Bunions
Ask the Podiatrist
DON’T EAT THE TURNIP!
--Dr. Jay C. Goldstein
Q. About two years ago my husband called my attention to a bump developing along the side of my big toe joint. He also noticed that my great toe was crooked; it was leaning toward my second toe. It didn’t hurt, and I assumed it was congenital. At first I ignored it. However, the bump has gotten larger, and my great toe is now abutting my second toe. For the past three months, I have had an ache in my great toe joint after long runs. The ache is getting worse. Yesterday I went to a party, wearing some dress shoes, which I don’t do very often. The joint hurt so much that I had to take my shoe off.
The problem you are developing is called a bunion, from the Greek bounion, meaning turnip. Apparently, the Greeks thought it resembled the vegetable, but clearly, this problem does not sound very appetizing.
WHAT IS A BUNION?
A bunion is a deformity of the great toe joint, along the inside of the foot. Note that the great toe is deviated toward the outside of the foot (toward the second toe) and the bone behind (connected to) the great toe is deviated toward the inside of the foot, creating the “bump.” The bump takes up room, and is prone to shoe pressure, causing the unfortunate recipient to require a shoe with a wider forefoot.
Most bunions develop when a bone, called the first metatarsal, drifts toward the other foot, or when the great toe drifts toward the second toe (see diagram). The muscles and tendons about the great toe joint then become unbalanced, causing the great toe and the first metatarsal to drift opposite of each other. Thus, once the process starts, the malalignment of the first metatarsal and the great toe reinforce each other, a vicious cycle. The bump (bunion) is actually bone (the first metatarsal). If the bump gets rubbed (shoe pressure), it becomes inflamed. The inflammation, or swelling, causes the bump to get even larger, which now takes up more room in the shoe. Since it takes up more room in the shoe it gets rubbed by the shoe even more, and the inflammation increases…and so on.
If the great toe continues drifting toward the second toe, it will eventually abut the second toe. Then one of three things will happen: The pressure between the toes may cause a soft corn to develop, the great toe may force the second toe to dislocate upward, or the great toe may drift under the second toe.
WHAT CAUSES A BUNION?
There are several etiologies that can cause a bunion to develop: genetics, shoes, the forces applied to our feet, trauma, and arthritis.
Genetics: Choose your parents wisely—trite, but true. Feet are comprised of 28 bones and even more joints. The bones can vary from one person to another regarding shape and position. The bones are an interlocking jigsaw puzzle. When they come together properly, they can and should be quite stable. However, some joints are aligned in a less stable fashion. Some people have more flexible ligaments that more easily give way when stretched. Some great toes are longer, more likely subjecting them to shoe pressure. Why can some people abuse their feet with relatively few repercussions, while others suffer foot problems following only minor provocation? Genetics. You’re right, it is not fair, but who said…
Shoes: Shoes are probably an even greater etiology of bunions than genetics. Many more females than males are treated for bunions—a gender-linked gene, or because of the shoes to which females are subjected? My money is on the shoes.
When China was a monarchy, it was deemed more god-like for the female royalty to have small feet. (I wonder from whence that idea came—surely not the female royalty?) The young girls’ feet were bound by leather thongs to keep them small. Subsequently, the girls became women with small (deformed) feet. Fortunately, they had lots of servants, because many were not able to walk, and had to be carried.
I submit that if I knocked on your front door bright and early each morning, and announced that I had come to bind your feet, I probably would not be allowed to enter. Yet, do not many people do the same thing to their own feet? If you continually hold toes in a malalignment with shoes that are too short, too narrow, and/or too pointed, is it so surprising when one day the toes say: “O.K., I give up. I can take a hint. If you want me to move over, I will.”
The above is not to suggest that females are the only ones who suffer from the vagaries of shoe styles and poor fit. However, King Louis XIV of France (who started the fashion of high-heeled shoes because he was short) to the contrary, our society seems to punish female feet more.
Abnormal forces: The forces to which our feet are subjected is an etiology over which we do not have as much control as the shoes we wear. These forces are determined by such diverse factors as the shape and length of our legs, the position and alignment of our hip and knee joints, the strength and length of our muscles and tendons, the way one bone interlocks with its neighbor, and the laxity of our ligaments.
Repetitive trauma: Trauma may influence the development of a bunion. The word trauma normally conjures up the thought of a large, acute force, such as the young lady who limped into my office four months after kicking a brick wall (in a fit of rage because her car was being towed away). However, more bunions are caused by small but repeated trauma, such as kicking a ball or going en pointe. Wearing a short shoe while running downhill would not be much different.
Arthritis: The last etiology that I will discuss here is arthritis. Arthritis can be divided into two large categories, traumatic and disease. The people described in the paragraph above would eventually develop painful degeneration of the joint because of the malalignment of the bones and/or the erosion of the cartilage (a substance that provides a smooth coating over the end of the bone where it forms a joint with the end of another bone).
The disease category of arthritis often involves heredity or a genetic predisposition, such as rheumatoid arthritis, psoriatic arthritis, and gout.
TREATMENT
Shoes: Treat your feet kindly. The easiest and best place to begin is with shoes, shoes that fit properly, and that have a shape that at least bears some resemblance to the human foot. The shoe should not press against the inside edge of the great toe, nor against the outside edge of the small toe. When standing, you should have at least the width of one thumb between your longest toe and the end of the shoe.
Much of the expense of a good jogging shoe is in the midsole. The midsole is responsible for most of the shock absorption. Do not try to run more than 500 miles in your shoes, no matter how good the upper appears.
The heel counter is another important feature of shoes. It should be very firm, and vertical to the ground. If it breaks down, or is no longer perpendicular to the ground, it needs to be retired; okay for the garden, but not for jogging.
Muscle balance: Proper muscle balance can be improved with gentle but diligent muscle strengthening and stretching. Generally, runners usually need to strengthen their extensors (along the front of their legs and tops of their feet) and stretch their flexors (along the back of their legs and the bottom of their feet).
Foot orthoses: Some people are born with foot bones that are very unstable. Such a foot is more likely to develop bunions, and other problems as well. Orthotic devices, in conjunction with mechanically stable shoes, can be very helpful.
Surgery: Unfortunately, there is no treatment other than surgery that will reverse a bunion. A reasonable analogy might be a cavity. In a very early stage, take prophylactic steps and maybe surgery can be avoided. In a moderate stage, take all the prophylactic steps you can, and if asymptomatic, observe. In an advanced stage, or if symptoms persist, the horse is out of the barn.
But whatever you do, this is one turnip not to be taken lightly!
Dr. Goldstein has been running for many years--without any turnips. He is Board Certified in Podiatric Surgery, in Podiatric Orthopedics, and also in Podiatric Medicine. Dr. Goldstein practices in Portland, Oregon