Bunion

A bunion is a bony deformity of the joint at the base of the big toe.

Information written and reviewed by Certified Doctors.

Contents

Introduction

A bunion is a bony deformity of the joint at the base of the big toe.

The main sign of a bunion is the big toe pointing towards the other toes on the same foot, which may force the foot bone attached to it (the first metatarsal) to stick outwards. The medical name for this toe deformity is hallux valgus.

This can change the shape of your foot and lead to swelling, pain and tenderness around the big toe.

These symptoms usually get worse if the bunion is left untreated, so it is best to see a doctor at some stage. Your doctor will be able to examine your foot and recommend treatments.

Read more about the symptoms of bunions and diagnosing bunions.

Why do bunions happen?

It is not known exactly what causes bunions, but it is linked to your family history. Wearing badly fitting shoes is thought to make the condition worse.

It is also thought that bunions are more likely to occur in people who have unusually flexible joints, and that this flexibility may be inherited. This is why bunions sometimes occur in children.

In some cases, certain health conditions, such as rheumatoid arthritis and gout, may also be responsible.

Read more about the causes of bunions.

How are bunions treated?

There are a range of treatments for bunions available.

Usually, non-surgical treatments will be tried first, including painkillers, orthotics (such as insoles), and bunion pads. However, these are only able to reduce the symptoms of bunions, such as pain. They do not improve the appearance of your foot.

Surgery may be considered if your symptoms are severe and do not respond to non-surgical treatment. The type of surgery used will depend on the level of deformity, how severe the symptoms are, your age, and any other associated medical conditions.

Read more about treating bunions.

Complications

If you don't seek treatment for bunions, they can lead to further problems. For example, bunions can cause arthritis in your big toe and they can also push your second toe out of place.

Problems can also result from bunion surgery. While surgery is usually effective (85% of cases improve symptoms), bunions can sometimes return.

Read more about the complications of bunions.

Can bunions be prevented?

The best way to reduce your chances of developing bunions is to wear well-fitted shoes, as shoes that are tight or have high heels can force your toes together.

You should make sure your shoes are the correct size and that they leave enough room for you to be able to move your toes freely.

Read more about preventing bunions.

Symptoms

The main sign of a bunion is the big toe pointing towards the other toes on the same foot.

Other symptoms may include:

  • pain in the affected area
  • a swollen, bony bump on the outside edge of your foot
  • pain and swelling over your big toe joint that is made worse by pressure from wearing shoes
  • hard, callused and red skin caused by your big toe and second toe overlapping
  • sore skin over the top of the bunion
  • changes to the overall shape of your foot

Changes to foot shape

If your bunion is particularly severe, it can change the overall shape of your foot. For example, a bunion can increase the width of your foot where it sticks out at the side or even push your second toe out of place.

If the bunion rubs on the inside of your shoe, wearing shoes may be uncomfortable. If your foot becomes very wide, it may be difficult to find shoes that fit at all.

The changes to your foot may also make it difficult to walk, as the big toe is used to propel yourself forward and help you balance.

Causes

A bunion is the result of a deformity in the joint of your big toe. It is not clear exactly why this happens.

Possible causes may include:

  • genetics (family history)
  • arthritis
  • other conditions
  • poorly fitting shoes

These are discussed in more detail below.

Genetics

If other members of your family have bunions, your risk of developing them is increased. However, this does not mean you will definitely develop bunions.

Arthritis

Types of arthritis thought to cause bunions are:

  • rheumatoid arthritis – inflammation (swelling) and pain in the joints that result from the immune system attacking the lining of the joints
  • gout – another common type of arthritis that causes painful inflammation in one or more joints
  • psoriatic arthritis – a type of arthritis associated with the skin condition psoriasis

Arthritis in your toe may also develop as a result of a bunion. Read more about the complications of bunions.

Other conditions

Several other conditions are thought to increase your chances of developing bunions. For example, conditions associated with loose ligaments, flexible joints and low muscle tone could increase the likelihood of bunions developing.

These conditions include neuromuscular conditions (such as cerebral palsy) and connective tissue disorders (such as Marfans syndrome).

Poorly fitting shoes

Poorly fitting shoes can contribute to the development of bunions. Bunions are rare in populations that do not wear shoes.

Wearing shoes that are too tight and do not fit properly is likely to make an existing bunion worse.

If your shoes are too tight, they may rub against your big toe joint. High-heeled shoes that are too tight will squeeze your feet, causing your big toe to remain in a bent position. This can stretch the toe, putting pressure on the nerves around it and leading to pain.

High heels also push most of your body weight forwards onto the front of your foot, which places considerable strain on your toe joints.

Diagnosis

You should see a doctor if you develop a bunion, as they can get worse over time.

It is important to get medical help if you have a bunion that is causing pain or discomfort, or if you are having trouble finding footwear that fits.

Foot examination

Your doctor will examine your foot and ask about symptoms you have, such as pain and swelling. You may be asked to move your big toe up and down to determine whether your range of movement is limited.

Your doctor may ask about your footwear, such as the types of shoes you wear and whether you have recently changed your footwear.

Your doctor will want to know about your general medical history, such as any surgery or treatments you have already tried for bunions, whether there is a history of bunions in your family and whether you do activities that place excessive pressure on your toes, such as long-distance running or dancing.

X-ray

If a bunion is suspected, you may be referred for an X-ray to assess how severe it is and to decide whether you need to be referred to a specialist.

During the X-ray, you will be asked to stand on your affected foot while the image is taken.

Treatment

Bunions may only need to be treated if the deformity is severe and you experience significant pain and discomfort.

Non-surgical treatment

Where possible, non-surgical treatment for bunions will be used. Your doctor can discuss the options with you.

Non-surgical treatments can ease the pain and discomfort caused by a bunion but cannot prevent a bunion from becoming worse over time.

Possible non-surgical treatments include:

  • painkillers
  • bunion pads
  • orthotics
  • wearing suitable footwear

These are discussed in more detail below.

Painkillers

If you have a painful bunion, painkillers, such as paracetamol or ibuprofen, may be recommended.

When using painkillers, always read the patient information leaflet that comes with the medicine and follow the recommended dose.

Bunion pads

As well as taking painkillers, using bunion pads may ease the pain of a bunion.

Reusable bunion pads, made of either gel or fleece, are available over the counter from pharmacies. Some are adhesive and stick over the bunion, while others are held against your foot by a small loop that fits over your big toe.

Bunion pads protect your foot from rubbing on your shoe and relieve the pressure over the enlarged joint at the base of your big toe. You can also use an ice pack or cold compress to help numb pain and reduce any swelling (see below).

Orthotics

Orthotics are devices placed inside your shoes which help realign the bones of your foot. They may help relieve the pressure on your bunion, which can ease the pain. However, there is little evidence orthotics are effective in the long term.

It is important the orthotic fits properly, so you may want to seek advice from your doctor or podiatrist (a specialist in diagnosing and treating foot conditions), who can suggest the best ones for you.

You can buy orthotics over the counter from pharmacies or they can be custom made by a podiatrist to fit your feet. Whether you need to buy an over the counter orthotic or have one specially made will depend on your individual circumstances and the severity of your bunion.

You can also use special bunion splints, worn over the top of your foot and your big toe to help straighten its alignment. Splints are available for both daytime and night-time use. However, there is little evidence to indicate splints are effective.

Toe spacers are also available, which can help reduce the pain caused by bunions.

However toe spacers or orthotics may be of limited use as they often compete with the bunion for the already limited space in the shoe.

Ice packs

If your toe joint is painful and inflamed, applying an ice pack to the affected area several times a day can relieve pain and inflammation. Never apply ice directly to the skin, wrap it in a cloth or tea towel first. A bag of frozen vegetables makes a good ice pack.

Suitable footwear

If you have a bunion, you are advised to wear flat or low-heeled, wide-fitting shoes. Shoes made from soft leather are ideal because they will relieve any pressure on the bunion.

Avoid narrow or slip on shoes. High heels can also make your bunion worse by putting excessive pressure on your toes.

Read more about choosing suitable footwear.

Surgical treatments

Surgery is the only way to correct a bunion. Bunions usually get worse over time, so a bunion left untreated is likely to get bigger and become more painful.

If your bunion is causing a significant amount of pain and affecting your quality of life, your doctor may refer you to be assessed for bunion surgery.

The aim of bunion surgery is to relieve pain and improve the alignment of your big toe. Surgery is not usually carried out for cosmetic reasons alone. Even after surgery, there may still be limits to the styles of shoe you can wear.

The operation will either be carried out under local anaesthetic or general anaesthetic.

Bunion surgery is often performed as a day procedure, which means you will not have to stay overnight in hospital.

Deciding to have surgery

When deciding whether to have bunion surgery, there are several things to consider, including:

  • your age
  • your medical history and general health
  • your occupation and lifestyle
  • your expectations of surgery
  • the severity of your symptoms

These are discussed in more detail below.

Age

Your age will be taken into consideration when deciding on bunion surgery. In children, bunion surgery is often delayed due to an increased risk of the bunion returning. This is because the bones are still growing.

You may be advised that non-surgical treatments are a better option than bunion surgery.

Medical history and general health

After surgery, your risk of developing problems is increased if you have other medical conditions that prevent or slow down the healing process. For example, problems with wound healing and infection are more likely if you have diabetes or problems with your circulation.

Following bunion surgery, you are also more likely to encounter problems if your bunion occurred as a result of another condition, such as rheumatoid arthritis.

Occupation and lifestyle

If you are a professional dancer or sportsperson, bunion surgery may only be recommended if you are unable to perform in your chosen field.

If you are very active and play a lot of sport, being able to move your big toe freely may be more important to you than how your toe looks.

Bunion surgery can make your toes less flexible, meaning you may not be able to return to the same level of physical activity as before the operation.

Your expectations of surgery

The success of your surgery will depend on the skill and experience of the surgeon, the severity of your bunions, the type of surgical procedure you have and your ability and willingness to rest after the operation.

Bunion surgery may be up to 85% successful in people who have it. However, after you have had surgery, there is no guarantee your foot will be perfectly straight or pain free. Surgery may reduce the flexibility of your big toe joint and you may experience stiffness in the area where the bunion was. Your toe may also be shorter than it was before you had surgery.

Read more about the complications of bunions.

The severity of your bunion

Surgery will only usually be recommended if your bunions cause considerable pain and non-surgical treatment has failed. This is because of the risks and complications associated with bunion surgery.

Your specialist will examine your foot and look at the results of your scans to assess the severity of your bunions and will help you decide whether surgery is right for you.

Types of surgery

There are many different surgical procedures used to treat bunions. The type of surgery recommended for you will depend on the severity of the deformity.

Your surgeon may use pins, wires or screws to hold the bones in place while they heal. Depending on the type of surgery you have, these may be left in your foot or removed later on.

Some of the surgical procedures for bunions are outlined below.

Osteotomy

An osteotomy is the most common type of bunion surgery. Although there are many different types of osteotomy, they generally involve cutting and removing part of the bone in your toe.

During the procedure, your surgeon will remove the bony lump and realign the bones inside your big toe. They will also move your toe joint back in line, which may involve removing other pieces of bone.

A procedure called distal soft tissue realignment may be combined with an osteotomy. This involves altering the tissue in your foot to help correct the deformity and improve the stability and appearance of the foot.

Arthrodesis

Arthrodesis involves fusing together two bones in your big toe joint (metatarsophalangeal joint). This procedure is usually only recommended for people who have severe deformities of the big toe joint, which make it too difficult for doctors to completely fix the joint or when there is advanced degeneration of the joint.

After arthrodesis, the movement of your big toe will be severely limited.

Excision (Keller's) arthroplasty

An excision arthroplasty involves cutting out the bunion and part of the bone of the joint at the base of the big toe. This creates a false joint that later heals when scar tissue forms. The procedure involves pinning the joint in place with wires, which will be removed around three weeks after surgery is carried out.

An excision arthroplasty can only be used in certain circumstances, and is usually reserved for severe, troublesome bunions in elderly people.

Minimally invasive bunion surgery

The National Institute for Health and Care Excellence (NICE) has published information about a new, minimally invasive surgical procedure that can be used to treat bunions. However, as the procedure is new, there is currently little reliable evidence of how effective or safe it is.

Whichever type of surgery you have, you will be under a local anaesthetic or general anaesthetic. One or more incisions will be made near the big toe so that bone-cutting instruments can be inserted. These are used to remove the bunion and to divide one or more bones located at the front of the foot.

The procedure aims to repair the tilting of the big toe and uses wires, screws or plates to keep the divided bones in place. It may be carried out using X-rays.

After the procedure, you may need to wear a plaster cast or dressing to keep your foot in the correct position until the bones have healed. It is likely you will given a special surgical shoe that enables you to walk on your heel.

After surgery

After bunion surgery, expect your foot and ankle to be swollen for three months or longer. While you are recovering, you will need to elevate your foot to reduce swelling and you will need crutches to move around.

You will not usually be able to wear normal shoes for at least six months after surgery. You may have a cast or bandage and postoperative shoes (shoes specially designed to allow heel walking and protect the bony cuts) before you can start wearing regular footwear. This will keep the bones and soft tissues in place while they heal.

Complications

Bunion surgery can sometimes cause further problems, as can leaving bunions untreated.

Untreated bunions

A bunion may get worse if left untreated, so it is worth seeing a doctor if you think you have one.

If bunions are left undiagnosed and untreated they can cause further problems, such as arthritis in the joint of the big toe.

The big toe can also cause deformity of the second toe, by pushing it out of place.

Read about the symptoms of bunions for more information on problems caused by bunions.

Surgical complications

In less than 10% of cases, complications occur after bunion surgery. These will depend on the type of surgery you have and can include:

  • infection
  • deep vein thrombosis (DVT) (blood clotting in a vein)
  • stiffness in the joints of your toes
  • a delay or failure of the bone to heal, or the bone heals in the wrong position
  • pain under the ball of your foot
  • damage to the nerves in your foot
  • prolonged swelling
  • continued pain
  • the need for further surgery
  • thickened scar tissue
  • the bunion coming back
  • complex regional pain syndrome – a condition that causes long-term (chronic) burning pain in one of the limbs

If you have any concerns after surgery or experience any of these complications, speak to your surgical team or doctor. They can give you advice about how to deal with these complications, including further treatment options.

Prevention

You can significantly reduce your risk of developing symptomatic bunions by wearing shoes that fit properly.

Symptomatic bunions are bunions that cause symptoms, such as pain.

Footwear

Poorly fitting shoes can contribute to the development of bunions. Bunions are rare in populations that do not wear shoes.

It is best to avoid wearing shoes with high heels or pointy toes. Wearing shoes that fit properly can reduce your risk of developing a symptomatic bunion.

Your shoes should be wide enough for your toes not to be forced together and there should be enough room for them to move. Shoes that are made of soft leather and are wide fitting are a good choice.

When selecting shoes, it is useful to have your feet measured properly because many people wear shoes that are the wrong size.

You may also want to visit a podiatrist (a foot specialist), who will examine your feet and give you advice about suitable footwear.

Wearing shoes that are too tight and do not fit properly is also likely to make an existing bunion worse.

Jo's story

Jo, a teacher from Finchley, north London, was 15 when she first noticed some bumps had appeared on her feet. At the age of 34, she had an osteotomy.

“I put up with the lumps for years. But as they grew bigger and bigger, they began to hurt quite a bit. It was frustrating not being able to wear all the lovely shoes I’d see in the shops. I would try them on, but my bunions just poked through, so I could never buy them.

“Eventually, I realised I had to do something about my feet. They were so sore all the time. I went to my doctor who referred me to Charing Cross Hospital, where I saw a consultant podiatrist. He examined both my feet very carefully. After talking me through his diagnosis, he suggested I have an operation called an osteotomy (a realignment of the joint). He recommended that I have one foot done at a time so I'd be able to hobble around on my one ‘good’ foot.

“After some thought, I decided that I didn’t want to go through the same procedure twice and that I would have both feet done together. The operation could be done as day surgery and luckily the waiting list wasn’t too long.

“The operation really wasn’t that bad. I went in at midday and was ready to go home around 4pm the same day. I had a local anaesthetic and the operation took around half an hour on each foot. There was a nurse with me all the time and I listened to my i-Pod to distract me.

“I was in a wheelchair for the first week after the operation. My feet were bandaged and swollen. I had to be careful not to put any weight on them for a few weeks, but after about three weeks, I was able to wear trainers and get around on crutches. After six weeks, I was back to normal.

"Having my bunions removed really is one of the best things I've ever done. My feet healed really well and the scars are tiny. Overall, my feet look fantastic.”

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