Bunion & Toe Conditions

A bunion, also known as Hallux Valgus, is a bone deformity caused by an enlargement of the joint at the base and side of the big toe. Bunions form when the toe moves out of place, angling toward the other toes. In some cases, the big toe even moves under or over the second toe.  Many people with bunions suffer from discomfort and pain from the constant irritation, rubbing, and friction of this bony prominence against shoes. The skin over the toe becomes red and tender. Because this joint flexes with every step, the bigger the bunion gets, the more it hurts to walk. Over time, bursitis or arthritis may set in, the skin on the bottom of the foot may become thicker, and everyday walking may become difficult—all contributing to chronic pain.

Wearing shoes that are too tight is the leading cause of bunions. Bunions are not hereditary, but they do tend to run in families, usually because of a faulty foot structure. Foot injuries, neuromuscular problems, flat feet, and loose ligaments can contribute to their formation. It is estimated that bunions occur in 33% of the population in Western countries.

Tailor’s bunions, also called a bunionette, is a protruding bone on the outer side of the foot that forms along the side of the little toe. It happens when the fifth metatarsal bone (the bone your little toe attaches to) enlarges and/or shifts outward. Often the 5th toe rotates and underlaps the 4th toe as well. Bunionettes can be painful, especially if it rubs and causes friction against the shoe. Reddening of the skin over this bony prominence is common and if there is swelling and burning pain, this is from a bursal sac and nerve that become inflamed. 

Wearing shoes that are too narrow and have a pointed toe box is the leading cause of tailor’s bunions. Similar to bunion deformities, bunionettes tend to run in families, usually due to a faulty foot structure. 

Bunionettes are bone deformities that do not go away without surgery, but often the pain can be relieved with conservative care.  First, we need to relieve the pressure and pain caused by irritation. Second, we want to stop any progressive growth of this enlargement. Commonly used methods for reducing pressure and pain caused by tailor’s bunions include:

• Protective padding, often made from silicone, to eliminate the friction against shoes and help alleviate inflammation and skin problems.
• Changing to carefully fitted footwear designed to accommodate this bunionette and not contribute toward its growth.
• Custom molded orthotic devices can help stabilize the joint and place the foot in the correct position for walking and standing and slow the progression of the deformity.
• Splints for nighttime wear to help the toes and joint align properly. This is often recommended for adolescents with bunions, because their bone development may still be adaptable.

Depending on the size of the enlargement, misalignment of the toe, and pain experienced, conservative treatments may not be adequate to prevent progressive damage from tailor’s bunions. In these cases, corrective surgery may be advised to remove the bony prominence and realign the toe. There are multiple procedures that can be used to remove a bunionette  and early intervention can help you avoid a more complicated surgery with a longer recovery time.

Hallux Rigidus is a disorder of the joint located at the base of the big toe. It causes pain, stiffness, and limits motion in the great toe joint. With time, this condition progresses and it gets increasingly harder to bend the toe.  “Hallux” is the medical term for big toe, while “Rigidus” indicates that the toe is rigid and cannot move. There are stages of this deformity and the early stage is called Hallux Limitus, which indicates that motion is limited and less than normal range which is 60 to 90 degrees upward. Hallux Rigidus is actually a form of degenerative arthritis.

The exact cause of this deformity is unclear but injury to this joint is often considered the most common reason followed by inherited malposition of the first metatarsal bone (either too much elevation or too long) which “locks” and “jams” the great toe joint and causes repetitive damage to the cartilage.Recent study found that 1 in 40 people over the age of 50 have Hallux Rigidus and there is a 2:1 predilection for females. Inflammatory arthritic conditions like gout and rheumatoid arthritis can also cause these joint changes.

There are multiple conservative measures available to treat this condition especially in the early stages. These include

• Protective padding, often made from silicone, to eliminate the friction of these bone spurs against shoes. 
• Changing to footwear with a deeper toe box, made of softer material, and less stitching and seams often with a more rigid sole to accommodate the enlarge joint.
• Custom molded orthotic devices can help reduce excessive motion and slow the progression of the deformity.
• Exercises and physical therapy to maintain joint mobility and prevent stiffness.
• Oral non-steroidal anti-inflammatory medication such as Ibuprofen may reduce pain and swelling in the joint.
• Steroid injection placed directly into the acutely painful joint can relieve inflammation for several weeks.
• PRP (platelet rich plasma) injections are a concentration of a patient’s own platelets obtained from a blood draw to accelerate the healing joints.

Depending on the stage of the Hallux Rigidus, surgery may be your best option. Early stage Hallux Limitus may be treated by a procedure called a “cheilectomy” which involves removal of the bone spurs around the great toe joint to allow increased motion and greater comfort in shoes. Any defects of the cartilage are drilled to promote new cartilage formation. Patients are encouraged to walk immediately afterwards and return to a shoe in just a few weeks. If the arthritis is more advanced, the two most common surgical procedures are “arthrodesis” which is permanent fusion of the great toe joint or “implant arthroplasty” which is resurfacing of the arthritic joint by implanting a device to replace the cartilage and restore joint motion and reduce pain. Both procedures have similar patient satisfaction rates and good outcomes.

A Hammer Toe is a contracture of the 2nd, 3rd and 4th toes in which the toe becomes bent at the first joint closest to the foot, causing it to resemble a hammer. Claw toe (contracture at both joints) and mallet toe (contracture at the second joint only) are related deformities. Painful corns (circular thickened skin areas) can form over the toe joint or on the tip of the toe as well as painful calluses can develop across the ball of the foot due to forward movement of the protective fat pad. Friction and pressure from shoes is a common symptom and can cause reddened bursal sacs over these toe joints. Hammer Toes can progress from flexible (contracture releases when pressure is applied behind the ball of the foot) to semi-rigid (contracture lessens with pressure) to rigid (contracture cannot be manually straightened). 

Common causes of these toe deformities include the wearing of high-heeled shoes or footwear with a tight toe box; imbalance of the toe muscles leading to instability; injury such as stubbing, jamming, or breaking a toe; heredity especially in those with high-arched feet or long toes; pressure from a bunion when the great toe moves inward; and arthritis such as rheumatoid type. According to a study, 3 percent of U.S. adults aged 21 and older (about 7 million people) have experienced hammertoe or claw toe. These conditions are significantly more common in females than in males.

If conservative treatments don’t help or the deformity has become more rigid, corrective surgery is an excellent option.  In more flexible toe deformities, a minor office procedure to release the tendon that’s preventing your toe from lying flat can be performed and you can wear your normal shoe in a few days. In some cases, the surgeon might need to remove a piece of bone to allow your toe to relax or fuse the joint to ensure the toe remains in a straight position. Surgery aims to reposition the toe, realign tendons, and remove deformed bone.