All About Bunions (Hallux valgus)

Bunion Diagram

Hallux valgus (Bunions) are a very common foot ailment
Does your big toe move in towards your little toes or is the joint at the base of your big toe thrusting outward, creating a bump that can be painful? If so, most likely you have Hallux valgus, most affectionately referred to as a bunion.
Bunions are common among many cultures and within many countries. Because of the prevalence of this foot disorder, a lot of medical information and research is easily available. There are many ways to intervene in the early stages, preventing the progression of the mal- alignment, and if necessary, there are many forms of surgery to remove the bunion.
It might make you feel better to know you are not alone. In the US alone, an estimate of over ½ of women have some degree of Hallux valgus, and a lesser amount among men *20.

What is a bunion?

In orthopedics, “bunions” and Hallux valgus are terms used to describe one of the most common ailments of the foot. A bunion is a misalignment of the two bones that form the base joint of the big toe (also called the metatarsophalangeal joint). Due to the misalignment, the big toe begins to angle inward towards the other toes, thrusting the base joint out further in the opposite direction. Aside from being unsightly, bunions can develop into an extremely serious, painful condition over time, if neglected.

What are the symptoms?
It is misleading to think you do not have a bunion unless you incur pain. In general, it can take many years for a bunion to develop, and especially to the point of pain. Early signs of a bunion include:

  • Early movement of the big toe towards the smaller toes
  • Bump on the base joint of the big toe
  • Deep dull “in the joint” pain
  • Pain on top or side of the big toe from shoe pressure
Progressive symptoms include:
  • Continued malpositioning of the big toe and base joint
  • Increasing pain when walking, running or standing
  • Formation of calluses on the medial border of the big toe
  • Chronic irritation of the skin and base joint bursa (small, fluid-filled sac designed to cushion friction between bone, muscle, tendons, and skin around a joint)
  • Progressive arthrosis (degenerative disease of the joint) and/or arthritis and stiffening in the base joint of the toe
  • Podiatric deformities such as hammer and claw toe

Stages of bunion severity

There are varying degrees of Hallux valgus. Once you suspect you have a bunion, visit your primary physician or a podiatrist to confirm whether you have Hallux valgus and to obtain advice. In the meantime, you can refer to the following stages to help understand the severity of the condition:

1st Degree

2nd Degree

 1st Degree Bunion  2nd Degree Bunion

Toe malpositioning below 20 degrees. No symptoms. A brace or splint can be used in this phase for early prevention!

Malpositioning between 20 and 30 degrees. Occasional pain. In this phase, a brace or splint is used more frequently to correct the malpositioning.

3rd Degree

4th Degree

 3rd Degree Bunion  4th Degree Bunion

Malpositioning between 30 and 50 degrees. Regular pain. Increasing restraints on activities. Pronounced malpositioning! A consultation with a medical care professional is recommended prior to using a brace or splint.

The most severe form of bunions, with malpositioning over 50 degrees and painful restraints on everyday activities. If your physician has recommended surgery, a brace or splint might be recommended to assist in post-surgical rehabilitation.

The causes of bunions

womens feet with high heels

Hallux valgus is most common among women ages 40 and over. Although it is less frequent for men to experience bunions, when they do suffer from this foot disorder, the mal-positioning of the big toe can be extreme and quite debilitating.
With the increased emphasis on playing and excelling in sports at earlier ages where constricted shoes are required, such as soccer, football, and ballet, and with the peer pressure to wear high-heeled constrictive fashionable shoes in the early teens, the onset of bunions is beginning to appear in people younger than forty.
Bunions are initially caused by genetic bone structure and often get worse by wearing tight, pointy-toed and high-heeled shoes as well as “load deformities” such as flatfoot and splayfoot. These deformities as well as excessive pronation where the foot rolls inward can place too much pressure on the big toe joint (metatarsophalangeal joint) causing the big toe to bend towards the smaller toes.Women are affected about nine times.

The consequences of bunions

The small joints of your feet support your body’s full weight as you walk, run and climb stairs throughout the day. The base joint of your big toe bears most of that stress. When your feet are properly aligned, the biomechanical system works beautifully; but with bunions, the mechanics change, shifting stress to the other joints in the foot. The base joint also begins to lose its range of motion. Combined, these factors can cause the base joint to become swollen and painfully inflamed, and can eventually lead to progressive arthrosis and/or arthritis.
Once a bunion develops to the point of restricting daily activities and exercise, weight gain and other related conditions may result.
Coincidentally, an additional five pounds of pressure is transferred to your joints for every one pound of weight you gain, further compounding the problem.
In the older population, ages 75 – 93, findings indicate that bunions have a significant detrimental impact on gait patterns that can in turn contribute to instability and risk of falling *23.  
Another unfortunate consequence of having a bunion is the cost of bunion surgery and the associated downtime which together can exceed $5000.
For these reasons early intervention to prevent the progression of the misalignment is highly recommended.

Early bunion prevention

If you have mild to moderate degrees of Hallux valgus (Stage 1 or 2), you can take steps to stop the progression, and in some instances, even correct the alignment and reduce the pain. But you must do the following:
1. Change shoes! Avoid flip flops, high-heeled shoes, and pointed, narrow toe box shoes.
2. Exercise your feet.
3. Medicine will not prevent or cure bunions. However, the use of non-steroidal anti-inflammatory drugs such as aspirin and ibuprofen, or acetaminophen, such as Tylenol may relieve the pain.
4. Use of bunion pads, metatarsal pads, and arch supports can help redistribute weight and move pressure away from the big toe.
5. Wear splints or braces. There are many types of orthotics that help correct the mal-positioning and reduce pain: toe gels, soft splints, rigid splints, and flexible splints.

More about splints and braces

Bunion Aid Treatment Splint

In general there are soft splints which help protect the bunion and there are rigid splints that support and pull the big toe away from the other toes.  More recently, an innovative patented technology has been introduced to the U.S. market. This award-winning hinged splint combines the comfort of a soft splint with the corrective support of a rigid splint to provide mobility and correction through the range of motion. The Bunion Aid Treatment Splint is recognized as the only chiropractor recommended splint for effective bunion treatment.  Because the Hallux valgus angle (HVA) is the main derivative of Hallux valgus, the HVA, therefore, is the most common measurement of correction. With daily compliance, the flexible hinged splint from Alpha Orthotics has been clinically proven to correct the malpositioning of the big toe in mild-to-moderate cases of Hallux valgus.

Surgical solution

If you have severe Hallux valgus, and your doctor recommends surgery, educate yourself on the various types of surgery and post-operative care.
With over 100 types of surgical techniques, many resources are available that provide clinical studies and information. The technique prescribed depends on the specific bunion condition and severity of the deformity. Trevor Prior, Consultant Podiatric Surgeon, Homerton University Hospital, provides an overview of the various types of surgeries *24:

  • Silvers procedure – this is the simplest procedure that involves removing the prominent bump on the inside of the foot. But because it doesn’t cure the underlying deformity, it will only be used in people with mild deformities or in older people. This is a short procedure and recovery is quick.
  • Austin (Chevron)/Reverdin - green osteotomies – these involve cutting the bone toward the end of the first metatarsal (the long bone leading up to the big toe), before fixing it back into a straighter position. You’ll need to rest the foot for two to four days. You’ll be able to do limited walking and on average, be able to get back into shoe 2-6 weeks after the operation. You’ll walk normally around three months after the operation.
  • Scarf osteotomy – This is similar to the above technique but because more bone is cut, it allows for slightly more correction. Recovery is the same as for the above procedure.
  • Base wedge osteotomy – This is for more serious deformities. A small wedge of bone can be removed from the base of the metatarsal. Recovery is longer. You’ll need to wear a non-weight bearing cast for 4-6 weeks (ie you can’t walk on it) and possibly a weight-bearing cast for 2-4 weeks.
  • Lapidus – This is very good for people that have a mobile metatarsal. By removing the bone in a wedge shape from either side of the joint at the base of the metatarsal, this allows the surgeon to correct the position of the metatarsal while fusing the joint, making it more stable. Recovery is similar to that of the base wedge.
  • Akin osteotomy - In many deformities, you need to straighten the big toe as well as the position of the first metatarsal. A small wedge of bone can be removed from the base of the big toe. This is usually done in conjunction with one of the above procedures and doesn’t lengthen the recovery period.
  • Keller arthoplasty – this involves removing the bone at the base of the big toe and essentially removing half of the big toe joint. However, this can leave the big toe a little bit unstable and is mainly used for older people with arthritis. Recovery is slightly quicker to that of the Austin procedure.

Post-op rehab is important

Once the surgery is performed, it is easy to conclude the bunion is gone forever. However, there are cases where the malpositioning of the big toe returns. Therefore it is important to follow the preventive measures on an ongoing basis:
1. Wear wide-fitting toe box shoes
2. Avoid constrictive, high-heeled shoes
3. Exercise your feet
4. Wear a corrective flexible bunion splint, as needed.
5. Get back to an active daily life.

Fred Lewis SF Giants

Even sports professionals, such as Fred Lewis of the San Francisco Giants, can be inflicted by bunions.
“Fred Lewis of the SF Giants was bothered by bunions for most of last year.  It’s impossible to know how many bases Fred Lewis would’ve stole if not for the bunions, but I’m gonna guess more than the 21 he did steal.  He also missed quite a few games with this chronic foot-to-path disease.  It’s hard to say how many home runs he would’ve hit if he didn’t miss all of those games, but, like a foot, I’m gonna go out say more than the 9 he did hit. *21

confused woman with bunions

Women are affected about nine times more often than men, suggesting the propensity of wearing stylish, constrictive shoes lead to the development of bunions *22.

Once a bunion develops to the point of restricting daily activities and exercise, weight gain and other related conditions may result.

“A review of surgeries indicates that up to 33% of people who have surgery for bunions are disappointed in the result, despite pain being reduced and the toe being straighter.” *25.