A common condition, commonly misunderstood. Bunions are one of the most common foot problems among adults in the U.S. Studies show that one quarter to one third of adult Americans have bunion deformities, with the incidence of bunions significantly higher in women and older adults. “This is a condition that we see very frequently,” says Robert S. Marsh, D.O., foot and ankle specialist at Orthopaedic Associates of Michigan Foot & Ankle Center. Despite the frequency of the condition, it is commonly misunderstood. A bunion typically appears as a bump on the inside edge of the foot, where the first metatarsal – or innermost bone of the foot – meets the big toe. People often think the bump is extra bone growth or a deformed bone. “A bunion is not a deformed bone,” explains Dr. Marsh. “It is a malaligned bone. In a true bunion, the first metatarsal shifts outward so the metatarsal head creates a prominence, or bump, on the inside of the foot near the big toe joint.” The severity of the condition varies significantly. Some people have a very mild foot deformity with a small bump and no pain, while others have a large bump, arch loss, deviation of the toes, chronic foot pain, and sometimes pain in the calf. Diabetics with neuropathy of the feet are also at higher risk for developing ulcers where the bump rubs against their shoe.
What causes bunions? Various factors, including a tight gastrocnemius (or calf) muscle and instability of the arch, contribute to formation of bunions. The tight calf muscle is often hereditary and can cause a bunion because it forces more loading, or pressure, on the forefoot. “Ultimately, this can contribute to instability in the bones, ligaments and tendons that form the arch,” says Dr. Marsh. “When it’s unstable, the arch starts collapsing and the metatarsal can shift.” Arch instability can also be brought on by obesity – again, due to chronic overloading of the foot. But, by far, the most common contributing factor is childbirth. “Bunions are most common in women who have had children. This happens because the hormones that affect their pelvis during childbirth also affect their feet,” explains Dr. Marsh. “The hormone is called relaxin, and it allows bones to move and spread. Over time, it can cause the structure of a woman’s feet to gradually stretch and the metatarsal to shift.”
What’s a mother (or anyone with bunions) to do? Knowing that childbirth, heredity and obesity are all contributing factors, is there anything that can be done to prevent bunions? “In general, we don’t have a clear answer to that,” says Dr. Marsh. “The main thing would be to watch your weight. Excess weight can contribute to several foot problems, including bunions, so it’s always a good idea to keep your weight in check.” Once a patient develops a mild bunion, doctors are certain about one thing when it comes to prevention: Surgery should never be used to prevent a worsening condition. “People ask me that a lot,” says Dr. Marsh. “If you’re pain free or only have mild symptoms, you should not get surgery to prevent further deformity. If you’re experiencing mild discomfort or difficulty fitting in shoes, we would start with more conservative recommendations like wearing shoes that have a wider toe box. Or, we may recommend getting fitted for an orthotic to support your arch and prevent it from collapsing. The majority of bunions don’t – and won’t – require surgery.”
A bunion is not just a bump – and shouldn’t be treated like one. However, if you do develop a more pronounced bunion and it’s causing chronic pain, stiffness or severe deviation of the toes, you should consult your doctor. He or she will evaluate your condition and determine if surgery is recommended. At that time, it’s important that you consult with an experienced foot and ankle specialist who is familiar with treatment of the entire foot and ankle and is knowledgeable about the various factors that contribute to bunions. If they recommend surgery, it’s also a good idea to get a second opinion. “I always tell patients that they should get a couple opinions. If they decide to have surgery, make sure they select a doctor who is experienced in bunion surgery,” says Dr. Marsh. “An orthopaedic surgeon who specializes in foot and ankle surgery understands that a bunion is not simply a bump, and it’s not a bone deformity – it involves the whole foot and likely the calf muscle,” he explains. “To successfully correct it long-term, you have to ask ‘why did the bunion form?’ Then you have to address the cause. If you don’t, it will come right back or you’ll have other problems.” For instance, in 80 to 90 percent of the bunion surgeries he performs, Dr. Marsh does a gastrocnemius recession to release the tight calf muscle and unload – or relieve pressure on – the forefoot. “I would typically combine that with a mid-foot fusion,” he says. “We correct the tight calf muscle and the shifting first metatarsal and the unstable areas of the first metatarsal phalange joint – that’s the only way to ensure long-term success.” Dr. Marsh encourages patients to take this big-picture approach when they seek a second opinion from a surgeon. “Ask the doctor to explain the procedure, then ask yourself if what the surgeon is recommending makes sense. They should be able to explain why the bunion formed, how they will address the various contributing factors and why they do each part of the procedure.”