A bunion (also known as hallux valgus) is a bony bump that forms at the base of the big toe. Bunions happen when the tip of the big toe gets pulled and angles out towards the second toe, causing the joint at the base of the big toe to protrude on the inner side of the foot. Over time, the skin around the bunion may become painful and red, and calluses (hard skin) can develop around the bunion. Smaller bunions may also develop over the joint of the fifth toe (also called bunionettes or tailor’s bunions).
Bunions can cause pain and swelling at the base of the big toe, and adversely affect your ability to walk and participate in sports. You may develop tingling and shooting pains if the nerves adjacent to the big toe are affected. In addition, bunions cause widening of the forefoot (front of the foot) and lead to difficulty with footwear. Bunions also contribute to hammer toe deformities in the adjacent second and third toes (discussed later).
Bunions are very common and can occur in all age groups. They tend to be much more common in women, who have an almost 10-fold risk compared to men. The exact cause of bunions is often unknown. However, some likely factors contributing to bunion formation, including:
- Prolonged stress on the feet and toes (such as from wearing high heel shoes with narrow toe boxes)
- Medical conditions such as rheumatoid arthritis and neurological problems
- Previous foot injuries
- Foot deformities that are present at birth such as flat feet
- Tight gastrocnemius or Achilles tendon leading to forefoot overloading
- Hereditary with a positive family history of bunions
Diagnosis of Bunions
Typically, bunions are diagnosed after a thorough history taking and examination of the foot, and further evaluated through X-rays of the feet.
It is important to diagnose and treat symptomatic bunions early, as neglected bunions can eventually become arthritic. Furthermore, the second and even third toes can become affected over time as the bunion deformity worsens and pushes against the lesser toes. This can lead to the formation of hammer toes, which causes pain under the ball of the foot that can affect walking, running and other daily activities.
Early treatment of symptomatic bunions is also important because such bunions are mostly at an intermediate stage and are amenable to correction through minimally invasive surgical (MIS) techniques. MIS surgery allows patients to benefit from small “keyhole” incisions (less visible scars), minimal pain and rapid recovery after surgery. When treatment is delayed and the bunion has become severe, MIS techniques are less successful and open surgery is often needed.
Like bunions, hammer toes are also a common foot problem afflicting the lesser toes (second to fifth toes). The affected toe is typically curled and cannot lie flat on the ground. Hammer toes typically occur when there is an imbalance between the pulling forces of the muscles, tendons and ligaments of the toes, leading to the joint in the middle of the toe being bent and stuck in a fixed upward position.
Hammer toes are often associated with sole pain at the ball of the foot, skin irritation over the top of the toe joints, and discomfort over the nail and tip of the affected toe. Over time, painful calluses may develop over the joints and the affected toes may stiffen into a fixed deformity. In the presence of a fixed hammer toe deformity, there may be difficulty with wearing normal shoes.
Causes of Hammer Toes
Hammer toes are the most common deformity of the lesser toes, and the second toe is often the most affected. In addition to being associated with bunion deformities, other contributory factors to hammer toes include:
- Prolonged stress on the feet and toes (e.g. work-related prolonged standing)
- Medical conditions such as rheumatoid arthritis and neurological problems
- Hereditary with a positive family history of hammer toes
- Previous toe injury
- Tight gastrocnemius or Achilles tendon leading to forefoot overloading
- Ageing
Diagnosis of Hammer Toes
Hammer toes are typically diagnosed after a thorough history taking and examination of the foot. X-rays of the feet can help your surgeon better assess the deformity and plan your treatment.
Non-Surgical Options
Footwear modification is important, and your doctors may suggest switching to shoes that have wider and taller toe boxes (i.e. no pointy toes), which provide more space in the front for the toes to move. Tight-fitting, narrow and high-heeled shoes should be avoided.
Shoe orthotics such as insoles and inserts are also typically recommended to help cushion the foot and distribute the pressure between the toes. Your doctor may refer you to a Podiatrist, who can offer specific footwear advice and provide insoles that are appropriate for your foot.
Depending on the severity of symptoms, your doctor may prescribe a short course of painkillers to help relieve pain and swelling; in addition, the use of ice packs can help reduce painful swelling.
Unfortunately, while these treatment measures can help improve symptoms, they do not treat the underlying problem and cannot correct the bunion and/or hammer toe deformities.
Conventional Open Surgery
If non-surgical treatment does not help relieve symptoms or if the toe deformities continue to worsen and become too painful to cope with, your doctor may recommend surgical intervention. It is important to understand that bunion and hammer toe surgery is typically not recommended for addressing only cosmetic concerns. Surgery should only be considered if these conditions are painful, cause difficulty with wearing shoes, or interfere with daily activities.
There are many surgical options available for the treatment of bunions and hammer toes. These include:
- Bone reshaping (known as “osteotomy”): making small cuts into the bones to change their shape and position for deformity correction
- Joint fusion: joining two adjacent bones together to correct deformity
- Tendon transfers: addressing muscle imbalances
- Resection arthroplasty: removing a diseased section of bone
Your surgeon will assess your toe deformity and your foot structure as a whole, before recommending the most holistic treatment option that is will provide you with the optimum outcome.
Traditional open surgeries typically involve the use of internal plates, screws and wires to correct toe deformities. These open surgeries utilise wide incisions along the foot that are fairly invasive and damaging to the soft tissues, leading to significant post-operative pain and swelling.
Additionally, conventional open surgery may involve a longer recovery time in a cast, which can last from weeks to months. Patients often have more difficulty walking in the immediate few weeks after surgery, and may require more prolonged physiotherapy to regain mobility.
Minimally Invasive Surgery (MIS)
Minimally invasive surgery (MIS) is an advanced treatment option for the correction of both bunions and hammer toes. MIS surgery is a technically demanding procedure that requires specialized training and experience to execute successfully and is performed by a relatively small subset of orthopaedic surgeons.
Your surgeon who is trained in MIS techniques will make one or two small “keyhole” incisions over the affected areas, then proceed with deformity correction by using tiny specialised bone-cutting instruments that have been purpose-built to reshape the bone while minimising soft tissue injury. The reshaped bone can then be stably fixed with small screws or wires. Depending on the number of toes affected and degree of deformity, the surgery can last from 45 to 90 minutes, and can usually be safely performed under regional or spinal anaesthesia.
Unlike conventional open surgery, minimally invasive surgery causes much less injury to the skin and soft tissues, and provides the benefits of less pain, faster recovery, earlier return to walking, and better early function. You can typically expect to walk in a special heel-bearing sandal on the same day after surgery, and casting is usually not necessary. Most patients are able to safely return home on the day of surgery or the following day. Many patients resume normal footwear and routine activities after 3 to 4 weeks.
Whilst minimally invasive (MIS) bunion and hammer toe surgery is still relatively new locally, it has been widely performed in Europe for many years. Studies have shown that with proper patient selection, MIS bunion surgery is as reliable, effective and safe as conventional open surgery. Furthermore, minimally invasive surgery provides the advantages of significantly less pain, more rapid recovery, fewer infection and wound complications, and far superior scar cosmesis.
If you are suffering from bunions and/or hammer toes, or if you are wondering if you have these deformities, you should make an appointment to visit your doctor. Early diagnosis and treatment of bunions and hammer toes are crucial – minimally invasive surgical (MIS) techniques greatly reduce pain and wound complications, minimise scar formation, and allow rapid recovery after surgery.
Minimally invasive (MIS) bunion and hammer toe surgery has been proven to provide excellent, reliable and safe results in the hands of an MIS-trained surgeon, and has emerged as a new standard of care in selected patients. If you are experiencing pain, consult with your surgeon if you are suitable for MIS bunion and hammer toe surgery. Early treatment matters.