Getting Relief from Painful Bunions

Have you or someone you know been suffering from pain in your big toe joint? If you have googled what can cause this type of pain, you may very well likely have come across some information about bunions. While there is no perfect way to know, estimates are that bunions are seen in 1 in 4 people. Some reports suggest 24-36%. You better believe that as podiatrists, we see thousands of bunions every year. Thankfully, not everyone walking into our office with a bunion has pain, but what happens if you do? There are so many treatments available for bunions and while the bunion you have today will not go away without surgery, conservative treatments can offer relief of pain as well.

So what is a bunion?

People tend to refer to any bump or pain of the big toe joint as a bunion. However, there are 2 types of ‘bunions’ that we see and treat every day.

Hallux Abductovalgus

Hallux is the latin term for the big toe and abductovalgus refers to an abnormal position the big toe is in when a person has a true bunion deformity. When you look down at your feet, a true hallux abductovalgus deformity appears as a bump or prominence on the inner aspect of the foot, often accompanied by a drifting and rotational position of the big toe towards the smaller toes. Pain can occur anywhere around the big toe joint. However this type of bunion is that which makes certain shoes uncomfortable to wear due to pressure causing pain on the bump itself.

Anatomically, the cause of a bunion is very often related to instability and muscular imbalance in the foot that over time allows the bone behind the big toe to drift toward the midline of the body, becoming little by little more prominent. That’s right – the bump you see is most often NORMAL bone rather than extra bone, just directed in an abnormal position.

There is certainly a genetic predisposition to develop hallux abductovalgus. Not to say any baby is born with a bunion, but rather we all inherit certain traits that lead to an altered transition of weight through the foot while walking, leading to compensation, instability and the development of deformities in the feet. There are even some patients we see who have what is classified as a juvenile bunion, this is when a bunion is present before the age of 18, often seen before the growth plates of our feet have fully developed.

Hallux Limitus and Hallux Rigidus

As mentioned earlier, hallux refers to the big toe. Limitus and rigidus quantify a certain level of stiffness or lack of motion in the big toe joint. Hallux limitus and hallux rigidus are most classically seen as a bump on the top of the big toe joint and often pain occurs on the bump on top with certain shoes. A feeling of stiffness, pain with range of motion through the big toe joint and even in more advanced stages clicking and grinding sensations can occur. This type of bunion can be considered an arthritic process of the big toe joint.

As with hallux abductovalgus, hallux limitus and hallux rigidus can occur due to inherited foot structure and foot mechanics. There are, however, many people that develop this condition due to an injury. A high school incident of turf toe can result in hallux limitus 10, 20 or more years later. Jamming the toe badly, whether you have fractured it or not, can also start a degenerative process in the big toe joint. Also, having hallux abductovalgus can cause degeneration of the joint over time due to the uneven pressure on the joint from the altered position of the big toe on the joint.

It is important to note that regardless of which type of bunion a person has, not all individuals have pain from these conditions. Knowing this helps in understanding why having a bunion doesn’t mean it has to be corrected, though ultimately most people choose to do this.

Capsulitis

Capsulitis is a term that refers to inflammation of a joint. Capsulitis can occur to any joint, but certainly is more possible if there is underlying pathology such as hallux abductovalgus or hallux limitus/rigidus present.  When it comes to bunions, capsulitis can be thought of as the ‘flare up’ of pain that can occur. In some instances, our patients cannot recall what may have caused a flare up. In others, it could be wearing a certain shoe they aren’t used to. It can be due to doing more than usual on the feet. It can even be due to underlying systemic arthrtides such as rheumatoid arthritis, lupus or gout (to name just a few).

When getting relief of bunion pain, a patient may just need this acute inflammation (capsulitis) to be managed. Here are a few ways we can accomplish this:

●  NSAIDS – nonsteroidal anti-inflammatories improve pain because they alleviate inflammation which is most often why the body is perceiving pain. A course for 2-3 weeks can be all someone needs to get things under control again.

●  Steroidal anti-inflammatories – some patients cannot take NSAIDs and some have such a severe flare up (often with gout) that steroidal anti-inflammatories may be preferred over NSAIDs. In many cases, this type of medication works faster, so taking this for only 1 week may be adequate to reduce pain and inflammation.

●  Icing – for those unable to take NSAIDs or other medications, or for those who want to do everything possible to calm down that joint, icing several times throughout the day helps to curb inflammation as well.

●  Strapping and padding – if the big toe joint is inflamed, immobilization with a splint can be useful to reduce stress on the joint that can otherwise exacerbate the inflammation and pain. Strapping is not anticipated to be needed long term, but just as with an ankle brace after an ankle sprain, it helps us to rest and support the aggravated joint without having to sit with your foot elevated for 2 weeks while things settle down. Padding can be used to provide some protection against friction from shoes that can happen on the prominence in bunions. Some padding loops around the toe and some can provide some relief of pressure between the big toe and the 2nd toe if you have pain from the rubbing of the two toes against each other. Silicone tape is another great way to reduce painful friction on the skin of the bony prominence.

●  Steroid injections – this is a more direct way to administer anti-inflammatory medications to the area of pain. Some resort to injections if oral medication has failed and others require injection due to contraindications to oral medications.

●  Physical therapy – many modalities available in PT can help to reduce pain and improve strength in the feet, though PT is not the preferred way to manage bunion pain. It is however very important post-operatively.

●  MLS laser – another form of anti-inflammatory, this non-invasive and non painful treatment can assist in reducing pain and inflammation of nerves around the big toe joint that can be a part of the pain you feel.

●  Custom orthotics – Whether they all are saying it or keeping it to themselves, patients often wonder how an ‘arch support’ can help their bunion. To be clear, the bunion you walk into our office with will not go away without surgery. The ads will certainly promise otherwise. Sandals, yoga toes, exercises are touted to get rid of bunions, but when you talk with your doctor about the root cause of the bunion, it will become clear why this isn’t the case. So how then can someone believe that an insert in your shoe will help your bunion? As discussed earlier, a true bunion (hallux abductovalgus) is linked with instability in the arch of the foot (in some cases more than one joint in the middle of the foot). By stabilizing this joint, not only can we optimize the function of your big toe joint, but we can assist the feet in more effectively and evenly distributing weight while you walk and stand which results in less overload to the joints leading to pain. For mild to moderate bunions (hallux abductovalgus), consistent use of custom orthotics helps to slow progression of the bunion down and reduce the likelihood of wear and tear in the foot that can cause flare ups of pain. In the case of hallux limitus or rigidus, orthotics are made differently depending upon the severity of the arthritis in the joint. In some instances, a modification in the orthotic can help to improve normal and nonpainful motion through the big toe joint. If the joint appears on xray and on your physical exam as being severe, the orthotics may include a modification to immobilize the joint to reduce bone on bone rubbing that leads to pain. Of all conservative treatments for bunions, custom orthotics are the most proactive form of treatment and in most instances, are critical prior to considering or scheduling surgery. There are also many podiatrists that encourage patients to wear orthotics even AFTER surgery for a bunion, as the position of 28 bones and even more joints within the foot are not all addressed when your bunion is corrected. This means that in some instances the custom orthotics help to reduce recurrence (think of the analogy of wearing a retainer after having had braces) and also to help combat any other pains that can arise due to the altered position and stress of joints after some types of surgery.

When conservative measures fail

Let’s say you have tried it all. Either you had relief that was short-lived, or you never felt like your pain resolved entirely. Surgery can be performed for both hallux abductovalgus and also for hallux limitus/rigidus. The type of procedure(s) recommended by your surgeon is based upon your specific condition as well as its severity and your surgical goals. Here are a few of the possible surgical treatments that your doctor may recommend.

●  Bunion with osteotomy – osteotomy is a cut of a bone, so with bunions, this allows your surgeon to move the prominent bone back over such that there is some realignment of the big toe joint and a smaller prominence.

●  Bunion correction with fusion of the midfoot – also called a Lapidus, this procedure is more popular today than in the past because not only does it address the deformity at its root cause (the instability in the joint in the midfoot) but with systems like Lapiplasty and Lapifuse, we now have enhanced stability with the hardware used in surgery that allow earlier walking after surgery. This also means it reduces some of the post-operative risks.

●  Cheilectomy – this procedure removes extra bone and is used in cases of earlier hallux limitus, where there is no or little suspected joint damage. This can reduce the prominence on top of the big toe joint by removing bone spurs that have formed.

●  Fusion of the big toe joint – this procedure can be used in instances of moderate to severe hallux rigidus as a more definitive treatment and while many worry what will happen when they can’t move their big toe joint anymore, the truth is that some experience pain because of this bone on bone motion and others don’t actually utilize the motion available in the big toe joint because they have accommodated for this condition for so long. In very severe hallux abductovalgus and a certain population of patients, fusions can be performed to provide a more predictable position of the big toe and more long lasting correction of the prominence.

Surgical procedures to alleviate bunion pain have variable recovery times and post-op restrictions. If you are facing surgical intervention for your big toe joint pain, your surgeon will ensure you understand what to expect in both the short-term and long-term post operative period.

If you suffer from big toe joint pain, the very first thing to do is consult an expert. Understanding your specific condition and what treatments are recommended for you is the key to a successful treatment plan. Call our office today if you want to meet with one of our excellent podiatrists to see what we can do for you!