What is a bunion? - Dr. Mark H. Tompkins

Conditions of the Foot
by Dr. Mark H. Tompkins

Bunions

What is a bunion? The medical definition of a 'bunion' is an adventitious bursa. This is a swelling and inflammation, which occurs over a bony prominence and looks like a 'bump'. The most common bunion affecting the human body is referred to as Hallux Abducto Valgus (HAV) or a bunion of the big toe joint. Hallux refers to the big toe and aducto-valgus refers to the angulations that develops within the big toe joint.

The second most common type of bunion occurring in the human foot is referred to as a Tailor's bunion (TB). This is a prominence or 'bump', which occurs on the outside of the foot at the base of the small toe. Both of these types of bunions cause irritation and pain at the site of contact with shoe gear. The most common type or pain that occurs with HAV or TB is referred to as bursitis . This is an inflammation process that occurs within the tissues over-lying the bony prominence. It typically occurs with shoe irritation at the site of the 'bump' and is relieved when the offending source is removed.

The nerve over-lying the bone may also become inflamed due to shoe irritation. This is referred to as neuritis and typically can radiate both into the toe or up into the mid-foot region of the foot. This type of pain may persist after the shoe is removed or commonly can cause sharp pains in the middle of the night. The third type of inflammatory process (and the worst type), which may occur with either type of bunion deformity, is called arthritis . Arthritis associated with either HAV or TB is a progressive process which occurs over several years leading to a chronic aching type pain that is typically present whether the shoe is on or not.

The pain is normally the worst early in the morning; after periods of increased activity; and, when the weather is cooler or there is more moisture in the air. Treatment for HAV and TB. Initial treatment for either condition is shoe modification. Simply purchasing shoes that limit the degree of irritation over the site of the 'bunion' can relieve the majority of 'bump pain'. Shoe therapy is obviously dependent upon the style-flexibility of each individual patient, but many more options are available in today's fashion-friendly shoe industry. There are many other 'non-physician' conservative type treatments available. These include, but are not limited to, types of accommodative pads or devices available in pharmacies or medical supply stores designed to relieve pressure and irritation over the 'bunion' area.

Various types of topical anesthetics or topically applied anti-inflammatory creams or ointments are available to ease the inflammation, i.e., Bengay®, Theragesic®, capsacin preparations are just a few. Additionally, any therapeutic anti-inflammatory treatment, such as an ice pack, heating pad, whirlpool, footbaths, or massage therapy may provide initial, temporary relief of mild to moderate bunion deformities. Also, over the counter anti-inflammatory medications, such as aspirin and its derivatives, help ease bunion pain. If these 'home remedies' do not provide sufficient relief of pain allowing individuals to take a normal step, consultation with a podiatric physician is recommended. Many times even subtle alterations in one's gait (walking pattern) over time can lead to more debilitating conditions such as severe arthritis in the hips, knees, or back. Many times leading to painful and debilitating joint replacement or fusion surgeries. The initial conservative treatments for either HAV or TB include, but are not limited to, the use of corticosteroid injections, oral anti-inflammatory medications, prescription orthoses (foot inserts), physical therapy, and custom molded shoes . The success of these various conservative treatments depends on a number of factors: 1) the severity of the HAV/TB deformity; 2) the individual patient's physiologic response to the conservative treatment(s); 3) the age of the patient; 4) the activity and health status of the patient; 4) the individual patient's subjective (and physiologic) pain threshold and tolerance; and 5) the individual patients flexibility with regards to shoes and activity. In the event that conservative treatment for either HAV or TB fails, and the patient continues to demonstrate significant pain, then surgical intervention is warranted. There are many definitions of failed conservative treatment and significant pain . The definition of failed conservative treatment includes the failure of all home treatments and conservative treatments available, over a period of at least 6 months, resulting in significant pain. Significant pain being a level of disability causing the individual to alter or change their gait (walking) pattern, i.e. shortening or lengthening the stride, walking on one side of the foot more than the other, or walking more on the front (or back) portion of the foot. This alteration in the gait pattern will not only lead to pain and disability in other areas of the same foot, but also the corresponding foot; and as mentioned above, will subsequently cause problems in the knees, hips, or back. There are numerous operative procedures that are available for the surgical correction of HAV and TB.

The exact procedure indicated for a particular patient is dependent upon a number of factors: 1) the objective, subjective, and physiologic severity of the HAV or TB deformity; 2) age, health status, and activity level of the patient; and 3) each individual patients' expectations and considerations. All surgical procedures for HAV and/or TB may be broken-down into 3 general categories*: "Bumpectomy" or the simple removal of the bump underlying the HAV/TB. Distal osteotomy or the cutting and relocation of HAV/TB at the end portion of the bone. Proximal osteotomy or the cutting and relocation of HAV/TB at the front portion of the bone. There are many different types of procedures within each individual category based on minor variations. Some general parameters regarding these general categories will be given in this narrative.

Bumpectomy procedures are commonly performed on more minor HAV/TB deformities and involves only the cutting and removal of the 'bump' portion of bone causing pain. These procedures typically require up to 6 wks of full weight-bearing healing of the surgical foot with the aid of a surgical shoe, and then progression into normal shoes. Distal osteotomy procedures involve the cutting and shifting of bone(s) (referred to as an osteotomy) at the portion of the deformed bone closest to the toes (the distal portion). These procedures typically require up to 6-8 wks of either full-, partial-, or non-weight bearing healing of the surgical foot with the aid of either a surgical shoe, removable cam-walker, or cast and/or crutches. Followed by progression into normal shoes. Proximal osteotomy procedures involve the cutting and shifting of bone(s) (an osteotomy same as above) at the portion of the deformed bone furthest from the toes (the proximal portion). These procedures typically require up to 4-6 wks of non-weight bearing of the surgical foot with the aid of a cast and crutches, and then progression into a surgical shoe for to 2-4 wks, and finally normal shoes. *Fusions are and additional category of corrective bunion procedures that involve the removal and joining (fusion) of a joint for correction of predominantly severe HAV deformities.

The majority of these procedures may be performed on an outpatient basis, under a twilight/local anesthesia, and take under and hour to perform. This is based upon individual surgeons training, expertise, and personal preference. For more information on bunions go to http://www.apma.org/topics/bunions.htm , or http://www.acfas.org/brbundef.html .

Conditions of the Foot by Dr. Mark H. Tompkins

Bunions

Conditions of the Foot
by Dr. Mark H. Tompkins