Bunions

Bunions are the most common deformity that affects the big toe.  A bunion is characterized by angling of the big toe towards the lesser toes, and a painful bump over the inside part of the base of the big toe.  This prominence (an area called the medial eminence) is caused by angling inwards of the metatarsal bone, and is not an actual growth of bone. (figure)

Bunions are caused by a combination of factors, including a familial predisposition, and wearing high-heeled shoes that are tight and narrow at the front.  Most bunions occur in women.  Sometimes other foot problems accompany bunions, including calluses and hammertoes (angling downward of the lesser toes).

The symptoms of a bunion include pain, swelling, and redness over the bony bump on the inside of the foot.  It can become painful to walk, because the big toe bends every time you take a step.   Shoes can become painful to wear, especially ones that are even a little bit tight. Usually, bunions become more painful as they get larger.  In severe cases, you can develop arthritis in the big toe as a result of the bunion.  However, a bunion that is not painful does not need surgical treatment, even a large one.

Treatment

When the deformity is mild, treatment is usually not necessary.  However, changing shoes to ones that have little or no heel, and are wider in the toe area (toe box) will be more comfortable and may help to prevent worsening of the bunion deformity.  If the bunion starts to become painful, other measures may help.  Bunions can cause pain in several different areas.  The medial eminence may be painful, the entire first toe joint may hurt, or there may be pain underneath some or all of the forefoot (the ball of the foot).

Pain over the medial eminence is the most common problem that affects bunion patients.  A “toe spacer” can be placed between the first and second toes and can provide some pain relief as it straightens out the bunion slightly.  Pads placed over the medial eminence itself are hard to keep in place and rarely help to relieve pain.

Pain underneath the first toe or lesser toes can be relieved by pads placed in the shoes in precise areas.  The pads help to take pressure off the prominent areas on the bottom of the foot.

Generalized measures to relieve bunion pain, such as physical therapy or foot stretching exercises, have not been shown to be helpful.  Orthotics are often prescribed, but are also rarely helpful in relieving pain over the bunion, but may help with pain felt under the ball of the foot.

Bunion surgery

When these above measures no longer help to relieve the pain in the big toe, surgery to correct the bunion deformity is considered.  Numerous surgical procedures have been recommended for bunions.  What is most critical is that the type of deformity is carefully evaluated, because one bunion surgery cannot be used for all types of bunions.  If the big toe joint is rotated out of place, the joint must be rotated back in place for the procedure to work.  Conversely, a bunion can occur with the big toe still “in place.”  If surgery is considered, the bunion must be corrected with the toe joint left in its current position.  In other words, one type of bunion repair does not work for everyone.

In all types of bunion repairs, ligaments and tendons (soft tissues) around the big toe joint are reconstructed, to allow the toe to be straightened. Most bunion procedures also require cutting the metatarsal bone, which is then fixed with metal screws to hold the bone in position until it heals.  It usually takes 2 to 4 months to fully recover from bunion surgery, which is why it is always the last course of treatment.

Dr. Roger Mann has been a pioneer in the treatment of bunions.  He has popularized what is now the most commonly performed bunion procedure, known as the “proximal crescentic osteotomy.”  In this procedure, the metatarsal bone is cut in a curved shape at the base of the metatarsal bone (toward the middle part of the foot).  Cutting the bone in this shape allows for the bone to be precisely repositioned to straighten out the toe.

Dr. Roger Mann has published the largest experience in the world on his results using the crescentic osteotomy.  95% of his patients were satisfied with the results of the procedure.  Both Roger and Jeffrey Mann have lectured extensively on this topic, and have written textbook chapters on the technique.  The Manns have performed thousands of bunion procedures, and have over 50 years combined experience with this surgery, undoubtedly one of the most extensive experiences in the United States.