Bunions and Beyond: How to Keep Your Feet Healthy
A bunion is a noticeable and often inflamed bony bump that develops at the base of the big toe, typically linked to hallux valgus—a condition where the big toe gradually shifts toward the second toe. This condition is relatively common, affecting around 2% of children between the ages of 9 and 10 and nearly half of all adults, with a higher occurrence in women. The term "bunion" is commonly used to describe the protruding metatarsal head and the irritated bursa that form due to this misalignment.
Symptoms:
Bunions are marked by a gradually worsening deformity at the metatarsophalangeal (MTP) joint, causing a painful bump on the inner side of the foot. As the big toe shifts toward the second toe, joint mechanics become disrupted, often leading to discomfort, swelling, and stiffness. This misalignment can result in ongoing pain, particularly over the bony prominence, and may interfere with walking or wearing certain shoes. Over time, the condition can progress, causing further joint dysfunction and mobility issues.
Diagnosis:
Physical Examination
A comprehensive foot examination should be conducted both in a seated and standing position. The assessment includes inspecting the skin for abnormalities or lesions, evaluating toenail condition, and analysing the alignment of the first ray. Pain localization should be determined through patient history and palpation. Discomfort at the medial eminence is a hallmark of hallux valgus, though patients may also experience generalized pain in the first metatarsophalangeal (MTP) joint, discomfort due to lesser toe deformities, or pain beneath the lesser metatarsal heads as a result of transfer metatarsalgia. A thorough neurovascular assessment is necessary to rule out vascular or neurological impairment.
The first ray should be evaluated for its range of motion, ligamentous stability, contractures, and the ability to passively correct deformities. Internal rotation of the hallux should also be assessed to determine the reducibility of the first ray in the frontal plane. Examination of the first MTP joint should include checking for skin changes, tenderness, crepitus, or restricted movement suggestive of arthritis. Additionally, associated conditions such as hammertoe deformity, pes planus, Achilles tendon contracture, or first ray hypermobility should be identified.
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Radiographic Examination
Diagnostic imaging should include weight-bearing anteroposterior (AP), lateral, and axial sesamoid views of the affected foot. Several key angles must be measured on the AP view, including the hallux valgus angle (HVA), the first-to-second intermetatarsal angle (IMA), and the distal metatarsal articular angle (DMAA). The DMAA, formed between the distal articular surface and the longitudinal axis of the first metatarsal, helps assess first MTP joint congruity, with values under 10 degrees considered normal. However, studies have shown that the reliability of the DMAA is lower than that of the HVA and IMA, as changes in DMAA may be influenced more by metatarsal head rotation rather than true angulation differences.
Another important consideration is the hallux valgus interphalangeal (HVI) angle, which is measured between the longitudinal axes of the distal and proximal phalanges. If this angle is significantly increased, additional surgical correction, such as an Akin osteotomy, may be required.
The sesamoid axial view provides insight into sesamoid positioning relative to the crista of the first metatarsal head, helping to identify sesamoid subluxation or metatarsal rotation. The "round sign," which assesses the shape of the lateral edge of the first metatarsal head on AP radiographs, is another useful indicator of metatarsal rotation. Additionally, the first MTP joint should be examined for signs of arthritis. Advanced imaging, such as weight-bearing computed tomography (CT), is gaining recognition for its ability to provide a three-dimensional evaluation of hallux valgus, enhancing understanding of its pathogenesis.
Risk Factors:
Hallux valgus is significantly more common in women, likely due to differences in foot structure, ligament flexibility, and footwear choices. While tight or high-heeled shoes can contribute by increasing pressure on the first metatarsophalangeal (MTP) joint, research comparing shoe-wearers and barefoot individuals has shown mixed results. Other key risk factors include genetics, age-related changes in joint mechanics, and foot structure abnormalities such as first ray hypermobility, flat feet, or metatarsus adductus. As people age, shifts in weight distribution and plantar loading patterns further increase the likelihood of developing this deformity.
Treatment:
Non-Surgical Treatment
The initial approach for managing symptomatic bunions focuses on non-surgical methods. Wearing well-fitted, accommodative footwear with a wide toe box and low heel is essential to reduce pressure on the affected joint. Over-the-counter bunion cushions can help alleviate discomfort, while shoe modifications or stretching, particularly under the guidance of a podiatrist, may improve comfort, especially for individuals with underlying conditions like diabetes or vascular disease.
There is some evidence supporting the use of nonsteroidal anti-inflammatory drugs (NSAIDs), orthotics, toe spacers, and splints for pain relief. However, their effectiveness varies, and they do not correct the deformity. Orthotic inserts, including medial arch supports and metatarsal domes, may help redistribute pressure, particularly in individuals with associated conditions like flat feet. Despite mixed findings in research, a trial of conservative treatment is often recommended, particularly for younger patients, those awaiting specialist consultation, or individuals unfit for surgery.
Surgical Treatment
Surgery is generally considered when conservative treatments fail to provide relief and the patient experiences persistent pain or functional limitations. The decision to operate is based on the severity of the deformity, patient symptoms, and overall health status. More than 100 surgical techniques exist, most involving bone realignment (osteotomy), joint fusion, or soft tissue procedures. The chevron and scarf osteotomies are commonly performed, with mild-to-moderate cases typically managed through distal metatarsal osteotomies, while more severe deformities may require proximal osteotomy or fusion.
Minimally invasive surgical techniques are gaining popularity, although studies suggest no significant advantage over traditional procedures in terms of patient outcomes or complication rates. Post-surgery, patients generally wear a stiff-soled shoe for six weeks and are restricted from driving until they regain normal function.
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Considerations for Referral
Referral to an orthopedic specialist is advised when non-surgical management is ineffective, and the patient is a suitable candidate for surgery. Factors such as functional impairment, co-existing conditions (e.g., rheumatoid arthritis, diabetes), and risk of skin breakdown should be evaluated. In cases of juvenile bunions, delaying surgery until skeletal maturity is preferred to reduce recurrence risk and avoid disrupting growth plates.
It is important to note that cosmetic concerns alone are not a justification for surgery. Pain relief remains the primary objective, as some patients may continue to experience footwear-related issues even after the procedure. Additionally, smoking is a relative contraindication due to its association with wound healing complications and delayed bone healing. Smoking cessation should be encouraged prior to surgery.
References
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Coughlin, M.J. and Jones, C.P., ‘Hallux valgus: demographics, etiology, and radiographic assessment’, Foot & Ankle International, vol. 28, no. 7, 2007, pp. 759-777.
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Munteanu, S.E., Menz, H.B., Zammit, G.V. and Landorf, K.B., ‘Foot orthoses for the management of hallux valgus: a randomized controlled trial’, Australian Journal of General Practice, vol. 49, no. 11, 2020, pp. 705-711.
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Perera, A.M., Mason, L. and Stephens, M.M., ‘The pathogenesis of hallux valgus’, The Journal of Bone and Joint Surgery, vol. 93, no. 17, 2011, pp. 1650-1661.
