What is a bunion?

A bunion is a bony bump on the side of the big toe. The medical name for bunion is “hallux valgus”.

Bunions develop over a long time and start to cause pressure and pain over the bump.  As the big toe drifts toward the second toe, it causes deformity and sometimes affects the second toe which begins to ride up in the air. These changes tend to increase with time can make it difficult to walk or wear certain shoes.

Bunions are very common and anyone can get one, but they are more common in women. This is often due to tight, narrow or high-heeled shoes that squeeze the toes and put a lot of pressure on the big toe joint in particular.

Most bunion pain is improved by wearing wide-fitting shoes to fit the bunion and accommodate the shape of the foot. Sometimes, if simple measures fail to control the pain and there is difficulty finding appropriate footwear, surgery may be needed.

Basic Foot Anatomy

The big toe has two joints - the bunion happens at the level of the metatarsophalangeal joint (MTP joint), between the metatarsal (the first long bone of the foot) and the phalanx (the first small bone of the big toe). The other joint in the big toe is the smaller one between the two small bones nearer the toenail.

A bunion occurs when the long metatarsal bone drifts outwards, and the phalanx bones of the big toe angle towards the second toe. The head of the metatarsal protrudes out and this is the bump that can be felt on the side of the toe. As this bump begins to rub on footwear, the skin and tissue around it get thicker, which makes the bunion even more prominent, inflamed and painful.

What happens if you leave bunions over time?

Bunions start slowly with a small deformity but they often get worse over time, especially if the cause is not addressed i.e. the patient continues to wear narrow, tight shoes. With time, the bunion can worsen, become more painful, and makes it more difficult to find appropriate footwear that fit. Once a bunion develops, it cannot be reversed but the progression and worsening can be slowed down by simple measures like changing the type of footwear (see below for more details).

A severe bunion changes the whole appearance of the foot where the big toe may bend right under the second toe. This pushes the second toe upwards (sometimes called a “hammer toe” or “claw toe”, causing it to rub on the inside of the shoe and this leads to callosities or corns on the knuckle of the second toe. This causes more deformity, discomfort and difficulty with walking. The big toe can also cause pressure on the smaller toes, squeezing them all together and again leading to pain and difficulty with walking and footwear choice.

Sometimes, in severe cases that are ignored for many years, the bunion can lead to damage to the cartilage of the main joint of the big toe. This is called osteoarthritis and it can cause chronic pain, joint stiffness and more deformity of the big toe.

Who is more likely to get a bunion?

Generally, bunions are much more common in females and there is usually a strong family history, suggesting that the condition has a genetic predisposition. They are often worsened by tight, narrow footwear, or shoes with high heels. The majority of cases happen in otherwise fit and healthy people, but bunions are sometimes associated with certain medical conditions such as rheumatoid arthritis, cerebral palsy, and hypermobility.

There are two broad types of bunions: the more common type that happens in middle aged and elderly people, and the rare type that occurs in adolescents.

Adolescent Bunion

These bunions are common in girls aged 10-16 and there is often a strong family history. It is also associated with generalised hyperlaxity or hypermobility, so unlike the adult type where the joint can feel stiff and the deformity is fixed, adolescent bunions are usually very flexible. They still cause the same pain and difficulty with finding shoes that fit.

Bunionette

A bunionette, sometimes called a "tailor's bunion," happens on the outside of the foot at the base of the little toe. Even though it is on the opposite part of the foot, a bunionette is much like a bunion and may cause very similar problems with a painful, red bump and a hard corn or callosity that constantly rubs on shoes.

What to expect when you see a specialist?

The foot and ankle specialist will take a thorough medical history, focusing on your symptoms of pain and whether there is difficulty in finding shoes that fit. It is important to know how the bunion is affecting your activities of daily living, hobbies, and sports. Next, a careful examination of your foot is performed to look for the degree of big toe deformity, involvement of the lesser toes, general width of the forefoot, and any associated signs such as a tight calf muscle (which can contribute to the overall deformity).

The specialist will diagnose the bunion based on your symptoms and no special tests are required, although an x-ray will usually be performed to check the alignment of the toes and exclude other changes such as osteoarthritis. The x-ray will also help the surgeon plan the surgery if that is ever needed. The x-ray must be done with you standing to recreate how the foot is aligned under normal day to day load.

Treatment

Most bunions can certainly be treated without surgery. Non-surgical treatment cannot correct or ‘reverse’ the bunion, but it can help to improve the pain and slow down the worsening of the bunion. In general, treatment can be divided into non-surgical or surgical:

1. Non-surgical Treatment

Footwear Modifications

In almost all cases, the easiest way to manage a bunion is by changing to shoes that are wide-fitting and do not have a narrow toe-box. This will accommodate the shape of the foot and avoids the pain from narrow, constrictive shoes. Avoid footwear that is completely flat with no arch support, including ballet-style flat shoes and flip flops, or pointy high-heeled shoes. Wide-fitting, laced footwear with soft insoles is preferred to closed, narrow shoes that have little ’give’ or flexibility.

Orthotics

Over-the-counter and custom-made orthotics can sometimes be useful in certain cases, such as those with flat feet. Although there is no medical evidence to support their widespread use or recommendation, devices such as gel pads, toe spacers, or splints may help in some cases. Because of the lack of supporting evidence, your specialist will not routinely recommend these devices.

Physiotherapy

The calf is made of two main muscles: the gastrocnemius and soleus. It is well-known that having a tight or ‘contracted’ gastrocnemius muscle can worsen any foot problem including bunion pain. In those patients with tight gastrocnemius muscles, stretching exercises to loosen these muscles may be beneficial, in combination with the other non-operative treatments.

Medications

If the bunion is inflamed, red and painful, then nonsteroidal anti-inflammatory drugs (e.g. ibuprofen and naproxen) can help to reduce the pain. If there is arthritis in the joint as well as a bunion, then strong painkillers may be required. Generally, these painkillers are taken for short periods only and you should always consult your specialist or GP about these medications and their side-effects.

2. Surgery

Surgery may be considered if the non-operative treatment has been tried and it fails to control your symptoms. The aim of surgery is to remove the bump, realign and straighten the toe and make the foot easier to fit into shoes. This makes the foot more natural-looking and prevents the friction of the bunion on the inside of shoes. Having bunion surgery will make it easier to find more comfortable shoes, but it does not mean you can return to wearing narrow, pointy shoes or high-heels – in fact, this may cause the bunion to recur.

Your foot and ankle surgeon will correct the bunion by realigning the bones. This is done by cutting them (the medical name for this is ‘osteotomy’) and fixing them in a straight position. There are a number of ways of performing the osteotomy, but the most common technique is with a ‘scarf’ osteotomy.

In most cases, surgery is performed as a day case, meaning that you go home on the same day but occasionally an overnight stay in hospital may be needed, particularly if you have other medical problems or if the operation is performed late in the evening. The procedure is often performed under general anaesthesia, but can be done under a nerve block or ‘regional anaesthesia’. A plastr cast is not routinely needed afterwards, but you are required to wear a special surgical sandal that keeps the toes from touching the ground and therefore allowing the osteotomy to heal without any complications.

In general, bunion surgery has excellent outcomes and the vast majority of patients are satisfied after the procedure. But as with all surgery, there are small risks such as infection, nerve injury, blood clots (DVT/PE), over- or under-correction, joint pain and/or stiffness, and a recurrence of the bunion (particularly in the younger patients).

Adolescent bunions are typically treated without surgery wherever possible. In rare cases where the pain and difficulty with footwear are very significant, surgery should be delayed if possible until most of the skeletal growth has occurred. The risk of recurrence must be highlighted as it is higher than in the adult bunion group. 

Want to keep learning?  Find out more about the author, Mr Ziad Harb.