop bunions and HAV simply have a bony structure that allows the deformities to develop (i.e. – a genetic predisposition to developing them). These people are destined to get bunions, regardless of shoes, activities, etc.
When should bunions be treated?
No simple answer. Most people have their bunions looked at by a professional when they start to hurt or interfere with shoes. By this time, they are often fairly advanced. Joint degeneration may have set in. If you notice a bump on the big toe joint and have no pain or problems with it, you may want to consider treatment in order to attempt to delay or stop progression. This can be done using proper shoes and custom foot orthotics. This combination of treatment does not work for everyone. Sometimes, bunions develop and progress no matter what you do. If you have had a bunion for years and it has not bothered you, it may never bother you, or at some point in the future it may progress. I recommend treatment of bunions using shoes and orthotics when:
1. The patient is young – treatment of juvenile bunions with orthotics should start early.
2. The bunion is painful or bothersome in some way.
3. The foot is clearly pronated and this is contributing to the development and progression of the deformity.
4. As a last option to try before surgical correction is undertaken (in some cases).
When is surgical correction necessary?
Again, no simple answer. Surgery can be done to reposition the joint in order to reduce pain and prevent the development of joint degeneration. Surgery can also be done to remove the bump (though usually this approach is not successful). If the bump is hurting in shoes and no shoes seem to be comfortable, orthotics may be very effective. They align the foot properly in the shoe and often minimize rubbing of the bump against the shoe. Conservative options are usually exhausted before surgery is considered. It is not an easy decision. Your best approach would be to get several opinions – perhaps from an orthopedic surgeon and a surgical podiatrist; and, talk to people who have had the surgery – as many as possible. You need to know what are the possible complications as well as the potential benefits of any type of surgery.
Please do not use this information to self-diagnose or design your own treatment plan. It is a guideline only.