Bunion

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Bunion
Other namesHallux abducto valgus, hallux valgus [1]
Hallux Valgus-Aspect pre op decharge.JPG
Specialty Orthopedics, podiatry
Symptoms Prominent, red, and painful joint at the base of the big toe [2]
Complications Bursitis, arthritis [2]
Usual onsetGradual [2]
CausesUnclear [1]
Risk factors Wearing overly tight shoes, high-heeled shoes, family history, rheumatoid arthritis [2] [3]
Diagnostic method Based on symptoms, X-rays [2]
Differential diagnosis Osteoarthritis, Freiberg's disease, hallux rigidus, Morton's neuroma [4]
TreatmentProper shoes, orthotics, NSAIDs, surgery [2]
Frequency~23% of adults [1]

A bunion, also known as hallux valgus, is a deformity of the MTP joint connecting the big toe to the foot. [2] The big toe often bends towards the other toes and the joint becomes red and painful. [2] The onset of bunions is typically gradual. [2] Complications may include bursitis or arthritis. [2]

Contents

The exact cause is unclear. [1] Proposed factors include wearing overly tight shoes, high-heeled shoes, family history, and rheumatoid arthritis. [2] [3] Diagnosis is generally based on symptoms and supported by X-rays. [2] A similar condition of the little toe is referred to as a bunionette. [2]

X-rays showing effect of bunion splints on angle of Hallux valgus in patients.jpg

Treatment may include proper shoes, orthotics, or NSAIDs. [2] If this is not effective for improving symptoms, surgery may be performed. [2] It affects about 23% of adults. [1] Females are affected more often than males. [2] Usual age of onset is between 20 and 50 years old. [1] The condition also becomes more common with age. [1] It was first clearly described in 1870. [1] Archaeologists have identified a high incidence of bunions in skeletons from 14th- and 15th-century England, coinciding with a fashion for pointy shoes. [5] [6]

Signs and symptoms

Drawing of a bunion Bunion (cropped).png
Drawing of a bunion

Symptoms may include irritation of the skin around the bunion, and blisters may form more easily at the site. Pain may be worse when walking.

Bunions can lead to difficulties finding properly fitting footwear and may force a person to buy a larger size shoe to accommodate the width of the bunion. If the bunion deformity becomes severe enough, the foot can hurt in different places even without the constriction of shoes. It is then considered as being a mechanical function problem of the forefoot.

Cause

High heels are associated with developing bunions. VerbildeteFusseNormaleFusse.gif
High heels are associated with developing bunions.

The exact cause is unclear. [1] It may be due to a combination of internal and external causes. [7] Proposed factors include wearing overly tight shoes, high-heeled shoes, family history [2] [3] and rheumatoid arthritis. The American College of Foot and Ankle Surgeons states that footwear only worsens a problem caused by genetics. [8]

Excessive pronation of the foot causes increased pressure on the inside of the big toe that can result in a deformation of the medial capsular structures of the joint, subsequently increasing the risk of developing bunions. [7] [9]

Pathophysiology

The bump itself is partly due to the swollen bursal sac or an osseous (bony) anomaly on the metatarsophalangeal joint. The larger part of the bump is a normal part of the head of the first metatarsal bone that has tilted sideways to stick out at its distal (far) end (metatarsus primus varus).

Bunions are commonly associated with a deviated position of the big toe toward the second toe, and the deviation in the angle between the first and second metatarsal bones of the foot. The small sesamoid bones found beneath the first metatarsal (which help the flexor tendon bend the big toe downwards) may also become deviated over time as the first metatarsal bone drifts away from its normal position. Osteoarthritis of the first metatarsophalangeal joint, diminished or altered range of motion, and discomfort with pressure applied to the bump or with motion of the joint, may all accompany bunion development. Atop of the first metatarsal head either medially or dorso-medially, there can also arise a bursa that when inflamed (bursitis), can be the most painful aspect of the process.

Diagnosis

X-ray showing measurements of HV and IM angles of hallux valgus. HV and IM angles of hallux valgus.jpg
X-ray showing measurements of HV and IM angles of hallux valgus.

Bunions can be diagnosed and analyzed with a simple x-ray, which should be taken with the weight on the foot. [10] The hallux valgus angle (HVA) is the angle between the long axes of the proximal phalanx and the first metatarsal bone of the big toe. It is considered abnormal if greater than 15–18°. [11] The following HV angles can also be used to grade the severity of hallux valgus: [12] [ unreliable medical source? ]

The intermetatarsal angle (IMA) is the angle between the longitudinal axes of the first and second metatarsal bones, and is normally less than 9°. [11] The IM angle can also grade the severity of hallux valgus as: [12]

Treatment

Conservative treatment for bunions include changes in footwear, the use of orthotics (accommodative padding and shielding), rest, ice, and pain medications such as acetaminophen or nonsteroidal anti-inflammatory drugs. These treatments address symptoms but do not correct the actual deformity. [13] If the discomfort persists and is severe or when aesthetic correction of the deformity is desired, surgical correction by an orthopedic surgeon or a podiatric surgeon may be necessary.

Orthotics

Gel toe spacers come in a variety of sizes and shapes. Pointe shoe toe spacers.jpg
Gel toe spacers come in a variety of sizes and shapes.

Orthotics are splints or regulators while conservative measures include various footwear like toe spacers, valgus splints, and bunion shields. Toe spacers seem to be effective in reducing pain, but there is no evidence that any of these techniques reduces the physical deformity. There are a variety of available orthotics including off-the-shelf commercial products and custom-molded orthotics, which may be prescribed medical devices. [14]

Surgery

Procedures are designed and chosen to correct a variety of pathologies that may be associated with the bunion. For instance, procedures may address some combination of:

Before and after effects of bunionplasty Bunionplasty Plastic Closure.jpg
Before and after effects of bunionplasty

At present there are many different bunion surgeries for different effects. The age, health, lifestyle and activity level of the patient may also play a role in the choice of procedure.

Traditional bunion surgery can be performed under local, spinal or general anesthetic. A person who has undergone bunion surgery can expect a 6- to 8-week recovery period during which crutches are usually required to aid mobility. An orthopedic cast is much less common today as newer, more stable procedures and better forms of fixation (stabilizing the bone with screws and other hardware) are used. Hardware may even include absorbable pins that perform their function and are then broken down by the body over the course of months. After recovery long term stiffness or limited range of motion may occur in some patients. Visible or limited scarring may also occur for patients.

Bunionectomy Bunionectomy.png
Bunionectomy

Related Research Articles

<span class="mw-page-title-main">Foot</span> Anatomical structure found in vertebrates

The foot is an anatomical structure found in many vertebrates. It is the terminal portion of a limb which bears weight and allows locomotion. In many animals with feet, the foot is a separate organ at the terminal part of the leg made up of one or more segments or bones, generally including claws and/or nails.

<span class="mw-page-title-main">Toe</span> Digit of a foot

Toes are the digits of the foot of a tetrapod. Animal species such as cats that walk on their toes are described as being digitigrade. Humans, and other animals that walk on the soles of their feet, are described as being plantigrade; unguligrade animals are those that walk on hooves at the tips of their toes.

<span class="mw-page-title-main">Pes cavus</span> Medical condition

Pes cavus, also known as high arch, is an orthopedic condition that presents as a hollow arch underneath the foot with a pronounced high ridge at the top when weight bearing.

<span class="mw-page-title-main">Hammer toe</span> Rigidly clenched toe due to deformity of related muscles or ligaments

A hammer toe, hammertoe or contracted toe is a deformity of the muscles and ligaments of the proximal interphalangeal joint of the second, third, fourth, or fifth toe, bending it into a shape resembling a hammer. In the early stage, a flexible hammertoe is movable at the joints; a rigid hammertoe joint cannot be moved and usually requires surgery.

<span class="mw-page-title-main">Varus deformity</span> Deformity in which the bone near a joint is angled inward

A varus deformity is an excessive inward angulation of the distal segment of a bone or joint. The opposite of varus is called valgus.

<span class="mw-page-title-main">Valgus deformity</span> Deformity in which the bone near a joint is angled outward

A valgus deformity is a condition in which the bone segment distal to a joint is angled outward, that is, angled laterally, away from the body's midline. The opposite deformation, where the twist or angulation is directed medially, toward the center of the body, is called varus.

<span class="mw-page-title-main">Flat feet</span> Foot arch deformity

Flat feet, also called pes planus or fallen arches, is a postural deformity in which the arches of the foot collapse, with the entire sole of the foot coming into complete or near-complete contact with the ground. Sometimes children are born with flat feet (congenital). There is a functional relationship between the structure of the arch of the foot and the biomechanics of the lower leg. The arch provides an elastic, springy connection between the forefoot and the hind foot so that a majority of the forces incurred during weight bearing on the foot can be dissipated before the force reaches the long bones of the leg and thigh.

<span class="mw-page-title-main">Morton's neuroma</span> Benign neuroma of an intermetatarsal plantar nerve

Morton's neuroma is a benign neuroma of an intermetatarsal plantar nerve, most commonly of the second and third intermetatarsal spaces, which results in the entrapment of the affected nerve. The main symptoms are pain and/or numbness, sometimes relieved by ceasing to wear footwear with tight toe boxes and high heels. The condition is named after Thomas George Morton, though it was first correctly described by a chiropodist named Durlacher.

<span class="mw-page-title-main">Hallux rigidus</span> Arthritis and stiffness affecting the base joint of the big toe

Hallux rigidus or stiff big toe is degenerative arthritis and stiffness due to bone spurs that affects the metatarsophalangeal joints (MTP) at the base of the hallux.

<span class="mw-page-title-main">Tailor's bunion</span> Medical condition

Tailor's bunion, also known as digitus quintus varus or bunionette, is a condition caused as a result of inflammation of the fifth metatarsal bone at the base of the little toe.

Foot and ankle surgery is a sub-specialty of orthopedics and podiatry that deals with the treatment, diagnosis and prevention of disorders of the foot and ankle. Orthopaedic surgeons are medically qualified, having been through four years of college, followed by 4 years of medical school or osteopathic medical school to obtain an M.D. or D.O. followed by specialist training as a resident in orthopaedics, and only then do they sub-specialise in foot and ankle surgery. Training for a podiatric foot and ankle surgeon consists of four years of college, four years of podiatric medical school (D.P.M.), 3–4 years of a surgical residency and an optional 1 year fellowship.

<span class="mw-page-title-main">Pigeon toe</span> Medical condition affecting the feet

Pigeon toe, also known as in-toeing, is a condition which causes the toes to point inward when walking. It is most common in infants and children under two years of age and, when not the result of simple muscle weakness, normally arises from underlying conditions, such as a twisted shin bone or an excessive anteversion resulting in the twisting of the thigh bone when the front part of a person's foot is turned in.

The forefoot is the anterior aspect of the foot, composed of the five metatarsal bones, the fourteen phalanges and associated soft tissue structures. It is a common site of pathology in podiatry, and is the anatomic region involved in such conditions as hallux valgus, hallux rigidus, and Morton's neuroma, among others. In cases of severe deformity, such as in Charcot joints seen with diabetic neuropathy, the forefoot can be reconstructed by arthroplasty.

<span class="mw-page-title-main">Syndesmosis procedure</span> Type of bunion surgery

Syndesmosis procedure is one of the more than twenty bunion surgeries currently being performed. While the majority of bunion surgeries involve the breaking and shifting of bones, syndesmosis procedure is one of few surgical techniques that use a soft-tissue or non-osteotomy (non-bone-breaking) approach to afford the same correction. More than 130 different surgical techniques have been described for correction of one single condition of the foot: the bunion deformity.

Freiberg disease, also known as a Freiberg infraction, is a form of avascular necrosis in the metatarsal bone of the foot. It generally develops in the second metatarsal, but can occur in any metatarsal. Physical stress causes multiple tiny fractures where the middle of the metatarsal meets the growth plate. These fractures impair blood flow to the end of the metatarsal resulting in the death of bone cells (osteonecrosis). It is an uncommon condition, occurring most often in young women, athletes, and those with abnormally long metatarsals. Approximately 80% of those diagnosed are women.

<span class="mw-page-title-main">Index of trauma and orthopaedics articles</span>

Orthopedic surgery is the branch of surgery concerned with conditions involving the musculoskeletal system. Orthopedic surgeons use both surgical and nonsurgical means to treat musculoskeletal injuries, sports injuries, degenerative diseases, infections, bone tumours, and congenital limb deformities. Trauma surgery and traumatology is a sub-specialty dealing with the operative management of fractures, major trauma and the multiply-injured patient.

Philip Radovic, D.P.M. is a professor and podiatric surgeon practicing in South Orange County, California.

<span class="mw-page-title-main">Toe box</span> Part of a shoe

The toe box is the section of footwear that surrounds the toes on closed-toe shoes. Toe boxes that are too tight can cause injuries and foot deformities, whereas wider toe boxes may be used to treat or prevent common foot conditions such as broken toes, bunions, and Morton's neuroma. Toe boxes come in a variety of shapes and styles of construction, some of which are a matter of fashion, and some of which are designed for specialized functions.

Treace Medical Concepts, Inc. is a medical device company, headquartered in Ponte Vedra Beach, Florida, specializing in the design, manufacture, and marketing of foot and ankle surgical devices and biologics. Lapiplasty, Treace’s novel primary surgical product, advanced the treatment of bunions, surgically correcting the metatarsal bone, for the first time, in all three dimensions.

<span class="mw-page-title-main">Akin osteotomy</span> Surgery to correct hallux valgus

Akin osteotomy is a surgical procedure often used in the treatment of hallux valgus deformity, more commonly known as a bunion. A bunion is a bony bump that forms on the joint at the base of the big toe, often resulting in the toe pointing abnormally toward the second toe. Akin osteotomy is usually performed in conjunction with other procedures to correct the alignment of the toe and relieve associated symptoms. This procedure was first described by Akin in 1925.

References

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  2. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 "Bunions". OrthoInfo - AAOS. February 2016. Retrieved 8 November 2017.
  3. 1 2 3 4 Barnish, MS; Barnish, J (13 January 2016). "High-heeled shoes and musculoskeletal injuries: a narrative systematic review". BMJ Open. 6 (1): e010053. doi:10.1136/bmjopen-2015-010053. PMC   4735171 . PMID   26769789.
  4. Ferri, Fred F. (2010). Ferri's Differential Diagnosis E-Book: A Practical Guide to the Differential Diagnosis of Symptoms, Signs, and Clinical Disorders. Elsevier Health Sciences. p. 323. ISBN   978-0323081634.
  5. Dittmar, Jenna; Mitchell, Piers (11 June 2021). "Fashion for pointy shoes unleashed a wave of bunions in medieval England". The Conversation. Retrieved 2021-06-28.
  6. Dittmar, Jenna M.; Mitchell, Piers D.; Cessford, Craig; Inskip, Sarah A.; Robb, John E. (2021-06-11). "Fancy shoes and painful feet: Hallux valgus and fracture risk in medieval Cambridge, England". International Journal of Paleopathology. 35: 90–100. doi: 10.1016/j.ijpp.2021.04.012 . ISSN   1879-9817. PMC   8631459 . PMID   34120868.
  7. 1 2 Brukner, Peter (2010). Clinical sports medicine (3 ed.). McGraw-Hill. p. 667. ISBN   9780070278998.
  8. "Bunions (Hallux Abducto Valgus)". Footphysicians.com. 2009-12-18. Archived from the original on 2011-12-08. Retrieved 2011-03-20.
  9. Chou, Loretta B. (19 June 2015). "Disorders of the First Metatarsophalangeal Joint". The Physician and Sportsmedicine. 28 (7): 32–45. doi:10.3810/psm.2000.07.1075. PMID   20086649. S2CID   21529142.
  10. Page 533 in: Sam W. Wiesel, John N. Delahay (2007). Essentials of Orthopedic Surgery (3 ed.). Springer Science & Business Media. ISBN   9780387383286.
  11. 1 2 Rebecca Cerrato, Nicholas Cheney. "Hallux Valgus". American Orthopaedic Foot & Ankle Society. Archived from the original on 2016-12-30. Retrieved 2016-12-30. Last reviewed June 2015
  12. 1 2 Piqué-Vidal, Carlos; Vila, Joan (2009). "A geometric analysis of hallux valgus: correlation with clinical assessment of severity". Journal of Foot and Ankle Research. 2 (1): 15. doi: 10.1186/1757-1146-2-15 . ISSN   1757-1146. PMC   2694774 . PMID   19442286.
  13. Hecht, PJ; Lin, TJ (March 2014). "Hallux valgus". Medical Clinics of North America (Review). 98 (2): 227–32. doi:10.1016/j.mcna.2013.10.007. PMID   24559871.
  14. Park, CH; Chang, MC (May 2019). "Forefoot disorders and conservative treatment". Yeungnam University Journal of Medicine. 36 (2): 92–98. doi:10.12701/yujm.2019.00185. PMC   6784640 . PMID   31620619. (see Figure Two for images of orthotics)