Bunions (Hallux Valgus)

Summary: Bunions

A bunion deformity is a common foot condition affecting the big toe characterized by a prominent bump on the inside of the forefoot (see Figure 1). The word bunion originates from the Latin root for the word “turnip.” The medical term for a bunion is hallux valgus. Hallux means “big toe” in latin -and valgus conveys that it is pointing away from the midline. Most bunions are painless. However, some bunions can lead to discomfort over the prominent bump –especially if patients wear tight fitting or stiff shoes. It is common for bunion deformities to “run in the family” and gradually increase in size over time. Most bunions can be treated without surgery. However, surgery is an option for the few patients who continue to experience disabling pain despite optimal non-surgical care.

Click Here for a Summary Handout about Bunions

Read More: 5 Things you probably didn’t know about bunions!

Clinical Presentation of Bunions

Most patients with bunions, even large bunions, will not have any symptoms. However, some patients with bunion deformities will report pain over the prominent bump on the inside of their forefoot (the medial eminence). They may also experience pain under the ball of the foot near the base of the second toe. Bunion symptoms vary in severity and can occur with standing, walking, or even at rest. Interestingly, there does not appear to be a connection between the size of the bunion and the patient’s symptoms. Bunion pain is often only present when restrictive shoes are worn (either a narrow or stiff toe box).

Bunions usually run in the family. A positive family history for bunions may be the single greatest risk factor for developing a bunion deformity. Often a patient will recall a first-degree relative (parent or sibling) having similar foot issues (bunion, flatfoot, toe deformity).

Bunions occur from a shift in the bones around the great toe. The big toe (the hallux) drifts toward the little toes (laterally) after its base (the first metatarsal) shifts to the midline (medially). The visible bunion reflects a combination of the movement of these bones. The noticeable bunion deformity results from the prominent first metatarsal bone (Figure 2) and any associated tissue swelling around this joint (from rubbing). In some cases, the big toe joint deformity can lead to arthritis.

Painful bunions simply result from the outer pressure of restrictive shoes on this area and the irregular joint stresses occurring from the toe deformity.

Physical Examination of Bunions

Physical examination of a patient with bunions typically reveals a prominent bump on the inside of the forefoot due to changes in the position of the first metatarsal bone and great toe. Drifting of these bones cause the big toe joint to rotate out of place (“subluxate”). This often results in redness and swelling along the bunion deformity which can be painful to touch.

Patients may also have a thickening of the skin (callus) at the base of their second toe in the sole of the forefoot. This occurs because the first toe drifts inward and the second metatarsal (the bone at the base fo the second toe) is often relatively long. This results in the “ball of the foot” carrying more weight which can lead to pain in this area due to a condition called metatarsalgia.

Imaging of Hallux Valgus Deformities

To fully evaluate a bunion deformity (hallux valgus) it is necessary to obtain standing x-rays of the foot. These x-rays are typically taken from the top (anteroposterior) (see Figure 2) and from the side of the foot (lateral). A physician can use these x-rays to classify the extent of the bunion deformity.

The degree of big toe angulation (Hallux Valgus Angle) can be measured on x-ray (Figure 2).

• Mild bunion deformities are considered if the big toe angulation is <20 degrees,
• Moderate bunion deformities measure from 20-40 degrees,
• In severe bunion deformities the great toe angulation is greater than 40 degrees.

Treatment of Painful Hallux Valgus Deformities

Non-Operative Treatment: Bunions

The initial treatment for almost all bunions should be non-operative. Symptoms can usually be greatly improved with simple interventions. Non-operative treatment may include adjusting the shoes or trying common products available at pharmacies, sporting goods stores, and through the internet. Elements of successful conservative treatment of bunions often include:

• Properly fitted shoes: Properly fitting comfort shoes with a wide non-constrictive toe box (made with soft materials) can be quite helpful in reducing the irritation over the prominent bunion. In some instances, it is helpful to stretch the inside aspect of the shoe. Jamming a foot with a bunion into a constrictive shoe will likely produce uncomfortable symptoms. Inspect your shoes/boots to see if the area over the bunion can be stretched. You might be surprised how easy this can be accomplished with a relatively inexpensive “shoe stretcher.”
• Bunion pads (bunion sleeve): Bunion pads may also be helpful in decreasing the symptoms associated with a bunion deformity (Figure 3). This thin silicone material lessens the rubbing over the bunion and decreases the irritation. A bunion pad should be combined with comfortable wider/soft shoes.
• A silicone toe spacer placed between the great toe and the second toe can help to straighten the bunion deformity and help re-align the big toe joint.
• Soft shoe inserts: Over-the-counter soft orthotics may also help bunion symptoms especially if there is more pain beneath the ball of the foot. Orthotics with a slight arch may be helpful for patients that have flat feet. Don’t forget that you may need to purchase a slightly larger shoe to comfortably wear the inserts.
• Bunion splints have often been used to treat the symptoms associated with hallux valgus. These splints are typically worn at night in an effort to reduce the bunion deformity. There is no evidence to suggest that these splints will reverse or slow the bunion deformity but some patient’s obtain some symptom relief by using bunion splints.

Operative Treatment of Bunions

Surgery should only be considered in patients who have failed non-operative options. Bunion surgery has the most success in patients with moderate to severe pain associated with the bunion, and SHOULD NOT be used solely for cosmetic reasons. Furthermore, all surgical patients must realize the prolonged time required for complete recovery from bunion surgery.

The primary indication for operative treatment of a bunion is pain that is not relieved by appropriate non-operative management. Although painless bunion deformities can slowly worsen or increase in size over time, surgical treatment is NOT recommended unless significant pain symptoms develop. “Preventative bunion surgery” is NOT recommended and can lead to disappointment.

The prolonged recovery time (3 – 12 months) associated with most bunion operations, combined with the potential for complications means that patients should be thoughtful about considering bunion surgery.

There are many different procedures that have been described to correct bunions. The type of operation your foot surgeon recommends to correct your bunion should be dictated by the severity of your bunion deformity and the surgeon’s preference. There are well over 150 different bunion correction procedures described in the orthopaedic literature. However, the broad categories of bunion correction procedures are listed below, some of which link to a page where the surgery and recovery are described in more detail.

• “Simple” bunionectomy: Removal of the prominence on the inside of the foot (medial eminence).
• Distal metatarsal osteotomy (Chevron): with great toe soft-tissue tightening (medial capsular tightening and distal soft-tissue repair). This involves cutting the bone near the toe joint.
• Proximal metatarsal osteotomy (Ludloff, Cresentic, SCARF, medial opening wedge): with great toe soft-tissue tightening (medial capsular tightening and distal soft-tissue repair). This also involves cutting the metatarsal bone along it’s shaft.
• Lapidus hallux valgus correction: This involves re-alignment and fusion of the first tarsometatarsal joint with distal soft tissue procedure.
• Great Toe Fusion (1st MTP joint arthrodesis): usually reserved with associated toe arthritis
• Akin osteotomy: Realignment bone cut at the base of the big toe
• Keller joint arthroplasty: Removal of the base of the great toe joint bone.

Please remember, bunion surgery is a serious operation and should not be considered “simple” regardless of your perception. There can be many misleading commercials suggesting an easy and quick recovery from bunions surgery but please be mindful of the risks. After all, your feet matter and shouldn’t be taken for granted.

When to see an orthopaedic foot specialist

For most people, sufficient education combined with following the above non-operative treatment measures will result in good function with fewer symptoms. Reasons to seek consultation with an orthopaedic foot specialist include:

• Persistent bunion pain that does not improve with shoe modification and other non-operative measures.
• Worsening bunion deformities that begin to involve the second toe, altering its alignment or causing additional pain.

Click Here for a Summary Handout about Bunions

Read More: 5 Things you probably didn’t know about bunions!

Edited May 29th, 2024

Previously edited by Eric Malicky, MD,  Daniel Guss, MD, M.B.A. and Jean Brilhault, MD

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