Bunions - does your big toe have one?

Does your big toe have pain, stiffness, deformation, or a prominent bump?

Sounds like you could have a bunion! A bunion is a deformity of the big toe where it starts to point diagonally away from the midline. There is often a bump on the inner side of the big toe that can be painful or just aesthetically displeasing. If left untreated, bunions will gradually worsen over several years or decades.

What causes bunions?

The scientific term for a bunion is a hallux valgus. It is a common condition, affecting 2.3% of adults aged between 18-65.

There are several causes of bunions:

  • Biomechanical factors

  • Traumatic injuries such as fracture or dislocation

  • Metabolic conditions such as inflammatory conditions (arthritis) or connective tissue disorders (Ehlers-Danlos syndrome, Marfan syndrome, Down syndrome

The most common but most complex cause of bunions is related to biomechanical instabilities that can occur from within the foot or all the way up into the hip and knee (or even the spine).

Examples of biomechanical factors can include tight calf muscles, being knock kneed, weak hip muscles, or excessive pronation. Examples of external factors include constricting footwear (e.g. high heels).

Biomechanics 101 – bunions and walking

Here is a simplified rundown to explain bunions. Some pronation (rolling in of the foot) must occur during walking and running to absorb ground-reaction forces, but overpronation creates too much mobility in the midfoot, decreasing stability in the foot. This can lead to decreased supination (lifting the midfoot and arch back up), over time this creates a rigid lever arm in the big toe, leading to stiffness.

During normal propulsion when walking (toe off) you need approximately 65o of big toe extension, but limitation in big toe mobility can cause the joint to drift away from the midline, leading to hallux valgus if there is enough foot mobility. If there is not enough mobility a condition called hallux limitus can form (literally meaning stiff big toe).

Treatment of bunions

Treatment of painful bunions initially consists of ice, non-steroidal anti-inflammatories (NSAIDs), relative rest, and taping techniques used to offload the big toe. Padding can also be used to reduce pressure and load on the joint.

Non-painful bunions can be treated conservatively through soft tissue releases and joint mobilizations to improve mobility of the foot and ankle, and perhaps higher up (hip, knee, spine).

An assessment of walking mechanics, footwear, and overall function is required to identify areas of weakness, stiffness, tightness, or lack of control/coordination. Orthotics are often prescribed to offload the area and improve mechanics of the foot. Weight loss is also an important factor in reducing load when walking and standing.

In some cases corticosteroid injection may be useful, but there have been no good quality studies to support its use in clinical practice, and relief may be short-lasting.

Surgical intervention may be required as a last resort, but the rehabilitation process is often lengthy and unsuccessful. For example, surgical repair of the big toe does not improve obesity, weakness, or overpronation, which may have been the cause of the bunions in the first place.

How can we help you at Physio Room?

Management of bunions often requires a multi-disciplinary approach. A thorough assessment of your overall function, posture, and mobility will be conducted by one of our physiotherapists.

We will look also at your gait (walking pattern) and footwear, which can also be done by our onsite sports podiatrist. If orthotics are required then our sports podiatrist will be ready to assist you!

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