Bunions (hallux valgus)
A bunion is the result of a deformity of the big toe. The long bone in the middle of the foot (metatarsal) becomes deviated towards the other foot, whilst the big toe (Hallux) pushes to towards the smaller toes. As a result the joint becomes prominent on the inside of the foot. This prominence is termed the bunion and it can often become inflamed if it rubs on shoes.
In severe cases a bursa (rather like a deep blister) is formed and this can become inflamed (bursitis). The abnormal position of the joint can cause wear and tear, resulting in arthritis within the joint. The medical term for this deformity is Hallux Valgus because the big toe assumes a valgus position.
What causes bunions?
There are many possible causes and they can be associated with diseases of the joints such as osteoarthritic and rheumatoid arthritis. However, poorly fitting shoes with narrow toe boxes can precipitate the problem although this is not the only contributing factor. Abnormal foot function can predispose to the deformity as bunions are found in races that do not wear shoes. In many cases, it can be an inherited problem with the condition present in more than one generation of the family.
Are women more likely to get the problem?
It is more common in women as they tend to wear tighter, narrower shoes with increased heel height. These shoes place a lot of pressure onto the joint and predispose to deformity.
Will it get worse?
Most of the evidence indicates that the deformity is progressive and deteriorates with age. For this reason, it is more common with increasing age.
What are the common symptoms?
- Redness around the joint
- Swelling around the joint
- Difficulty in shoes
- Difficulty in walking
- Stiffness in the joint
How is it recognised?
Clinical examination and a detailed history allow diagnosis. X-rays help to evaluate the extent of the deformity and the degree of arthritis within the joint.
What can I do to reduce the pain?
There are several things that you can do to try and relieve your symptoms:
- Wear good fitting shoes
- Avoid high heels
- Wear a pad over the bunion
- See a podiatrist
What will a podiatrist do?
If simple measures do not reduce your symptoms, there are other options:
- Advise appropriate shoes
- Advise exercises
- Advise on a night splint
- Consider prescribing orthotics
- Advise on surgery
The way in which your foot loads during walking can place increased stress on the big toe joint. Special shoe inserts (orthotics) can relieve this stress and reduce pain. Specific exercises to strengthen the small muscles of the toe and splints to hold the toe in a corrected position overnight may help.
Will this cure the problem?
Probably not. Whilst there is some limited evidence that night splints and exercises may slow down the progression of the deformity, there is no evidence that any of these treatments will correct the deformity.
What will happen if I leave it alone?
The symptoms may well settle, especially if you are careful with shoes, but the deformity is likely to progress. In one study that followed patients for 1 year, only 24% who had no intervention reported an improvement compared with 46% of those provided orthotics and 83% who had surgery.
How can I cure the deformity?
The only effective way of correcting the deformity is to have an operation.
How does the operation correct the deformity?
There are in the region of 130 different operations for correcting Hallux Valgus deformities. The simplest involves removal of the painful prominence on the side of the joint. However, this does not correct the underlying deformity, will not resolve any deeper joint pain and will predispose to recurrence.
The majority of operations aim to correct the deformity by realigning the metatarsal and hallux so that the toe is straight. This involves cutting the bone(s), realigning them and fixing them in a corrected position with either screws or wires.
In severe cases of arthritis, more destructive joint procedures are necessary and involve either removing a portion of the joint or fusing (surgical fixation) the joint so that it no longer moves. This is rarely necessary.
I have heard it is very painful.
The nature of the operation means that there will be pain and swelling, usually worse the night after surgery. However, with modern anaesthetic techniques and pain killers, this can be well controlled. The level of pain experienced varies greatly from patient to patient with some experiencing no significant discomfort.
Will I have to have a general anaesthetic?
Not if you did not want one. Many of these procedures are performed perfectly safely under local anaesthetic. Some patients worry that they may feel pain during the operation but it would not be possible to perform the operation if this were the case.
Will I have to stay in hospital?
No. As long as you were medically fit and have adequate home support, many patients are able to have this type of operation performed as day surgery and go home.
Will I have to have a plaster cast?
Not necessarily. In the majority of cases, newer techniques mean patients do not need a plaster cast and can walk a lot sooner. However, in more severe cases, this may be necessary due to the nature of the operation required for adequate correction. In these instances, you may not be able to walk on the foot for up to 6 weeks.
Are there a lot of complications?
There are risks and complications with all operations and these should be discussed in detail with your specialist. However, with bunion surgery it is important to remember that you may be left with some pain and stiffness and the deformity may reoccur in the future. This is why it is not advisable to have surgery if the deformity is not painful and does not limit your walking. A thorough examination of your foot is important so that these complications can be minimised.
Although every effort is made to reduce complications, these can occur. In addition to the general complications that can occur with foot surgery, there are some specific risks with bunion surgery:
- The toe may not be perfectly straight.
- The toe may be stiffer than before the operation, which could affect the heel height of the shoes you wear. Whilst this may improve it can be permanent.
- You may get discomfort in other parts of your foot during the recovery period. This generally settles.
- A small number of patients get overloading beneath the ball of the foot / small toes due to reduced function of the big toe joint. This is known as transfer pain or metatarsalgia. If this is permanent, special insoles or further surgery may be recommended
- There is always a possibility that the deformity may return in later life.
When will I be able to walk again and wear shoes?
In the majority of cases, you will able to walk with the aid of crutches within 2-4 days but you will remain somewhat limited for the first 2 weeks.
Some patients are able to return to wider shoes within two weeks with 60% of patients in shoes at 6 weeks and 90% in 8 weeks.
Swelling generally starts to reduce at 6-8 weeks and the foot will be beginning to feel more normal at 3 months although the healing process continues for 1year.
Some patients, due to the nature of the operation necessary to correct the deformity, require a plaster cast which cannot be walked on for 6 weeks. This is often followed by a further cast or removable walking boot which allows a gradual return to walking for a further 2-6 weeks. This will delay the recovery process.
When will I be able to drive again?
When you feel able to perform an emergency stop. This is generally between 4-8 weeks post operatively but you should always check with your insurance company first.
When will I be able to return to work?
If you are able to get a lift and have a job that is not active and you can elevate your foot, you may be able to return after 1-2 weeks. Generally, patients return to work between 4-8 weeks depending on the type of job, activity levels and response to surgery.
When will I be able to return to sport?
Although the healing process continues for up to 1 year, you should be able to return to impact type activity at around 3 months. This will depend on the type of operation you need and how you respond to surgery.