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Burton J. Katzen, DPM
Caring For Painful Bunions
Metro Foot Care Centers
. http://www.marylandfootdoctor.com

Caring For Painful Bunions

The most common cause of hallux valgus and bunion deformities is somewhat controversial. Most researchers believe that it is a combination of hereditary tendencies and biomechanical imbalances. However, some cases are due to environmental factors, such as poorly fitting footwear. The fashionable shoes worn by many women are more constraining than the shoes worn by men and are felt by many to also be a factor in developing hallux valgus. This would help to explain the 10 1 ratio of females to males seen with this disorder.
The term hallux (big toe) valgus (deviation toward the second toe) denotes only the deformity, which is a deviation of the big toe toward the outside of the foot. Hallux valgus is not synonymous with bunion, which is derived from the same root as “ban” or “bunch,” and means an area of swelling, inflammation, and pain. In connection with the foot, the term bunion usually refers to the prominent inside portion of the first metatarsal head and especially to the bursa or bursa plus bony overgrowth accompanying it. A bursa and/or bony overgrowth may or may not accompany hallux valgus.
Contributing Factors
As stated previously, the most common cause of bunions and hallux valgus is a combination of hereditary tendencies and biomechanical imbalances. However, there may be many other contributing factors. Excessive pronation, commonly seen as flat-feet, places excessive stress on the inside of the big toe during the toe-off phase of gait, forcing it in a valgus direction toward the smaller toes. Wearing high heel shoes with pointed toes create a structural imbalance that may lead to this painful condition. Metabolic conditions, such as arthritis, gouty arthritis, and rheumatoid arthritis may be predisposing factors to the deformity. Injuries to the big toe joint may also lead to bunion manifestation.
As the bunion develops, the head of the metatarsal bone enlarges from shoe irritation. The bunion sufferer begins to experience pain and discomfort in the area of the bill of the great toe, especially after prolonged periods of walking or exercise. A bursa (sac of fluid) forms over the inner or top aspect of the bony prominence. The area then becomes more painful due to the inflammation in the bursa and neighboring joint. Very often, the great toe is angled toward the second toe and may overlap or underlap it. Therefore, the mechanical imbalances and the development of the bunion can create deformities of all the lesser toes eventually requiring extensive forefoot surgery.
The first choice in the treatment
of bunion deformities is to discover
them early in life so a conservative,
mechanical approach may be used.
This may include strappings and bio-
mechanical orthotics. However, once the great toe is deviated, the only permanent cure is a surgical procedure to place the great toe in proper anatomical position relative to the metatarsal head. For temporary relief, injections, oral anti-inflammatories, bunion pads, strappings, or toe separators may be utilized. Of course, changing shoe gear is also of great value, and for mild adult deformities, a custom made biomechanical orthotic may be recommended.
Surgical Correction
If the bunion deformity is of a simple nature, a simple bunionectomy (removal of the bump with no straightening of the toe) can be performed to reduce the enlarged bone. However, when the great toe is also deviated and a straightening is desired, the deformity must be reduced by a surgical osteotomy (fracturing of bone) of the great toe or first metatarsal to place it in proper anatomical position. If arthritis is present in the joint, this will also be dealt with at the time of surgery. It is important that an arthritic joint be dealt with in an early stage, so that future joint destructive procedures, implants, and fusions will be avoided. This is especially important in younger patients.
Bunionectomies are usually performed on an outpatient basis with the patient under light I.V. sedation and local anesthesia. No pain will be felt at the time of surgery from either the needles or the procedure. Usually, no casts, pins or screws are required, and the patient may begin light ambulation within 24 to 48 hours. If an osteotomy is required, the patient is in a surgical shoe for an average of four weeks before he/she may begin attempting casual closed shoes. If no osteotomy is necessary, the patient may attempt closed shoes after two weeks. Of course, healing time varies greatly from individual to individual depending on compliance with instructions, health, circulation, etc.

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