Bunion (Hallux Valgus)

What happens in a bunion

The big toe joint is the first metatarsophalangeal (MTP) joint, where the first long foot bone (metatarsal) meets the big toe. In hallux valgus, the first metatarsal drifts toward the midline of the body, while the big toe angles toward the smaller toes. The head of the metatarsal sticks out, forming the bump. A fluid-filled sac (bursa) over the bump can become inflamed, and thickened skin forms where shoes rub. Over time, the toe can rotate, overlap the second toe, and the joint can develop arthritis.

A bunionette (tailor's bunion) is a similar bump on the outside of the foot at the base of the little toe.

Causes and risk factors

The exact cause is not fully understood. Contributing factors include:

• Inherited foot shape: bunions often run in families. The inherited structure of the foot, such as a mobile first metatarsal joint, makes a bunion more likely.
• Footwear: narrow, pointed and high-heeled shoes squeeze the toes together. They do not cause bunions by themselves but make them worse and more painful.
• Sex: much more common in women.
• Flat feet and loose ligaments.
• Inflammatory arthritis: rheumatoid arthritis can cause bunions and other toe deformities.
• Neuromuscular conditions and previous foot injury.

Symptoms

• A bony bump on the inside of the foot at the base of the big toe
• Pain or soreness over the bump, worse in tight shoes
• Redness, swelling or a burning feeling over the joint
• Corns or calluses where the toes overlap or rub
• Stiffness or reduced movement of the big toe
• Pain in the ball of the foot under the second toe (metatarsalgia), as weight shifts away from the big toe
• Hammer toe of the second toe

Pain does not always match how large the bunion looks. Some large bunions are painless, while small ones can hurt a lot.

Bunion vs other big toe problems

Diagnosis

A clinician examines your foot standing and sitting, checks movement of the big toe, looks for calluses and other toe deformities, and checks circulation and sensation. Weight-bearing X-rays measure the angles between the bones, show how severe the bunion is, and reveal any arthritis. These measurements help plan surgery if it is needed.

Treatment

Non-surgical treatment

These do not straighten the toe, but they often relieve pain:

• Shoes: choose shoes with a wide, deep toe box, soft uppers and low heels. Avoid pointed and high-heeled shoes. A shoe repair shop can stretch the area over the bunion.
• Pads and cushions: non-medicated bunion pads, gel sleeves or moleskin protect the bump from pressure.
• Toe spacers and splints: silicone spacers between the first and second toes can ease rubbing. Night splints may relieve discomfort but do not correct the bone alignment.
• Orthotics: shoe inserts can redistribute pressure, especially with flat feet or pain in the ball of the foot.
• Ice after activity for 15 to 20 minutes, wrapped in a cloth.
• Pain relief: acetaminophen (paracetamol) or ibuprofen at the label dose, or a topical NSAID gel.
• Activity changes: avoid long periods of standing in tight shoes.
• Steroid injection for an inflamed bursa, occasionally.

Bunion surgery

Surgery is considered when pain persists despite shoe changes and other measures, or when the bunion affects walking or daily activities. It is not recommended for cosmetic reasons alone. There are many procedures, chosen by bunion severity:

• Osteotomy: cutting and realigning the first metatarsal, held with screws or plates. Common for mild to moderate bunions.
• Soft tissue repair: tightening and loosening ligaments around the joint, usually combined with an osteotomy.
• Lapidus procedure: fusing a joint further back in the foot, for severe or unstable bunions.
• Joint fusion (arthrodesis): for severe bunions with arthritis.
• Minimally invasive techniques: done through small incisions in suitable cases.

Recovery typically involves a special shoe or boot for about 6 weeks, with swelling lasting several months. Full recovery can take 6 to 12 months. Risks include stiffness, infection, nerve irritation, delayed bone healing, recurrence and overcorrection.

Outlook

Bunions usually get slowly worse over years. Many people manage well with appropriate shoes and padding. Surgery relieves pain and improves alignment in most people, though recurrence is possible.

Prevention

You cannot change inherited foot shape, but you can slow progression and reduce pain by wearing well-fitting shoes with plenty of toe room, keeping heels low, and treating flat feet with supportive footwear or orthotics.

Frequently asked questions

What causes bunions?

Bunions are mainly caused by inherited foot structure, which allows the big toe joint to drift out of alignment. Narrow, pointed and high-heeled shoes make them worse and more painful. Flat feet, loose ligaments and inflammatory arthritis such as rheumatoid arthritis also contribute.

Can bunions go away without surgery?

No. Once the bones have shifted, they will not straighten on their own, and spacers or splints cannot correct the alignment permanently. However, wider shoes, pads, orthotics and pain relief can control symptoms well, and many people never need surgery.

How do I relieve bunion pain?

Wear shoes with a wide toe box and low heels, use bunion pads or gel sleeves, try toe spacers, ice the joint after activity, and take acetaminophen or ibuprofen at the label dose. Orthotics can help if you have flat feet. See a foot specialist if pain persists.

When should I have bunion surgery?

Surgery is considered when the bunion causes persistent pain or limits walking and daily activities despite changes in footwear and other treatments. It is not recommended just for appearance. A foot and ankle surgeon will choose the procedure based on X-rays and the severity of your bunion.

What is a tailor's bunion?

A tailor's bunion, or bunionette, is a bony bump on the outside of the foot at the base of the little toe. It causes similar symptoms of rubbing, redness and pain in tight shoes, and is treated in the same way, with wider shoes, padding and occasionally surgery.