Understanding Bunions: The Basics

A bunion, medically known as hallux valgus, is a bony bump that forms on the joint at the base of your big toe. This condition occurs when some of the bones in the front part of your foot move out of place, causing the tip of your big toe to be pulled towards the smaller toes and forcing the joint at the base of the big toe to stick out. 

This deformity can lead to various symptoms, including pain, swelling, and discomfort, especially when wearing shoes. The decision to undergo surgery for a bunion is not straightforward and depends on multiple factors, including the severity of the symptoms, the degree of deformity, and the impact on your daily life.

The Anatomy of a Bunion

To understand when to have bunion surgery or whether surgery is necessary, it is essential to grasp the anatomy of a bunion. Your foot consists of numerous bones, ligaments, and tendons that work together to support your weight and enable movement. 

The big toe, or hallux, plays a crucial role in maintaining balance and proper gait. A bunion forms when the first metatarsal bone, located just behind the big toe, shifts toward the opposite foot. The toe slips on the knuckle joint and points towards the neighboring second toe. 

Problems occur because the joint at the base of the big toe protrudes or because of secondary problems affecting the smaller toes. Over time, the big toe misalignment can lead to changes in the surrounding tissues, including inflammation of the bursa (a fluid-filled sac that cushions the joint), thickening of the skin over the bunion, and even leading to the development of arthritis within the joint.

Symptoms and Impact on Daily Life

The symptoms of a bunion can vary widely, ranging from mild discomfort to severe pain. Common symptoms include:

• Pain and Tenderness: Bunion pain is often localised around the joint at the base of the big toe. This pain may be persistent or intermittent, worsening with prolonged standing, walking, or wearing tight shoes.
• Swelling and Redness: The skin over the bunion may become swollen, red, and tender to the touch. This inflammation can be exacerbated by friction from shoes.
• Limited Movement: As the bunion progresses, the range of motion in the big toe joint (metatarsophalangeal joint) may decrease, making it difficult to bend or straighten the toe.
• Corns and Calluses: Due to the abnormal pressure placed on the foot, corns and calluses may develop on the sole or the side of the foot.
• Foot Deformity: In severe cases, the big toe may overlap or underlap the adjacent toes, leading to further deformity and discomfort.
• Pain in the ball of the foot (metatarsalgia): Once the big toe is not straight, it is not strong. Extra work has to be done by the smaller toes. This can lead to pain and eventually hammer toe formation, with the smaller toes clawing up.

The impact of these symptoms on your daily life can be significant. If your bunion causes chronic pain, interferes with your ability to walk or perform daily activities, or limits your choice of footwear, it may be time to consider surgical intervention. However, surgery for cosmetic reasons is not recommended because of the long recovery and the small risks of surgery.

How Experienced Clinicians Approach Treatment 

Experienced surgeons and medical professionals understand the gravity of recommending  surgery and generally take a cautious and measured approach. For these professionals,  surgery is not simply a solution but a final option after all other avenues have been explored. 

1. Comprehensive Evaluation 

Before recommending surgery, experienced clinicians conduct thorough evaluations that  often include reviewing medical history, conducting physical examination, ordering imaging  studies (like X-rays, MRIs, or CT scans), and considering the patient’s overall health and  comorbidities. They also assess the patient’s lifestyle, goals, and preferences. 

For example, in a patient with Achilles tendon pain, an experienced clinician will not rush to  recommend surgery without first considering physiotherapy, activity modification, orthotics  and injections. 

2. Collaboration and Multidisciplinary Approaches 

In many cases, experienced clinicians work collaboratively with other healthcare  professionals, such as physiotherapists, pain specialists, or rheumatologists, to develop a  comprehensive treatment plan. This multidisciplinary approach ensures that all treatment  options are considered before recommending surgery. 

By collaborating with experts from various fields, the surgeon can ensure that the decision  to operate is made only after non-surgical treatments have been exhausted, and the  patient’s overall health and recovery potential are considered. 

3. Emphasis on Conservative Treatment 

Many experienced clinicians emphasize conservative treatment options as the first line of  care. This could include lifestyle changes, medication, physiotherapy, orthotics, injections,  or even watchful waiting in certain cases. These non-surgical interventions often provide  significant relief and improve patient outcomes without the need for invasive procedures. 

For conditions like osteoarthritis, where surgery may eventually be necessary, experienced  clinicians will try non-surgical interventions, such as exercise, weight loss, and medications,  before recommending joint surgery.

4. Risk-Benefit Analysis 

Every surgical decision involves a careful risk-benefit analysis. Surgeons weigh the potential  benefits of the procedure against the risks, including the patient’s age, comorbidities, and  the potential for post-operative complications. Surgery is only recommended when the  potential benefits significantly outweigh the risks and when all other treatment options have  been tried and found to be insufficient. 

For example, in elderly patients with heart disease, a surgeon may be reluctant to  recommend a major operation unless it is absolutely necessary due to the increased risk of  complications from anesthesia or surgery itself. 

Non-Surgical Treatments: The First Line of Defense

Before considering when to have bunion surgery, it’s essential to explore non-surgical bunion treatment options. These conservative approaches aim to alleviate pain, reduce inflammation, and slow the progression of the deformity. Some common non-surgical treatments include:

• Footwear Modifications: Wearing shoes with a wide toe box, low heels, and soft uppers can help reduce pressure on the bunion and provide relief from pain. Custom orthotics or shoe inserts can also help correct foot mechanics and distribute weight more evenly across the foot.
• Padding and Taping: Padding the bunion with moleskin or gel-filled pads can help reduce friction and prevent irritation. Taping the foot can also help maintain proper alignment and reduce strain on the joint.
• Ice and Anti-Inflammatory Medications: Applying ice to the bunion and taking over-the-counter anti-inflammatory medications (such as ibuprofen) can help reduce pain and swelling.
• Calf stretches: Many bunion sufferers have naturally tight calf muscles and this is believed to exacerbate the problems. Calf stretches at home can be helpful, as is physiotherapy.
• Physiotherapy: Exercises to strengthen the small muscles of the foot and improve flexibility can help maintain joint mobility and prevent further deformity.
• Injections: Corticosteroid injections may be used to reduce inflammation and relieve pain, particularly in cases where bursitis (inflammation of the bursa) is present.

These non-surgical treatments can be effective in managing the symptoms of a bunion, particularly in the early stages of the condition. However, they do not address the underlying structural deformity and may not be sufficient for severe cases.

Non-surgical treatments cannot “cure” hallux valgus, but do help to manage the symptoms and avoid the long recovery and risks associated with surgery.

When to Have Bunion Surgery

Surgery is typically considered when non-surgical treatments fail to provide adequate relief or when the bunion significantly impacts your quality of life. The decision to undergo surgery is highly individual and should be made in consultation with a qualified orthopedic surgeon. Several factors may indicate the need for surgery, including:

• Severe and Persistent Pain: If you experience constant or severe pain that limits your ability to walk, exercise, or wear shoes comfortably, surgery may be necessary to alleviate the discomfort.
• Progressive Deformity: If the bunion continues to worsen over time, leading to increased deformity and difficulty in wearing shoes, surgery may be the best option to correct the alignment and prevent further deterioration.
• Failed Conservative Treatments: If you’ve tried non-surgical treatments without significant improvement in your symptoms, surgery may be the next step in managing your bunion.
• Arthritis in the Joint: In some cases, bunions can lead to arthritis in the big toe joint, causing stiffness, pain, and reduced mobility. Surgery may be necessary to address both the bunion and the arthritic changes.

Types of Bunion Surgery

There are many surgical procedures available to correct bunions, which reinforces the fact that no one solution is perfect for all patients. The type of surgery recommended will depend on the severity of the bunion, the degree of deformity, and your overall health. Sometimes additional procedures to deal with e.g. hammer toes or tight calf muscles are recommended in addition. Some common types of bunion surgery include:

• Osteotomy: This is the most common type of bunion surgery. It involves cutting and realigning the bones in the foot to correct the deformity and rebalance the toe on the end of the knuckle bone (metatarsal). The bones are then stabilied with screws, pins, or plates to hold them in place during the healing process. Occasionally the metalwork has to be removed at a later date, but in most instances it is left permanently.
• Arthrodesis: In this procedure, the joint at the base of the big toe is fused shut to eliminate pain and correct the deformity. Arthrodesis is typically reserved for severe cases of arthritis or when other surgical options are not viable.
• Exostectomy: Also known as a bunionectomy, this procedure involves removing the bony bump on the side of the foot without realigning the bones. While this can provide pain relief, it does not address the underlying deformity and may not be sufficient for more advanced cases. This is seldom used in modern surgical practice.
• Resection Arthroplasty: This procedure involves removing a portion of the damaged joint and reshaping the bone to create a more functional joint. Resection arthroplasty is often used for patients with severe arthritis or those who have had previous unsuccessful bunion surgeries.
• Minimally Invasive Bunion Surgery: This technique involves making several small incisions rather than one medium sized one. Although popular in some European countries there is no specific advantage. Surgical outcomes are the same as for osteotomy. Minimally invasive surgery is not suited to every case.

Recovery and Post-Operative Care

Recovery from bunion surgery varies depending on the type of procedure performed and your overall health. Generally, you can expect the following during the recovery process:

• Immobilisation: After surgery, your foot may be placed in a bulky bandage and surgical shoe to protect the area and ensure proper healing. Weight-bearing activities are limited for the first two weeks to allow time for skin healing.
• Pain Management: Pain is not common after surgery, since local anaesthetic injections are used to numb the area. Your doctor will prescribe pain medications and it is important to take these religiously for the first 2-3 days after the operation even if there appears to be no pain. If you wait until the local anaesthetic wears off to begin tablets then pain builds up quickly. Icing the area to reduce swelling helps a little.
• Physiotherapy: Once the initial healing phase is complete, physiotherapy is important to improve range of motion, strengthen the foot, and restore normal function.
• Gradual Return to Activity: It may take several weeks or months before you can resume normal activities, such as walking, exercising, and wearing regular shoes. Some degree of swelling persists even beyond 6 months after surgery. Follow your doctor’s recommendations to ensure a safe and successful recovery.
• Long-Term Results: Bunion surgery is generally effective in relieving pain and correcting deformity, but it may take several months to see the full benefits. In some cases, the bunion may recur, particularly if underlying factors such as improper footwear or foot mechanics are not addressed.

Risks and Considerations

Like any surgical procedure, bunion surgery carries risks, including infection, nerve damage, blood clots, and complications related to anesthesia. There is also a risk that the bunion may return, particularly if post-operative care instructions are not followed or if the underlying causes of the bunion are not addressed. 

Additionally, some patients may experience stiffness, reduced range of motion, or ongoing pain after surgery. Rarely the bunion is too straight afterwards with a gap between the big toe and the second toe. 

It’s essential to discuss these risks with your surgeon and weigh them against the potential benefits before deciding to proceed with surgery. Thankfully it is very rare (but not impossible) for the foot to be worse after surgery.

Making the Decision: Is Surgery Right for You?

Deciding if and when to have bunion surgery is a personal choice that should be made based on your individual circumstances. Consider the following questions when making your decision:

• How Severe Are Your Symptoms? If your bunion causes significant pain, interferes with your daily activities, and limits your ability to wear shoes, surgery may be a reasonable option. Surgery is not advisable for purely cosmetic reasons.
• Have You Tried Conservative Treatments? If non-surgical treatments have not provided sufficient relief, surgery may be the next logical step.
• What Are Your Goals? Consider what you hope to achieve with surgery. If your goal is to relieve pain, correct deformity, and improve your overall quality of life, surgery may be worth considering.
• Are You Prepared for Recovery? Bunion surgery requires a commitment to the recovery process, which always involves several weeks or months of limited activity, physical therapy, and follow-up appointments. Ensure that you are prepared for the time and effort required to achieve a successful outcome.
• What Are the Risks? Discuss the potential risks and complications with your surgeon and consider whether you are willing to accept these risks in exchange for the potential benefits of surgery. Problems occur only rarely, but if you suffer a complication then it can cause you a great deal of trouble and even result in the foot being worse rather than better.

Conclusion 

Bunions (hallux valgus or metatarsus primus varus) are a common foot condition that can cause significant pain, discomfort, and deformity. 

While non-surgical treatments can be effective in managing symptoms, they may not be sufficient for severe cases. Bunion surgery offers a potential solution for those who experience persistent pain, progressive deformity, or a significant impact on their quality of life. 

However, surgery is not without risks, and the decision to undergo the procedure should be made in consultation with a qualified healthcare professional. By carefully weighing the benefits and risks, considering your individual circumstances, and exploring all available treatment options, you can make an informed decision about whether bunion surgery is right for you.