Bunions

What is a Bunion?
Bunions are often described as a bump on the side of the big toe. This bump is due to a change in the structural alignment of the bones in the foot, where the big toe angles towards the smaller toes. The big toe joint becomes enlarged due to the fact that the first metatarsal bone appears at an abnormal angle. This leads to a wider forefoot and causes problems with footwear.

Epidemiology
Bunions are common in over a quarter of adults older than 40 years of age however can also be present in children. Prevalence of the painful great toe increases with age and is higher in women, possible due to tighter footwear and also women have looser ligaments (connect bone to bone).

Causes/Risk Factors

Genetics
Some people have a genetic predisposition to the condition. This can be due to the shape of the joint itself or foot type which can affect the mechanics of how it works and result in joint changes.
Footwear does not cause them but high heeled and tight and narrow footwear can exacerbate the deformity and cause pain. 

Injury
Some bunions are the result of a traumatic injury.

Medical Conditions
They can occur when there is a lot of movement in the foot joints (hypermobility).
Neuromuscular conditions such as stroke can cause a positional change in the big toe.
Systemic conditions such as rheumatoid arthritis can cause bunions due to ligament laxity
Foot problems can be more serious if you have diabetes. It can reduce your sensation increasing the risk of a wound.

Signs and Symptoms
Many people do not have any symptoms and do not require treatment. Others can experience:
• Swelling and redness at the big toe joint (bursa) or thickening of the skin at the base of the big toe which causes pain and rubbing on shoes.
• Burning and numbness if there is a trapped nerve.
• Lesser toe changes such as hammer or claw toes. Abnormal weight distribution under the lesser toes can be painful and impair balance which can increase the incidence of falls.
• Development of painful hard skin and corns from friction against footwear.
• Abnormal weight bearing can cause reduced motion of the big toe. It can also cause pain under the second toe which will feel like walking on a marble. Callous and corns may also be present.

Treatments
There is no need for treatment if you have no symptoms.

Footwear
Keep pressure off the affected joint by:
• wearing comfortable shoes which have a wide and deep toe box to reduce rubbing, callous and pain
• wear footwear with a lace or adjustable strap as they can be adjusted to the width of your foot
Avoiding high-heeled shoes or narrow, pointed shoes as they compress the toes and cause pain.
• Avoiding slip-on or backless shoes as they cause your toes to claw as you walk to grip and stabilise the foot and therefore increasing joint pressure and muscle tiredness.

Please see our Footwear Leaflets for further advice

Foot Care
Remove any hard skin that has developed over the joint by filing it gently with a file and applying a moisturising cream to soften the skin

Lifestyle
If you are overweight losing weight will reduce the load going through your feet when you are standing or walking.

Medication
Taking pain killers such as paracetamol and ibuprofen when needed to reduce pain and inflammation.

Padding
Padding covering the toe joint can deflect rubbing and friction away from the joint.

Cryotherapy
Applying an ice pack (covered in a towel to prevent burns) can help reduce pain and swelling.

Orthoses
Orthoses, such as shop bought arch supports will not cure a bunion but can sometimes relieve pain.

Night splints may improve foot pain however does not slow or prevent progression of a bunion

Cryotherapy
Applying an ice pack (covered in a towel to prevent burns) can help reduce pain and swelling.

Activity
Make changes to any activity that regularly stresses the big toe.
Keeping the joint mobile can help reduce pain by relieving stiffness:

1. Hold the big toe with one hand and bend the toe upwards as far as it will go and hold for 10 seconds. Repeat several times.
2. Hold the big toe with one hand and bend the toe downwards as far as it will go and hold for 10
seconds. Repeat several times.
3. Hold the big toe with one hand and move the toe in a circular motion. Repeat several times.
4. Stand about 40 cm away from a wall and put both hands on the wall at shoulder height, feet
slightly apart, with one foot in front of the other. Bend the front knee but keep the back knee
straight and lean in towards the wall to stretch. You should feel the calf muscle tighten. Keep
this position for 45 seconds then relax. Do this twice, then switch to the other leg. Repeat this twice a day 
5. Repeat exercise 4 however bring the back foot forward slightly so that the back knee is also slightly bent. Repeat this twice a day.

Injection Therapy
Steroid injections can offer pain relief and reduce inflammation if pain is severe.

Surgery
The Podiatry Department can intervene in earlier stages. Later stages may require ongoing surgical referrals. Surgery to straighten toes is only endorsed by this NHS Trust, College of Podiatry and Royal College of Surgeons in the later stages of the condition if there is extreme pain. It is not offered for cosmetic purposes.

Diagnosis
Investigations such as X–rays are not needed. Diagnosis and clinical findings are based on observations.

Red Flags
Please see your GP or appropriate healthcare professional urgently if:
• Your foot is painful, swollen and hot.
• There is a wound over or around the bunion
• You develop a high temperature and feel hot and shivery
• You notice a rapid development of a bunion
• You have reduced circulation.