Unsightly and uncomfortable: bunions

DW: How does a bunion arise?

Dr. Stephan von Rüdiger: This involves a weakness of the connective tissue, in most cases hereditary, that leaves the ligaments and fascia unable to keep the foot as steady – especially with extra pressure. This leads to a splaying of the foot, where the first metatarsal bone’s head shifts away from the foot to form a bump. The big toe then tilts out of place to create the “hallux valgus”. Hallux means “big toe”, and valgus refers to the bent direction. The result is an imbalance in the muscles and tendons, which pull the toe further into this hallux valgus position.

Do excessively tight and tall shoes play a part in the emergence of a bunion?

It’s definitely a factor – but an overestimated one. There are surveys from Africa involving women who have been walking barefoot all their lives. And there, too, we see bunion misalignments. We can therefore conclude that it’s not solely down to the shoes. But high heels are not helpful, creating significant pressure on the joints and leading to misalignments in the joints. This is how they can encourage the development of a bunion.

Is a bunion a cosmetic of medical problem?

It begins as just a cosmetic problem, but can rapidly become a medical problem. This misalignment leads to symptoms, initially in the ball of the foot. They are followed by pressure discomfort in the area of the big toe, which leans against the second toe and causes further pressure there. Then there is an impact on neighboring structures, meaning a continuation of the misalignments. They can potentially create claw toes and hammer toes. In such cases, we recommend surgery.

How is a bunions treated?

If the symptoms are not too advanced, e.g. a young patient who has a splay foot and an emerging bump but no pain, I would not operate. For preventive reasons I certainly would recommend shoe inlays and perhaps some physiotherapy. Not in the case of small children, however, as everything can take a positive course naturally. First, however, definitely conservative solutions.

When should surgery be performed?

If the patient is in discomfort and has already tried all the conservative options, then surgery is advisable. If the pain is not yet too extreme, we might still have to operate because we know the condition is worsening and will lead to further damage – as we have seen with many patients. Look at arthrosis. The more advanced the misalignment, the more complicated and difficult the correction will be. We used to operate at the latest possible point due to the poor outcome of other methods back then. Today we have new, joint-preserving methods, which is why we advise patients, including the young, to have preventive surgery.

Many patients are reluctant to undergo surgery. What happens when surgery does not take place with serious cases?

Generally the discomfort and misalignment worsen over time. Then there are secondary complications such as further misalignments in the toes, arthrosis, stiff joints, and structural changes in the entire body, which can no longer be reversed. You can grow old with a bunion with no absolute need for surgery. What we can say is that patients are generally better off after surgery.

Which surgical method is standard today?

Standard procedure is almost always surgery where the joint linking the big toe is retained and function is resumed.In the old days, the joint would be destroyed in the process, and there were over 100 different methods. More recently they were reduced to around ten. The aim today is to determine the kind of misalignment individually using physical examinations and X-rays. When the stage and kind of misalignment have been determined, it is clear which method of surgery of those ten is required. There is no one cures-all method. And what is common among most surgery methods is the patient being able to use the foot right after the operation.

What measures can we take to prevent developing bunions?

Use shoe inlays as soon as possible. When symptoms first arise, physiotherapy can help. You should do that at home as well. And very important: minimize your use of high heels.

Dr. Stephan von Ruediger has 20 years’ experience as an orthopedic surgeon working exclusively with foot-related problems.

http://www.fusschirurg-berlin.de/

Interview: Marita Brinkmann