Bunions
May 10, 2016
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A bunion is not simply a bump on the side of the foot. It is a complex change in the shape of the big toe joint (first metatarso-phalangeal joint) that leads to increasing pain and arthritis as it gets worse. Though many bunions are not painful, as they get worse they can become more and more painful, which leads to difficulty in walking and doing the normal activities of life.

The medical name for a bunion is Hallux Abducto Valgus, which means the big toe and the bone behind the big toe (called the first metatarsal) become angled and the cartilage, which provides the lubricant for the joint to move smoothly, becomes shifted. This happens because the big toe moves away from the center of the body and the first metatarsal moves closer to the center of the body. Because the cartilage is shifted, it wears away at a faster rate than normal and can lead to early arthritis and severe pain as time passes. Usually as the bump gets larger and the toe gets pushed over farther, the pain and arthritis get worse.

There are several causes of bunions, most of which are hereditary. Flat foot and flexible flat foot are among the most common causes. Other causes include trauma/fracture, high arches (also known as cavus foot), hereditary nerve problems and in some cases there is no known cause. The reason a flat foot most often causes a bunion is because of the way a person walks when there is not an arch to properly support the foot. Normally the arch helps the foot push the body forward during walking or running. With a flat foot, there is no arch to help push the body forward, so the foot turns outward instead, which puts the big toe in a bad position and the body pushes on the big toe from the side, instead of from the bottom. The big toe is not designed to be pushed from the side, so it gets forced away from the center of the body, leading to a shift in the toe and a larger bump on the side of the metatarsal bone.

So, the strategy to help improve the pain and prevent the bunion from getting worse is to support the arch. This support can come in the form of shoes, pre-made orthotics and custom orthotics. A shoe alone is usually not enough to properly support the arch if someone has a very flat foot or very flexible foot. Shoes are made as a blank and usually have very little arch support. Orthotics provide a better and more custom fit to any shoe. Pre-made orthotics are designed as an average of everyone’s foot type, but some can be selected for certain foot types to fit a person somewhat better. Many people do extremely well with pre-made orthotics. Custom orthotics are made by taking a mold of the foot and making an orthotic that is exactly made for the person. They are made of stronger and more long-lasting materials also.
There are other devices that are made to help with bunion pain. A bunion splint is a brace that helps straighten the big toe, which helps to put the cartilage back where it belongs. This splint does not make the toe grow back where it belongs, but it does help to make the toe work better as long as it is worn. A toe separator is a device that is put between the big toe and 2nd toe, keeping them separated. This can also help the big to cartilage be in a better position, but like the bunion splint, it only works when worn and will not permanently fix the bunion.

Also, there are medications and injections that can help the pain of a bunion. The pain from a bunion is most often due to inflammation (swelling of the joint and tissues) and medications can help to slow it down. Non steroid anti-inflammatory drugs (NSAIDs), such as ibuprofen or naproxen, can help with the swelling that is the cause of the pain. An injection of steroid into the joint also can help reduce the inflammation.

If the treatments listed above do not work well enough, surgery to correct the position of the joint is the next step. Many different operations can be performed to place the joint in the right position to keep the cartilage from wearing down and decrease the pain. Which operation is chosen is based on many things and x-rays of the foot are very important in making the decision. The doctor looks at the position of the big toe and metatarsal as well as the other joints of the foot to decide which operation is best. The recovery time is different depending on which operation is needed.

In most cases, the operation needed is a shifting of the metatarsal bone, to bring it back to where it belongs. To do this, the bone must be cut and held in place with screws. These screws stay in the bone and usually don’t have to be removed. The big toe must also be shifted, but usually doesn’t need a bone cut. The large bump on the side of the foot is also removed. When finished, the big toe is straighter and the bump is gone. The joint also moves more smoothly and the pain is improved. The recovery period for this operation is a little different for each person, but on average the patient walks with a special shoe for about 4-6 weeks, which is the time it takes for the bone to heal. After that, the patient starts wearing a tennis shoe and slowly goes back to regular activities. The patient will also need to do exercises to keep the big toe joint moving and may need to have physical therapy for the best results. The incision for this operation is usually around 2 inches long and is put in an area where it heals very well with a small scar.

In some cases, the operation needed is a little more complicated. In people with very flexible feet, or for bunions that are very large, a different operation is needed. This operation has a bone cut also, but it is done in a different area and it is necessary to take away one of the joints to make the flexibility of the foot more normal. Screws and a plate are usually used to hold the bone in the right position and bring the metatarsal back where it belongs. The big toe is straightened and the bump is removed, just like in the other operation. The recovery time for this operation is a little longer. Usually the patient is in a cast for 6 weeks, followed by walking in a boot for a few weeks. Because this operation is a little more complicated, the scar is usually a little longer, but is still small and most often heals so that it is not easy to see.

There are many other operations for bunions but these two are the most commonly used at Advanced Foot and Ankle Center. With every bunion, the doctors at Advanced Foot and Ankle center take great care when looking at all parts of the problem and then select the best treatment. Whether you need orthotics, a splint or surgery, you and your bunion will be given the time and care they deserve.

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