October 15, 2010
Dear Mayo Clinic:
How bad do bunions have to get before surgery is required?
Consider surgery when a bunion is painful every day, and you can no longer find comfortable shoes. But before surgery, exhaust all conservative approaches. Surgery to remove a bunion can be complicated and is not a quick fix. Recovery can take a few months.
A bunion is an abnormal bony prominence that develops on the base of the toe joint. Bunions usually occur on the big toes but the little toes can also be affected. The little toe version is called a bunionette. Not all bunions cause problems, but some are painful enough to interfere with day-to-day activities.
Bunions develop over time due to abnormal motion and pressure on the toe joint. Pain may occur over the bony prominence, which can vary in size. The joint at the base of the toe may be swollen, and the surrounding tissue may thicken. Bunions often occur in tandem with hallux valgus, a condition where the big toe is bent toward the second toe, pushing the bunion out past the normal profile of the foot. The resulting bulge on the side of the foot near the toe joint can be associated with intermittent or persistent pain.
Bunions usually are irritated by ill-fitting shoes. The worst offenders are high-heeled dress shoes with narrow pointed toes. Even when this type of shoe fits correctly and is not too tight, the design forces the shoe to bend the toes inward, causing friction and abnormal movement of the toe joints.
Not all bunions are related to shoe use. A hereditary structural defect in the foot can cause bunions. Arthritis can also contribute to bunions.
Most people can manage bunions successfully with conservative approaches including the following:
Shoes: The first stop is the shoe store. Shoes should have a wide, deep area for toes to avoid rubbing and putting pressure on the bunion. A shoe repair shop may be able to spot-stretch a shoe to reduce pressure in the area of a bunion.
Padding: Applying pads or cushioning around the bunion may help. Avoid over-padding, which might increase pressure.
Shoe inserts: They can help avoid abnormal foot motion. Options include over-the-counter arch supports or orthotics prescribed by a physician.
Medications: Over-the-counter pain relievers (acetaminophen or nonsteroidal anti-inflammatory drugs such as ibuprofen or naproxen) can help with pain.
When these approaches don't stop the pain, it's time to talk to a surgeon. Many different operations can help with bunions and related foot deformities. For example, the "bump" or damaged joint may be removed; the toe bones may be realigned or permanently joined (fused); or a portion of the bone may be removed. With so many options, it's important to work with an experienced orthopedic surgeon or podiatrist who has special training in foot surgery. And, it may be wise to seek a second opinion before making a final decision.
After surgery, patients may temporarily wear a surgical shoe or a cast. Some patients need to keep all weight off the foot for a time and use crutches or a knee caddy.
The goal of surgery is to relieve pain and improve function. Surgery should not be done for cosmetic reasons or to get patients back in high-heeled shoes. Done correctly, surgery can result in significant pain relief for most patients, although patients may not be totally pain free. And surgery may not help everyone. I encourage people to work closely with a specialist to determine the best medical and surgical treatment options for them.
ā Gordon Weller, D.P.M., Orthopedic Surgery, Mayo Clinic, Rochester, Minn.