Bunion is the name given to a prominent bump on the inside of the foot at the base of the great toe. The medical term is hallux abductovalgus. Bunions tend to increase in size and severity as time goes on, and they can become painful for a variety of reasons such as soft tissue irritation (bursitis) related to rubbing on tight fitting shoes, inflammation of the joint capsule (synovitis), or from arthritis of the great toe joint from moving in a position for which it was not designed.
Bunions occur in approximately 1 in 4 adults and as age increases, so does the incidence of bunions. Women develop bunions more than men, and bunions can occur in small children to elderly patients. They often run in families but certainly don’t have to.
It’s important to know that not all bunions require surgery. Initial conservative treatment is usually helpful and is directed at reducing pressure and inflammation over the painful bony prominence. This is accomplished with wider shoes and padding. For inflammation, the RICE protocol (Rest, Ice, Compression, and Elevation), anti-inflammatories, and perhaps a cortisone injection if warranted are usually quite effective during the early phases of bunion development. Other popular treatments such as bunion splints and toe spacers that hold the great toe in a corrected position yield mixed results. They may help the toe feel better but do nothing to keep the toe in the corrected position when not wearing the device. Orthotics are specialized shoe inserts that are intended to address the forces in the foot that lead to the formation of bunions in the first place. They can slow down or halt the progression of bunions, but unfortunately will not cause a bunion disappear once developed.
So when should one consider having a bunion surgically corrected? No two bunions are created equally and there are many factors that come into play when attempting to answer this question.
I’ve seen patients with severe bunion deformities (think big toe crossing under the second toe) that had no pain. Conversely, I’ve seen patients with relatively mild degrees of deformity that couldn’t wear shoes because the pain was so severe. There are many reasons that this may be the case and further workup usually reveals the answer as to why. The degree of deformity is almost always less important than one’s ability to walk without pain and function at a high level regardless of how bad a bunion may appear. I always ask a few questions when helping patients decide if a bunion surgery is best for them, such as “Do you have difficulty wearing shoes without pain? Even wide shoes? Is the pain keeping you from doing things you would otherwise be doing (i.e. exercise, hiking, work, etc.)? Have the symptoms failed to resolve or substantially improve with first trying conservative measures? Has the deformity significantly worsened over a short period of time (less than a year)?” If the answer to these questions is “yes”, then we usually further discuss what surgical options may result in long-term pain relief in addition to appropriate expectations following bunion surgery.
When discussing bunion surgery with your doctor, there are many things to consider. There are many different surgical procedures to fix bunions and if you see 5 different doctors, you may very well get 5 different opinions on which procedures work best. Procedure selection and rational comes down to individual patient factors, severity of deformity, apex of the deformity, surgeon preference, and a patient’s given expectations following a surgery. For instance, I may choose very different procedures based on postoperative expectations for a 25 year old athlete versus an 87 great grandmother even though they may have a similar deformity.
Recovery can vary significantly depending on which procedures are performed. A bunionectomy surgery could be a simple procedure (shaving a painful bump) to a quite complex surgery (fusing multiple unstable joints with plates and screws), and that’s the difference between being weight bearing and back into normal shoes in 2 weeks versus 2 months of being non-weight bearing on crutches. Your average bunionectomy surgery (~70% of cases) will consist of 6 weeks of weight bearing in a protective cast boot before transitioning back into normal shoes; however, high impact activities such as running and jumping may need to be put off for an additional 1-2 months. Recovery is a gradual process and people heal at different rates.
In some instances, bunions can come back even after surgery. This doesn’t happen very often, but it certainly is a possibility and something of which all patients should be aware and consider prior to surgery. One can re-develop a bunion for the same reasons that they developed the bunion in the first place, although surgical correction is usually enough to counteract the body’s desire to want to re-develop a bunion. For instance, hyper-mobility and excessive pronation (over collapse of the arch) are common predisposing factors that can lead to bunion formation in certain patients. A beautiful surgical correction can be obtained, but if hyper-mobility is not addressed (or is greater than the surgical correction) then these patients are much more likely to have a recurrence. Hyper-mobility is managed with appropriate procedure selection and/or orthotics in most cases. Other factors that increase the chance of recurrence are a rounded metatarsal head (as opposed to more of a square shape), early onset of bunion deformity (childhood), family history, returning to inappropriate shoes, and adherence to postoperative protocol.
Deciding to proceed with an elective foot surgery, no matter how major or minor, is a process. It is worth discussing with friends, family, your employer, and your foot and ankle surgeon before committing to anything. There is unfortunately a lot of misinformation out there and speaking with a specialist will help you sort through the facts, develop accurate expectations, and make an informed decision. Having appropriate expectations will play a large role in determining your satisfaction with your results after bunion surgery. With careful preoperative planning and discussion, bunion surgery yields predictable results and a high rate of patient satisfaction.