• National Bunion Day

#AskTheExperts! Bunion Specialists answer your questions!

We asked Senior Podiatry Lecturer Dr Jill Ferrari to answer some frequently asked questions - submitted by you! - all about bunions.

Dear Dr Jill, I have a large Bunion on my right foot, will I get one on my left foot automatically, or does it not work like that?

We know that bunions typically occur bilaterally and so the chances are that you will develop one on the other foot. However, there is always an exception to the rule and if your bunion was due to an unusual bone structure in just the one foot (for example, a very short metatarsal), or due to a trauma damaging one particular structure, then you might find it will not develop on the other foot. Either way, it may well not be as bad on the other foot.

Dear Dr Jill,

My bunions are luckily not painful, but they are ugly and big and I also have a ganglion beside one of them. Are there any options instead of surgery?

There is no strong evidence that anything other than surgery will change the angle of the joint. Most of the research has primarily considered pain and patient satisfaction rather than just the joint angle. So there are treatments such as manipulation, orthoses and toe splints that suggest short term improvements but no study has looked at whether the improvements can be sustained longer than six months, for example. Some people do find that using foot orthoses will realign the hallux and metatarsal, but the compromise is that these need to be worn in flat, fastening footwear.

Dear Dr Jill,

My bunions aren’t bad at the moment - is it inevitable that they will get worse? Do they get more painful as they get larger? Will wearing heels make them worse, or is it more important to wear properly-fitting shoes?

We know that bunions are more prevalent with increasing age, but we do not know much about how the deformity progresses over time. It is possibly a very individual thing and some people's develop quickly and others slowly. Some will progress to an end point where the joint is effectively dislocated and others stop at a just mild shift of joint alignment.

The "largeness" of a bunion is made up of two factors, i. how much the head of the metatarsal pushes out on the inside of the foot, ii. how much extra bone (osteophytes) forms around the joint. It is likely that the larger the bunions get, the more painful they will become because of problems with pressure and rubbing of footwear, the extra bone formation trapping local superficial nerves against footwear or the joint not being able to bend freely during walking. Wearing heels and pointed-toe footwear are thought to speed up the onset of bunions ("exciting" factors) but it is not known whether they can worsen a bunion. You probably know what the answer will be if you ask a podiatrist about wearing heels and good-fitting / good style shoes!

Hi Dr Jill

I’m 52 and I have bunions on both feet. My right foot gives me more pain and trouble than my left. What I’d like to ask is this: is there anything that I can do to try and improve the bunion as such, perhaps realign my toe joint - or is it just too late? My GP tells me that my bunions are not severe enough to have surgery and I’ve seen splints etc on line that say they’ll help to realign the toe but really are these products any good or is there anything else I can do to help?

We think bunions occur due to the underlying foot structure and shape of your bone, your degree of flexibility (ligament laxity) and your mechanics (how the bone load and joints function in walking). You cannot alter your foot structure (without surgery), you cannot change your natural degree of flexibility (but splinting could - although the research to support this is lacking, and the practicalities of walking with splints on is yet to be easily overcome), but you can alter the bone loading and joint movement. This can be achieved with footwear and orthoses. It is "too late" to permanently realign the toe but improved alignment or improved function might be achievable. If you are willing to compromise on footwear for your day-to -day wear, it is probably worthwhile speaking to a podiatrist to get their opinion on your foot function and whether orthoses could impact on it in a way that is beneficial to the 1st metatarsophalangeal (bunion) joint.

Hi Dr Jill, I pronate when I walk, which I believe has made my bunions worse. Two questions: does pronation impact your overall gait and, therefore, your knees and hips? And what can I do to counter pronation?

We know that pronation often has a knock-on effect to the functioning of the joint formed between the great toe and it's metatarsal. Often pronation pushes the metatarsal upwards which has the effect of locking the joint, pushing bones together so that damage to the cartilage and subsequent arthritis occurs. Or it can push the metatarsal outwards which is how bunions may start. In the same way that pronation at the rearfoot can affect the joints in the front of the foot, it can also affect the joints up the leg and into the back. The reason for this is that the main bone involved in pronation (the talus) forms part of the ankle joint and can therefore influence the movement of the other bones in the ankle- the tibia and fibular. Depending on how you pronate (as the bones will move in certain directions depending upon your individual joint axes), some people will create a large amount of rotation of the tibia which impacts on the knee function, can then impact of the rotation of the femur, into the hip and then the back. There are several things you can do counter the pronation - specific muscle strengthening will help control some of the movements created, conscious postural control, supportive footwear will change the timing and movements of the rearfoot, orthoses can also control the degree of movements and timing of the movements. As a podiatrist, these are the treatments I would consider, a physio / osteopath / chiropractor may well have additional ideas.

Dr Jill Ferrari's colleague, Suzy Speirs (a Consultant Podiatric Surgeon), was on board to answer questions specifically related to bunion surgery.

Hello! Can you have corrective surgery for bunions successfully more than once? My original operation was in 1980 but they returned about 10 years ago.

Yes, you can have a repeat operation to successfully correct a bunion that has recurred following previous surgery. Although it is disappointing when surgery fails, this can happen for a variety of reasons. The surgeon may not have been a foot specialist, the wrong procedure may have been chosen, the patient may not have followed the post-operative instructions, adversely affecting the outcome of surgery by not resting, injuring the foot or not doing the exercises. In some cases there is no obvious reason for recurrence of the bunion and you may just have been unlucky!

Revision surgery is never as straightforward as the primary operation so you should discuss the pros and cons with your surgeon carefully in order to make an informed decision. Repeat surgery may require more complex realignment of the bones in more than one direction, necessitate a bone graft to lengthen a bone that has shortened or involve fusing the big toe joint because it is damaged and stiff. There may be a period of immobility post-operatively. Every revision case is unique but there is no reason why a good outcome canʼt be achieved with appropriate planning and the right advice from your specialist.

Dear Experts, I’ve heard about minimally invasive bunion surgery that can be done whilst awake, and under which you can walk soon after surgery. What are your thoughts on that type surgery – is it successful even for severe bunions? Is it possible to avoid surgery for severe bunions, or does delaying only make things worst? Do you recommend surgery on both feet at the same time?

Minimally invasive surgery (MIS) is becoming increasingly popular with patients, it is offered more frequently in private practice. Special training is required. Operations are performed through a smaller skin incision and visualisation is aided by the use of intra-operative X-rays. Patients are attracted to this type of surgery by the promise of smaller, more cosmetic scars and a quicker return to work and activities. What we must not forget is that skin and bone healing times remain the same regardless of the size of the incision made. Procedures are technically more challenging due to a lack of visibility. There are also limitations in the amount of correction achievable and the ability to stabilise the bone fragments adequately with screws or wires whilst they heal. Post-operative complication rates appear to be slightly higher with MIS. There remains much debate as to whether there is a place for MIS bunion surgery, so Iʼm afraid the jury is still out!

Bunion surgery can be performed while the patient is awake and this is common practice in the field of Podiatric Surgery. Anaesthetic is injected behind your knee or around your ankle to selectively numb the foot only (local anaesthetic). Patients do not have to watch the operation and you can listen to music or chat to a member of staff during the procedure which generally lasts a maximum of an hour.

Surgery performed in this manner enables you to leave hospital more quickly by helping to avoid the unwanted side effects of general anaesthesia. However, if your preference is to have a general anaesthetic and go to sleep for your surgery, this is also an option.

Modern screws and plates now enable immediate or early weight-bearing with crutches in a post-operative shoe or boot following bunion correction. This helps reduce the risk of a blood clot (thrombosis), maintain muscle strength and joint mobility and helps facilitate an earlier return to footwear, work and sporting activities.

We know that bunions increase in size overtime, but symptoms do not always deteriorate proportionally. As a bunion gets larger, the protective surface (cartilage) within the big toe joint often degenerates and the joint becomes stiffer and more painful. Normal bunion corrections are not as successful when joint damage is present. Surgical options become more limited and procedures such as joint fusion are often more appropriate. So, if your bunion is symptomatic it is better to get specialist advice regarding treatment options sooner rather than later.

Unless bunions are small, I tend to avoid operating on both feet at the same time. However, many people opt to have both bunions corrected at the same time privately due to cost and concerns regarding recovery time. When surgery is performed on both feet, crutches are required for an extended period, activities are more limited and there is an increased risk of falling or sustaining a fracture. Generally I advise a period of 6 months between feet to allow full recovery and to assess the outcome from the first operation.

Hello Experts! I have had a bunion on one foot but after three operations I am still in pain. I have a bunion on my other foot and question whether I should have that one done as I am in pain with it. Or should I leave well alone?

It is difficult to comment on individual cases without knowing all the facts, but undergoing 3 operations on one foot to correct a bunion is unusual. I do not know if you sustained a post-operative complication, whether these operations were performed by the same surgeon in relatively quick succession or over a number of years by different surgeons. As mentioned before, revision surgery is never straight-forward and post-operative complications can affect the eventual outcome of surgery. There is no reason why you should require more than one operation to correct your other bunion. If you are fit and healthy, the correct procedure is chosen, you follow the surgeon’s advice, have family support/help and give yourself enough time to recover fully, a good outcome should be achievable. Seeking a second opinion from another foot and ankle surgeon is always an option.

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