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Hallux valgus Content Supplied by NHS Choices
Introduction

A bunion is a bony deformity of the joint at the base of the big toe. The medical name is hallux valgus.

The main sign of a bunion is the big toe pointing towards the other toes on the same foot, which may force the foot bone attached to it (the first metatarsal) to stick outwards.

Other symptoms may include:

  • a swollen, bony bump on the outside edge of your foot
  • pain and swelling over your big toe joint that's made worse by pressure from wearing shoes
  • hard, callused and red skin caused by your big toe and second toe overlapping
  • sore skin over the top of the bunion
  • changes to the shape of your foot, making it difficult to find shoes that fit

These symptoms can sometimes get worse if the bunion is left untreated, so it's best to see a GP. They'll ask you about your symptoms and examine your foot. In some cases, an X-ray may be recommended to assess the severity of your bunion.

Anyone can develop a bunion, but they're more common in women than men. This may be because of the style of footwear that women wear.

What causes bunions

The exact cause of bunions is unknown, but they tend to run in families. Wearing badly fitting shoes is thought to make bunions worse.

It's also thought that bunions are more likely to occur in people with unusually flexible joints, which is why bunions sometimes occur in children.

In some cases, certain health conditions, such as rheumatoid arthritis and gout, may also be responsible.

Read more about the causes of bunions.

Treating bunions

There are a number of treatment options for bunions. Non-surgical treatments are usually tried first, including painkillers, orthotics (insoles) and bunion pads.

However, these can only help to reduce the symptoms of bunions, such as pain. They don't improve the appearance of your foot.

Surgery may be considered if your symptoms are severe and don't respond to non-surgical treatments. The type of surgery will depend on the level of deformity, the severity of your symptoms, your age, and any other associated medical conditions.

Read more about treating bunions.

Complications

If bunions aren't treated, they can lead to further problems. For example, they can cause arthritis in your big toe and push your second toe out of place.

Problems can also develop after bunion surgery. While surgery is usually effective (symptoms are improved in 85% of cases), bunions can sometimes return.

In less than 10% of cases, complications occur after bunion surgery. These will depend on the type of surgery you have and can include:

  • stiffness in your toe joints
  • a delay or failure of the bone to heal, or the bone healing in the wrong position
  • pain under the ball of your foot
  • damage to the nerves in your foot
  • prolonged swelling and continued pain
  • the need for further surgery

Read more about the complications of bunions.

Preventing bunions

The best way to reduce your chances of developing bunions is to wear shoes that fit properly. Shoes that are too tight or have high heels can force your toes together. Bunions are rare in populations that don't wear shoes.

Make sure your shoes are the correct size and that there's enough room to move your toes freely. It's best to avoid wearing shoes with high heels or pointy toes.



Causes of bunions

A bunion is the result of a deformity in the joint of your big toe. The exact cause isn't clear.

However, possible causes may include:

These are discussed below.

Genetics

If other members of your family have bunions, your risk of developing them is increased. However, this doesn't mean you'll definitely develop bunions.

Arthritis

The types of arthritis thought to cause bunions are:

  • rheumatoid arthritis - inflammation and pain in the joints because of the immune system attacking the joint lining
  • gout - a type of arthritis that commonly affects the big toe
  • psoriatic arthritis - a type of arthritis associated with the skin condition psoriasis

Arthritis in the toe may also develop as a result of a bunion.

Read more about the complications of bunions.

Other conditions

A number of other conditions are also thought to increase your chances of developing bunions.

For example, conditions associated with loose ligaments, flexible joints and low muscle tone could increase the likelihood of bunions developing.

These include neuromuscular conditions, such as cerebral palsy, and connective tissue disorders, such as Marfan syndrome.

Poorly fitting shoes

Poorly fitting shoes can contribute to the development of bunions. Bunions are rare in populations that don't wear shoes.

Wearing shoes that are too tight and don't fit properly is likely to make an existing bunion worse.

Shoes that are too tight may rub against your big toe joint. High-heeled shoes that are too tight will squeeze your feet, causing your big toe to remain in a bent position. This can stretch the toe, put pressure on the nerves around it and lead to pain.

High heels also push most of your body weight forwards onto the front of your foot, which places considerable strain on your toe joints.



Treating bunions

A bunion may only need to be treated if it's severe and causing significant pain and discomfort.

The various treatments for bunions are outlined below. You can also read a summary of the pros and cons of the treatments for bunions, allowing you to compare your treatment options.

Non-surgical treatment

If possible, non-surgical treatment for bunions will be used, which your GP can discuss with you.

Non-surgical treatments can ease the pain and discomfort caused by a bunion, but they can't change the shape of your foot or prevent a bunion from getting worse over time.

Non-surgical treatments include:

  • painkillers
  • bunion pads
  • orthotics
  • wearing suitable footwear

These are discussed in more detail below.

Painkillers

If your bunion is painful, over-the-counter painkillers such as paracetamol or ibuprofen may be recommended.

When using painkillers, always read the patient information leaflet that comes with the medicine and follow the recommended dose.

Bunion pads

Bunion pads may also ease the pain of a bunion. Reusable bunion pads, made of either gel or fleece, are available over the counter from pharmacies.

Some are adhesive and stick over the bunion, while others are held against your foot by a small loop that fits over your big toe.

Bunion pads stop your foot rubbing on your shoe and relieve the pressure over the enlarged joint at the base of your big toe.

Orthotics

Orthotics are placed inside your shoes to help realign the bones of your foot. They may help relieve the pressure on your bunion, which can ease the pain. However, there's little evidence that orthotics are effective in the long term.

It's important that the orthotic fits properly, so you may want to seek advice from your GP or podiatrist (a specialist in diagnosing and treating foot conditions), who can suggest the best ones for you.

You can buy orthotics over the counter from pharmacies, or they can be custom-made by a podiatrist to fit your feet. Whether you need to buy an over-the-counter orthotic or have one specially made will depend on your individual circumstances and the severity of your bunion.

You can also use special bunion splints, worn over the top of your foot and your big toe to help straighten its alignment. Splints are available for both daytime and night-time use. However, there's little evidence that splints are effective.

Toe spacers are also available, which can help reduce the pain caused by bunions. However, toe spacers or orthotics may be of limited use because they often compete with the bunion for the already limited space in the shoe.

Ice packs

If your toe joint is painful and swollen, applying an ice pack to the affected area several times a day can help to relieve the pain and inflammation.

Never apply ice directly to your skin. Wrap it in a cloth or tea towel. A bag of frozen vegetables makes a good ice pack.

Suitable footwear

It's recommended that you wear flat or low-heeled, wide-fitting shoes if you have a bunion. Shoes made from soft leather are ideal because they'll relieve any pressure on the bunion.

Avoid narrow or slip-on shoes. High heels can also make your bunion worse by putting excessive pressure on your toes.

Surgery

Surgery is the only way to correct a bunion. A bunion will usually get worse over time, so if it's left untreated it's likely to get bigger and become more painful.

If your bunion is causing a significant amount of pain and affecting your quality of life, your GP may refer you to be assessed for bunion surgery.

The aim of surgery is to relieve pain and improve the alignment of your big toe. Surgery isn't usually carried out for cosmetic reasons alone. Even after surgery, there may still be limits to the styles of shoe you can wear.

Bunion surgery is often carried out as a day procedure, which means you won't have to stay in hospital overnight. The procedure will either be carried out under a local anaesthetic or a general anaesthetic.

Deciding to have surgery

When deciding whether to have bunion surgery, there are several things to consider including:

  • your age - in children, bunion surgery is often delayed because of the risk of the bunion returning
  • your medical history and general health - problems with wound healing and infections are more likely in certain conditions such as diabetes; you're also more likely to develop problems if your bunion is caused by a condition such as rheumatoid arthritis
  • your occupation and lifestyle - bunion surgery can make your toes less flexible, and you may be unable to return to the same level of physical activity
  • your expectations of surgery - bunion surgery has about an 85% success rate, but there's no guarantee that your foot will be perfectly straight or pain-free; the success of surgery depends on the type of procedure, the experience of the surgeon and your ability to rest after the operation
  • the severity of your symptoms - surgery will usually only be recommended if your bunions are causing considerable pain and non-surgical treatments have been unsuccessful

Types of surgery

There are a number of different surgical procedures used to treat bunions. The type of surgery recommended for you will depend on the severity of the deformity.

Your surgeon may use pins, wires or screws to hold the bones in place while they heal. Depending on the type of surgery you have, these may be left in your foot or removed later on.

Some of the surgical procedures for bunions are described below.

Osteotomy

Osteotomy is the most commonly used and proven type of bunion surgery. Although there are many different types of osteotomy, they generally involve cutting and removing part of the bone in your toe.

During the procedure, your surgeon will remove the bony lump and realign the bones inside your big toe. They'll also move your toe joint back in line, which may involve removing other pieces of bone, possibly from the neighbouring toes.

A procedure called distal soft tissue realignment may be combined with an osteotomy. This involves altering the tissue in your foot to help correct the deformity and improve the stability and appearance of the foot.

Arthrodesis

Arthrodesis involves fusing together two bones in your big toe joint (metatarsophalangeal joint).

The procedure is usually only recommended for people with severe deformities of the big toe joint, which make it too difficult for doctors to completely fix the joint, or when there's advanced degeneration of the joint.

After arthrodesis, the movement of your big toe will be severely limited and you won't be able to wear high heels.

Excision (Keller's) arthroplasty

An excision arthroplasty involves removing the bunion and the toe joint. A false joint is created by scar tissue that forms as a result of the operation.

The procedure involves pinning the joint in place with wires, which will be removed around three weeks after surgery is carried out.

An excision arthroplasty can only be used in certain circumstances, and is usually reserved for severe, troublesome bunions in elderly people.

Minimally invasive bunion surgery

In 2010, the National Institute for Health and Care Excellence (NICE) published guidance about a minimally invasive surgical procedure to treat bunions. The aim of the procedure is to repair the tilting of the big toe.

The technique can be carried out under a local anaesthetic or a general anaesthetic, using X-rays or an endoscope for guidance. The type of endoscope used will be a long, thin, rigid tube with a light source and video camera at one end

One or more incisions will be made near the big toe so that bone-cutting instruments can be inserted. These will be used to remove the bunion and to divide one or more bones located at the front of the foot.

Wires, screws or plates will be used to keep the divided bones in place. After the procedure, you may need to wear a plaster cast or dressing to keep your foot in the correct position until the bones have healed. You may be given a special surgical shoe that enables you to walk on your heel.

As the procedure is relatively new, there's little in the way of reliable evidence regarding its safety or effectiveness.

See the NICE guidance about the surgical correction of hallux valgus using minimal access techniques (PDF, 93kb).

After surgery

After bunion surgery, your foot and ankle may be swollen for three months or longer. While you're recovering, you'll need to keep your foot raised to reduce swelling, and you'll need crutches to move around.

It's likely that you'll be unable to wear normal shoes for at least six months after surgery. You may have a cast or bandage and postoperative shoes (shoes specially designed to allow heel walking and protect the bony cuts) before you can start wearing regular footwear. This will keep the bones and soft tissues in place while they heal.



Complications of bunions

Bunion surgery can sometimes cause further problems, as can leaving bunions untreated.

Untreated bunions

Many bunions will never cause problems, but some may get worse if left untreated, so it's worth seeing your GP if you have one.

Untreated bunions can lead to further problems, such as arthritis in the joint of the big toe. The big toe can also cause deformity of the second toe, by pushing it out of place.

Surgical complications

In less than 10% of cases, complications occur after bunion surgery. These will depend on the type of surgery you have and can include:

  • infection
  • deep vein thrombosis (DVT)
  • stiffness in your toe joints
  • a delay or failure of the bone to heal, or the bone healing in the wrong position
  • pain under the ball of your foot
  • damage to the nerves in your foot
  • prolonged swelling and continued pain
  • the need for further surgery
  • thickened scar tissue
  • the bunion returning
  • complex regional pain syndrome - a condition that causes long-term burning pain in one of the limbs

Speak to your GP or surgeon if you have any concerns after surgery, or if you experience any of these complications. They can advise you on how to deal with these complications, including further treatment options.



'I realised I had to do something about my feet'

Jo Burland, a teacher from Finchley, north London, was 15 when she first noticed some bumps had appeared on her feet. At the age of 34, she had an osteotomy.

"I put up with the lumps for years, but as they grew bigger and bigger, they began to hurt quite a bit. It was frustrating not being able to wear all the lovely shoes I'd see in the shops. I would try them on, but my bunions just poked through, so I could never buy them.

"Eventually, I realised I had to do something about my feet. They were so sore all the time. I went to my GP, who referred me to Charing Cross Hospital, where I saw a consultant podiatrist. He examined both my feet very carefully. After talking me through his diagnosis, he suggested an operation called an osteotomy (a realignment of the joint). He recommended having one foot done at a time, so I'd be able to hobble around on my one "good" foot.

"After some thought, I decided that I didn't want to go through the same procedure twice and that I'd have both feet done together. The operation could be done as day surgery, and luckily the waiting list wasn't too long.

"The operation really wasn't that bad. I went in at midday and was ready to go home around 4pm the same day. I had a local anaesthetic and the operation took around half an hour on each foot. There was a nurse with me all the time, and I listened to my iPod to distract me.

"I was in a wheelchair for the first week after the operation. My feet were bandaged and swollen. I had to be careful not to put any weight on them for a few weeks, but after about three weeks I was able to wear trainers and get around on crutches. After six weeks, I was back to normal.

"Having my bunions removed really is one of the best things I've ever done. My feet healed really well and the scars are tiny. Overall, my feet look fantastic."

 
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