Bunion - Hallux Abductovalgus
A bunion is an excessive widening of the forefoot that occurs as the end of your first metatarsal (long bone in front of your foot behind your big toe) splays away from the rest of the metatarsals. The appearance of a wide forefoot is exaggerated due to the fact that the big toe begins pointing to the outside of the foot instead of pointing straight ahead. This bad position leaves the appearance of a bump or prominent bone on the inside of the ball of the foot. This bump often becomes reddened and enlarged due to the fact that there are few shoes available to accommodate this wide deformed forefoot. Rather than the shoe being the shape of the foot, although it might be in all other areas of the shoe, the bunion begins to shape the shoe and a noticeable expansion is seen in the upper part of the shoe. This shoe molding however is not without consequences for the bunion. The pressure from the shoe on the bump irritates the skin on the side and top of the bump, which is not designed to resist rubbing like the skin on the bottom of the foot. Consequently, redness, blistering, callus formation, bursitis and nerve damage (numbness or sharp pains) are a few of the symptoms related to the shoe rubbing on the bunion. As if that were not enough of a bad situation, bunions also hurt inside of the joint and on the bottom of the joint, because as they progress, they become progressively more dislocated and unstable, often overloading the adjacent joints.
Conservative treatment should be initiated as early as possible and consist of: 1. Splinting of the great toe to not allow it to migrate towards the outside of the foot. 2. Range of motion exercises designed to manipulate the great toe into adduction, the opposite of where it wants to go. 3. Supporting the joints in the back of the foot that are allowing the forefoot to be unstable and the first metatarsal bone to drift to the inside. 4. Selecting only shoes that allow the bunion splint to keep the big toe pointing straight ahead. A good way to see if the shoe will be wide enough in the forefoot to accommodate your bunion is to shop for shoes with removable liners (insoles) and stand on the liner after you have removed it from the shoe. If your bunion is wider than the insole, the shoe will squeeze and constrict your bunion and create the symptoms noted above.
Tapering toeboxes are to be avoided by those with bunions. They will hasten the progression. If your bunion is not addressed by the conservative measures listed, your podiatrist may recommend a bunionectomy, the collective term used to describe a variety of bone and soft tissue procedures designed to realign your great toe and reduce the bump. The procedures chosen have to do with numerous factors, too numerous to list here, but some of them are measured angular displacement of the joints involved, (primarily the metatarsophalangeal joint), the degree of pain as well as the degree of joint dislocation and cartilage damage within the joint, flexibility of adjacent joints and flexibility of soft tissues in the area.
Some of the more advanced cases require cast immobilization and prolonged non weight bearing recovery periods. And as is the case with any surgery, no guarantees. Like so many other foot conditions, bunions also should be approached from a preventative standpoint and the suggestions mentioned above should be employed to slow the progression of the deformity.
Some predisposing conditions may be arthritis, trauma, laxity of connective tissues (ligamentous laxity), limb segment inequalities (limb length discrepancies), genetic factors, possibly flatfoot or the overpronated foot, and shoes.
Bunion surgery is an art as well as a science and is best performed by those who have an understanding of the multifaceted mechanics of the first metatarsophalangeal joint (big toe and 1st metatarsal joint) and its surrounding structures. Bunion surgery involves much more than just removing the bump to be effective, and is best followed up with long-term support for flat and flexible feet.
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