Bunion Problems

author : AMSSM

comments : 0

Painful bunions are notoriously difficult to treat. There is a lack of strong scientific evidence to make any definitive recommendations but there are a few things you can do.

Member question

I have a bunion on my right foot. The bunion is quite pronounced and my big toe has started to cross the toe next to it.

Four years ago I was given a steroid injection into the toe joint under aesthetic, this has worked well and means the toe joint is pain free.

My bunion however has changed my gait, my physio tells me I lean backwards slightly and this puts more weight through my heels rather than the ball of my foot.  This in turn has had a knock on effect, I've had right knee problems and left hip problems. My left glute medius muscle is weak and this has given me stiff hips and lower back problems!

I'm 48 and I guess perhaps my body is starting to notice a bit of wear and tear!

Right now I'm concentrating on building up my core strength so I can support my back better.  I do glute specific exercises in the gym with my PT and I wear orthotics in my running shoes to help take my weight forward.  

All of this helps. My question:  Should I really be addressing the root of my problem and have surgery to correct my toe joint?

Answer by Dr. Masaru Furukawa, MD MS
Member AMSSM 

Dear Bunion,

From your description of your great or first toe, it certainly sounds like you have a bunion or what we in the medical field call hallux valgus, or outward angling of your great toe. Despite the obvious bunion, there are several other structures and conditions that can cause chronic overuse pain of your great toe: hallux limitus or rigidus are conditions caused by osteoarthritis or wear-and-tear of toe joint leading to severe limitation in the range of motion of the great toe. You also have sesmoid bones underneath the great toe (a small version of a knee cap under your great toe!) that can get irritated or even develop stress fractures with over use.  Though less likely, irritation of a bursa that sits between your 1^st and 2^nd toe and metatarsalgia, or the irritation of tip of your 2^nd mid-foot bone can be mistaken for great toe pain.

Much of these conditions can be diagnosed with a thorough history and physical examination. X-rays can be helpful for characterizing bunions and hallux limitus/rigidus.  Sesmoid stress fractures are difficult to definitively diagnose by just exams and x-rays so your doctor can get either a bone scan or MRI to further evaluate for this condition.

Painful bunions are notoriously difficult to treat. There is a lack of strong scientific evidence to make any definitive recommendations, but so far, there are no non-surgical treatments (orthosis, injections, toe braces, etc) that have been shown to effectively treat bunions. There is however, good evidence to show surgery to be more effective than watchful waiting, or orthotics for the treatment of bunions. However, there are no studies whatsoever looking at the outcomes of bunionectomy surgery on runners.  There are several bunion surgeries available but I cannot comment on the type of surgery that is best as I am not a surgeon.

It is difficult to know if the bunion you have is causing the running gait changes. Since the bunion developed over a period of years, your gait likely adjusted naturally over time. Running with a heel strike is not necessarily a bad thing. In fact some of the fastest runners in the world run with a heel strike. The current trend toward forefoot running comes from studies showing decreased risk of lower extremity injuries in a population of chronic forefoot strikers when compared to heel strikers. Statistically, running on the heels may increase your risk for lower leg injury, but for you, if heel striking is not causing a problem then there is no need to alter your foot-strike patterns. I would avoid orthotics that alter your center of gravity or foot strike patterns too quickly as it will likely cause problems elsewhere. On a similar note, surgery for your bunion will likely alter your gait patterns dramatically and there is certainly no guarantee that the changes will result in improvement of your other ailments. If you notice asymmetries in gait, I would recommend focusing on core stabilization exercises and gait training with running drills and observed runs. Remember your gait changes probably took years to develop so be patient with your re-training.

To prevent further exacerbating your bunion pain, buy wide-toed running shoes. Most running shoe companies carry various widths. During your non-training time, avoid wearing high heels and shoes with narrow toe boxes. Many people, including my wife, find their bunion unsightly but you should really consider wearing open toed shoes at work. If this is not an option sometimes padding the bunion can relieve pain. Try not to run through bunion pain, treat it early with ice and cut back on running miles. Start with halving the mileage. Focus on swimming during this time of relative rest, as most triathletes are guilty of neglecting their swimming any way!

Dr. Masaru Furukawa, MD MS

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date: June 28, 2012