Bunions

A bunion is a disorder of the great toe in which it is displaced towards the second toe. The onset of this deformity is generally chronic. The signs and symptoms include:

• Bump at the joint of the base of the big toe
• Rotation of the toe
• Bulging of the head of the big toe
• Burning or tingling pain at the metatarsophalangeal joint (the joint that connects the bones of the foot to the toe)
• Thickening of the skin at the base of the big toe
• Toe tenderness
• Limitation in walking
• Difficulty in wearing shoes

The frequency, duration, and severity of pain increase as the disease progresses.

Interesting fact: Bunion is derived from the Latin word "bunion," which refers to enlargement.

Each foot has five bones, known as metatarsal bones, numbered one to five from the hallux (great toe) to the small toe. These bones are connected to the bones of the toes, known as phalanges, through metatarsophalangeal joints (MTP). Numerous bands of tissues and muscles help hold bones and joints in place.

The exact cause of a bunion is unclear, but it is thought to occur due to a complex interplay of the following factors:

• Imbalance of the muscles of the foot can cause slight misalignment of the toe.
• Increased pressure at the first MTP joint.

The muscle imbalance and increased pressure at the MTP joint push the great toe towards the second toe. This increased tension also raises the hallux angle—the angle created between the phalanx (toe bone) and the first metatarsal. These forces strain the ligaments, eventually causing them to rupture.

These changes are seen as a “bump” at the base of the big toe. Due to increased pressure at the MTP joint, the deformity worsens as the individual walks.

The following risk factors can trigger the formation of bunions:

1. Family history: Individuals with a family history of foot problems are more likely to develop bunions.
2. Foot problems: Individuals with specific foot problems are more likely to develop bunions. The deformities that increase the chances of foot problems include:
   • Flat foot: A condition in which the arches on the inside of the feet flatten when pressure is applied.
   • Abnormal and excessive mobility of the first toe.
   • Excessive foot pronation: The rolling of the foot towards the inner side while walking.
3. Gender: Women are more prone to developing bunions, mainly due to the use of high heels. High heels can cause pain in the heels, back, and knees.
4. Arthritic conditions: People with arthritis have an increased chance of developing foot problems.
5. Connective tissue disorders: These disorders cause inflammation of the tissues, which may weaken the support of the joint, predisposing individuals to develop bunions. Connective tissue disorders that can cause bunions include Marfan syndrome, Ehlers-Danlos syndrome, and Down syndrome.
6. Muscle imbalance and postural dysfunction: Disturbed muscle balance and postural dysfunction due to certain medical conditions, such as stroke and cerebral palsy, may lead to the development of bunions. This occurs because the limited range of motion of the big toes causes bony protrusions.
7. Types of shoes: Individuals who wear the following types of shoes are more prone to bunions:
   • Tight shoes
   • Poorly fitted shoes
   • Narrow and pointed shoes
   • Heels
8. Occupation: People in occupations that involve a lot of standing and walking are more susceptible to bunions. Such professions include:
   • Teaching
   • Nursing
   • Ballet dancers
   • Athletes

The doctor obtains a thorough medical history along with an understanding of symptoms. The following steps aid in the diagnosis of a bunion:

1. Physical examination
   In most cases, bunions can be easily diagnosed through a physical examination of the foot. Doctors gently move the toe to determine whether pain occurs during motion.
2. X-rays
   X-rays provide images of dense structures such as bone. They help to check:
   • Alignment of the toes
   • Damage to the MTP joint
   • Arthritis associated with bunions
3. Ultrasound
   Ultrasound is recommended in severe cases where the person experiences numbness and tingling sensations in the feet. It helps to reveal the involvement of nerves.
4. Magnetic resonance imaging (MRI)
   Any changes in the foot's structure may lead to other types of damage, such as fractures. This is diagnosed through an MRI scan, which can also reveal any inflammation in the nerves of the feet and toes.

• Choose the right footwear: Choosing the proper footwear can easily prevent most cases of bunions. Before buying footwear, it is advised to check the following parameters:
  • Comfort: The shoes should provide instant comfort when worn. There should be no pinching or rubbing sensation.
  • Size: Ensure the footwear has proper length and width. Avoid selecting size based on markings, as it may vary by style and brand.
  • Support: Footwear with arch support minimizes the chances of developing a bunion.
• Rest your feet: Proper rest is essential between physical activities that exert pressure on the feet. It is advisable to remove shoes for a few minutes at regular intervals to allow your feet to breathe.
• Have your feet measured regularly: The size of our feet changes as we age. Therefore, it is essential to measure the size of both feet regularly and adjust footwear accordingly. Fit shoes to the larger foot, as most people have one foot larger than the other.
• Maintain a healthy weight: Excess body weight increases pressure on the feet, raising the incidence of foot problems, including bunions. Maintaining a healthy weight can help prevent bunions by reducing pressure on the big toe joint.

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I. Nonoperative management

1. Changing the shoes: The primary treatment approach involves changing footwear. Individuals with bunions are advised to wear wider shoes with low heels to correct the toe's alignment.
2. Orthotics: These are shoe or heel inserts designed to reduce pain. Two types of orthotics are available: over-the-counter (OTC) and custom orthotics. OTC orthotics can be used by anyone, while custom orthotics are specially designed according to the size of the sole.
3. Medical bunion pads: These pads are placed inside the shoe to act as a cushion, providing protection and support to the foot and ankle. They help reduce the weight placed on the foot while walking, which alleviates pain.
4. Splints: A splint is a supportive device that keeps the affected part static. It is readily available and meant to be worn on the foot, helping to alleviate pain and promote healing.
5. Ankle braces: Ankle braces help limit motion and support the foot and ankle, reducing pain and preventing further injury. They are typically made of fabric.
6. Toe spacers: These separators maintain space between the toe muscles, helping to reduce pain and assisting in foot-strengthening exercises.

II. Medications

Anti-inflammatory medications such as paracetamol, ibuprofen, and naproxen may be prescribed to reduce toe pain and swelling. In severe cases, cortisone injections might also be administered.

III. Operative management (Surgery)

Surgery is often recommended if the individual experiences:

• Persistent pain and difficulty walking despite changes in footwear and nonsurgical procedures.
• Chronic big toe inflammation.
• Drifting of the big toe towards the smaller toes.
• Inability to bend and straighten the big toe.

The primary aim of surgery is to reduce pain by adjusting the position of the big toe. Several types of surgeries are available for bunions, performed based on X-ray diagnosis and physical findings. In most cases, a hospital stay is not required after bunion surgery; however, recovery may take several weeks.

IV. Postoperative care

Postoperative care depends on the type of surgery performed. Right after surgery, individuals may be able to bear weight on the foot using a stiff-soled shoe. In some cases, individuals are advised to remain immobile for a short period. Most exercises are recommended to start after the removal of sutures.

The following recovery tips can help heal the wound faster and reduce pain:

• Keep the dressings dry for at least two weeks.
• Massage the affected area after the removal of the bandage.
• Keep the feet elevated for the first few weeks to reduce pain.
• Apply ice packs on the foot for 30 minutes every 1-2 hours during the first few days.
• Avoid putting weight on your foot.

A few home remedies can help manage bunions. However, make sure to consult your healthcare provider before initiating any of these:

1. Hot and Cold Therapy
   Hot and cold therapy for the affected area can provide relief from painful and swollen bunions. Cold therapy involves soaking the bunion in cold water, which reduces swelling by constricting blood vessels. Soaking the feet in warm water helps manage soreness by improving blood flow. Ice and heating packs can also be used as alternatives to soaking the feet in water.
2. White Vinegar
   Vinegar helps soften hard skin and possesses antibacterial and antifungal properties. It can be applied by mixing three parts vinegar with one part water. Apply the solution to the affected area and cover it with a bandage. Leave it overnight for optimal results.
3. Olive Oil
   Olive oil increases blood circulation and helps alleviate pain. It can be massaged directly into the area for 10-15 minutes every day.
4. Castor Oil
   Castor oil has anti-inflammatory properties that help reduce swelling and pain associated with bunions. It can be applied by wrapping a cloth dipped in warm castor oil around the affected area.
5. Epsom Salt
   Epsom salt also possesses anti-inflammatory properties. Soak the feet in warm water with Epsom salt.

The constant pressure on the big toe can lead to several complications. These include:

• Corns and calluses (thick, rough, and hardened layers of skin)
• Pointing up of the toe head
• Inflammation of the bursae – fluid-filled sacs that cushion the bones, tendons, and muscles near the joints
• Pain and swelling in the ball of your foot
• Deformation of the toe nails
• Difficulty in walking

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Foot exercises are beneficial in maintaining the strength and flexibility of the feet. Individuals with bunions are advised to perform at least three sets of the following exercises daily:

• Pickups: This involves picking up 10 to 20 small objects from a seated position using the toes.
• Curls: This activity involves curling a towel on the floor while sitting in a chair. The toes are then curled around the towel and pulled towards yourself by bending the knees.
• Stretches: In this exercise, the toes are kept pointed and then curled for 5 seconds. For maximum effect, this activity should be repeated at least ten times.
• Rolling: This involves moving an object along and around the length of each foot for two to three minutes.