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Bunion

The hallux valgus deformity (bunion) is defined as a lateral deviation of the great toe on the first metatarsal. The symptoms include irritated skin, pain and joint redness.


Presentation

The chief sign of a bunion is the big toe bending towards the other toes of the same foot causing a protruding structure medially. Bunions usually cause pain and soreness around the toes and redness of the skin. A swollen bony structure is seen on the medial side of the foot. Bunions can cause difficulty and pain when wearing shoes.

The skin where the big toe overlaps the second toe becomes hard and reddened. The overall shape of the foot is changed due to the bunion. The bunion increases the width of the foot making it difficult to find a well fitting shoe. The big toe is normally used to thrust the foot forward and maintain balance. Due to bunion formation these functions are affected and hence, it may cause difficulty in walking. Due to friction, blisters are commonly seen to form over the bunion and other toes.

Toe Pain
  • When is surgery recommended for bunions or big toe pain? If your bunion or big toe pain limits your activities and all conservative options have failed, surgery may be necessary. Joint pain may be a sign of degeneration of joint cartilage.[footankle.com]
  • In addition to great toe deformity, other reasons that you may benefit from bunion surgery include: Severe great toe pain that limits your everyday activities, including walking and wearing reasonable shoes.[emoryhealthcare.org]
  • Signs You May Have a Bunion Bulging growth on your big toe joint Pain or redness surrounding the bunion Big toe bent toward other toes Restricted motion of the big toe Pain while wearing shoes or doing normal activities Discomfort from Bunions Many people[320foot.com]
  • Stress fractures, osteochondral defects, and gout are other causes of toe pain. X-rays are essential for accurate diagnosis. Nonoperative measures can reduce pain, but surgery is an option for recalcitrant cases.[doi.org]
  • A reddening or inflammation of the bump Blisters and/or callouses in and around your first and second toes Pain when walking or wearing restrictive shoes (such as high heels) Your second toe overlapping your first toe Ingrown toenails Sores between your[footsmart.com]
Toe Swelling
  • Chronic big toe swelling that doesn't improve with rest or medications. Toe deformity - a drifting in of your big toe toward the small toes.[emoryhealthcare.org]
  • Symptoms include: A bony bump at the base of the big toe Swelling, redness, and soreness of the big toe joint Thickening of the skin at the base of the big toe How is it diagnosed? Your healthcare provider will examine your foot.[summitmedicalgroup.com]
  • Symptoms The signs and symptoms of a bunion include: A bulging bump on the outside of the base of your big toe Swelling, redness or soreness around your big toe joint Corns or calluses — these often develop where the first and second toes overlap Persistent[drugs.com]
Localized Pain
  • Possible signs and symptoms associated with plantar warts include: Focal growth or groupings of darkened or callus skin patches along the bottom of the foot Irregularity of skin texture and thickness Localized pain, worsening with pressure Small, clotted[nwfootankle.com]
Burning Pain
  • Red, callused skin may also cover the bunion, but the most noticeable feature of a bunion is the burning pain, which intensifies with pressure. Relieving the pressure often stops the burning pain.[livestrong.com]
  • A rarer presentation is burning pain or tingling in the dorsal aspect of the bunion, which indicates entrapment neuritis of the medial dorsal cutaneous nerve.[patient.info]
Family History of Arthritis
  • history, rheumatoid arthritis [2] Diagnostic method Based on symptoms, X-rays [2] Differential diagnosis Osteoarthritis, Freiberg's disease, hallux rigidus, Morton's neuroma [3] Treatment Proper shoes, orthotics, NSAIDs, surgery [2] Frequency 23% of[en.wikipedia.org]
Keratosis
  • Note any keratosis that suggests abnormal friction from abnormal gait. Associated deformities may include second digit hammer toes and flexible or rigid flat foot.[patient.info]
  • Calluses that develop a core or seed inside of them are known as intractable plantar keratosis (IPK). IPK’s are generally located under the metatarsal heads, and are frequently misdiagnosed as plantar warts.[nwfootankle.com]
Foot Pain
  • Abstract Foot pain discourages physical activity, and less activity harms overall health. Bunion, extra bone and tissue at the base of the big toe, is a frequent cause of foot pain.[ncbi.nlm.nih.gov]
  • Other possible complications of bunions include: toe or foot deformity stiff toe chronic toe or foot pain Contact your doctor immediately if you experience these symptoms and also have diabetes or any signs of infection.[healthline.com]
  • . — Nina Bahadur, SELF, "8 Shoe Mistakes That Could Definitely Be Causing Your Foot Pain," 18 Apr. 2018 So can having bunions or hammertoes, or having a condition like rheumatoid arthritis that can cause joints to swell. — Nina Bahadur, SELF, "8 Shoe[merriam-webster.com]
  • Mistakes That Could Definitely Be Causing Your Foot Pain," 18 Apr. 2018 The PerfectFit Pointe inserts are made from a moldable putty that fills in gaps created by uneven toes and protects pressure points around bunions and corns. — Claire Martin, New[merriam-webster.com]
  • Bunions develop gradually over time, but you may not have any foot pain initially.[runnersconnect.net]
Metatarsalgia
  • The most common complication (9%) was second metatarsalgia. This was found in one patient with a pre-existing callus, and two patients due to technical error.[ncbi.nlm.nih.gov]
  • Although lateral metatarsalgia did occur, the most common area of persistent pain remained the first metatarsal. Six of 18 procedures had marked loss of active joint motion, associated with pain and an unsatisfactory result.[ncbi.nlm.nih.gov]
  • Most people who develop metatarsalgia are comfortable with a simple insole in the shoe but occasionally surgery is required.[bofas.org.uk]
  • […] untreated, a bunion may also cause: Bursitis, a condition in which the bursa (a fluid-filled sac that cushions bones, tendons, and muscles near the joints) of the big toe becomes inflamed and painful Hammertoe, an abnormal bend in the joint of the toe Metatarsalgia[everydayhealth.com]
  • Metatarsalgia. This condition causes pain and inflammation in the ball of your foot. Prevention To help prevent bunions: Choose shoes carefully.[drugs.com]
Joint Deformity
  • INTERPRETATION: The type of first MTP joint deformity in patients with CP may be predicted by the type and distribution of movement disorder, and by GMFCS level.[ncbi.nlm.nih.gov]
  • The primary goal of most early treatment options is to relieve pressure on the bunion and halt the progression of the joint deformity.[calpma.org]
  • Source: Based on information from the American College of Foot and Ankle Surgeons Outcomes and complications of bunion surgery Variations among toe-joint deformities and surgical techniques make it difficult to evaluate the results of bunion surgery.[health.harvard.edu]
  • After bunion surgery, both pain and joint deformity can be reduced significantly for most patients.[footankle.com]
Distractibility
  • Use of a Kirschner wire for distraction and capsular flaps in the Keller interpositional arthroplasty. J Am Podiatr Med Assoc. 2008 Jul-Aug. 98(4):326-9. [Medline]. Turnbull T, Grange W.[emedicine.medscape.com]
  • Use of a Kirschner wire for distraction and capsular flaps in the Keller interpositional arthroplasty. J Am Podiatr Med Assoc . 2008 Jul-Aug. 98(4):326-9. [Medline] . Turnbull T, Grange W.[emedicine.medscape.com]
Withdrawn
  • A Cochrane review in 2004 found very little good evidence on which to assess either conservative or operative treatments and the update in 2009 was withdrawn [ 16 ].[patient.info]
Dystonia
  • In contrast, non-ambulant adolescents, at GMFCS levels IV and V, with dystonia or mixed tone, more commonly had dorsal bunions.[ncbi.nlm.nih.gov]
  • Those studied had foot dystonia (painful muscle contractions). The results? 85% of participants found great benefit from wearing YogaToes over a period of three months. There are hundreds of reviews by people who love YogaToes . Surgeries avoided.[yogapro.com]
Forgetful
  • Just slip your foot in and forget the pain. Exclusive gel conforms, protects and soothes tender bunion area. It acts as a barrier, preventing blisters and continued rubbing from footwear which can lead to increased irritation of the sensitive area.[amazon.com]
  • While it’s always good to research your options thoroughly yourself, don't forget to consult with your doctor! Learn more about Bunions here: Bunions - The Complete Injury Guide 11 Best Toe Separators for Overlapping Toes Sources:[vivehealth.com]
Abnormal Gait
  • Note any keratosis that suggests abnormal friction from abnormal gait. Associated deformities may include second digit hammer toes and flexible or rigid flat foot.[patient.info]

Workup

The bony bump and swelling formed due to the bending of the big toe is indicative of bunion formation. History will include pain, discomfort, soreness and redness around the joint. One may check the range of movement of the toes. Details regarding the types of footwear used will also be needed which will usually include history of wearing poorly-fitting or narrow-fitting footwear. In case any family history of such bunions is present, then it must be mentioned.

Laboratory studies can benefit the surgeons to check out for any other accompanying conditions or problems. A complete blood count (CBC), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) will help to rule out any existing infections. A test to check RA factor and uric acid are needed for assessment of rheumatoid arthritis or gout accompanying the bunion formation.

An X-ray may be advised to check its severity, causes and prognosis. A standing foot X-ray in AP and Lateral planes is obligatory to determine the type of surgery required for bunion rectification [14]. Also, an oblique, non-standing film can be taken for a different view of the metatarsal head and hind foot. In cases, where the sesamoid bone appears to be affected (eg. fracture or avascular necrosis), an x-ray of the sesamoid view may be necessary. All this history and X-ray information is combined and then the best surgical procedure to be done for the patient is decided.

Treatment

When treating a patient with a bunion, it is necessary to be aware of the patient’s demands and expectations from the treatment [15].

Conservative treatment includes changes in the footwear and use of different orthotics i.e. padding and shielding in the shoes. Resting the foot and applying ice can help soothe symptoms. Painkillers such as paracetamol or ibuprofen help in relieving the pain. In case of infections antibiotics may be used. These treatments aim to relieve the symptoms and do not correct the actual deformity.

Surgery is performed by an orthopaedics or podiatric surgeon in cases where the discomfort is severe or when a deformity needs to be corrected. Understanding and distinguishing each component of the deformity is the key to successful surgery. Surgery is intended to straighten the joint and relieve the pain and not only to enhance to external look of the foot. There are different types of surgeries used to treat bunions. The choice depends on the severity of the bunions, size and shape of foot, accompanying conditions like arthritis, age of the patient and his health status. One must examine and assess the vascular status, any neuropathies if present, arthritis, muscle strength and tightness, the range of motion of the first MTP joint. Also, check for signs of general ligamentous laxity [16] [17]. The operations range from trimming parts of the joint, to complete artificial replacement of the big toe joint. Commonly osteotomy is performed. Presently local anaesthesia is preferred over general or spinal anaesthesia for the surgery.

Prognosis

When treatment is directed to each element of the deformity, then satisfactory results are achieved. When surgery is performed one can get long-term relief from discomfort and deformity. Since bunion is a progressive deformity, one has to be careful even after surgery to avoid recurrence. It is important to check the severity and rule out other underlying problems like gout, RA etc. for better prognosis.

Post-surgery patients must use comfortable foot-wear and take utmost care to avoid ill-fitting or narrow shoes for long term relief form bunions. Recurrent deformity and stiffness are the common complications seen.

Etiology

Studies show that bunions are linked to one’s family history, the inheritance pattern being autosomal dominant with incomplete penetrance [3].

Poorly or ill fitting, narrow, tight or small shoes are also known to cause bunions or at least worsen the situation [4]. Wearing heeled shoes contributes to bunion formation [5] [6] [7]. A study done amongst people from Asian and Chinese cultures that don’t wear shoes, no cases of bunions were found, adding credibility to the theory that bunions result from ill-fitting shoes [8].

Other causes which are inherited include joint flexibility and arch height [9]. Loose ligaments and low muscle tone increase chances of bunion development. Neuromuscular conditions like cerebral palsy or connective tissue disorders can precipitate bunion formation. Arthritis like rheumatic or psoriatic arthritis or gout can also be responsible for bunions.

Epidemiology

The prevalence of bunions is significantly high in females as compared to males. The female to male ratio is 8 to 9:1 and going as high as 15:1 [10] [11]. The main reasons for this difference in the prevalence are due to the footwear habits [5] [6]. The initial changes tend to occur during adolescence or may be even earlier in cases of children suffering from bunions but the main onset is observed to be in the age group of 30 to 60 years [12] [13].

Sex distribution
Age distribution

Pathophysiology

Bunions are researched to be genetic. The basic factors involved could be flat-feet, increased flexibility of the ligaments, abnormally structured bones and/or neurological factors. Certain studies conclude that poorly or ill fitting footwear are the main causes of bunions. There are other studies which conclude that the main causes are genetic and that footwear only worsens or aggravates the condition which is related to the genetic bony make-up.

When the shoes are too tight or narrow, they tend to rub against the big toe joint. Most high-heeled shoes are tight and narrow from the front causing the great toe to bend inwards nearer the second toe. This bending and pressing of the toe can cause pain due to nerve impingement. Also, due to high-heeled shoes the entire body weight is transferred onto the front foot straining the toe joints.

The bending of the first metatarsal bone causes the small sesamoid bones under it to get deviated gradually. The sesamoid bones function is to help the flexor tendon in bending downwards.

Prevention

One can prevent bunions by wearing good well-fitting footwear. Avoid foot-wear that is narrow or tight. High-heeled or pointed shoes increase the chances of bunion formation. Use padding to prevent bunions from further injury. Try the shoes on both feet. Use an insole for the shoe which is loose but don’t cramp the larger foot by using a smaller shoe. For flat-feet use arch supports or orthotic shoe inserts.

Summary

A bunion is a bony deformity of the joint base of the great toe. It is also called Hallux vagus. Hallux = great toe, valgus = abnormal angulation of the great toe associated with bunion anomalies and abductus = abnormal drifting or inward leaning towards the second toe.

It involves the first toe, with first phalanx abduction and pronation, and first metatarsal adduction, pronation, and elevation, along with capsular and ligamentous derangement [1] [2].

Patient Information

A bunion is a bony deformity at the base of the great toe of the foot. The great toe gets angled towards the second toe forming a bump sticking outwards. This changes the shape of the foot causing swelling, pain and tenderness around the big toe. The causes are unclear but studies prove it is inherited in the family. Ill-fitting footwear which is narrow, pointed or tight is known to cause bunions. Due to narrow shoes the bones of the toe are pushed inwards towards the other toes. The skin over the angled joint tends to rub on the inside of the shoes. This leads to thickening, inflammation of the overlying skin and tissues surrounding the affected joint.

Wearing high-heeled shoes puts entire body weight on the toes. The feet are squeezed and the big toe remains bent which causes nerve damage and pain. It can be diagnosed by looking at it. An X-ray of the foot helps to evaluate the severity of the deformity and understand the structural abnormality of the toes. This information is needed to decide the treatment methods.

Conservative treatment includes rest, ice application, painkillers and change of footwear. Surgery is a chosen to improve the appearance of the foot and to straighten the joint with long term pain relief. Post-surgery one must be choose footwear which is comfortable and wide fitting to prevent recurrences.

References

Article

  1. Bauer T, Biau D, Lortat-Jacob A, Hardy P. Percutaneous hallux valgus correction using the Reverdin-Isham osteotomy. Orthop Traumatol Surg Res. 2010 Jun;96(4):407-16.
  2. Mann RA, Coughlin MJ. Hallux valgus--etiology, anatomy, treatment and surgical considerations. Clin Orthop Relat Res. 1981 Jun;(157):31-41.
  3. Piqué-Vidal C, Solé MT, Antich J. Hallux valgus inheritance: pedigree research in 350 patients with bunion deformity. J Foot Ankle Surg. 2007 May-Jun;46(3):149-54.
  4. Klein C, Groll-Knapp E, Kundi M, Kinz W. Increased hallux angle in children and its association with insufficient length of footwear: a community based cross-sectional study. BMC Musculoskelet Disord. 2009 Dec 17;10:159.
  5. Coughlin MJ, Thompson FM. The high price of high-fashion footwear. In: Jackson DW (Ed.) Instr Course Lect. 1995;44: 371-77.
  6. Frey C, Thompson F, Smith J, et al. American Orthopaedic Foot and Ankle Society women's shoe survey. Foot Ankle. 1993 Feb;14(2):78-81.
  7. Nguyen US, Hillstrom HJ, Li W, Dufour AB, et al. Factors associated with hallux valgus in a population-based study of older women and men: the MOBILIZE Boston Study. Osteoarthritis Cartilage. 2010 Jan;18(1):41-6.
  8. Shulman, Pod.D, Samuel B. Survey in China and India of Feet That Have Never Worn Shoes. The Journal of the National Association of Chiropodists. 1949; 49:26-30.
  9. Bonney G, Macnab I. Hallux valgus and hallux rigidus; a critical survey of operative results. J Bone Joint Surg Br. 1952 Aug;34-B(3):366-85.
  10. Hardy RH, Clapham JC. Observations on hallux valgus; based on a controlled series. J Bone Joint Surg Br. 1951 Aug;33-B(3):376-91.
  11. Nery C, Coughlin MJ, Baumfeld D, Ballerini FJ, Kobata S. Hallux valgus in males--part 1: demographics, etiology, and comparative radiology. Foot Ankle Int. 2013 May;34(5):629-35.
  12. Coughlin MJ. Roger A. Mann Award. Juvenile hallux valgus: etiology and treatment. Foot Ankle Int. 1995 Nov;16(11):682-97.
  13. Piggott H. The natural history of hallux valgus in adolescence and early adult life. J Bone Joint Surg. 1960;42:749-60.
  14. Chhaya SA, Brawner M, Hobbs P, Chhaya N, et al. Understanding hallux valgus deformity: what the surgeon wants to know from the conventional radiography. Curr Probl Diagn Radiol. 2008 May-Jun;37(3):127-37.
  15. Tai CC, Ridgeway S, Ramachandran M, Ng VA, et al. Patient expectations for hallux valgus surgery. J Orthop Surg (Hong Kong). 2008 Apr;16(1):91-5.
  16. Klaue K, Hansen ST, Masquelet AC. Clinical, quantitative assessment of first tarsometatarsal mobility in the sagittal plane and its relation to hallux valgus deformity. Foot Ankle Int. 1994 Jan;15(1):9-13.
  17. Robinson AH, Limbers JP. Modern concepts in the treatment of hallux valgus. J Bone Joint Surg Br. 2005 Aug;87(8):1038-45.

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Last updated: 2019-07-11 22:53