Bunion

Definition

A bunion is an abnormal enlargement of the joint (the first metatarsophalangeal joint, or MTPJ) at the base of the great or big toe (hallux). It is caused by inflammation and usually results from chronic irritation and pressure from poorly fitting footwear.

Description

A displacement of two major bones of the foot (hallux valgus) causes bunions, although not everyone with this displacement will develop the joint swelling and bone overgrowth that characterize a bunion. One of the bones involved is called the first metatarsal bone. This bone is long and slender, with the big toe attached on one end and the other end connected to foot bones closer to the ankle. This foot bone is displaced in the direction of the four other metatarsals connected with the toes. The other bone involved is the big toe itself, which is displaced toward the smaller toes. As the big toe continues to move toward the smaller toes, it may become displaced under or over the second toe. The displacement of these two foot bones causes a projection of bone on the inside portion of the forefoot. The skin over this projection often becomes inflamed from rubbing against the shoe, and a callus may form.

The joint contains a small sac (bursa) filled with fluid that cushions the bones and helps the joint to move smoothly. When a bunion forms, this sac becomes inflamed and thickened. Inflammation of the bursa is called bursitis . The swelling in the joint causes additional pain and pressure in the toe.

Bunions can also form on the bones that attach the little toe to the foot (the fifth metatarsal bone). These bunions are called tailor's bunion or bunionette.

Causes & symptoms

Bunions may form as a result of abnormal motion of the foot during walking or running. One common example of an abnormal movement is an excessive amount of stress placed upon the inside of the foot. This leads to friction and irritation of the involved structures. Age has also been noted as a factor in developing bunions, in part because the underlying bone displacement worsens over time unless corrective measures are taken.

Wearing improperly fitting shoes, especially those with a narrow toe box and excessive heel height, often causes the formation of a bunion. This forefoot deformity is seen more often in women than men. The higher frequency in females may be related to the strong link between footwear fashion and bunions. In fact, in a recent survey of more than 350 women, nearly 90% wore shoes that were at least one size too small or too narrow. Shoes without proper arch supports contribute to bunions, since they allow the foot to roll inward (pronate,) putting more pressure on the joint of the big toe.

Because genetic factors can predispose people to hallux valgus bone displacement, a strong family history of bunions can increase the likelihood of developing this foot disorder. Various arthritic conditions and several genetic and neuromuscular diseases, such as Down syndrome and Marfan syndrome, cause muscle imbalances that can create bunions from displacement of the first metatarsal and big toe. Other possible causes of bunions are leg-length discrepancies (with the bunion present on the longer leg) and trauma occurring to the joint of the big toe. Persons with flat feet or gout are at increased risk for developing bunions.

Symptoms of bunions include the common signs of inflammation such as redness, swelling, and pain. The discomfort is primarily located along the inside of the foot just behind the big toe. Because of friction, a callus may develop over the bunion. If an overlapping of the toes is allowed, additional rubbing and pain occurs. Inflammation of this area causes a decrease in motion with associated discomfort in the joint between the big toe and the first metatarsal. If allowed to worsen, the skin over the bunion may break down causing an ulcer, which also presents a problem of potential infection. (Foot ulcers can be particularly dangerous for people with diabetes, who may have trouble feeling the ulcer forming and healing if it becomes infected.)

Diagnosis

A thorough medical history and physical exam by a physician is always necessary for the proper diagnosis of bunions and other foot conditions. X rays can help confirm the diagnosis by showing the bone displacement, joint swelling, and, in some cases, the overgrowth of bone that characterizes bunions. Doctors will also consider the possibility that the joint pain is caused by or complicated by arthritis (which causes destruction of the cartilage of the joint), gout (which causes the accumulation of uric acid crystals in the joint), tiny fractures of a bone in the foot (stress fractures), or infection, and may order additional tests to rule out these possibilities.

Treatment

The first step in treating a bunion is to remove as much pressure from the area as possible. A foam-rubber pad may be worn at night while sleeping to separate the big toe from the other toes. Various taping techniques can be useful to realign the toe and decrease friction and rubbing that may be present. Most patients are instructed to rest or choose exercises that put less stress on their feet, at least until the misalignment is corrected.

Persons with bunions should wear shoes that have enough room in the toe box to accommodate the bunion. High-heeled shoes and tight-fitting socks or stockings should be avoided. Sandals are a good choice. Shoes may be stretched to provide more comfort or customized to relieve pressure on the affected area. Shoes should be removed periodically during the day to give feet a break. Dressings and pads help protect the bunion from additional shoe pressure. Arch supports can reduce the pressure on the bunion. The application of splints or customized shoe inserts (orthotics) to correct the alignment of the big toe joint is effective for many bunions. These can correct the excessive pronation (turning inward) so that the pressure is not continually on the big toe.

Deep friction massage techniques by a physical or massage therapist can be helpful to increase circulation, reduce inflammation, and prevent soft tissue build-up. Physical therapy also provides useful approaches, such as ultrasound, to help retard or reverse the formation of the bunion.

One study found that using an extract from marigold (Tagetes patula ) with a protective pad led to a reduction in the size and pain of bunions. A used chamomile tea bag applied to a bunion may be helpful. Massaging with essential oil of chamomile or with a cream containing chamomile may provide relief. The homeopathic remedy Calcarea phosphorica can be useful in balancing the bone formation and remodeling.

Soaking the affected foot in warm water may reduce pain. Elevating the affected foot and applying ice and compression to the bunion can be helpful, especially after exercise .

Dietary supplements and dietary changes may help to treat bunions. Vitamins which may be helpful in treating the bursitis associated with bunions include A, B complex, C, and E. Increasing the intake of protein may also be beneficial.

Acupuncture can be useful in treating the symptoms as the spleen meridian is roughly where the pain occurs. Other treatments may help stabilize the foot.

Allopathic treatment

Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil, Motrin), acetaminophen (Tylenol), or naproxen sodium (Aleve) may be taken to help reduce bunion pain. Physicians may also use steroid injections with local anesthetic around the bunion to reduce inflammation. Other drugs may be necessary should an infection occur.

If conservative treatments are not successful, surgical removal of the bunion may be necessary to correct the deformity. This procedure is called a bunionectomy, and there are many variations on the operation, which is usually performed by a surgeon who specializes in treating bone conditions (orthopedics) or by one who specializes in treating the foot (podiatry). The procedure chosen depends upon the angle of the bone misalignment, condition of the bursa, and strength of the bones. Most bunionectomies involve the removal of a section of bone and the insertion of pins to rejoin the bone. Sometimes the surgeons may move ligaments (which connect bone to bone in the joint) or tendons (which connect bone to muscle) in order to realign the bones.

Expected results

Often, modifications in footwear allow a good recovery without a need for surgery. If surgery is necessary, complete healing without complications requires approximately four to six weeks. Even after surgery corrects the bone misalignment, patients are usually instructed to continue wearing low-heeled, roomy shoes to prevent the bunion from reforming. Complications of bunions include infection of the bunion and inflammation and arthritic changes in other joints as a result of difficulty in walking.

Prevention

Prevention begins with proper foot wear. Shoes with a wide and deep toe box are best. High-heeled shoes should not be worn for longer than three hours at a time. If a bunion is present and becomes inflamed, the foot should be elevated with the application of an ice pack over the painful area for not more than 20 minutes every other hour. Daily exercise strengthens the muscles of the legs and feet and may prevent bunion formation. Women who wear high-heeled shoes should do calf stretches on a regular basis. Use of arch supports or custom made orthotics can help people whose feet rotate inward as they walk or those with different leg lengths. Stretching the Achilles tendon can counteract stresses on the forefoot.

Resources

BOOKS

Richard B. Birrer, et al. Common Foot Problems in Primary Care, 2nd ed. Philadelphia, PA: Hanley & Belfus, Inc., 1998.

PERIODICALS

Cimons, Marlene. "Bothersome Bunions." Runner's World 34 (May 1999): 46+.

ORGANIZATIONS

American Orthopedic Foot and Ankle Society. 222 South Prospect, Park Ridge, IL 60068.

American Podiatry Medical Association. 9312 Old Georgetown Road, Bethesda, MD 20814.

OTHER

"Foot Pain." WebMD. http://my.webmd.com/content/dmk/dmk_article_40037.

Griffith, H. "Complete Guide to Symptoms, Illness & Surgery." The Putnam Berkley Group, Inc., 1995. Available at: http://www.thriveonline.com.

Belinda Rowland

Bunion

Definition

A bunion is an abnormal enlargement of the joint (the first metatarsophalangeal joint, or MTPJ) at the base of the great or big toe (hallux). It is caused by inflammation and usually results from chronic irritation and pressure from poorly fitting footwear.

Description

A displacement of two major bones of the foot (hallux valgus) causes bunions, although not everyone with this displacement will develop the joint swelling and bone overgrowth that characterize a bunion. One of the bones involved is called the first metatarsal bone. This bone is long and slender, with the big toe attached on one end and the other end connected to foot bones closer to the ankle. This foot bone is displaced in the direction of the four other metatarsals connected with the toes. The other bone involved is the big toe itself, which is displaced toward the smaller toes. As the big toe continues to move toward the smaller toes, it may become displaced under or over the second toe. The displacement of these two foot bones causes a projection of bone on the inside portion of the forefoot. The skin over this projection often becomes inflamed from rubbing against the shoe, and a callus may form.

The joint contains a small sac (bursa) filled with fluid that cushions the bones and helps the joint to move smoothly. When a bunion forms, this sac becomes inflamed and thickened. The swelling in the joint causes additional pain and pressure in the toe.

Causes and symptoms

Bunions may form as a result of abnormal motion of the foot during walking or running. One common example of an abnormal movement is an excessive amount of stress placed upon the inside of the foot. This leads to friction and irritation of the involved structures. Age has also been noted as a factor in developing bunions, in part because the underlying bone displacement worsens over time unless corrective measures are taken.

Wearing improperly fitting shoes, especially those with a narrow toe box and excessive heel height, often causes the formation of a bunion. This forefoot deformity is seen more often in women than men. The higher frequency in females may be related to the strong link between footwear fashion and bunions. In fact, in a recent survey of more than 350 women, nearly 90% wore shoes that were at least one size too small or too narrow.

Because genetic factors can predispose people to the hallux valgus bone displacement, a strong family history of bunions can increase the likelihood of developing this foot disorder. Various arthritic conditions and several genetic and neuromuscular diseases, such as Down syndrome and Marfan syndrome, cause muscle imbalances that can create bunions from displacement of the first metatarsal and big toe. Other possible causes of bunions are leg-length discrepancies, with the bunion present on the longer leg, and trauma occurring to the joint of the big toe.

KEY TERMS

Orthopedics— A medical specialty concerned with treating diseases, injuries, and malformations of the bones and supporting structures, such as tendons, ligaments, and muscles.

Orthotic— A device or brace to control, correct, or compensate for a bone deformity.

Podiatry— A medical specialty concerned with treating diseases, injuries, and malformations of the feet.

Symptoms of bunions include the common signs of inflammation such as redness, swelling, and pain. The discomfort is primarily located along the inside of the foot just behind the big toe. Because of friction, a callus may develop over the bunion. If an overlapping of the toes is allowed, additional rubbing and pain occurs. Inflammation of this area causes a decrease in motion with associated discomfort in the joint between the big toe and the first metatarsal. If allowed to worsen, the skin over the bunion may break down causing an ulcer, which also presents a problem of potential infection. (Foot ulcers can be particularly dangerous for people with diabetes, who may have trouble feeling the ulcer forming and healing if it becomes infected.)

Diagnosis

A thorough medical history and physical exam by a physician is always necessary for the proper diagnosis of bunions and other foot conditions. X rays can help confirm the diagnosis by showing the bone displacement, joint swelling, and, in some cases, the overgrowth of bone that characterizes bunions. Doctors will also consider the possibility that the joint pain is caused by or complicated by arthritis (which causes destruction of the cartilage of the joint), gout (which causes the accumulation of uric acid crystals in the joint), tiny fractures of a bone in the foot (stress fractures), or infection and may order additional tests to rule out these possibilities.

Treatment

Conservative

The first step in treating a bunion is to remove as much pressure from the area as possible. People with bunions should wear shoes that have enough room in the toe box to accommodate the bunion and avoid high-heeled shoes and tight-fitting socks or stockings. Dressings and pads help protect the bunion from additional shoe pressure. The application of splints or customized shoe inserts (orthotics) to correct the alignment of the big toe joint is effective for many bunions. Most patients are instructed to rest or choose exercises that put less stress on their feet, at least until the misalignment is corrected. In some cases, physicians also use steroid injections with local anesthetic around the bunion to reduce inflammation.

Surgery

If conservative treatment is not successful, surgical removal of the bunion may be necessary to correct the deformity. This procedure is called a bunionectomy, and there are many variations on the operation, which is usually performed by a surgeon who specializes in treating bone conditions (orthopedics) or by one who specializes in treating the foot (podiatry). Surgeons consider the angle of the bone misalignment, the condition of the bursa, and the strength of the bones when they choose which procedure to use. Most bunionectomies involve the removal of a section of bone and the insertion of pins to rejoin the bone. Sometimes the surgeons may move ligaments (which connect bone to bone in the joint) or tendons (which connect bone to muscle) in order to realign the bones. After this procedure, the bones and other tissues are held in place while they heal by compression dressings or a short cast. The individual must refrain from vigorous exercise for six weeks.

Alternative treatment

Deep friction massage techniques by a physical or massage therapist can be helpful to increase circulation, reduce inflammation, and prevent soft tissue build up. Physical therapy also provides useful approaches such as ultrasound to help retard or reverse the formation of the bunion. Various taping techniques can be useful to realign the toe and decrease friction and rubbing that may be present. The homeopathic tissue salt Calcarea phosphorica can be useful in balancing the bone formation/remodeling.

Prognosis

Often modifications in footwear allow a good prognosis without surgery. If surgery is necessary, complete healing without complications requires approximately four to six weeks. Even after surgery corrects the bone misalignment, patients are usually instructed to continue wearing low-heeled, roomy shoes to prevent the bunion from reforming.

Prevention

Prevention begins with proper foot wear. Shoes with a wide and deep toe box are best. High-heeled shoes should not be worn for long periods of time. If a bunion is present and becomes inflamed, the foot should be elevated with the application of an ice pack over the painful area for not more than 20 minutes every other hour. If pain and swelling continue, a podiatrist or physician should be contacted.

Resources

ORGANIZATIONS

American Orthopedic Foot and Ankle Society. 222 South Prospect, Park Ridge, IL 60068.

American Podiatry Medical Association. 9312 Old Georgetown Road, Bethesda, MD 20814.

OTHER

Griffith, H. Winter. "Complete Guide to Symptoms, Illness & Surgery." ThriveOnline. 〈http://thriveonline.oxygen.com〉.

bunion swelling or thickening around the first joint of the big toe. The toe is forced inward and compresses the other toes. The fluid-filled sac, or bursa , in the toe joint becomes inflamed (a condition called bursitis), which may lead to pain, deformity, and an inability to wear ordinary shoes. Bunions may arise from years of wearing ill-fitting shoes. However, congenital bone deformities are usually indicated when they occur on both feet. Proper foot care, especially in selecting shoes, is the most important aspect of treatment and prevention. The toes can often be straightened by pads or splints, and orthopedic shoes are generally prescribed. Serious cases may require surgery.

Bunions

The Price of Style

What Causes Bunions?

How are Bunions Treated?

Resources

Bunions (BUN-yunz) are foot deformities caused by displacement of certain bones. A bunion is visible as a bump on the side of the foot at the joint at the base of the big toe.

KEYWORDS

for searching the Internet and other reference sources

Orthopedics

Orthotics

Podiatry

The Price of Style

When Natalie began her job at the bank, she finally could afford to indulge her love of stylish shoes. The higher the heel and the pointier the toe, the better. However, after several months, the inner side of Natalie’s right foot, especially around the base of the big toe, began to swell and turn red. As it rubbed against her shoe, the bump on her foot grew bigger. After a few weeks, even sneakers hurt her foot. Natalie knew she had a bunion; bunions ran in her family, and her foot looked just like her mother’s and grandmother’s feet. She counted the days until her appointment with a podiatrist (po-DY-a-trist), or foot specialist.

What Causes Bunions?

Hallux valgus

The medical term for bunion is “hallux valgus”: hallux means big toe, and valgus means a deformity pointing away from the middle of the body. A bunion is formed when the first metatarsal (MET-a-tar-sal), which is the long bone along the inner side of the foot, pushes out at the base of the big toe, and the big toe is displaced toward the smaller toes. The first metatarsal and one of the big toe bones meet at the first joint of the big toe; the bump characteristic of a bunion is caused by inflammation and swelling of this joint.

Anyone can develop a bunion

Bunions are a very common and painful foot deformity. Anyone, including children, can develop a bunion. However, bunions are most common in women over 30, possibly because of shoe choice. Narrow, pointy, high-heeled shoes can speed up the formation of a bunion in people who are susceptible to developing them. People who have flat feet or low arches also are more prone to develop bunions than people with higher arches.

Pronation and other foot abnormalities

Foot abnormalities are a common cause of bunions. For example, people whose feet are rotated so that the inside edge of the foot hits the ground first when they walk (pronated feet) are prone to bunions. Many people have a genetic susceptibility to developing bunions, and bunions also may develop in association with arthritis.

How are Bunions Treated?

Natalie had the classic symptoms of a bunion: the inner side of her foot was deformed by a red, swollen, painful lump the size of a large marble; she also had a big callus (an area of hard thick skin) along the inner side of her foot; her other toes overlapped one another; and sometimes the skin over the bunion became infected.

Before treating the bunion, Natalie’s podiatrist took x-rays of her foot to examine the foot bones. She had a large and well-developed bunion, and he decided to inject medication into her big toe joint to reduce the swelling. He also prescribed devices called orthotics* that fit into her shoes to help reduce pressure and weight on her big toe. To help reduce swelling, the podiatrist told Natalie to take aspirin, put ice packs on her foot, and soak her foot in mineral salts. She also would have to give up the high heels.

* orthotic

is a support or brace for weak or ineffective joints or muscles.

Osteotomy

These treatments did not work for Natalie, and ultimately she had bunion surgery. The podiatrist performed an osteotomy (os-tee-OT-o-mee), which means “cutting of bone.” After giving Natalie local anesthesia to block pain in her foot, the podiatrist removed areas of the metatarsal that had thickened, and he used a small titanium (ty-TANE-ee-um) screw to hold the bones in their correct position. Like almost all bunion repairs, Natalie’s was successful. She was walking again the day of the surgery and was back to work in four days.

See also

Arthritis

Flat Feet

Resources

Book

Tremaine, M. David, M.D., and Elias M. Awad, Ph.D. The Foot and Ankle Sourcebook: Everything You Need to Know. Lowell House, 1998.

Organizations

American Podiatric Medical Association, 2 Chevy Chase Circle NW, Washington, DC 20005. The APMAs website features information about bunions and other disorders affecting the feet. http://www.apma.org

American College of Foot and Ankle Surgeons, 515 Busse Highway, Park Ridge, Illinois 60068. This organization’s website provides information about foot health, foot and ankle deformities, and foot injuries. http://www.acfas.org

bunion (bun-yŏn) n. an area of thickened tissue overlying the joint at the base of the big toe. It arises when a bursa develops around the joint in response to friction and pressure from ill-fitting footwear and is commonly associated with hallux valgus.

bunion XVIII. Formerly also bunnian, -on, bunyan, -on; rel. to dial. (E. Anglian) bunny swelling, earlier bony (XV), and obs. dial. (Essex) boine — OF. buigne (mod. bigne) bump on the head.

bun·ion / ˈbənyən/ • n. a painful swelling on the first joint of the big toe.

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