Introduction
What's Bunion or Hallux valgus?
Bunion is a type of skeletal deformity, referring to the outward deviation of the joint where the big toe connects to the foot. Bunions are a complex anatomical deformity and present significant challenges in treatment. This condition is the most common pathology involving the big toe.
Suggested department for consultation: Orthopedics
- It is recommended to seek medical attention promptly; surgery may be considered for severe symptoms.
- Avoid standing for long periods and excessive walking.
- Choose shoes that are wider at the front and without high heels.
Symptoms
What are the symptoms of Bunions?
- The symptoms of bunions include:
Thickening of the skin at the protruding part of the first metatarsophalangeal joint, sometimes accompanied by redness and swelling, leading to bursitis of the big toe (the soft tissues around the bone spur become inflamed and fluid accumulates due to long-term friction and pressure from shoes). - Deformity with the big toe deviating outwards, causing local pain, affecting walking, and potentially leading to local ulceration and infection.
- Rotational deformity of the big toe deviating outwards, which affects the second and third toes, leading to hammer toe formation and a widening of the forefoot.
– Skin thickening at the second and third metatarsal bones due to increased weight-bearing, forming calluses (hard and smooth keratin thickening due to long-term compression and friction, commonly known as corns).
Does Bunions have a significant impact?
- Bunions directly affects normal walking and the aesthetic appearance of the foot.Patients may also experience bursitis of the big toe, pain, calluses (commonly known as foot corns), corns, claw toes, and other toe deformities, which can significantly impact daily life.
What are the complications of Bunions?
- Bursitis: The first metatarsal bone turns inward, and the head of the first metatarsal bone protrudes inward. The protruding part is often rubbed by the shoe upper, which can further develop into bursitis. The skin develops ulcers and infections, causing severe pain.
- Corns: The big toe protrudes outward, which can squeeze the second toe, causing the second toe to lift and be located above the big toe. The interphalangeal joint bends and forms a hammer toe. The skin on the dorsal side of the second toe can form corns due to long-term friction from the shoe upper.
- Partial dislocation of the first metatarsophalangeal joint: The big toe protrudes outward, and the second toe is forced to lift. As the disease continues to worsen, it can cause a phenomenon of partial dislocation of the first metatarsophalangeal joint, causing significant pain.
- Osteoarthritis of the first metatarsophalangeal joint: In patients with hallux valgus, the first metatarsal bone shifts inward, causing the head of the first metatarsal bone to form a bone spur on the inside of the foot and develop osteoarthritis. The patient’s pain worsens, the activity is limited, and it can greatly affect walking.
Etiology
What causes Bunion to form?
There are many reasons for bunions, mainly congenital inheritance and improper force applied later in life.
Genetics is an important factor in the development of bunions, especially in adolescent patients.
Many studies show that patients with bunions often have a positive family history (i.e., more than one person in the family suffers from the condition).
The occurrence of bunions may be significantly related to wearing inappropriate shoes.Narrow, pointed-toe shoes may be the primary cause of bunions.
Bunions are also commonly seen in patients with systemic arthritis, such as those with rheumatoid arthritis, where repeated synovitis leads to the destruction of the metatarsophalangeal joint capsule, ultimately causing the deformity of the toe deviating outward. Additionally, flat feet can easily lead to bunions due to improper force distribution on the foot.
Who is prone to developing Bunion?
- People with family members who have bunions.
- Women are more likely to develop bunions than men.
- Individuals with a family history of bunions who also wear ill-fitting shoes for prolonged periods are most susceptible to developing bunions.
- Patients with flat feet.
Why are most Bunion sufferers women?
Among bunion patients, over 80% are women, with only about 20% being men, for the following reasons:
- Women often wear pointed high heels, which can put abnormal pressure on the toes;
- Over 50% of bunion sufferers have a genetic predisposition, which is predominantly matrilineal (i.e., the likelihood of inheriting bunions is higher in girls than in boys).
Diagnosis
How to diagnose Bunion?
The symptoms include localized pain and swelling, affecting shoe-wearing and walking. X-ray shows subluxation of metatarsophalangeal joint, medial hyperplasia of the first metatarsal head (commonly known as “bone spur”), and internal rotation of the first metatarsal head.
How to determine the severity level of the Bunion deformity?
- Mild: No symptoms, the deformity does not worsen over a long period, and there is no obvious abnormality visible when wearing socks. It is not recommended for these patients to undergo surgery.
- Moderate: There is pain in the big toe and the foot (around the big toe or between the big toe and the second toe). The pain can be relieved by resting or changing shoes. The deformation can be mild or severe, but the X-ray shows good joint alignment, no dislocation, and the big toe has not rotated.
- Severe: The deformation is severe, the joint is dislocated, or the big toe has rotated. In this stage, the front foot is generally noticeably widened, affecting shoe-wearing.
- Complex deformity: It also affects the second and little toes, causing pain, or there is severe flatfoot, and there is a large area of calluses on the sole of the foot. Surgery is more challenging.
Treatment
How to treat Bunion?
Conservative treatment
Conservative treatment can be carried out for patients who only have deformities without symptoms or with mild symptoms:
Wear looser shoes, not pointy heels：This can reduce friction on the medial protrusion and delay the progression of hallux valgus and other toe deformities by reducing the compression on the forefoot.
Placing a soft pad in the shoe can relieve pressure on painful areas of the foot;
Using a bunion pad, night splint, and toe spacer may temporarily relieve pain and slow the progression of the deformity;
A bursitis can be treated with hot compresses or physical therapy at a regular hospital;
Walking barefoot at home can help strengthen foot muscles.
Surgical Treatment
If conservative treatment does not alleviate the symptoms of bunions, it is recommended to undergo surgery (including traditional and minimally invasive surgery) to correct the bunions. There are many surgical methods, but no single method is suitable for all bunion patients. The appropriate surgical method should be chosen according to the specific circumstances of the patient.
What conservative treatment does Bunion have?
For patients with early-stage hallux valgus who experience mild pain, non-surgical conservative treatments can be considered.
Nonspecific Treatments: Reducing physical activity and wearing loose-fitting shoes can alleviate pain. Topical medications such as Voltaren (diclofenac gel) or oral pain relievers like Celebrex (celecoxib) may be used to manage pain. Heat therapy and physical therapy can also be effective. In some cases, localized injection therapy at the pain site or using bandages to immobilize the forefoot and correct the inward deviation of the big toe may be beneficial. However, most conservative treatments address symptoms rather than the underlying cause, and pain often recurs after a period of time.
Use of Orthotic Devices: Various orthotic devices are available to correct hallux valgus, with different types required for different severities and types of deformities. Typically, wearing orthotic devices at night for eight hours daily over three months can help reduce pain symptoms and slow the progression of the deformity to some extent.
Bunion pain when what method to deal with?
Oral Medications: Nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin and ibuprofen can be taken for pain relief. However, these medications are contraindicated for pregnant and breastfeeding women.
Massage and Manipulation: Regularly massaging the big toe or moving it towards the inner side of the foot can promote local blood circulation and alleviate pain.
Padding and Splinting: Placing a cotton pad between the big toe and the second toe, or using a splint on the inner side of the big toe during sleep, can help correct the deformity and reduce pain.
Shoe Modifications: When wearing shoes, place a layer of gauze over the protruding metatarsal head, the big toe, and the dorsal side of the second toe to reduce friction from the shoe upper against these areas.
Barefoot Rest: Minimize the time spent wearing shoes and rest barefoot as much as possible.
Surgical Intervention: For patients with severe bursitis, significant pain, and deformity, early surgical treatment is recommended. The surgery aims to remove the overgrown bone and bursa, thus providing a definitive solution for pain relief.
When should you consider surgery for Bunion ?
The need for surgery depends on the condition. It is recommended to have surgery as soon as possible if any of the following applies:
- The deformity is significant, and wearing shoes is restricted.
- Pain that cannot be well relieved after adjusting shoes.
- X-ray shows poor metatarsophalangeal joint alignment, or joint dislocation.
- The deviation of the big toe affects the second toe, or there is pain in the little toe.
- Some patients have other needs: such as needing to wear high heels or needing to adjust their appearance.
What are the common methods for bunion corrective surgery?
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Soft tissue surgery: This method changes the stress points of local muscles, primarily by severing the adductor hallucis at its endpoint on the proximal phalanx and relocating it to the fibular side of the first metatarsal head, with the McBride procedure being representative.
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Osteotomy: This involves removing a portion of bone to relax contracted soft tissues and relieve symptoms. Common surgeries include the Mayo and Keller procedures.
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First metatarsophalangeal joint fusion: This method involves fusing the joint to correct the deformity locally and eliminate pain.
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Corrective osteotomy of the first metatarsal: This may be performed alone or in combination with soft tissue surgery or bone removal surgery.
Can Bunion surgery have any side effects?
Bunion surgery is relatively mature and its treatment effects are well-recognized. However, it also carries many potential risks.
Firstly, the surgical incision is usually quite large and the surgery can cause significant damage to the surrounding soft tissues, ligaments, blood vessels, and nerves. This often results in postoperative foot mobility issues and poor blood flow, leading to pain.
Secondly, the use of internal fixation or plaster cast external fixation post-surgery for a prolonged period can slow down recovery, with a high likelihood of causing restricted local function and movement around the ankle.
Is it better to have Bunion surgery as early as possible?
Patients should have surgery as soon as possible when there are symptoms of pain or when the deformity is getting worse.
If the deformity does not worsen over a long period and there are no uncomfortable symptoms, temporary conservative observation can be adopted.
However, if the deformity gradually worsens and involves the 2nd to 5th toes, other toe surgeries are required, and the surgical effect may be poorer. Therefore, surgery should be carried out as soon as possible when the deformity shows a trend of worsening.
What is internal fixation used in Bunion surgery?
Internal fixation refers to the tools used to stabilize bones after they are realigned during surgery. Generally, metallic internal fixators such as steel plates, tension band wires, tension screws, and percutaneous Kirschner wires are used.
In clinical practice, the types of internal fixation commonly used in bunion surgery include Kirschner wires, domestic nail plates, and imported nail plates.
Why is internal fixation necessary in Bunion surgery?
The most common method in bunion corrective surgery involves osteotomy, which changes the load-bearing points of the foot.
This type of osteotomy is essentially creating a controlled fracture to correct the deformity. Patients with fractures generally need steel plates to stabilize the fractured ends to prevent poor healing or the recurrence of deformity due to improper loading.
Does the internal fixation need to be removed after bunion surgery?
The foot has little soft tissue, so if the internal fixation is small and there is no discomfort, it can be left in place. However, it is normal for the fixation to break over time. If the fixation is large and causes discomfort, it may need to be removed.
What should be noted after Bunion surgery?
- Do not engage in early weight-bearing activities and do not remove the bandage arbitrarily, to prevent altering the corrected foot stress positions achieved during the surgery.
- Enhance nutrition, as adequate nutrition can accelerate the healing of bone fractures and shorten the time it takes for the correction of deformities.
- Regular follow-up examinations are necessary. Monitoring through X-ray examinations and outpatient physical examinations can help observe whether the surgical area is recovering well.
- Under the guidance of a doctor, strengthen exercises. Active movement in the later stages post-surgery can accelerate the functional recovery of the metatarsophalangeal and ankle joints, reducing the occurrence of complications such as joint stiffness.
What are the stages of recovery after Bunion surgery?
- Bone Healing: During the healing period of the osteotomy, it is important to minimize movement to prevent displacement of the bone ends. This typically lasts up to 6 weeks post-surgery.
- Range of Motion Recovery: Generally, at 4 weeks post-surgery, the toe should be gently lifted to 30° with the help of the hand, by 6 weeks it should reach 45°, and at 3 months it should be able to be lifted to 60°, with at least 30° of active dorsiflexion.
- Functional Recovery: This includes the recovery of the toe’s gripping strength, the disappearance of numbness in the skin and lateral pain in the little toes, and the reduction of swelling in the forefoot (these conditions generally begin to improve in the third month after surgery). Therefore, minor skin numbness and foot swelling within the first 3 months post-surgery are often normal.
life
What should patients with Bunion pay attention to in their diet?
The diet of people with hallux valgus is the same as that of normal people; there is no need to avoid any specific foods.
How to Properly Wear Shoes and Care for Your Feet with Hallux Valgus？
Preventive Measures: The main measure to prevent hallux valgus is to avoid wearing pointed-toe high-heeled shoes. These shoes can cause compression, pressure, and friction on the forefoot, and the instability caused by high heels can lead to deformities and pain in the feet, which in turn can cause hallux valgus. It is also advisable not to wear high heels while driving to avoid excessive pressure on the feet. High heels shift the body’s center of gravity onto the forefoot, especially the metatarsophalangeal joint. When driving, the feet habitually rely on the heels to press the accelerator and brake, highlighting the metatarsophalangeal joint, which can easily trigger the onset of hallux valgus.
Choosing the Right Shoes: Opt for shoes with a wider front and no heels to reduce pressure on the feet and allow the toes to move freely within the shoe. If the work environment requires wearing high heels, choose shoes with heels no higher than 4 cm. Keep a pair of comfortable flat shoes in the office to alternate with high heels, reducing localized fatigue. At home, immediately remove high heels and walk barefoot to relieve leg and foot fatigue. Soak your feet in warm water to alleviate soft tissue spasms and massage your toes to promote blood circulation.
Special Considerations for Flat Feet: For those with flat feet, wear corrective shoes or insert flat foot insoles into regular shoes for correction.
Managing Mild Hallux Valgus: For patients with mild hallux valgus, place a cotton pad between the first and second toes, and at night, bind a straight splint on the inner side of the big toe to correct the deformity. Daily, manually move the big toe inward to control the progression of the condition.
Can patients with hallux valgus still participate in sports?
Yes, patients with hallux valgus can choose sports that put less stress on the toe area, such as swimming and sit-ups, to avoid exacerbating pain due to exercise.
When there is no significant pain, patients with hallux valgus can also participate in sports that put stress on the feet, provided they wear suitable shoes and do not experience increased pain in the toe area during or after the activity.
How can hallux valgus be treated through rehabilitation training?
Hallux valgus can be alleviated by specific joint mobilization training, foot muscle training, and lower limb balance and strength training to relieve pain and improve the motor function of the lower limbs in patients with hallux valgus.
- Joint mobilization training can alleviate pain in the joints of patients with hallux valgus and increase joint flexibility. Individuals with hallux valgus can perform joint mobilization by sliding the first metatarsophalangeal joint (the joint formed by the hallux and the first metatarsal bone) from inside to outside, as well as dynamic joint mobilization.
- Foot muscle training can strengthen the muscles of the foot sole, improve the shape of the arch, and prevent the aggravation of hallux valgus due to the collapse of the arch.
- Lower limb balance exercises (single-leg standing): Individuals with hallux valgus may have impaired balance function in the lower limbs due to changes in foot shape. Engaging in lower limb balance exercises can help improve their balance ability and reduce the risk of falling.
- Lower limb muscle strength training: Patients with hallux valgus may experience reduced lower limb activity due to pain, which can lead to muscle atrophy, weakened strength, decreased balance ability, and affect overall lower limb motor function. Patients with hallux valgus can avoid these issues by training the muscles of the lower limbs, including the thigh and calf muscles.
Prevention
How to Effectively Prevent Hallux Valgus?
Increase Outdoor Activities and Exercise: Engage in outdoor activities and exercise regularly. Maintain a balanced diet that includes milk, eggs, soy products, vegetables, and fruits. Supplement with calcium if necessary.
Weight Management: For individuals who are overweight, it is important to control diet and reduce weight to lessen the burden on the joints.
Avoid Prolonged Wearing of Pointed-Toe High Heels: Avoid wearing pointed-toe high heels for extended periods. In daily life, opt for shoes with a wider front, especially during exercise or long-distance walking.
Minimize Prolonged Standing and Excessive Walking: Avoid standing for long periods and excessive walking to prevent unnecessary stress on the feet and joints.