What is the main cause of bunions?
The vast majority of bunions affect people with a genetic pre-disposition to the condition. It is said that there are bunion-proof feet and bunion-prone feet. It is therefore, very much a hereditary condition. Almost invariably there is a family history and the reason why women are more commonly affected is because of the shoes that women tend to wear. Having said that a female with bunion-proof feet could wear bunion-provoking shoes and never develop the condition, whilst anyone, male or female, with bunion-prone feet might still develop the condition even if he/she never wears shoes at all. A famous study from over 50 years ago showed that 6% of Hong Kong fishermen have bunions and they had never worn shoes in their lifetime.
When should a patient seek medical help?
An Irish patient once told me that her father used to say…”If you want to forget all your problems, put on a pair of tight shoes.”
Bunions can be extremely painful but they can also be totally asymptomatic. Anyone with pain which affects their ability to wear shoes might want some guidance from a doctor, even if they don’t want to contemplate surgery.
A common condition that develops as a direct consequence of bunions, is hammering of the second toe (a cock-up deformity) and this is usually, but not always, associated with pain in the ball of the foot under the second toe MTP joint. Left alone, this symptom will result in deformity which will never spontaneously correct and often progresses in a relentless fashion, ultimately resulting in dislocation of the joint. Therefore anyone with pain under the second MTP joint in association with a bunion should seek help as a matter of some urgency. Sadly this is often misdiagnosed as a Morton’s neuroma. In 2003 I coined the expression “Moron’s neuroma” when this wrong diagnosis is made. The best way to distinguish between the two conditions is to ask a patient whether he/she is more comfortable walking on a wooden floor with or without shoes. People with a Morton’s neuroma invariably say “barefoot” and those with an inflamed 2nd MTP joint will say the opposite.
The other group of patients with a bunion who need to seek help are those in whom an infection of the bunion occurs. This is usually in the elderly but one infection will lead to frequent recurrent infections unless the bunion is corrected.
What can a patient do to help manage the pain themselves?
The easiest way to deal with the pain is to wear roomy shoes or open sandals or no shoes at all. This advice isn’t always well received and it is often not practical for an individual to follow. Going up half a shoe size may help but often, once a bunion has made its presence felt, this advice is too late. Sadly pain-killers don’t touch the sides and physiotherapy is rarely, if ever, helpful.
What are the most effective treatments options? Surgical and non-invasive?
The only “cure” for a bunion is surgery to correct the deformity. Having said that there are lots of simple things a patient can do to put off or avoid surgery but they all involve a change in shoes which, as outlined above, is often not practicable. Podiatrists have some tricks up their sleeves but only surgery can correct deformity. I have never met a patient who has been cured by a “bunion-correcting” splint but I’ve met many patients who have tried them.
How long is the recovering period if a patient undergoes surgery?
There are many different surgical techniques for bunion correction. Rarely a simple shaving of a bunion or a slight straightening of the proximal phalanx will do the trick and this is something that patients recover from in about 6-8 weeks or less. Sadly, the majority of patients with a bunion require a metatarsal osteotomy and often other procedures (such as hammer toe correction etc). Most patients who are honest will tell you it takes up to six months to recover but there will always be some who recover faster and indeed some more slowly than that. A patient once came to me for a third opinion because the first surgeon had said she would be walking the day after surgery whilst the second one had said she would not be in fashion shoes for six months. I pointed out that both statements were factually correct because patients do walk the day after surgery but bandaged, in a post-operative shoe, with crutches and the walking involves doing little more than going to the bathroom.
Are there any common misconceptions about Bunions?
I can’t think of a medical condition more associated with myths and misconceptions, than bunions! I am convinced that whilst some people sit on the fence about certain subjects it seems that everybody has an opinion about bunions and they are not shy about expressing their views. Although I have never done it, I have often contemplated what I would hear if I went to a bar and struck up a conversation with complete strangers on the subject of bunions.
The misconceptions can be summed up in the following sentence that I have heard regurgitated many times. “Oooh…Bunions… well what I know is that bunion surgery is very painful, takes six weeks to get over and it doesn’t work or makes you worse.”
The truth is that the pain associated with surgery can be managed easily and only really lasts for a few days at most. The recovery is six months not six weeks and it DOES work in the majority of cases if the right operation is done well AND the patient follows the post-op instructions. It never ceases to amaze me how far some people deviate from the advice given. In response to the advice to go home and elevate the foot for two weeks to ensure wound healing and avoid infection, one patient was surprised that wrapping her foot in Clingfilm and kneeling all day in a flowerbed on day 2 resulted in infection.
I think it is incumbent on all of us who are practising medicine to manage patients’ expectations and not dupe them into believing their recovery is going to be rapid when it is not. I know I shall never be able to dispel all the myths, but it will not stop me trying. What I find fascinating is that even in the second decade of the 21st century, the vast majority of patients do not realise that foot and ankle surgeons do bunion surgery and surgical podiatrists are not medically qualified, despite the fact that they perform surgery.
LFAC Consultant Mark Davies (Founder)
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