BUNIONS AND BUNIONETTES
Bunions and bunionettes can frequently affect athletes. There is a great deal of misunderstanding about bunions. First, the pronunciation isn't always correct. It rhymes with the word "onion". In fact, the Greek word "bunion" and the Latin word "bunio" mean turnip, so this isn't too far-fetched from the onion that we know today. Bunions are a very common problem in the feet of human beings. Women especially are prone to get this enlargement over the first toe of the foot. Technically speaking, the only place we can apply the term bunion correctly is to the first toe joint where the big toe joins the foot, called the first metatarsophalangeal (MTP) joint.
The cause of the bunions is not definitely known, although heredity seems to play a big part. We do know that in societies where there is a tendency not to wear shoes, there is the same incidence of bunions that we have in developed society; however, their bunions are not painful! Therefore, it would seem that bunions that are painful generally are related to wearing shoes that are too tight in this area. After the bone protrudes, then a bursa is formed over the bone. A bursa is a sack of fluid and everyone has bursas all over their body situated at places in the tissue where friction would otherwise develop. This particular joint already has a bursa, but in the case of bunions, the bursa becomes quite enlarged with extra fluid and it become painful. Usually, it is this bursa over the bony prominence that is the painful thing, not the bone itself.
Treatment varies for this problem. There are splints that can be worn at night to try to correct this problem and there are shoes that can be purchased that give this area plenty of room. These measures can at least stop the pain. If there is a biomechanical abnormality, it should be alleviated with orthoses (often incorrectly called "orthotics"). There are at least fifty surgical procedures which have been developed for this area of the foot to try to relieve the patient of a bunion. Some of these are good; some of them fail miserably. In recent years, a realignment of this bone and removal of some of the excess bone in this area has been one of the most rewarding procedures. Surgery is not always 100% successful, although we do have good results now that we are doing proper alignment for proper indications. It is not good surgical judgement to operate on bunions strictly for a cosmetic standpoint. The reason this is true is one can go into surgery with painless bunions and come out minus the bunions, but with painful feet. About 5% of those who have bunion surgery wind up with more pain after the surgery than before. For this reason, surgery needs to be considered for some time before it is actually performed. An opinion from one who does a lot of foot surgery is probably a good idea. Even better, seek the advise of a member of the American Orthopaedic Foot and Ankle Society, whose members have special expertise in this area. For nonoperative treatment, see a Certified Pedorthist (C.Ped.).
The "bunionette" is related to a bunion, although it is on the fifth toe on the lateral or outside of the foot. A bunionette is caused by the same problem that causes a bunion; the bone deviates a little more than it should, there is pressure put upon it and then a bursa forms over the area. A bunionette can be corrected in much the same way as a bunion and fairly often, both of these procedures may be necessary to correct the painful problems the patient is experiencing. A proper shoe will prevent or at least minimize the need for surgery for both of these, simultaneously.
Young girls in their mid to late teens, if they have early bunions, will probably progress to very painful and deformed feet. For this reason, it is recommended that they have a reputable surgeon, who does a good amount of foot surgery, evaluate them for possible correction of this bone while they still young. This is recommended because we know the natural history of the disease. What happens is that the space between the bone gets wider while the big toe deviates laterally and dislocates off the end of the metatarsal bone. Sometimes it gets underneath the second toe and sometimes it rotates where the side of the toe is actually being walked on. Perhaps not all of these young girls will require surgery, but nevertheless, the feet should be x-rayed and the angle checked between the first metatarsal and the second metatarsal. If the angle is 10 degrees or more, then likely they are going to get into trouble. If so they need to be followed closely to see if any problem is developing.
Many of you have seen your mother or grandmother with horrible looking feet that are not painful, and indeed, they have adapted to these bunions and the malalignment of the toes by wearing wider shoes. If they can do this successfully, then these feet do not need to be operated on. However, if the feet become more painful, then a realignment procedure probably should be done to allow them to be active in their old age. A lot of times, the patients become inactive and more susceptible to injuries and disease just because their feet hurt. They just don't want to get out and do their exercise, their walking or their chores because of painful feet. This type of patient very often can be helped with the realignment procedures. Even athletes may require surgery, but the recovery time for athletes (except swimmers), is longer than for the general public.
Many times exercises have been recommended for bunions, and indeed, sometimes exercising and wearing night splints to help hold the big toe over will postpone the time that surgery is required and possibly eliminate the need for surgery, but not very often.
Occasionally, in spite of the best possible surgery, a bunion may recur, even to the point that repeat surgery is needed. This occurs in about 5% of all feet, especially in severe cases.
TYPES OF BUNIONS
A positional bunion develops when a bony growth on the side of the metatarsal bone enlarges the joint, forcing the joint capsule to stretch over it. As this growth pushes the big toe toward the others, the tendons on the inside tighten. This, in turn, forces the big toe further out of alignment, The bunion presses against the shoe, irritating the skin and causing further pain.
TREATMENT: POSITIONAL BUNIONECTOMY. The bump is removed. A wedge of the joint capsule may be removed to reposition it. Tight tendons may be released.
FOLLOW-UP CARE. Your toe is apt to be stiff at first, but will loosen up as you move it. You may need to wear a special wooden shoe and, possibly, a splint for about three to four weeks.
MILD STRUCTURAL BUNION
Structural bunions occur when the angle between the first and second metatarsal bones increases to a point where it is greater than normal. The increased angle of the metatarsals makes the big toe bow toward the other toes. Sometimes bony growths may form. Irritation and swelling may often follow. The tendency toward developing this painful condition is usually inherited.
TREATMENT:STRUCTURAL BUNIONECTOMY. The surgeon repositions the bone. Without the bowing of the metatarsals, the bunion disappears, but any bony enlargement will also need to be removed.
FOLLOW-UP CARE. Since the bone has been cut, healing takes several weeks. You may need to wear a splint and a special shoe for roughly 6-8 weeks. Then athletic endeavors may be slowly resumed.
SEVERE STRUCTURAL BUNION
A structural bunion becomes severe when the angle between the metatarsal bones of the first and second toes grows greater than the angle of a mild structural bunion. Again, a tendency toward developing this condition is usually inherited. The big toe bows toward the others, sometimes causing the second and third toes to buckle (hammertoes). Irritation, swelling, and pain may increase when the tight shoes are worn.
TREATMENT: BASILAR OSTEOTOMY. A wedge of bone is removed so the surgeon can reposition the metatarsals. Tiny wires or screws may be used to stabilize the bone.
FOLLOW-UP CARE. Your foot and ankle may be immobilized by a cast (from your toes to below your knee). You may be asked not to bear weight on this foot for a few weeks. Return to athletics requires twice as long as for surgery for mild structural bunions.
While not a true bunion, this condition is often associated with bunions. Bunions, left untreated, can increase wear and tear in the joint of the big toe, break down the cartilage, and pave the way for degenerative diseases such as arthritis. (Osteoarthritis is the breakdown of joint cartilage from normal aging; rheumatoid arthritis involves other parts of the body as well.) Pain and stiffness are symptoms of both.
TREATMENT: ARTHROPLASTY WITH PLASTIC IMPLANT. First, any bunion is removed; then the degenerated joint is removed and replaced with a silastic (plastic) implant.
Unfortunately, these plastic joints often wear out after a few (5-15) years and may break and/or require a replacement or salvage operations; however, for the proper indications, they may be the best operative procedure, especially for elite athletes.
FOLLOW-UP CARE. You may be able to walk in a day or two after surgery. Your doctor may prescribe a splint or a special shoe to be worn for several weeks.
NOTE: If the patient is not a rheumatoid patient and is fairly young, the best treatment may be to fuse the big toe joint. If this is the case, a cast may be required for several weeks after surgery. Fusion, however, severely limits what some athletes can do, but rarely prevents lifting, relatively static athletic endeavors.
Also, if there are hammertoes, especially ones that cross-over (or under) the big toe, they should be treated simultaneously with the bunion.
If bunionettes are painful, they also may be treated at the same time as the bunion.
1. Henry, A.J., Waugh, W., The Use of Footprints in Assessing the Results of Operations for Hallux Valgus Accompanying Keller's Operation and Arthrodesis, J. Bone JOint Srg., 57B, pg. 478, 1978.
2. Keller, W.L., Further Observations on the Surgical Treatment of Hallux Valgus and Bunions, NY Med., J, 95, Pg. 696, 1912.
3. Keller, W.L., Surgical Treatment of Bunions and Hallux Valgus, NY Med. J., 80, ph. 741, 1904.
4. Lapidus, P.W., The Author's Bunion Operation from 1931 to 1959, Clin, Orthop., 16, pg. 119-135, 1960.
5. Mayo, C.M., The Surgical Treatment of Bunions, Ann. Surg., 48, pg. 300, 1908.
6. Miller, J.W., Distal First Metatarsal Displacement Osteotomy: Its Place in the Schema of Bunion Surgery, J. Bone Surg., 56A, pg. 923, 1974.
7. McBride, Earl D., The Surgical Treatment of Hallux Valgus Bunions, American Journal of Orthopedics, pg. 46, Feb., 1963.
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