Introduction
Our feet often change as we get older. Sometimes the big toe starts leaning in towards the other toes, and a bump may start appearing on the joint at the base of the big toe.
Known as a bunion (medical term: hallux valgus), this is more likely to happen in women. It is one of the most common foot deformities. Many people have a bunion with only mild symptoms, or no symptoms at all. But bunions can also cause pain and pressure.
Wearing suitable shoes can relieve the symptoms. Surgery is the only treatment that can get rid of bunions.
At a glance
A bunion is a type of foot deformity. The big toe leans in towards the other toes, and a bump appears on the joint at the base of the big toe.
This may – but doesn't always – lead to problems.
The possible causes include having genes that increase your risk, weak connective tissue and shoes that are too tight.
Wearing comfortable shoes and strengthening the muscles in your feet can help to prevent and relieve symptoms caused by bunions.
Surgery is an option for severe, painful bunions.
Symptoms
In people who have a bunion, the first metatarsal bone gradually moves sideways towards the other foot. As a result, the front of the foot becomes wider and the joint at the base of the big toe bulges out. The big toe leans in towards the other toes, sometimes deforming them too. Bunions can be painful, but not all of them are – even if they're very big.
The pain is usually felt in the toes, on the bulging big toe joint or along the bottom of the foot. The big toe joint mainly hurts when you wear shoes that are too tight. If the bulge is very big, it might even hurt when wearing loose-fitting shoes. Bunions can sometimes damage nerves in the big toe, leading to numbness. The skin on the sole of the foot often becomes thick and hard. The big toe joint may be red and swollen, and sometimes inflamed too. It also becomes harder to move the big toe. Hammer toes or claw toes might develop as well. If that happens, the other toes are bent in the middle or push against each other. Corns often form on the affected toes.
Bunions can increase the likelihood of osteoarthritis in the big toe joint and lead to chronic pain. Last, but not least, the resulting deformity can make you unsteady on your feet, increasing the risk of falls.
Causes
Several factors influence the risk of developing a bunion. Some people are more likely to have bunions because of their genes. Contrary to popular belief, tight shoes aren’t the main cause. But they can contribute to the development of bunions and make the problem worse – especially shoes with high heels and pointed toes. Some people regularly wear tight shoes and never get bunions. And some people nearly always wear comfortable shoes with enough room, but develop a bunion anyway.
The risk of bunions is greater in people who have weak connective tissue, a short Achilles’ tendon, short calf muscles, or a joint disease such as rheumatoid arthritis. But they can also develop as a result of having a splayfoot or flatfoot.
Prevalence
Bunions are far more common in women than in men – probably because they tend to have weaker connective tissue in their feet and are more likely to wear tight, high-heeled shoes. It is estimated that about 1 out of 3 people over the age of 65 have a bunion to some degree.
Diagnosis
To determine whether foot problems are being caused by a bunion, the doctor will check whether the joint at the base of the big toe is bulging, look at the position of the toes in relation to each other, and see how well they can move. He or she will also look at the position of the legs. The examination is done while the patient is standing, walking and sitting. The doctor also looks at the state of the skin on the foot, checks for signs of osteoarthritis, and asks about the symptoms and how – if at all – they affect everyday life activities. To get a clearer diagnosis, the foot is x-rayed in a standing position.
Bunions can vary a lot in severity. The severity is determined based on the angle between the big toe and the foot bone leading up to it (the first metatarsal bone).
The difference between a “normal” big toe joint and a bunion isn’t always clear. Many people have mild bunions that never cause any problems.
Prevention
To prevent bunions, people are advised to wear comfortable, flat shoes. If there’s enough room for the front of the foot, there’s less pressure on the toes and the ball of the foot. Other advice includes walking barefoot in order to strengthen the foot muscles and allow the feet and toes to be in their natural position. Some doctors recommend using orthopedic shoe inserts (insoles). But there’s not a lot of research on how well this can prevent bunions.
Treatment
Bunions can get worse over time. Treatment is only needed if they cause problems. The most suitable treatment will depend on a number of factors, including the symptoms, the type of deformity, and whether the person has other medical conditions such as rheumatoid arthritis, diabetes or vascular (blood vessel) disease.
There are various conservative (non-surgical) treatments that aim to relieve the symptoms of bunions: Only a few good-quality studies have looked into how well they work, though.
Splints: These toe-spacers or toe-supports are used to keep the big toe in a normal position. The aim is to relieve the symptoms and slow down the progression of the bunion – although it’s not clear whether this is possible. They can’t correct the misalignment. Splints are typically used at night.
Well-fitting shoes: People are advised to wear flat shoes that give the toes enough room. If the toes or big toe joint hurt, bunion pads can be used. If the middle part of the foot hurts (metatarsalgia), the toes can be cushioned or supported using shoe inserts or wearing special “rocker bottom shoes.” Walking barefoot as much as possible is also recommended.
Physical therapy (physiotherapy): Special exercises can be done to try to strengthen and stretch the foot muscles.
Painkillers: These may include non-steroidal anti-inflammatory drugs (NSAIDs) in the form of tablets or an ointment. Due to potential side effects, tablets should only be used over a short period of time.
But only a few studies have looked into these treatments. They suggest that measures such as physical therapy, wearing well-fitting shoes and using splints can't really provide relief.
If the symptoms are severe and no other treatment helps, surgery may provide relief. Surgery is the only way to treat the cause of the symptoms, by correcting the misalignment. But there’s no guarantee that surgery will make the symptoms go away completely, and it can have side effects.
Further information
When people are ill or need medical advice, they usually go to see their family doctor first. In our topic "Health care in Germany" you can read about how to find the right doctor – and our list of questions can help you to prepare for your appointment.
Sources
Deutsche Gesellschaft für Orthopädie und Orthopädische Chirurgie (DGOOC). Hallux valgus (S2e-Leitlinie, in Überarbeitung). AWMF-Registernr.: 033-018. 2014.
Hollander K, Heidt C, Van der Zwaard BC et al. Long-Term Effects of Habitual Barefoot Running and Walking: A Systematic Review. Med Sci Sport Exer 2017; 49(4): 752-762. [PubMed: 27801744]
Hurn SE, Matthews BG, Munteanu SE et al. Effectiveness of non-surgical interventions for hallux valgus: a systematic review and meta-analysis. Arthritis Care Res (Hoboken) 2021. [PubMed: 33768721]
Klugarova J, Hood V, Bath-Hextall F et al. Effectiveness of surgery for adults with hallux valgus deformity: a systematic review. JBI Database System Rev Implement Rep 2017; 15(6): 1671-1710. [PubMed: 28628523]
Nix SE, Vicenzino BT, Collins NJ et al. Characteristics of foot structure and footwear associated with hallux valgus: a systematic review. Osteoarthritis Cartilage 2012; 20(10): 1059-1074. [PubMed: 22771775]
Wülker N, Mittag F. The treatment of hallux valgus. Dtsch Arztebl Int 2012; 109(49): 857-867; quiz 868. [PMC free article: PMC3528062] [PubMed: 23267411]
Zirngibl B, Grifka J, Baier C et al. Hallux valgus: Etiology, diagnosis, and therapeutic principles. Orthopade 2017; 46(3): 283-296. [PubMed: 28251259]
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