Austin Foot and Ankle - Bunions, Hammertoes, Forefoot Surgical Treatments

5000 Bee Cave Road
Suite 202
Austin, TX 78746
(512) 328-8900
fax (512) 328-8903

HOME

Bunions

As part of your comprehensive exam with Dr. Craig Thomajan DPM, you will recieve a complementary interactive video presentation. This 40 minute presentation defines Bunion correction in depth from start to finish.

Even though bunions are a common foot deformity, there are misconceptions about them. Many people may unnecessarily suffer the pain of bunions for years before seeking treatment.

What is a Bunion?
Bunions are often described as a bump on the side of the big toe. But a bunion is more than that. The visible bump actually reflects changes in the bony framework of the front part of the foot. With a bunion, the big toe leans toward the second toe, rather than pointing straight ahead. This throws the bones out of alignment, producing the bunion's "bump."

Bunions are a progressive disorder. They begin with a leaning of the big toe, gradually changing the angle of the bones over the years and slowly producing the characteristic bump, which continues to become increasingly prominent. Usually the symptoms of bunions appear at later stages, although some people never have symptoms.

What Causes a Bunion?
Bunions are most often caused by an inherited faulty mechanical structure of the foot. It is not the bunion itself that is inherited, but certain foot types that make a person prone to developing a bunion. Although wearing shoes that crowd the toes won't actually cause bunions in the first place, it sometimes makes the deformity get progressively worse. That means you may
experience symptoms sooner.

Symptoms
Symptoms occur most often when wearing shoes that crowd the toes—shoes with a tight toe box or high heels. This may explain why women are more likely to have symptoms than men. In addition, spending long periods of time on your feet can aggravate the symptoms of bunions. Symptoms, which occur at the site of the bunion, may include:

Pain or soreness
Inflammation and redness
A burning sensation
Perhaps some numbness

Other conditions which may appear with bunions include calluses on the big toe, sores between the toes, ingrown toenail, and restricted motion of the toe.

Diagnosis
Bunions are readily apparent--you can see the prominence at the base of the big toe or side of the foot. However, to fully evaluate your condition, the foot and ankle surgeon may take x-rays to determine the degree of the deformity and assess the changes that have occurred.

Because bunions are progressive, they don't go away, and will usually get worse over time. But not all cases are alike--some bunions progress more rapidly than others. Once your foot and ankle surgeon has evaluated your particular case, a treatment plan can be developed that is suited to your needs.

Treatment
Sometimes observation of the bunion is all that's needed. A periodic office evaluation and x-ray examination can determine if your bunion deformity is advancing, thereby reducing your chance of irreversible damage to the joint. In many other cases, however, some type of treatment is needed. Early treatments are aimed at easing the pain of bunions, but they won't reverse the deformity itself.

These options include:

Changes in shoewear. Wearing the right kind of shoes is very important. Choose shoes that have a wide toe box and forgo those with pointed toes or high heels which may aggravate the condition.
Padding. Pads placed over the area of the bunion can help minimize pain. You can get bunion pads from your foot and ankle surgeon or purchase them at a drug store.
Activity modifications. Avoid activity that causes bunion pain, including standing for long periods of time.
Medications. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may help to relieve pain.
Icing. Applying an ice pack several times a day helps reduce inflammation and pain.
Injection therapy. Although rarely used in bunion treatment, injections of corticosteroids may be useful in treating the inflamed bursa (fluid-filled sac located in a joint) sometimes seen with bunions.

Orthotic devices. In some cases, custom orthotic devices may be provided by the foot and ankle surgeon.

When is Surgery Needed?
When the pain of a bunion interferes with daily activities, it's time to discuss surgical options with your foot and ankle surgeon. Together you can decide if surgery is best for you.

Recent advances in surgical techniques have led to a very high success rate in treating bunions.

A variety of surgical procedures are performed to treat bunions. The procedures are designed to remove the "bump" of bone, correct the changes in the bony structure of the foot, as well as correct soft tissue changes that may also have occurred. The goal of these corrections is the elimination of pain.

In selecting the procedure or combination of procedures for your particular case, the surgeon will take into consideration the extent of your deformity based on the x-ray findings, your age, your activity level, and other factors. The length of the recovery period will vary, depending on the procedure or procedures performed.

A Problem in Your Big Toe
Your big toe is the hardest-working toe. Every time your foot pushes off the ground, this toe supports most of your body’s weight. Because the big toe is so critical to movement, any problem with it can make walking or even standing painful. A bunion (excess or misaligned bone in the joint) is one of the most common big toe problems. In addition to causing pain, a bunion changes the shape of your foot, making it harder to find shoes that fit. But you don’t have to hobble for the rest of you life. Bunions can be treated. With your doctor’s help, your feet can feel and look better.

What Causes Bunions?
Although they may develop on the fifth (little) toe, bunions usually occur at the base of the big toe. Bunions are often caused by incorrect foot mechanics. The foot may flatten too much, forcing the toe joint to move beyond normal range. In some cases, joint damage caused by arthritis or an injury produces a bunion. And some people are born with the tendency to develop bunions. If you’re at risk for developing a bunion, wearing high-heeled or poorly fitting shoes makes the problem worse.

Types of Bunions
Positional (mild) bunions arise from the growth of new bone. Structural (severe) bunions result when the joint at the base of the toe shifts position. Many bunions are a combination of both types.

Positional Bunions
As new bone grows, the joint enlarges. This stretches the joint’s outer covering. Force created by the stretching pushes the big toe toward the smaller ones. Eventually, the inside tendons tighten, pulling the big toe farther out of alignment.

Structural Bunions
When the angle between the bones of the first and second toes is greater than normal, the big toe slants toward the smaller ones. In severe cases, this may also cause the second and third toes to buckle.

Physical Exam
To determine the best treatment for your problem, your doctor may ask if and when your bunion causes pain. Your doctor may also test how far and how smoothly the affected joint moves. To see if incorrect foot mechanics is causing your problem, your doctor may watch how your feet rotate and flatten as you walk.

Testing
X-rays may be taken of your foot to show the position of the big toe joint. Your doctor may also want to see whether the bunion is affecting other bones in your foot.

How are Bunions Treated?
If a bunion is not painful or severe, your doctor may recommend that you wear a different style of shoes. Or you may be prescribed custom-made shoe inserts (orthoses) to control incorrect foot mechanics. For painful or severe bunions, outpatient surgery may be recommended after surgery, you’ll soon be on your way home and ready for recovery.

Shifting Soft Tissue
To realign the affected joint, any tight tendons on the inside of the toe are released (cut). New bone that makes up the bunion is shaved away.

Shifting Bone
The most common bunion surgery reduces the angle between the first and second toes. Bones in the big toe joint are realigned and the bunion is shaved away. Ligaments and tendons around the joint may be tightened to hold it properly in place.

Removing Bone
If a structural bunion is severe, a piece of bone is removed for the first metatarsal (the big bone behind the big toe joint). Once repositioned, this bone may be held in place with pins or screws. Any new bone that makes up a bunion is shaved away.

After Surgery
Bunion Surgery can both reduce pain and improve the appearance of your feet. For best results, see your doctor as scheduled and follow all recovery instructions.

Healing Takes Time
Your foot will be bandaged after surgery. If soft tissues were shifted, you may be given a splint to limit foot movement for a while. In such cases, the majority of healing should occur within a few weeks. If bone was cut, you may need to wear a surgical shoe or your foot may be placed in a cast. Depending on the extent of the repair, healing may take several months.

Hammertoes

WHAT'S THE PROBLEM?
Hammertoe is the general term used to describe an abnormal contraction or "buckling" of the toe because of a partial or complete dislocation of one of the joints of the toe or the joint where the toe joins with the rest of the foot. As the toe becomes deformed, it rubs against the shoe and the irritation causes the body to build up more and thicker skin to help protect the area. The common name for the thicker skin is a corn. At first, this thick skin helps reduce irritation to the bone prominence, but as the skin becomes thicker, it adds to the pressure from the shoe. Periodic trimming of the corn may give temporary relief. However, over a period of time, a bursa may develop and if it becomes inflamed (bursitis), the area becomes red, swollen and painful. It may also become infected.

There are two joints in the lesser toes and one joint in the great toe. If the deformity occurs in the joint nearest the nail, it is called a mallet toe and the corn will usually develop on the tip of the toe. This is due to the pressure being on the tip of the last toe bone rather than at the fat pad under the tip of the toe. If the deformity is at the other toe joint, or where the toe joins the foot, it is called a hammertoe and the corn will occur on the top of the toe. Corns may also develop between toes. These are usually due to a rotation of the toe, rather than a contraction (buckling). This can cause the joints to rub together and may create small bone spurs that cause corns in a similar manner. Do not confuse corns with calluses that occur on the bottom of the feet. They are generally caused by other conditions, although a severe hammertoe may create downward pressure on a metatarsal bone at the ball of the foot, and add to the cause of a callus.

HOW DOES IT FEEL?
A hammertoe may be present but not always painful unless irritated by shoes. One may have enlarged toe joints with some thickened skin and no redness or swelling. However, if shoes create pressure on the joint, the pain will usually range from pinching and squeezing to sharp and burning. Cramping in the toes, foot and leg may develop from the muscles and tendons functioning in abnormal positions because of the deformed joints. In long standing conditions, the dislocated joints can cause the pain of arthritis.

LET'S DO A TEST!
The diagnosis of hammertoes is initially made by a simple exam of your feet. X-rays may be necessary to evaluate the severity and type of deformity. Additional lab tests may be necessary to rule out infection or other medical conditions.

HOW DID THIS HAPPEN?
Although there is little doubt shoes are responsible for causing corns, the size, shape and other characteristics of our feet are hereditary. The contraction and/or rotation of toes can be the result of poor mechanics of the foot, resulting in over-pronation. This results in low or flat arches, which cause the muscles and tendons of the foot to twist the toes and joints away from their normal position. High arched feet (over-supination) can also result in similar conditions. A severe bunion may cause a hammertoe, as the great toe twists over or under the second toe, causing it to dislocate. Shoes cause the corn, as the bony top of the toe rubs on the toe box of the shoe, but the underlying problem is the abnormal position of the toe joints, which may be hereditary. The crooked toe is irritated by shoe pressure on the joint or spur. As a result, the skin becomes thicker to form a protection. The thicker the skin, the more pressure and eventually, a bursitis under the corn may develop. This causes the joint to become red, swollen and painful. Additionally, the skin can break down and become infected.

WHAT CAN I DO FOR IT?
The most important thing is to purchase well fitted, comfortable, low heeled shoes that do not irritate the crooked toe. Also, make sure your stockings are not tight, causing the toes to contract. High heel shoes should be worn at a minimum, as they cause the tendons of the toes to pull them up into an contracted position. Tennis type and walking shoes have significantly decreased the complaint of many people with hammertoe deformities. Although the crooked toe is still present, it may not hurt if the shoe is large enough.

BATH TUB SURGERY IS NOT A GOOD IDEA! Trimming corns with a razor blade may give temporary relief, but is dangerous, as you can cut yourself and cause an infection. Non-medicated pads from the drug store do give relieve from shoe pressure and are helpful. However, if the toe becomes red and swollen, consult with your family podiatrist right away.

WHAT WILL MY DOCTOR DO FOR IT?
Your doctor will examine you and make a differential diagnosis. That is, decide what type of hammertoe you have and rule out other medical conditions. Treatment may range from more appropriate footgear to periodic trimming and padding of the corn. Cortisone injections may be indicated if a bursitis is present. Antibiotics may be utilized in the presence of infection. Removable accommodative pads may be made for you. If conservative treatment is unsuccessful, surgical intervention may be suggested. In the early stages, when the toe joints are flexible, this may involve a minor procedure, such as cutting or lengthening the tendons to straighten the toe. If the toe is relatively straight and the corn is caused by pressure on a spur, the enlarged bone may be remodeled and the spur removed. In more advanced cases, when the joint is dislocated, part of the bone at the joint may be removed.

Temporary pins may be used to keep the toe straight while it is healing. Sometimes, the removed bone is replaced with a synthetic joint implant, to straighten the toe and help it function properly.

Most of these toe surgeries can be performed in the office or the outpatient surgery under local anesthesia. Sometimes you can wear sandals after surgery and other times, a special stiff soled shoe is used so you can walk right away.

CAN I PREVENT IT FROM HAPPENING AGAIN?
After either conservative treatment or surgery, follow your doctor's orders, which may include advice regarding proper footgear, minimal use of high heel shoes, accommodative padding, or an orthotic worn inside the shoe to balance and improve the function of your feet.