Bunions

&

Tailor's  bunion

BUNION (AKA HALLUX VALGUS DEFORMITY)

WHAT IS A BUNION?

A bunion develops when the first metatarsal bone moves away from the smaller metatarsal bones and the

big toe moves towards the second toe, thus creating a bump around the big toe joint. A similar thing can

occur with the 5th metatarsal and toe. This is called a Tailor’s bunion. The bony bump that is seen along

the inside of the foot is actually the head of the 1st metatarsal bone. Sometimes bony spurs and

degenerative changes can also occur here.

 

CAUSES & RISK FACTORS:

Bunions may develop for a variety of reasons, but most of the time it is related to genetics. Based on your

foot type and the way in which you walk (the pathomechanics), certain tendons pull and gain mechanical

advantage over other tendons, causing instability of joints and foot deformities, including bunions. Injuries,

neuromuscular conditions, and shoe gear (or the lack thereof) can also contribute to the onset and/or

progression of the bunion deformity. 

 

Females are more likely to develop bunions; however, I have personally seen teenage boys with bunions,

so do not think it is only women who wear high heels that get bunions! Remember, the deformity (or foot type that predisposed a person to develop the deformity) is often inherited. 

 

SYMPTOMS:

Sometimes, one will only experience pain around the bunion bump. The pain is exacerbated with shoe gear because of the rubbing. The irritation of shoe gear against the bunion can also lead to redness and swelling, as well as a bursa (a fluid-filled sac inside the foot) around the 1stmetatarsal head. 

 

If there is hypermobility in the foot, sometimes the pain is even higher up in the foot at the 1st metatarsal-cuneiform joint. As the deformity progresses, bone spur can also develop along the top of that joint. 

 

DIAGNOSIS:

Clinical exam:

Even though a bunion is easily identified simply by sight, it is important to perform a thorough examination, both non-weightbearing and weight-bearing, to determine the severity of the deformity as well as the presence of any other associated deformities.

 

The non-weightbearing exam involves palpation of the bunion site to confirm the site of tenderness. The available motion around the 1st metatarsal-phalangeal joint (1st MTPJ) and the 1st metatarsal-cuneiform joint should also be assessed. Any catching, clicking, or crepitus within the 1st MTPJ should be noted as these could be signs of associated arthritis, which is not uncommon in severe bunions because of the joint asymmetry.

 

After evaluating the bunion while the person is seated, it is just as important to have the person stand for further evaluation. It is better to see the position of the 1st ray and bunion site while standing to determine the severity of the deformity. In the presence of a severe bunion, the big toe may be tracking (or track bound) laterally and sometimes one may even see the 1stand 2ndtoes crossed. While the person is standing, their foot type can also be examined. It is good to note this because oftentimes foot type and the related biomechanics are a major contributor of bunion deformity. 

 

Radiographs:

X-rays are often taken to help further evaluate bunions. Several different angles are measured, which help determine where the deformity is originating from and the severity of deformity. X-rays are also routinely used for surgical planning.

 

TREATMENT:

The only way to correct the deformity is with surgery. However, it is important to try conservative care first because there are always risks associated with surgery. Conservative treatment is aimed at trying to slow down the progression of the deformity and to help improve one’s symptoms.

 

Conservative Treatment Options:

Shoe gear

It is important to wear good, supportive tennis shoes, or walking shoes, as much as possible and avoid barefoot walking and use of flat shoes and flip-flops. Shoes with a wider toe box can also help accommodate for the increased width of the foot in the presence of the bunion.

 

Orthotics

These are devices that go into shoes to help cushion, support, and control abnormal motion(s) of the feet. They can also help with the alignment of the lower extremity more proximally, including the knees, hips, and back. They can be purchased off-the-shelf or be custom-made.

 

Pads

Bunion sleeves, toe sleeves, and toe spacers are all over-the-counter products that can be used to help pad the areas of increased pressure. They will not correct the deformity, but just provide added cushion to the foot while wearing closed-toe shoes.

 

Anti-inflammatory medications

Over-the-counter pain medications can help with acute exacerbations of pain around the bunion site, but they should not be used chronically.

 

Surgical Treatment Options:

Each surgeon has their own treatment protocol for bunions; therefore, it is important for the surgeon to have a discussion with the patient so that both are comfortable with the plan of care. As mentioned before, there are always risks associated with surgery, including infection, continued pain, functional limitations, and recurrence. There is also a recovery period after surgery, so one needs to be prepared to possibly be immobilized and/or off the foot for several weeks to months. Therefore, the decision to undergo surgery is not an easy one and should not be taken lightly.

 

When it comes to deciding which surgical procedures should be performed, several things must be considered, including the severity of the deformity, along with the patient’s age, bone density, and activity level. The goals of the surgery are to decrease the deformity and improve the patient’s pain and functional level. 

 

Distal Metatarsal Osteotomy (DMO)

For mild to moderate bunion deformities, a DMO can be performed, which involves cutting the

metatarsal head and then translating it laterally. One or two screws can be used to fixate and hold

the position of the 1stmetatarsal. Additional soft tissue procedures are done to balance and hold the

1st ray in the corrected position.

 

Postoperatively, a postop shoe or walking boot is typically used for about 6 weeks while the

osteotomy site heals. Then you can slowly transition back into regular shoes and increase your

activity level, as tolerated. It may be 3 months, or longer, before you are able to participate in higher

impact activities.

 

Proximal Metatarsal Osteotomy (PMO)

For moderate bunion deformities, a more proximal procedure (e.g. opening based wedge osteotomy,

closing based wedge osteotomy) can be performed to get more correction.

 

Because the osteotomy cuts are made more proximally along the 1stmetatarsal, a non-weightbearing

cast for a few weeks may be required before transitioning to a walking boot and then back into

regular shoes at 6-8 weeks after surgery.

 

Modified Lapidus Procedure (1st Metatarsal-Cuneiform Joint Fusion)

For severe bunion deformities, a modified Lapidus procedure is often performed, which involves

realigning the 1stmetatarsal-cuneiform joint and fusing it.

 

To have a successful joint fusion, the fusion site must not have motion after the procedure; therefore,

a non-weightbearing cast is often used for about 6 weeks. Depending on the surgeon and type of

fixation, though, other types of immobilization devices may be used and duration of

non-weightbearing may differ. Despite possibly having a longer non-weightbearing period compared

to the other bunion surgery procedures, you may be able to return to a regular shoe at about

6-8 weeks after surgery.

TAILOR'S BUNION (AKA BUNIONETTE)

HISTORY:

The term “tailor’s bunion” dates back to the 19th century when tailors would sit cross-legged, putting pressure along the lateral sides of their feet, causing irritation, callus formation, and pain to the 5th metatarsal head (1). Today, a tailor’s bunion is more commonly considered a structural or biomechanical deformity (1).

 

CAUSES:

There are several potential causes for a painful tailor’s bunion. Tight shoe gear or any sort of pressure can cause irritation to the 5th metatarsal head, especially in the presence of a large metatarsal head. Lateral lower of the 5th metatarsal and increased splay between the 4th and 5th metatarsals can also cause a tailor’s bunion deformity (1,2).

 

SYMPTOMS:

Pain, if present, is around the 5thmetatarsal head and is usually exacerbated with shoe gear. The irritation of shoe gear against the bunionette can also lead to redness and swelling.

 

DIAGNOSIS:

Clinical exam:

A bony prominence (the 5th metatarsal head) will be found and there might be pain with palpation of the bump. As a result of shoe irritation, some redness and swelling may be localized around the bony bump. In certain situations, a callus or even a bursa (a fluid-filled sac inside the foot) is also present. 

 

Imaging:

X-rays can be used to further examine the 5th metatarsal and bunionette site. Looking at the 5th metatarsal head, the head can be evaluated for size, shape, and presence of any cysts. Certain angles can also be measured, which help determine the where the deformity is originating, how severe it is, as well as help with surgical planning.

 

TREATMENT:

The only way to correct the deformity is with surgery. However, it is important to try conservative care first because there are always risks associated with surgery. Conservative treatment is aimed at trying to slow down the progression of the deformity and/or to help improve one’s symptoms.

 

Conservative Treatment Options:

Callus debridement

Trimming of the callus can help with the pain, but it should be done by a healthcare professional. At home, for maintenance, routine use of a pumice stone or emory board can be tried.

 

Shoe gear

It is important to wear good, supportive tennis shoes, or walking shoes, as much as possible and avoid barefoot walking and use of flat shoes and flip-flops. Shoes with a wider toe box can also help accommodate for the increased width of the foot in the presence of the tailor’s bunion.

 

Orthotics

These are devices that go into shoes to help cushion, support, and control abnormal motions of feet. They can also help with the alignment of the lower extremity more proximally, including the knees, hips, and back. They can be purchased off-the-shelf or be custom-made.

 

Pads

Pads can be used in two ways. They can either be used to cushion the area or to offload the area (e.g. donut pad). Over-the-counter products can be purchased to protect the area while wearing shoes.

 

Anti-inflammatory medications

Over-the-counter pain medications can help with acute exacerbations of pain around the bunion site, but they should not be used chronically.

 

Surgical Treatment Options:

If conservative treatments fail, surgery can be considered. The goal with surgery is to alleviate pain, resect any bony prominence, and/or improve the anatomic alignment. Therefore, options include resection of the bony bump, 5th metatarsal osteotomies, and even resection of the entire 5th metatarsal head. 

 

 

References:

1. Ajis, A., Koti, M., & Maffulli, N. (2005). Tailor’s bunion: a review. The Journal of foot and ankle surgery, 44(3), 236-245.

2. Thomas, J. L., Blitch, E. L., Chaney, D. M., Dinucci, K. A., Eickmeier, K., Rubin, L. G., ... & Vanore, J. V. (2009). Diagnosis and treatment of forefoot disorders. Section 4. Tailor's bunion. The Journal of Foot and Ankle Surgery, 48(2), 257-263.

Disclaimer: The above information is meant for educational purposes only and should not be construed as medical advice. Should you feel that you are suffering with a painful Bunion or another foot-related issue, please schedule an appointment to see the doctor.

Podiatry

Consulting

Running Programs

  • Facebook - White Circle
  • Twitter - White Circle
  • Instagram - White Circle
  • LinkedIn - White Circle