Bunion

A bunion is a bony deformity of the joint at the base of the big toe. This joint is known as the metatarsophalangeal (MTP) joint. The medical name for a bunion is hallux valgus.

Structure of the foot

The foot is divided into three parts:

  • the hindfoot
  • the midfoot
  • the forefoot

The forefoot (front part of the foot) is made up of five bones called the metatarsals. These join the midfoot to the bones inside the toes. The big toe is usually in line with the first metatarsal, the second toe is in line with the second metatarsal and this pattern of alignment continues for each metatarsal and toe.

Bunions

Sometimes, the big toe can become angled outwards towards the middle of the foot and second toe. This forces the top of the first metatarsal to stick out from the side of the foot at the base of the big toe. If this happens, the bones can become misaligned and a painful bunion can form.

It is not known exactly what causes bunions, but wearing badly fitting shoes is thought to make the condition worse.

Research also suggests that bunions may run in families. It is thought that bunions are more likely to occur in people who have unusually flexible joints, and that this flexibility may be inherited.   

In some cases, certain health conditions, such as rheumatoid arthritis and gout, may also be responsible for the formation of bunions. These conditions cause pain and inflammation in the joints. See Bunion - causes for more information.

Who is affected by bunions?

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

Outlook

A range of treatments is available for bunions, including:

  • painkillers
  • modifying footwear
  • orthotics, such as insoles, bunion pads and toe spacers

Surgery may be considered if a person's symptoms are severe and do not respond to non-surgical treatment. The type of surgery used will depend on the level of deformity, the severity of any other associated symptoms, the patient's age and any other associated medical conditions.

Bunion surgery is usually effective, with up to 85% of cases resulting in improvement to symptoms. However, the deformity can sometimes return after bunion surgery.

See Bunion - treatment for more information about the range of available treatments. 

Bunions sometimes cause pain. Other symptoms may include:

  • a swollen, bony bump on the outside edge of your foot
  • pain, tenderness and swelling over your big toe joint that is made worse by pressure from wearing shoes
  • your big toe turned outwards at an angle towards your other toes
  • 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 overall shape of your foot

Changes to foot shape

If your bunion is particularly severe, it can change the overall shape of your foot. For example, a bunion can increase the width of your foot where it sticks out at the side.

If the bunion rubs on the inside of your shoe, wearing shoes may be uncomfortable. If your foot becomes very wide, it may be difficult to find shoes that fit at all.

Pain

Pain is an unpleasant physical or emotional feeling that your body produces as a warning sign that it has been damaged.

Inflammation

Inflammation is the body's response to infection, irritation or injury. It causes redness, swelling, pain and sometimes a feeling of heat in the affected area.

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The exact cause of bunions is unknown, but possible causes may include:

  • genetics (family history)
  • arthritis
  • other conditions 
  • poorly fitting shoes  

These possible causes are discussed in more detail below.

Genetics

If other members of your family have bunions, your risk of developing them is increased.

Arthritis

The types of arthritis thought to cause bunions are:

  • rheumatoid arthritis - inflammation (swelling) and pain in the joints that results from the immune system attacking the lining of the joints
  • gout - another common type of arthritis that causes painful inflammation in one or more joints
  • psoriatic arthritis - a type of arthritis that is associated with the skin condition psoriasis

Other conditions

Several other conditions are thought to increase your chances of developing bunions. For example, conditions that are associated with loose ligaments (ligamentous laxity), flexible joints and low muscle tone could increase the likelihood of bunions developing. These conditions are listed below.

Neuromuscular conditions

  • cerebral palsy - a neurological condition (of the brain and nervous system) that affects a child's co-ordination and movement
  • Charcot-Marie-Tooth disease - a group of genetic conditions that causes damage to the nerves outside the central nervous system
  • multiple sclerosis- a neurological condition that can cause muscle weakness and balance problems

Connective tissue disorders

  • Marfans syndrome - a genetic condition that affects the body's connective tissues (which provide support and structure to other tissue and organs)
  • Down's syndrome - an uncommon genetic condition that can cause learning difficulties and distinct physical characteristics, including loose joints

Poorly fitting shoes

Poorly fitting shoes can contribute to the development of bunions. Bunions are rare in populations that do not wear shoes.

Wearing shoes that are too tight and do not fit properly is likely to make an existing bunion worse.

If your shoes are too tight, they 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, putting pressure on the nerves around it and leading 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.

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Bunions usually get worse over time, so if you develop one, see your GP. It is important to get medical help if you have a bunion that is causing pain or discomfort, or if you are having trouble finding footwear that fits.

Foot examination

Your GP will examine your foot and ask you about any symptoms you have, such as pain and swelling. You may be asked to move your big toe up and down to determine whether your range of movement is limited.

Your GP may ask you about your footwear. For example, they may ask you about:

  • the types of shoes you wear
  • how frequently you wear particular types of shoes
  • whether you have recently changed your footwear

Your GP will also ask about your general medical history. Tell them about any surgery or treatments you have already tried for bunions, such as bunion pads or over-the-counter painkillers.

Your GP may also ask you whether there is a history of bunions in your family and whether you do any activities that place excessive pressure on your toes, such as long-distance running or ballet dancing.

Your GP will want to establish what is causing your bunion. They will want to find out whether your bunion is due to an underlying condition, such as arthritis

Radiographic imaging

Your GP may refer you for radiographic imaging to assess the severity of your bunion and to decide whether you need to be referred to a specialist.

A radiograph is a detailed image that allows the bony structure of your foot to be clearly seen and the extent of the deformity caused by the bunion to be assessed.

During the radiographic imaging procedure, you will be asked to stand on your affected foot while the image is taken.

Pain
Pain is an unpleasant physical or emotional feeling that your body produces as a warning sign that it has been damaged.
Swelling
Inflammation is the body's response to infection, irritation or injury. It causes redness, swelling, pain and sometimes a feeling of heat in the affected area.
X-ray
An X-ray is a painless way of producing pictures of the inside of the body using radiation.

Bunions may only need to be treated if they cause significant pain and discomfort and if the deformity is severe.

Non-surgical treatment

Where possible, non-surgical treatment for bunions will be used. Your GP can discuss the possible treatment options with you.

Various non-surgical treatments can be used to ease the pain and discomfort caused by a bunion. However, these treatments cannot stop a bunion from becoming progressively worse over time.

Possible non-surgical treatments include:

  • painkillers
  • bunion pads
  • orthotics, such as insoles, bunion pads and toe spacers
  • modifying your footwear

These are discussed in more detail below.

Painkillers

If you have a painful bunion, painkillers, such as paracetamol or ibuprofen, may be recommended.

When using painkillers, read the patient information leaflet that comes with the medicine and always follow the recommended dose. Do not use ibuprofen if you have a stomach ulcer or if you have had one in the past.

See the Health A-Z topic about Ibuprofen for more advice. 

Bunion pads

As well as taking painkillers, using bunion pads may 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 protect your foot from rubbing on your shoe and relieve the pressure over the enlarged joint at the base of your big toe. You can also use an ice pack or cold compress to help numb pain and reduce any swelling (see below).

Orthotics

Orthotics are devices that are placed inside your shoes and help realign the bones of your foot. They can relieve the pressure on your bunion, which can help ease the pain caused by the deformity.

You can buy orthotics over the counter from pharmacies or they can be custom made by a podiatrist (a specialist in diagnosing and treating foot conditions) 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.

It is important that the orthotic fits you properly, so you may want to seek advice from your GP or podiatrist, who can suggest the best ones for you.

If it is felt that you need to have a custom-made orthotic, the following criteria will be taken into consideration to ensure that it is suitable for you:

  • material - orthotics can be made from a number of different materials including graphite, polypropylene, leather and cork. The material that best suits your lifestyle will be chosen
  • thickness - orthotics are available in various thicknesses to provide comfort and control when you walk. The thickness of your orthotics will depend on how heavy you are
  • liner - a cushioned liner will be used to cover the top of your orthotic. A variety of materials can be used, including leather and vinyl
  • post - a post can be added either to the front or the back of your orthotic to add control when you walk 
  • height and width - the height and width of your orthotic can be modified to add comfort and to suit the shape of your foot and the severity of your bunion

You can also use special bunion splints, which are 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.

Toe spacers are also available, which can help reduce the pain caused by bunions.

Ice packs

If your toe joint is painful and inflamed, applying an ice pack to the affected area several times a day can relieve pain and inflammation. Before applying an ice pack, wrap it in a cloth or tea towel. Never apply ice directly to the skin.  

Surgical treatments

Surgery is the only way to correct a bunion. Bunions usually get worse over time, so a bunion that is left untreated is likely to get bigger and become more painful.

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

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

The operation will either be carried out under local anaesthetic (where the affected area is numbed but you are awake during the procedure) or general anaesthetic (where you will be completely unconscious).

Bunion surgery is usually performed as a day case procedure, which means you will not have to stay overnight in hospital.

Deciding to have surgery

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

  • your age
  • your medical history and general health
  • your occupation and lifestyle
  • your expectations of surgery
  • the severity of your symptoms

These are discussed in more detail below.

Age

Age is a factor that will be taken into consideration when deciding on bunion surgery. In young people, bunion surgery is often delayed due to an increased risk of the bunion returning. This is because the bones are still growing.

You may be advised that non-surgical treatments are a better option than bunion surgery.

Medical history and general health  

After surgery, your risk of developing problems is increased if you have other medical conditions that prevent or slow down the healing process. For example, problems with wound healing and infection are more likely if you have diabetes or problems with your circulation.

Following bunion surgery, you are also more likely to encounter problems  if your bunion occurred as a result of joint stiffness (contracture) or inflammatory arthritis.

Smoking is also a risk factor.

Occupation and lifestyle

If you are a professional dancer or sportsperson, bunion surgery may only be recommended if you are unable to perform in your chosen field. 

If you are very active and play a lot of sport, being able to move your big toe freely may be more important to you than how your toe looks. However, surgery may make your toes less flexible.

If you have bunion surgery, you may not be able to return to the same level of physical activity as before the operation.

Your expectations of surgery

The success of your surgery will depend on the skill and experience of the surgeon, the severity of your bunions, the type of surgical procedure you have and your ability and willingness to rest after the operation.

Bunion surgery may be up to 85% successful in people who have it. However, after you have had surgery, there is no guarantee that your foot will be perfectly straight or pain free. Surgery may reduce the flexibility of your big toe joint and you may experience stiffness in the area where the bunion was. Your toe may also be shorter than it was before you had surgery.

The severity of your bunion

Surgery will only usually be recommended if your bunions cause considerable pain and non-surgical treatment has failed. This is because of the risks and complications associated with bunion surgery.

Your specialist will examine your foot and look at the results of your radiographic images to assess the severity of your bunions and will help you decide whether surgery is right for you.

Types of surgery

Numerous surgical procedures are used to treat bunions. The type of surgery that is recommended for you will depend on the severity of the deformity and how far the bones in your foot have moved as a result of the condition. Pre-existing wear and tear in the joint will also be taken into consideration.

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 outlined below.

Osteotomy  

An osteotomy is the most common type of bunion surgery. It involves 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 will also move your toe joint back in line, which may involve removing other pieces of bone.

Distal soft tissue realignment

Distal soft tissue realignment can be used to correct a mild bunion deformity. This type of surgery aims to correct the deformity using soft tissue procedures, such as tendon release and capsular tightening, to help improve the stability and appearance of the foot and big toe joint.   

Distal soft tissue realignment can be carried out on its own, although it is usually performed at the same time as an osteotomy.

Arthrodesis

Arthrodesis involves fusing together two bones in your big toe joint (metatarsophalangeal joint). This procedure is usually only recommended for people who have severe deformities of the big toe joint, which make it too difficult for doctors to completely fix the joint, such as severe rheumatoid arthritis, or where there is advanced degeneration of the joint.

After arthrodesis, you will not be able to move your big toe at the metatarsophalangeal joint (the base of the big toe).

Excision (Keller's) arthroplasty

An excision arthroplasty involves cutting out the bunion and part of the bone of the joint at the base of the big toe. This creates a false joint that later heals when scar tissue forms. 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 very elderly people. 

Minimally invasive bunion surgery

The National Institute for Health and Clinical Excellence (NICE) in the UK has recently published information about a new, minimally invasive surgical procedure that can be used to treat bunions. However, as the procedure is new, there is currently little reliable evidence of how effective or safe it is.

Whichever type of surgery you have, you will be under a local anaesthetic or general anaesthetic. One or more incisions will be made near the big toe so that bone-cutting instruments can be inserted. These are used to remove the bunion and to divide one or more bones located at the front of the foot.

The procedure aims to repair the tilting of the big toe and uses wires, screws or plates to keep the divided bones in place. It may be carried out using X-rays.  X-rays use small doses of radiation to take images of the bones.

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. It is likely that you will given a special surgical shoe that enables you to walk on your heel.

After surgery

After bunion surgery, expect your foot and ankle to be swollen for three months or, in some cases, longer. While you are recovering, you will need to elevate your foot to reduce the swelling and you will need crutches to move around.

You will not usually be able to wear normal shoes until three to four months after surgery. You may have a cast or bandage and postoperative shoes (shoes that are 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.  

Treatment Pros Cons
Bunion pads and insoles

Helps to reduce pressure on bunion and relieve pain

  • Readily available
  • No side effects or complications
  • Not always effective
  • Does not improve appearance of foot
Surgery: removing the bony bump
In a procedure called a bunionectomy, the bony lump is removed
  • Can correct a mild bunion deformity and improve appearance of the foot
  • Will not correct more significant bunions
Surgery: toe bones fused

This is called arthrodesis. Two bones in the big toe are fused together, improving stability and alignment of bones, and reducing pain

  • An effective treatment for people who also have arthritis or a severe deformity
  • If fusion occurs, the deformity will not come back
  • Loss of movement in the big toe, which could affect walking
  • Long recovery time 
  • Can result in post-operative infection, DVT, pain, loss of feeling in the foot and failure of the bones to join properly
Surgery: half of toe joint removed

Known as Keller's arthroplasty, half the bone in the toe joint is removed. The remaining bones are straightened

  • May be effective in treating severe deformities in elderly people
  • May be an effective treatment for people with associated infection
  • Shorter recovery time than other types of surgery (six weeks)
  • Not recommended for active and younger patients
  • Inability to move the big toe properly
  • Inability to put the soft part of the toe on the ground when walking (known as a 'cock-up deformity')
  • Can result in post-operative infection, DVT, weakness, recurrence of the deformity and pain under the ball of the foot
  • Always results in shortening of the big toe
Surgery: cutting and realigning the bone
In a procedure known as an osteotomy, the bone is cut to allow it to be placed in a certain way to help correct the deformity (sometimes a small wedge of bone is removed)
  • Can relieve pain
  • Improves appearance of the foot
  • Long recovery time - it can take three to six months for the foot to settle down
  • Bunion can return
  • Possible complications are infection, small breaks in the bones that were operated on, loss of feeling in the big toe, stiffness, swelling and shortening of the big toe (which can cause pain in nearby parts of the foot)
Surgery: minimal access techniques
Less invasive surgery, where only small incisions are made near the big toe so that bone-cutting instruments can be inserted to correct the deformity
  • Recovery is quicker
  • A relatively new procedure, so not much evidence available regarding its safety and effectiveness
  • Potential risks include nerve injury, infection, toe stiffness, tendon injury, recurrent deformity and DVT

Complications after bunion surgery

Several complications can occur after bunion surgery. These will depend on the type of surgery you have and can include:

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

If you have any concerns after surgery or experience any of these complications, speak to your surgical team or GP. They can give you advice about how to deal with these complications, including further treatment options.  

You can significantly reduce your risk of developing symptomatic bunions by wearing shoes that fit properly. Symptomatic bunions are bunions that cause symptoms, such as pain.

Footwear

Poorly fitting shoes can contribute to the development of bunions. Symptomatic bunions are rare in populations that do not wear shoes. Wearing shoes that are too tight and do not fit properly is likely to make an existing bunion worse. If your shoes are too tight, they may rub against your big toe joint.

It is best to avoid wearing shoes with high heels or pointy toes. Wearing shoes that fit properly can reduce your risk of developing a symptomatic bunion.

Your shoes should be wide enough for your toes not to be forced together and there should be enough room for them to move. Shoes that are made of soft leather and are wide fitting are a good choice.

If your shoes are too tight, have them professionally stretched. When selecting shoes, it is useful to have your feet measured properly because many people often wear shoes that are the wrong size.

You may also want to visit a podiatrist (a foot specialist), who will examine your feet and give you advice about suitable footwear.

Content provided by NHS Choices www.nhs.uk and adapted for Ireland by the Health A-Z.

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