Bunions

What is a bunion?
A bunion is a bump on the big toe side of the foot and is actually bone. It may be red and painful whether you are walking or resting. The first metatarsal, the large bone located where the toe meets the foot, rotates outward and pushes your big toe inward toward your other toes. This can sometimes cause your toes to overlap, which causes pain.

What causes bunions?
Bunion formation runs in families, so if a parent or other relative has a bunion, you have a higher risk of also developing a bunion. Bunions can be irritated by friction from ill-fitting shoes. Wearing high-heeled shoes puts unwanted pressure on the joints of the forefoot, which can result in painful bunions. Bunions may be caused by a congenital anatomical deformity, flat feet, a tight Achilles tendon, polio, or rheumatoid arthritis. Even if you develop a bunion, it may not progress to the point where it needs surgical correction. Nonsymptomatic bunions can be managed by appropriate shoe wear.

When choosing shoes, follow these tips:

  • Judge the shoe by how it fits and feels on your foot, not by the size marked on the shoe or the box.
  • Measure your feet regularly as you grow older. Foot size changes with age.
  • Try on shoes late in the day when your feet are at their largest.
  • Do not wear shoes that feel too tight. Do not expect them to stretch.
  • Make sure your heel fits comfortably in the shoe with minimum slippage.
  • Walk around in the shoe to make sure it fits well.

Diagnosing bunions
Diagnosis of bunions is based on physical examination, a complete history of your symptoms, and diagnostic studies. Diagnostic studies help the podiatrist determine the precise nature of the deformity. He or she can determine the extent of the problem with the big toe and how much the second toe is involved. Your podiatrist will assess your standing and walking to determine whether or not your gait is affected. Your range of motion will be tested as well, and a vascular and neurologic assessment will also be made prior to treatment.

Conservative treatment of bunions
Before surgical correction of bunions is undertaken, the podiatrist may treat your bunion with conservative measures.

Conservative treatment modalities include:

    • Activity modification, rest and elevation of the affected foot;
    • Changing to footwear that puts less pressure on the tender area;
    • Soaking the foot in warm water;
    • Anti-inflammatory medications;
    • Steroid injection into the area surrounding the affected joint;
    • Orthotic devices;
    • Using cushioned padding in the shoes;
    • Taping the foot to retain normal positioning;
    • Physical therapy, including ultrasound therapy or whirlpool baths.

Surgical correction of bunions
If nonsurgical treatment is not successful, your podiatrist may suggest surgery. Studies show that 85-90% of patients who have bunion surgery are satisfied with the results. The goal of bunion surgery is not to improve the cosmetic look of your foot. The goal of such surgery is to relieve your pain and correct your foot deformity.

If your bunion causes foot pain that restricts your everyday activities, you may benefit from bunion surgery. Other indications for surgical correction include chronic inflammation that does not improve with rest or medication.

Preparation for surgery
If you decide to have bunion surgery, your podiatrist or your personal physician will assess your general health. You may need preoperative clearance from your primary care or treating physician. Conditions such as diabetes, rheumatoid arthritis, or circulatory difficulties could negatively impact your healing and could increase postoperative pain.

Be sure to tell your podiatrist what medications you take regularly, including herbal or natural remedies. Follow your podiatrist’s instructions on which medications you should or should not stop taking before surgery.

You may or may not be required to have blood tests, cardiac testing, chest X-ray, or urinalysis in addition to foot X-rays or other imaging studies.

The usual surgical outcome
Most patients have a significant decrease in pain after surgery and greatly improved alignment of the big toe. Your outcome will depend on how severe your bunion deformity was before surgery, your medical condition, your age, and your compliance with postoperative instructions. In general, there may be some degree of swelling of the foot for three to six months following surgery.

Your podiatrist will follow you closely during this postoperative period and recommend exercises or physical therapy to improve foot strength and range of motion. Depending on the extent of your condition, you can expect a recovery period of at least six to eight weeks, or longer. During that time you may be required to wear a special shoe or boot, or even a cast to provide stability to the foot. Your doctor will tell you when you can walk on your foot again.

Risks of bunion surgery and potential complications
Even the most minor surgical procedure has a degree of risk. Your podiatrist will go over the most common problems that have occurred after bunion surgery. These include infection, recurrence of pain, nerve damage (which could be chronic), recurrence of the bunion, poor healing, bleeding, scarring, blood clots, or allergic reaction. Most complications are treatable, but may increase your recovery time. Although it is rare, you could experience stroke, heart attack, loss of a limb, or death.

Your podiatrist will go over all these possibilities with you so you have a full picture of what to expect. After he or she has described these potential risks to you, you will be asked to sign a form called an informed consent form. Be sure to ask questions if you are uncertain about what you are being told, and make sure your questions are answered to your satisfaction. Your signature on this form indicates that your questions have been answered and you have been informed of the risks and potential complications of bunion surgery.

Types of bunion surgery
Your podiatrist will determine which type of surgical procedure is right for you. There are many different types of surgical procedures for treating bunions, many of which are named after the doctors who developed them. Examples of these are Keller bunionectomy, McBride technique, and Austin osteotomy. Ask your doctor to explain the type of procedure he or she feels is best for you.

Many bunion surgical procedures are done as outpatients. You will be asked to arrive at the outpatient facility one to two hours before the surgery, and can usually go home an hour or two after the surgery. The procedure itself will take about one hour.

The type of anesthesia used will depend on the type of surgery done, your condition, and the anticipated length of the surgery. Most bunionectomies are done with a local anesthetic agent to numb the area. In some cases you may have general anesthesia. After surgery you will go to the recovery room. You will have one or more scars after the surgery, depending on the type of surgery performed.

Postoperative recovery
It is important that you follow your podiatrist’s instructions completely following the surgery. You will be following up with visits to your podiatrist regularly for several months after your surgery.

You should call the office immediately if you notice any of the following:

    • Fever of 101oF or higher and/or chills;
    • Persistent, uncomfortable warmth or redness around the dressing;
    • Persistent or unbearable pain;
    • Bloody drainage;
    • Nausea and/or vomiting;
    • Pain, redness, or swelling in one or both legs;
    • Feeling anxious;
    • Chest pain, shortness of breath, or coughing.

You will be sent home after surgery with a dressing to hold your toe in the realigned position. You may or may not receive a special surgical shoe to wear for some time. You should notify your podiatrist if your dressing comes off or gets wet, or if you notice blood or other drainage on it. It is very important to leave the dressings in place and not get them wet or dirty. If you have difficulty with your dressings, call your podiatrist.

Postoperative office visits
Ordinarily you will see your podiatrist three or four days after surgery for a dressing change, and postoperative X-rays may be taken at that time. About two weeks after surgery your podiatrist will remove the stitches. Once the stitches are removed, you may be able to bathe normally. Be sure to ask your doctor for instructions.

Your doctor will let you know when you can start to wear shoes, and the best type for you. You should continue to faithfully do the exercises your podiatrist has given you. Apply skin emollients, such as aloe vera or vitamin E, around the healing wound as directed. Your doctor will instruct you on when you can walk, drive, and resume other activities.

The postoperative course varies for individuals. For some patients, swelling may last longer and healing may take more time than anticipated. You should try to keep your foot elevated as much as possible immediately after the surgery. Your doctor may instruct you to apply ice to your foot. If so, ask him or her to provide you with specific instructions on how to do this. You could experience some swelling in your foot for several months following the surgery. Contact your doctor if you have questions about your swelling.

Exercise
Be sure to engage in the exercises your podiatrist recommends. These exercises will help restore your range of motion and your foot strength. Do not engage in any strenuous or weight bearing exercises that are not recommended by your podiatrist.