By Dr. Steven Gershman
When I think of bunions, I think back to when I was growing up and can still picture seeing old women with shoes cut out on the big toe side and very wide feet. Where the shoe was cut out there was a bump on the side of the foot sticking out. In my first few years of practice I had some older women patients coming in with similar shoe modifications made. Thankfully, now I no longer see this as there are shoes available that preclude the need to cut them open to handle bunions on feet. This blog will explain bunions and the best shoes and sandals for bunions.
What is a bunion?
So, what is a bunion? A bunion is a bump on the big toe side of the foot (medial side) just below the big toe. This bump is actually bone, the head of a bone in the foot called the first metatarsal. There can be an inflamed soft tissue sac of fluid called a bursa over the bone, but the bump is bone. In general, this bump is in concert with a wide splay foot so that it protrudes out even more. The first metatarsal bone just behind the big toe actually moves away from the remainder of the metatarsals and the head of the bone protrudes out.
In most cases the bunion is part of a more complex deformity called hallux abducto valgus or hallux valgus. Hallux is the medical term for the big toe. Abducto or abduction is the term for the big toe deviating toward the small toe side of the foot (lateral side). It can be severe enough that the big toe impinges on the second toe, sometimes going under the second toe and sometimes going over the second toe. This can create a secondary foot condition, a hammertoe of the second toe, which is a deformity of the toe where it buckles and raises up in the middle and the end of the toe pulls down. Finally, valgus means a rotation of the big toe where the bottom of the toe rotates up to end up on the side facing the second toe.
What causes a bunion?
How does this significant deformity occur? There are a few reasons for a bunion to form.
- • Genetics: In many cases it is a genetic tendency passed down from generation to generation more commonly in women. The underlying causes are still being studied, but in general, theory is that there are biomechanical flaws in the foot altering the foot function leading to over pronation and resulting abnormal stresses while walking or standing. Over time, this causes damage and stretch to the ligaments that hold the bones together allowing increased motion in the foot and a resulting shift in the bones causing the deformity.
- • Gender: Women generally have more flexible ligaments to allow them to give birth and are more prone to this occurring. Ligaments stretch more during pregnancy adding to the looseness.
- • Ill-fitting shoes: To add insult to injury, many women's shoes are a major contributor to the deformity as they often squeeze the toes together due to tight narrow toe boxes often found on many "fashionable" shoes. This constant squeezing is like braces on teeth that shift the teeth through constant pressure. Many women's shoes function in the same manner forcing the big toe over toward the second toe. High heels add even more force on the forefoot which exacerbates the deforming force of the narrow shoe toe box. While shoes by themselves probably don't cause bunions, they speed up the formation and add to the amount of deviation of the bones causing more severe bunions.
Before I go further on bunions, there is another deformity that often is related to and can be found in conjunction with hallux abducto valgus. This deformity has many different names including tailor's bunion, bunionette, bunion on the little toe and pinky toe. The term tailor's bunion came about due to tailors sitting crossed legged to sew in ancient times causing a bump on the small toe side of the foot. In effect, this deformity is a mirror image of the bunion on the big toe. On the little toe side of the foot is the fifth metatarsal bone which is behind the little toe. With a tailor's bunion, the fifth metatarsal moves away from the foot so that its head protrudes forming a bump which is called a bunionette. Similar to Hallux valgus where the big toe deviates toward the second toe, in a tailor's bunion the fifth toe moves toward the fourth toe. In many cases there are bunions on both sides of the foot as the same forces that cause bunions also cause Tailor's bunions. The result is a very wide splay foot with the big toe and small toe deviated toward the middle of the foot. This type of foot has major issues fitting shoes.
Bunions can hurt for several reasons.
- • Pressure and irritation: Pressure on the bump itself from shoes as most shoes don't allow enough room for the protruding bump or bumps on both sides of the foot. In these cases, the bunion bump becomes irritated by the shoe rubbing and can be inflamed and painful. This is the most common symptom.
- • Big toe joint: The abnormal big toe position causes damage to the joint and its cartilage causing jamming of the joint, arthritis, and pain.
- • Hammertoe formation: Sometimes a bunion can create a hammertoe on the second toe from the big toe impinging on it. This hammertoe can cause pain from the shoe rubbing its top as it sticks up in the shoe, and from it's joint to the foot being damaged and inflamed from the deformity.
- • Gait alteration: Bunions can change a person’s gait due to the abnormal shape of the forefoot which destabilizes it, reducing its ability to function normally. This change in gait can cause pain in the foot, the knees, hips, and back.
How to treat bunions
So, how does one treat bunions or relieve bunion pain? The many techniques available to correct a bunion and tailor's bunion are beyond the scope of this blog, however the basic principle is to alleviate pain. When dealing with bunions and tailor's bunions, the only true treatment is surgery to repair the deformity. Every surgeon evaluates the individual patient to decide which procedure to recommend. If you are considering bunion surgery, ask for a full explanation of the purposed surgical plan. Bunionectomies are performed by podiatrists quite frequently and by orthopedists who are foot and ankle specialists.
- • Osteotomy: a surgical procedure to cut the metatarsal bone and change its position while moving the big toe and/or little toe back to its anatomical position. Usually this requires pins or screws to hold the bone in place while it heals.
- • Bumpectomy: a procedure that removes just the bunion or bump on the side of the foot but not correcting the joint or big toe position or the same on the little toe side. A bumpectomy is a simple but only partially effective "cure" as the deformity still exists but at least it is easier to fit shoes.
- • Minimally invasive bunion surgery: some surgeons chose to perform this. This is surgery done through a small hole or several holes rather than an open incision. For some patients this can be done but it is not universally done at this point due to the need for extensive correction of several anatomical parts during many bunionectomies.
Shoes for bunions
The title of this blog is "The Best Shoes for Bunions". To begin with, many patients prefer to avoid surgery for several reasons. So, the question is how do I as a podiatrist relieve bunion pain without surgery? It all starts with SHOES. The best shoes and sandals for bunions will have the following features:
- • Width: I recommend extra wide shoes and sometimes extra extra wide shoes to accommodate the wide splay foot that develops with bunions and tailor's bunions. The wide width will not squeeze the foot and create a pressure free environment for the bunion. Unfortunately, most footwear brands only carry medium widths which can exacerbate the condition. Your best bet is to look at orthopedic brands such as Orthofeet that specialize in wide width footwear with options up to 6E!
- • Toe box: The other key feature is not just the width but the shape of the toe box in the front of the shoe. The toe box which houses the bunion has to be round and not pointed. I have seen many shoes labelled wide but having narrow shaped toe boxes which defeat the purpose of the wide width. Also, the toe box needs to be high to accommodate the often-related hammertoe on the second toe which protrudes up. In addition, the big toe also can stick up with a bunion and so the shoe needs extra height in the toe box. Orthofeet shoes are especially designed for this purpose with round wide roomy toe boxes that are also tall. I wear them myself as does my wife as we both have very wide forefeet that need the room that Orthofeet offers.
- • Orthotic insole: orthopedic shoe companies design shoes with built in orthotic insoles which help in stabilizing the deformed foot especially where there is excess pronation. An orthotic can slow down the continued worsening of the deformity and reduce pain by redistributing forces on the damaged forefoot joints.
- • Extra depth: a deep shoe construction along the entire shoe is also a big feature that is required for bunion accommodation. An extra depth shoe generally has more total room and the ability to handle an insert. Orthofeet shoes are extra deep to allow accommodation for the deformity and a custom insole.
- • Soft and seam-free interiors: having a soft seamless inner lining that is padded with foam and a flexible outer material or uppers without overlays, provide gentle contact with the bunion and help relieve bunion pain.
- • Stretch fabric uppers: when the shoes are constructed with materials that are flexible and stretch, they conform to the contours of the foot, hence the bunion bump, and don’t apply any pressure on it. Orthofeet has many stretchable shoes and sandals that work exceptionally well for bunions.
- • Heel to toe drop: the best shoes need to be low to the ground with low heels as any heel height is counter-productive to a forefoot with bunions and/or tailor's bunions. If the heel is elevated even a small amount, extra force is put on the forefoot jamming it forward causing stress to the already damaged joints, further destroying cartilage and adding to the deformity speeding up the process of more deformity and causing more pain.
- • Heel counter: Shoes should also have a firm heel counter and firm outsole for stability. Pronation, which is excess motion of the foot, causes bunions to form and continue to progress. So, the shoe needs to be stable to reduce the pronation motion.
Other treatment of bunions
There are numerous "Bunion relievers" on the market for sale. Some of them are gimmicks while others can provide pain relief. However, a bunion cannot be "corrected" by any of them.
- • Simple bunion pads over the bump can help relieve some of the irritation from shoe rubbing and cushion it from further injury.
- • Some socks have built in "bunion shields" which also can help protect the bunion from the shoe. Other socks, such as Orthofeet Bunion Socks, are designed with a split toe technology that includes a seam between the first and second toe to help separate it from the other toes. This also reduces rubbing and irritation.
How to prevent bunions
Is there a way to prevent bunions? Yes and no.
Yes, you can slow down the progression and severity of the deformity but no in most cases if the tendency is there to form bunions, it will still occur regardless. To slow down the progression and amount of deformity it still comes down to shoes. Poorly made or fit shoes with high heels and narrow toe boxes will speed up the process and add to the deformity. Once the joint position changes from these bad shoes it is PERMANENT. So, I warn all my patients the best thing they can do for their feet is switch to more appropriate shoes early in life. If they pronate a lot or have hypermobility, then orthotic insoles are needed.
Finally, as a podiatrist I always have my patients bring in their shoes on their first visit to my office. So many issues on the feet are related to shoes. Proper shoes can reduce foot problems and treat many others. Bunions and tailor's bunions are especially affected by shoes. My mother had severe bunions on both feet before necessary surgery. To help avoid this I always wear appropriate shoes and orthotics. I wear Orthofeet shoes and have for 30 years. So far, my feet allow me to walk daily for exercise and ran 7 marathons when younger. I do not have bunions or major deformities on my feet.