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Please see foot & ankle anatomy for more information about the big toe anatomy.
A bunion is also known as a hallux valgus deformity.
Contrary to what most people believe, it is not a growth of bone, but actually when the two bones that make up the big toe joint point the wrong way. This is something that typically occurs slowly over several months to years.
The deformity is quite complex and involves not just the big toe but often the lesser toes as well. As well as the obvious bony abnormality there is soft tissue imbalance as well.
A bunion deformity can be mild in the early stages, but with time can become progressively more severe and painful.
Clinical picture of a patient with a severe bunion (hallux valgus) deformity. The 1st metatarsal bone moves medially (yellow arrow), the big toe (hallux) moves laterally (white arrow) pushing the second toe out of position, the big toe also rotates so that it rests on its side (red arrow). The blue lines indicate where the metatarsal (foot) bones are positioned. The bump or “bunion” is a result of an angular deformity as well as localised bone and soft tissue swelling which is very apparent in this case.
X-ray demonstrating the changes associated with a bunion compared to a normal foot. 1 – the big toe (hallux) turns on to its side, 2 – the sesamoid bones are no longer covered by the 1st metatarsal head, 3 – the 1st MTP joint is no longer congruent (when the two joint surfaces are properly aligned), 4 – prominent bump (medial eminence), A – the big toe (hallux) deviates laterally towards the lesser toes and displaces them, B – the 1st metatarsal deviates medially
X-rays demonstrating how the sesamoid bones are no longer in their correct anatomical position. In a patient with a bunion the sesamoids no longer lies in their groove and the resulting abnormal biomechanics can cause pain (yellow and amp; red). Note the straight lesser toes in the normal x-ray
Several factors can contribute to the formation of bunions although often there is no identifiable underlying cause.
Bunions can be associated with the following issues:
Patients with bunions can experience a significant amount of pain. The pain maybe felt at the site of the bump, the big toe joint, the second toe joint or elsewhere in the foot.
The prominent bump can get inflamed and irritated by rubbing against shoes (often those that are too small) and occasionally the skin can break down, split open and get infected.
Clinical picture of a patient with a hallux valgus deformity who has a painful medial eminence
The foot widens as a result of the deformity, this makes finding suitable and comfortable shoes a challenging shopping experience. Unfortunately, the longer you have a bunion, the more likely you are to develop arthritis in the big toe joint.
Many patients develop painful corns and callosities due to the abnormal pressure areas that result because of the bunion. This can be directly over the medial eminence of the big toe joint or as a result of the 2nd toe deformity.
A callosity results at the site of abnormal pressure, the thickened skin is the normal compensatory response. Unfortunately callosities can be quite painful. If you try and remove a callosity it will always come back as long as the abnormal pressure and load is still being applied.
Clinical picture demonstrating a severe bunion resulting in a crossover 2nd toe deformity with a painful callosity over the PIP joint
The big toe is big for a reason, it takes almost half of the weight transmitted through the toes when walking and standing. A bunion stops the big toe from working properly. Patients with bunions end up transferring the load first onto the second toe and then the other lesser toes. This is called transfer metatarsalgia. Not surprisingly the second and other lesser toes are not designed to bear the extra load, and as a result, several complications can occur:
Radiograph demonstrating transfer metatarsalgia
Clinical picture of a patient with a painful bunion who is off loading the big toe and as a result, develops transfer metatarsalgia
The big toe will also force the second toe out of its normal position, which may eventually have a domino effect on all the other toes.
Clinical picture a foot with lateral deviation of the lesser toes in a patient with a large bunion deformity
The bunion deformity will never improve on its own and will most likely continue to deteriorate if left untreated.
Typical symptoms of a bunion (Hallux valgus) include:
Not all patients with bunions complain of pain at the site of the bunion. This patient has painful 2nd TMT joint arthritis which developed as a result of her bunion (hallux valgus) deformity.
Investigations help confirm the diagnosis, grade the severity of the condition and where applicable, aid in pre operative planning.
Plain radiographs are a quick and effective way of confirming bunion (hallux valgus) deformity in a foot. In the early stages of the condition, the deformity can be quite subtle. Most people however present when there is an obvious clinical and radiological deformity, often with additional complications such as lesser toe deformity.
Plain radiographs (x-rays) provide the following information:
Foot x-ray of a patient with a severe bunion and associated complications
Bunion deformities are classified by the degree of deformity as assessed by weight-bearing radiographs (x-rays).
Many people have bunions that are not symptomatic. The degree of deformity does not necessarily correlate with the degree of pain or symptoms. However, generally longstanding and severe bunion deformities tend to be painful.
Untreated, bunion deformities tend to get worse. This may happen quite rapidly but may also take many years to occur.
Patients with longstanding bunions can develop problems in adjacent bones, joints and soft tissues such as:
Radiograph (x-ray) of the feet demonstrating arthritis in the big (1st MTP) joint on the left in a patient with an associated bunion deformity (note the prominent medial eminence)
Radiograph (x-ray) of the foot in a patient with a severe bunion deformity and arthritis in the midfoot
Radiograph (x-ray) of the foot, of a patient with a severe bunion deformity and 2nd MTP joint arthritis (note also has midfoot arthritis)
Clinical picture of a foot in a patient with a bunion (hallux valgus) deformity with associated crossover toe deformity
A – AP, B – oblique and C – lateral radiographs (x-rays) of the foot demonstrating dislocation and crossover deformity of the 2nd toe
Serial radiographs (x-rays) of the foot demonstrating a 2nd metatarsal stress fracture in a patient with a hallux valgus deformity A – at initial presentation B – 6 weeks C – 3 months (healed)
Patients with secondary complications of a bunion (hallux valgus) deformity tend to have poorer surgical outcomes than in patients with an uncomplicated mild to moderate bunions.
Patients with 2nd toe involvement (hammer toe, crossover toe, 2nd MTP joint instability and 2nd MTP joint arthritis) have a higher re-operation rate and poorer outcome than patients with an isolated bunion.
Non-operative management for bunion (hallux valgus) deformity aims at relieving pain and return to full activity including sports whenever possible. It is likely to be most effective in the early stages of the condition.
It should always be the first line of treatment. Options include:
A period of rest from sports and exercise that bring on symptoms. Avoiding high impact activities and sports that involve lots of turning, twisting and bending of the toes such as running, dancing, basket ball etc.
A shoe with a stiff sole that prevents motion at the big toe joint will ease symptoms. A shoe with a wide and deep toe box that can accommodate any deformity and avoid any painful rubbing against shoes. A shoe with a rocker bottom can also ease symptoms. Avoid or minimise the time spent wearing high heels if not already doing so.
Custom orthotic may help by correcting associating conditions such as pes planus, flexible flatfoot deformity.
Some patients experience symptomatic relief from bunion (hallux valgus) splints, pads and toe spacers.
The use of non-steroidal anti-inflammatory drugs (NSAIDs) can decrease discomfort in patients with a bunion who have associated big toe arthritis by reducing inflammation in the joint.
The use of paracetamol and other painkillers to help reduce pain levels.
Surgical management is reserved for patients who have failed to respond to non operative treatment.
Patients should understand that the decision to undergo surgery should not be taken lightly.
Any intervention is considered in a step wise manner, with the least invasive procedure carried out first.
Regardless of the degree of deformity, or the operative intervention chosen, a frank discussion of the risks and benefits of surgery will always be undertaken prior to surgery.
It is also important to appreciate the amount of time it takes for full recovery. Although recovery and rehabilitation varies from patient to patient, on average patients take up to 1 year to be fully recovered.
Patients who have this expectation set before surgery, find that the postoperative experience is more likely to match their expectations.
A variety of surgical options exist which need to be tailored to the individual and the stage of the disease:
The aim of surgery is to correct the underlying deformity and restore normal big toe (1st MTP) joint biomechanics. Restoration of the sesamoid – metatarsal articulation is also important for a good outcome.
Before and 6 weeks post operation x-rays demonstrating correction of a severe bunion deformity at The London Foot and Ankle Clinic
Sesamoid radiographic views A – in a patient with a bunion B – in a patient post surgical correction of their bunion (halux valgus) deformity – note normal position of both sesamoid bones in their grooves under the metatarsal head, and the screw used to fix the scarf osteotomy
Scarf and Akin osteotomy involves the following:
This operation has a success rate of roughly 95%. Success defined as a pain free joint with a good range of motion and good to excellent deformity correction.
The operation can in the correct patient be done using a minimally invasive surgical (MIS) technique or a mini open procedure. The operation is undertaken under a general anaesthetic and as a daycase procedure.
The operation is usually done one foot at a time. If both feet are operated on there is no “good” foot to weight bear on. Recovery and complications may be greater in bilateral surgery.
Radiographs of the foot A – pre operative mild bunion (hallux valgus) deformity B – post operative bunion correction with a Scarf and Akin osteotomy (note the smaller medial bump, covering of the sesamoids, restoration of the congruency of the joint and straightening of the toe)
Clinical photograph of a foot, before and 2 weeks after bunion correction surgery
As for Scarf and Akin osteotomy when there is minimal arthritis in the big (1st MTP) joint. Patients should be aware that there may be persistent pain in the big toe joint despite correcting the bunion due to persistent arthritis in the 1st MTP joint.
Radiographs (x-rays) of the foot in a patient with a moderate bunion (hallux valgus) deformity A – pre operative B – post operative (note excellent surgical correction and persistent arthritic change in the 1st MTP joint)
A 1st MTP joint fusion is performed in the presence of severe bunion (hallux valgus) deformity and arthritis in the big (1st MTP) toe joint. Painful movement is sacrificed for a pain free but stiff and straight toe. Patients have excellent function following this operation.
Radiographs before and after of the foot in a patient with a longstanding bunion and arthritis in the 1st MTP joint treated with a 1st MTP joint fusion at The London Foot and Ankle Clinic
The most common lesser toe deformity is 2nd hammer toe deformity.
For details of the treatment of the associated lesser toe deformity please go to the relevant pages:
Patients with lesser toe deformities tend to have slightly poorer outcomes than patients with only an isolated bunion deformity. This is because patients with lesser toe and associated foot complications have had symptoms for longer and by default are more severe.
It should be borne in mind that complications can result from a condition with or without surgery.
Complications can occur as with any type of surgery. Please see Complications for more detailed explanation of post surgical complications.
A – Before and B – After x-rays of the foot in a patient who has undergone bunion surgery, note the darker areas in the bone after surgery indicating disuse osteopenia
Note – this list is not exhaustive and is meant as a guide.
Please read the information regarding what to expect post surgery on this website.
Remember that below is a guide to recovery and that everyone heals at different rates and some people do take longer. Use this information to help you understand your condition, possible treatment and recovery. The timeframes given below are a minimum, it is important that you appreciate this when considering surgery as your healing and recovery may take longer.
Almost all surgical procedures for bunion (hallux valgus) deformity correction will be undertaken as a day case.
You will have a bandage applied similar to this during the operation.
Post operative bandage of the foot
Please do not remove your bandages until you are seen by your surgeon Mr Malik at the two week post operative clinic appointment. You will also be provided with a stiff soled black post operative shoe. Please ensure you wear this whenever you are weight bearing.
Post operative stiff soled shoe
For the first 48 hours you will be allowed to touch weight bear using two crutches. After 48hrs you can weight bear as tolerate. The physiotherapist will guide you after your operation and before your discharge from hospital with the use of crutches and mobilising.
For the first two weeks following your surgery please keep your foot elevated to the level of your heart for 95% of the time. It is recommended you stay at home during this period.
High elevation of the foot and ankle
Naturally most people do not have a hospital bed at home. The same effect can be achieved by lying in a bed or lengthways on a sofa, with pillows behind your back and under your foot. You cannot have your leg elevated sitting in a chair. It is strongly advised that during the first two weeks you are house bound.
To minimise risk of infection keep the foot dry and cool. Avoid humid and hot environments. Keep the foot dry and when showering wear a Limbo bag.
To minimise the risk of blood clots please move your foot and ankle at regular intervals. Please ensure you are well hydrated. If you have a risk of blood clots please notify Mr Malik who may organise for you to have blood thinning injections as a precaution.
You will be reviewed at the clinic and your dressings removed. Your wound will be checked.
Clinical photograph of a typical bunion wound 2 weeks post op. This patient adhered to the strict post-operative instructions and as a result has a dry wound with minimal swelling at 2 weeks.
The wound should be dry, minimal redness if any, slight bruising and with mild to moderate swelling. The foot will be more swollen and less well healed if it has not been kept elevated.
At this stage if the swelling has subsided sufficiently you will be advised to keep your foot in an elevated horizontal position 75% of the time during the day. At night keep one pillow under the foot. It is also advisable not to walk or stand for more than 15 minutes at a time as the foot will swell and start to hurt. You will require to wear the special post operative shoe for another 4 weeks. Short trips can be made outside, within limits of pain and swelling.
Driving will be permitted for short trips if the left foot has been operated on and you drive an automatic. If the right foot has been operated on it will be at least 7 to 8 weeks before any driving is advisable. This is because the right foot is your braking foot and you need to feel safe to do an emergency stop.
Scar desensitisation should start as soon as the wound has completely healed. You can do this by massaging cream (E45 for example) into the scar and around the wound area.
Commence exercises of the lesser toes 3 weeks after surgery and continue for 3 months. These exercises included active resistive and passive toe flexion and extension. They also include intrinsic foot muscle strengthening exercises.
You will have radiographs taken just before you are seen in clinic. You will go over these with Mr Malik and compare the before and after operation images. For a fusion it will generally take at least 6 weeks to show evidence of fusion, sometimes it can take as long as 3 months particularly if you are a smoker.
At this stage if your healing is progressing satisfactorily swelling and bruising should have subsided considerably, although expect some degree of swelling for at least 3 to 4 months.
You will be able to start wearing normal footwear (swelling permitted) around 8 weeks post surgery, although stiff soled shoes are advisable.
Clinical photograph of a foot, before and after bunion correction surgery
Final clinical examination. Discharge if satisfactory.
Please see guidance above and information here. Ultimately it is the responsibility of the patient to decide if they are safe to drive. A good way of knowing is if you can stamp your right foot heavily on the ground to mimic an emergency brake. If you have any hesitation or pain then it should suggest you are not safe to drive. Remember prolonged driving involves keeping your feet in a dependant position. This will worsen the post operative swelling.
This really depends on you and your job. If you have a job that involves a lot of standing, walking and is manual it may be 8 to 12 weeks. If you have a sedentary job, for example in an office and you have a reasonable commute you may be able to go back to work at 2 weeks, although this would be exceptional and not the norm.
Excellent pain relief and deformity correction. Ability to participate in sports by 6 months. Sometimes up to a year before the foot feels “normal” and fully healed.
Yes you should be able to participate in most sports. Certain activities that require the big toe to bend significantly may be difficult, for example certain Yoga positions.
I had found my foot increasingly painful in every day situations and foot wear was becoming a problem regarding fitting and comfort.
I think I was most concerned about how I would manage having my foot raised 95% of the time for 2 weeks. In fact it was easy, due mainly to having a very supportive husband and family and planning ahead with meals etc.
I was told by friends who had this operation that it would be painful but I didn’t experience any pain at all and only some low level discomfort which lasted about 2 hours.
I woke from my anaesthetic feeling absolutely fine. I had no drowsiness or nausea and no pain and went home a few hours later.
I may be one of the lucky ones having experienced no pain whatsoever and only minimal short term discomfort.
Without a doubt making sure I didn’t use my foot too much and ensuring I kept it elevated 95% of the time. Walking with crutches was easy, as was the stairs.
Don’t put off the operation. Plan for when you are going to be incapacitated with meals and things to do to keep you occupied.
Follow Mr Malik’s instructions to the letter. I kept my foot cool, dry and elevated, above my heart day and night for the first two weeks. After that I was still careful to make sure my foot was elevated most of the time, which I’m sure helped me heal quickly.
I decided to have my bunion treated because it caused me pain in my foot and leg and it was hard to find shoes that fitted.
My only concern before the operation was the recovery time.
The operation went very well, no problems at all. I was relieved not to have my foot in plaster like when my right foot bunion was removed 13 years ago. At that time the recovery was very long (the procedure was not done by Mr Malik), but not this time.
The most challenging part of having my bunion operated on was laying flat with my foot up for the first weeks but pre-planning what to do in that period helped: reading, listening to podcasts, doing crosswords, sorting out the family photos and creating albums and watching a bit of t.v.
The days went quickly as I settled into a routine and just knew I couldn’t do anything else.
Be patient and don’t try to do too much too quickly. Increase your walking week by week at your own pace, if your foot swells up rest and cool it down with ice if necessary.
I am 23 and have had bunions for as long as I can remember. I thought I was lucky as they didn’t cause me much pain during my daily routine, only causing pain when I exercised, however when I was 21 I qualified as a nurse. The work hours involve being on my feet for 12.5hrs and made standing or walking for too long extremely painful; I couldn’t ignore the general discomfort in my feet anymore as they had become continuously painful.
My biggest concern was being in pain afterwards. Unfortunately, this was inevitable as I had bilateral bunions; this means that less pain block can be given to each ankle as it needs to be evenly split between the two deformities. It was painful for the first few days, but after that I did not take any pain relief for the duration of my recovery. The pain was not anything worse than I expected; if I kept up with pain relief I found that even during the night initial post-operative pain was bearable.
I’ve read many blog posts over the last few months and I’ve begun to realise I had a good and straight forward recovery. Dr Malik is a brilliant and very calm surgeon; he fully prepared me for what to expect from the operation and recovery and provided advice on a number of occasions, during my post-operative recovery, at times when I was uncertain as to the best way for me to assist my body in it’s recovery. The operation went as expected. After the initial few days of pain and being very immobile/relying on others, I got into a routine.
The most challenging part was relying on other people for a long time and being immobile. I was expecting to heal quickly as I am young, however this wasn’t the case. The first piece of advice I would give anyone deciding to have this surgery would be that you must not be impatient with your body; by having an operation which involves you to be so immobile, and in my case weight-bearing on the operated areas due to having both feet done, the recovery can take a lot longer than expected. You’ve got to be flexible and relaxed about what the recovery period will be, as rushing your recovery can have long-term implications. I needed longer off work than I’d expected so if you mentally prepare yourself for this you will have a much easier time.
Don’t put it off; it might sound like I had the operation at an early stage in my life, however I had known it had to be done for years. I was just putting it off until “the right time”, but by doing so I made my feet much worse. The result of my decision to put off the surgery caused the bunion on my left foot to be so badly impacted that it made it very hard for Dr Malik to get it back to it’s natural angle. The worse the bunion, the harder they are to correct. Timing is a huge factor and it is so important to have support and people around in the first few weeks and so you must plan ahead. I would strongly advise that you get a wheelchair where you can raise your leg up. I got one in the last month of recovery and it means you can take trips outside without your feet swelling; this helps with the sanity as much as the recovery! See the recovery as a positive and take the opportunity to take up some new hobbies which you would have otherwise not started to keep your mind busy… I’ve started knitting!
“Mr Malik and his team provide first class care, for which I am very grateful. Mr Malik is an excellent consultant, he was caring, thoughtful and understanding. I was very worried about having complex surgery to correct a bunion and 3 toe deformities on my right foot. He is a great surgeon and person, I am now well on the way to recovery and would recommend him to anyone.”
Angela Sturgess 5/10/2016
“I can honestly say I would recommend Mr Malik to anyone. He is so kind and put me at ease from the off. He operated in October on my left foot and has corrected the deformity well, excellent Surgeon and as long as you follow his post op advice you will have great results. Waiting for the right foot to be operated on now with no worries at all. Thank you Mr Malik and your team.”
Suzie Best 28/4/2016
“I am delighted with the results achieved by Mr Malik. He put me at ease from the first appointment, explained everything in plain English and displayed a reassuring amount of confidence in what could be done. I wouldn’t hesitate to recommend Mr Malik to anyone. I have a straight foot after many years of pain and am delighted. Thank you Mr Malik and your team.”
Sophie Duffy 17/2/16
“The whole experience was good. Having healthy feet is so important and being able to walk pain free after a speedy recovery is great. I strongly recommend anyone with foot problems to see Mr Malik and get his expert advice on what to do.”
Mrs C Sidenius 8/2/16
“I am now the proud possessor of two new feet – all due to the skill, care and friendly attention Mr. Malik gave to the daunting task of straightening and repairing my toes for me.
My heartfelt thanks for making a much dreaded experience so much more endurable and pleasant than I had anticipated.”
Elizabeth Smith 13/12/15
“Nothing to worry about. Excellent surgeon, now happy to have the other foot done.”
Gay Titley 30/11/15
“My mum’s foot was in such a terrible state, as a family we were very concerned that the surgery would be too drastic to undertake, as she is a lady of advancing years. But Mr Malik took the time to explain to any member of the family who wished to know and did an amazing job. He removed a severe bunion and corrected, through surgery and pinning, the toes that had all headed off in a direction of their own, and to look at it now, you wouldn’t believe it was the same foot. Mum is still in the process of fully recovering but the future is so much brighter having been cloudy. THANK YOU VERY MUCH, Mr Malik!”
Patient’s daughter 4/11/15
“I had bunions on both feet which where very painful, I got referred to Mr Malik. Mr Malik knew exactly what needed to be done and explained it all in clear detail and plan of action, I came out my meeting with Mr Malik feeling relieved and confident that I’m finally going to be free of pain.
My first operation was in November 2013, I had 3 months off work due to having both feet done at the same time. My feet had to be elevated during the healing process. Even when I came out of hospital Mr Malik was very helpful, any questions I had I could contact Mr Malik and right away he would give me advice and insure I was comfortable. It wasn’t as painful as I thought it was going to be during and after the healing process.
After nearly 2 years, one of the screws started to loosen resulting in a lump at the top of my big toe which was also quite painful. I therefore contacted Mr Malik and a meeting and X-ray was booked in right away. 1 month later I had the operation to get the screw removed. I felt comfortable and welcomed before I had the procedure, I was also explained in detail about what Mr Malik was going to do. 2 weeks with my foot rested & elevated and I’m now back to normal.
As a teenager I would strongly recommend Mr Malik, If your suffering with similar symptoms from bunions. It has changed my life, my scars on the side of my toes are a bit tender but all is well no more pain or being uncomfortable. Outstanding results. Thank you Mr Malik and the team for everything, I will forever be grateful.”
Laura Hayes 4/9/15
“I was happy to follow all of the advice that Mr Malik gave me and I am very pleased with the result. It is wonderful to be free from pain.”
Mrs J Everil 29/4/15
Orthopaedic Outpatient Department
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