BUNIONS

Do you notice a deformity over the big toe? Does it seem like hard callus is forming over the big toe’s joint? Do you like wearing pointed shoes? Are you flat-footed? Have you trained for ballet before? Do you have diabetes, rheumatoid arthritis, or osteoarthritis? Answering yes to some of these questions may point towards you having a case of bunion.

What is a Bunion?

Bunion is a deformity of the big toe. In the medical field, it is known as hallux valgus. The first forefoot bone points outward while the big toe points inward causing an outward pouching of the junction between them called the metatarsophalangeal joint (MTP). Bunion is not an acute medical phenomenon and occurs gradually over time due to a myriad of factors. Cartilage over the 1^st MTP may develop over time and feel like a hard callus in a process called exostosis. Pain, swelling, or tenderness often accompanies this deformity. If the bunion becomes severe, difficulty of moving the big toe occurs.

What are the causes of bunions?

The following are the common causes, but not limited to, developing bunions:

• Genetics

Most experts say that bunions are hereditary. Hypermobility of the 1^st forefoot bone and MTP is a known cause of developing bunions. Other family lineages are just predisposed to developing them.

• Improper foot mechanics

Improper foot mechanics are one the most common causes of bunions. Wrong training techniques, especially for ballet dancers, can cause bunion deformity over time because the 1^st MTP is responsible for 50% of the foot’s movement. Having a flat foot also produces bunion because it causes rolling of the foot inward called pronation. Pronation causes pointing of the first forefoot bone outward that leads to developing bunion. Having a long second toe alters foot mechanics too.

• Women

Women are more affected than men because of their choice of footwear. Wearing high heels and flat shoes without adequate sole thickness both increase the risk for developing bunions. It is not the preference of these shoes but the impact of these shoes on altering foot mechanics that cause bunion formation. Repeatedly altered foot mechanics weakens the muscles of the soles and predispose the big toe to hallux valgus.

• Diabetes, Rheumatoid Arthritis, and Generalized Osteoarthritis

Diabetic patients have impaired balance and position sense of the toes. This lack of proprioception alters the foot mechanics that lead to outward deviation of the 1^st forefoot bone. Rheumatoid arthritis damages the cartilage in between bones that cause laxity of the joints. This leads to developing deformities in multiple joints of the body and includes bunions. Generalized osteoarthritis has joint deformities as one of its unwanted consequences. Cartilaginous damage and subsequent weakness of the foot muscles can lead to bunion formation.

• Obesity

Obesity alters the foot biomechanics and increases loading of the big toe. It also causes weakness of the muscles of the soles. All of these effects of obesity can cause bunions.

Diagnosis of bunions

Bunions are diagnosed clinically. One should seek the advise of a physician once there is pain, swelling, or tenderness of the big toe or its joint. Noticing a deformity warrants an immediate visit to prevent progression of the bony irregularity. X-rays can be requested to confirm the deviation from normal anatomy of the 1^st MTP, 1^st forefoot bone, and big toe and rule out fractures.

Treatment

• Ice compress

Applying ice compress brings down swelling and provides pain relief. Here’s how to apply ice compress:

1. Ice application is preferably done for 15 minutes over the affected area.
2. Make sure to wrap the ice over a cloth in order to avoid skin burns. Check the skin every 5 minutes to make sure that the skin does turn extremely red.
3. Apply ice compress 3x a day with at least an hour rest between applications.
4. Immediately discontinue ice application if you feel that it is too cold or there is a burning sensation.

• Non-steroidal anti-inflammatory drugs (NSAIDs)

Non-steroidal anti-inflammatory drugs are effective in reducing pain and swelling caused by bunion. For those with kidney problems, a topical NSAID can work effectively too.

• Use appropriate footwear

The size of the shoes should be at least ½ inch longer than the big toe. This prevents cramming of the toes to prevent pain. Small or big footwear also alters the foot biomechanics.

• Bunion correctors

A lot of over-the-counter bunion pads, sleeves, and reliefs are effective in reducing symptoms caused by bunion. These items also provide feedback to the brain to prevent further deviation of the forefoot bone or big toe.

• Rehabilitation

Strengthening of the muscles in the soles of the foot can help prevent progression of bunions. One of the most popular exercises is towel curl exercise.

Towel curl exercise:

1. Spread out a towel, cloth, or resistance band over the floor.
2. Step on one edge of the towel with the heel pressing against the floor. Point the toes toward the ceiling to lift them off the floor. You can do the exercise while standing or sitting down.
3. Use all the toes to grab a piece of fabric or rubber towards you until the free opposite edge of the towel is drawn.
4. Repeat for 3 sets. Rest for 1 minute between sets.

• Corticosteroid injection

Injection of steroid directly into the joint reduces swelling and pain. Make sure to strengthen the foot muscles after the injection to prevent recurrence of pain and correct the underlying cause of bunions.

• Surgery

Surgery is reserved for patients whose symptoms do not respond to the abovementioned treatment techniques. The goal of surgery is to decrease pain, improve function, and correct the anatomical deviations.