Hallux Valgus (Bunion)

At Schoen Clinic, you can receive comprehensive advice from our foot and ankle specialists and discuss which treatment is best for your symptoms.

Overview

A bunion refers to a prominence of the metatarsal bone on the outside of the big toe.  It leads to the big toe drifting outwards and the head of the bone becoming prominent on the inside of the foot.  This is also referred to as hallux valgus in medical terminology. 

Causes & Symptoms

The cause of bunions is essentially multifactorial. We now know that genetics predisposes you to having bunions and bunion deformities can run in families.  This is mainly because of the inherited predisposition to having flexible ligaments and hypermobility. Wearing shoes or high heels can encourage bunion formation in those who are predisposed. There are people who have worn high heels all their lives who do not have bunions, and there are ones who have bunions who have not worn heels, but what is important to know is that in time, if a bunion has developed wearing shoes with high heels or narrow toe boxes can be difficult and there will be persisting pain on the prominence of the bunion.   

In the initial stages, a bunion may be completely pain free. Essentially, if your shoes are not rubbing on the prominence of the bunion then there will be no symptoms. However, those who wear narrow shoes or high heels may experience pain, the bunion may in time become inflamed, red and uncomfortable. Occasionally, patients may complain that their feet hurt at the end of the day, or when they are wearing tight shoes.  Specialist footwear for example, work boots or ski boots may become a problem. 

When the bunions are more advanced there may be symptoms in-between the toes when they rub against each other. This is mainly between the big toe and the second toe, but sometimes causes problems with neighbouring toes too.  As weight bearing changes, patients tend to weight bear mainly on the second toe metatarsal rather than the big toe, this can result in pain underneath the second or third toes. It is not uncommon for a callus or hard skin to appear in this area and in more advance cases there may be deformities of the second or third toes, known as hammer toe deformities.

Diagnostics

When you attend your appointment for assessment of bunions, your consultant will examine your foot and ankle but also the entire lower limb. This will give your surgeon an opportunity to see how your foot is on weight bearing and during walking, and also to examine the range of motion of the big toe and the degree of flexibility that your metatarsal has. It will also give them the opportunity to examine the lesser toes to see if there are any deformities or symptoms in those areas. 

An x-ray of the affected foot is normally requested and this will be in the weight bearing position to assess the angles that the various bones are making with each other and the degree of the displacement of the first metatarsal.

Treatment

Bunions - surgery is not the only option

Many patients with bunions can manage their symptoms without the need for surgical correction.  There are a number of modalities that can be helpful. Changing your footwear is key. Basically wearing shoes that are wide around the toes and have a low heel can help alleviate the symptoms.  Physiotherapy and strengthening of the small muscles within the foot can help with symptoms of foot pain in general and there are certain exercises that may be helpful. Toe spacers can help, if there is any friction between the toes or to help with controlling a hammer toe deformity if this is rubbing in footwear. These splints or spacers are not likely to resolve any defomrity and are only there to relieve friction smptoms. 

 

Surgical Treatment:

If the non-surgical methods described above fail and you have ongoing symptoms or, if there are problems arising in the second or third toes because of the bunion, then one could consider surgery to correct the bunion.  

The aim of surgery is to realign the first metatarsal so that it is no longer pointing towards the inside of the foot. This is done through an incision on the inner aspect of your foot and the first metatarsal bone is cut and then realigned and fixed with screws (Scarf or Chevron osteotomy). At the same time, a correction of the actual big toe bone may also be required to realign it so that it is more straight (Akin osteotomy). This will also need to be fixed with a staple or a screw.

Whilst there are hundreds of operations described to correct a bunion. The combination of a Scarf and Akin osteotomy is now considered the gold standard and the vast majority of UK surgeons choose this surgery for the correction of bunion deformity with very high success rates.

On occasions, if there is a lot of arthritis within the big toe joint, as well as a bunion, then you may be recommended to have a big toe fusion surgery to straighten the bunion, but also to get rid of the arthritis pain.  Very rarely, if the deformity is severe, you may be required to have a fusion operation in the mid foot, known as a lapidus fusion but your surgeon will discuss your particular case with you.

Aftercare

If you have had an osteotomy and fixation (your metatarsal bone has been broken and fixed) it will take some time for the bone to heal and to become one unit again. Fortunately however with modern techniques available, you will not need a plaster cast and you can walk on your foot from day one. Generally, the time taken for the bone to heal is around six weeks. In this time, you will use a special forefoot relief shoe, where the weight is taken on the heel rather than the forefoot.

The surgery is performed as day surgery, and you are able to walk on the foot immediately after the operation.  We normally give you a local anaesthetic block around the ankle, as such you will have no pain on the first day, as the foot will be completely numb.  Weight bearing on the heel can commence in the special shoe on the first day. 

Any bandaging and dressings are removed at two weeks to assess the wounds, to ensure that there is no infection or any problems with wound healing and thereafter you would be wearing the shoe alone with a padded dressing over the wounds. At six weeks following the surgery, if x-rays are satisfactory, you will be asked to remove the shoe and you can wear a comfortable and wide fitting shoe.  Normally there is some persisting swelling that will last around three but sometimes up to six months following surgery, and in that time you may need to wear a wide fitting and comfortable shoe.  In our experience, after around three to six months the foot can resume a normal function without any limitations and you can return to wearing your favourite shoes and participating in sporting activities.