Painful bunions? Surgery isn’t always necessary

Many people are told that to find relief of their bunion pain, they either need to wear bulky cushions over the bumps or find wider or even open shoes.   They may also be told that if the bunion continues to be painful, they would need surgery to correct the deformity.  Unfortunately, a third, often effective option is not discussed; orthotics.  Before you stop reading and call me a quack for promoting an insert you wear under your foot to reduce pain on a bump that is on the side of your foot, hear me out, because I see this all the time.  And it works.  This explanation may keep you comfortable and out of the operating room at the same time.


First of all, you have to understand the nature of bunions and bunion pain.  A bunion is a combination of a boney prominence behind the big toe and the toe angling toward the second toe.  The bump is not an enlargement of the bone, or an abnormal growth of bone.  It is the normal bone that has slowly, over many years, moved into an abnormal position.  Bunions occur because of a muscle imbalance.  If your feet are not as stable as they should be, if they pronate or flatten too much when you step down, then you will develop a slight muscle imbalance, as the muscles in your feet are trying to stabilize them.  Unfortunately, they can’t provide enough stability, so instead, they start to pull the bones and toes into abnormal positions.  This leads to the big toe moving toward the second toe, and the metatarsal behind it moving the other way, hence a bunion.


So now you have this big bump on the side of your foot.  That, in and of itself, doesn’t mean you need surgery.  First of all, if it doesn’t hurt, I don’t recommend that you have it surgically corrected.  It may never hurt.  I would, however, recommend custom orthotics in order address the instability that has led to the development and progression of the bunion.  Properly made orthotics will eliminate the muscle imbalance and slow down, or ideally stop the progression of the bunion.  They won’t get rid of the bump, but if it’s not painful, there’s no need to remove it.  So the goal at this point is to prevent it from getting larger, and becoming painful to the point where surgery may be necessary.  By the way, even when surgery is necessary, I almost always recommend orthotics afterward, since the surgery only addresses the bump, and not the instability that led to the development and progression of the deformity to begin with.  Orthotics should help prevent the bunion from coming back.


Now, let’s say you have a bunion, and it is painful.  It may be painful with shoe pressure, and even painful when walking barefoot.  So why would a bunion be painful when walking barefoot if there’s no shoe pressure on it?  This has to do with the mechanics of your big toe joint.  The base of the big toe rotates upward and around the rounded metatarsal head behind it.  When the metatarsal head stays down, as it would when a stable foot steps down, the big toe rotates smoothly up and around the metatarsal head.  But when you step down on an unstable foot, the arch flattens because the first metatarsal bone elevates up excessively.  The big toe can’t rotate up and around the elevated metatarsal head, and the joint jams.  This jamming causes an inflammatory response in and around the joint.  As a result of the inflammatory response, the joint then becomes painful with motion, and with pressure from shoes, when it otherwise may not have been painful.  (Try this on your own big toe joint: while you are sitting, hold your first metatarsal down and flex your big toe upwards as much as you can.  Now hold the metatarsal up as high as you can and then try to flex the toe upward again.  With a very flexible first metatarsal, less motion will be available at the big toe joint.)


This is where orthotics come in.  Custom-molded orthotics are designed to maintain the most supportive position for your feet, usually with the highest arch possible.  That means that orthotics will prevent the first metatarsal from elevating up excessively when you step down, allowing a normal amount of motion at the big toe joint.  When the joint functions normally and the big toe is allowed to flex all the way over the metatarsal head without jamming, no inflammation develops.  If there is no inflammation in the joint, the bunion may not be painful with shoe pressure.


I know that’s a long explanation as to why orthotics may help keep you from needing bunion surgery, but an understanding of the mechanics and physics involved is crucial to understanding this concept.  It even alludes some doctors, which is why orthotics are not always discussed as an option when treating bunions and big toe joint pain.  So often, in an attempt to avoid or delay bunion surgery, i will recommend orthotics to a patient.  While some may be skeptical, most are willing to try them in an effort to prevent the need for surgery.  And so often, a month or so after getting their orthotics, they tell me that they are pain free.  It may sound crazy to some people, but when you understand the mechanics involved, it makes all the sense in the world.


And since orthotics are still recommended after surgery in order to maintain the most supportive position and foot function, and they just might help get rid of the bunion pain without surgery, there’s really no reason not to try orthotics before considering bunion surgery.  If you still have pain and need surgery, you still have the orthotics to wear afterward.  You won’t need to be remolded for new inserts.


If you have a bunion and you’ve been afraid to talk to your doctor because you think surgery is the only option, come in and see us at Kansas City Foot and Ankle.  While we are all experts in bunion and reconstructive foot and ankle surgery, our goal is to get you comfortable quickly, and keep you out of the operating room whenever possible.  Call 816-943-1111 to schedule an appointment.