What is a bunion (hallux valgus)?

Hallux valgus is the medical term for a bunion. A bunion is not simply a lump or an extra growth of bone on the side of the big toe. It develops because the bones of the big toe gradually change position, causing the characteristic prominence on the inner side of the foot.

Bunions are common and usually develop because of a combination of factors rather than a single cause. There is often an inherited tendency, although foot shape, ligament flexibility and some forms of arthritis can also contribute. Factors associated with developing a bunion include:

• An inherited tendency or family history
• The shape and mechanics of the foot
• Generalised ligamentous laxity (“double-jointedness”)
• Some forms of arthritis, particularly inflammatory arthritis
• Footwear may aggravate symptoms from an existing bunion, although it is not usually the sole cause

What symptoms can a bunion cause?

Not all bunions are painful. Some people have quite marked deformity but relatively few symptoms, while others find even a smaller bunion troublesome. Common symptoms include:

• Pain or inflammation over the bunion, particularly where it rubs against footwear
• Difficulty finding comfortable shoes because of the width or shape of the forefoot
• Pain in the big toe joint, sometimes associated with arthritis
• Painful corns or areas of hard skin (callus) beneath or around the big and lesser toes
• Crowding or deformity of the lesser toes, particularly the second toe
• Pain beneath the ball of the foot (metatarsalgia) as the way load passes through the forefoot changes
• Difficulty with walking, exercise or sport in more symptomatic cases

The appearance of a bunion alone is not usually a reason for surgery. Treatment should be guided primarily by pain, problems with footwear and the effect the bunion is having on your activities and quality of life.

Is a bunion the same as arthritis of the big toe?

No. A bunion (hallux valgus) and arthritis of the big toe (hallux rigidus) are different conditions, although occasionally a patient can have both.

In hallux valgus, the main problem is a change in the alignment of the big toe and first metatarsal, producing the characteristic bunion prominence. In hallux rigidus, the main problem is damage to the cartilage of the big toe joint. This can cause pain, stiffness and bony prominences around the joint, often particularly on the top of the foot.

Hallux rigidus may therefore be painful even when barefoot and commonly causes pain when the big toe bends during walking. The treatment is different from that used for a straightforward bunion.

How are bunions assessed?

Assessment starts with understanding what problems the bunion is actually causing you. The size of the deformity on its own does not determine whether treatment, or surgery, is appropriate.

During your consultation I will usually assess:

• Your symptoms — including pain, rubbing from footwear and pain beneath the forefoot or lesser toes
• Your expectations and priorities — including walking, work, sport and the footwear you would like to return to
• The shape and flexibility of your foot and big toe, as well as the position of the lesser toes
• The way your foot functions when standing and walking
• Any associated problems, such as arthritis, flat foot, lesser-toe deformity or generalised ligamentous laxity
• Your general health, medications and other factors that may affect treatment or recovery

Weight-bearing X-rays are usually important because they show the position of the bones while you are standing on the foot. They help me assess the severity and pattern of the deformity, the condition of the big toe joint and whether there are other features that need to be considered when planning treatment.

The aim of the consultation is not simply to decide which operation to perform. It is to establish why your foot is painful, whether the bunion is responsible, and whether non-surgical treatment or surgery is most appropriate for you.

What are the treatment options for a bunion?

Without an operation

Many bunions do not require surgery. If your symptoms are manageable, simple measures may be all that is needed. These treatments cannot reliably straighten the underlying deformity, but they can make the foot considerably more comfortable.

• Choose footwear with a wide toe box to reduce pressure over the bunion and crowded toes.
• Avoid shoes that consistently aggravate your symptoms. This may include narrow, pointed or high-heeled footwear, although different people tolerate different shoes.
• A toe spacer or protective pad can sometimes reduce rubbing between the big and second toes or pressure over the bunion.
• Insoles (orthoses) may be helpful where foot mechanics or another part of the foot is contributing to symptoms, although they do not correct the bunion itself.
• Corns and areas of painful hard skin can often be treated by a podiatrist.
• Simple painkillers or anti-inflammatory medication, when medically appropriate, may help during a painful flare-up.

Splints and spacers may temporarily improve the position or comfort of the toe while they are being worn, but in an adult they should not be expected to permanently correct a structural bunion.

There is no need to have an operation simply because a bunion is present. If these measures allow you to wear suitable shoes and undertake the activities you want with acceptable symptoms, continuing with non-surgical treatment is entirely reasonable.

When is bunion surgery considered?

Bunion surgery may be considered when your symptoms are significant and appropriate non-surgical measures are no longer allowing you to do the things you want comfortably. The decision is based on your symptoms, examination and weight-bearing X-rays rather than simply the appearance or size of the bunion.

There are many different operations used to correct hallux valgus. The appropriate procedure depends upon the pattern and severity of the deformity, the condition of the big toe joint and other features of your foot.

In my practice, SCARF and AKIN osteotomies are commonly used to correct symptomatic bunions where this technique is appropriate. The operation realigns the bones rather than simply removing the visible prominence.

If you are considering surgery, I have a separate detailed guide to SCARF and AKIN bunion surgery explaining the operation, recovery, walking, return to work, driving and potential risks.

Other operations may sometimes be more appropriate. For example, a Lapidus procedure may be considered for certain more severe or unstable deformities, while fusion of the big toe joint (1st MTP joint) may be appropriate when significant arthritis is also present. The choice of operation is individualised following examination and weight-bearing X-rays.

What are the risks of bunion surgery?

Bunion surgery is generally successful, but no operation is without risk. Potential complications include infection, problems with wound healing, nerve irritation, stiffness, problems with bone healing or fixation, recurrence of the deformity, persistent pain and blood clots (DVT/PE). Some complications are uncommon but can be significant.

The particular risks depend upon the operation being considered, your foot and your general health. I will discuss these with you individually before any decision is made to proceed with surgery.

My detailed SCARF and AKIN bunion surgery guide explains the operation, recovery and potential complications in more detail.

Bunion surgery should not normally be undertaken simply to improve the appearance of the foot. The potential benefits of surgery need to justify its risks and recovery.

Bunion surgery should not normally be undertaken simply to improve the appearance of the foot. The potential benefits of surgery need to justify its risks and recovery.