May 7, 2019
Symptoms of bunions include pain, restricted movement of the big toe, swelling and redness. Dr. Ali Rahnama discusses what causes bunions and how we treat them.
Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.
Host: We’re speaking with Dr. Ali Rahnama, a foot and ankle surgeon at MedStar Washington Hospital Center. Thank you for joining us, Dr. Rahnama.
Dr. Rahnama: Thank you for having me. It’s a pleasure.
Host: Today we’re discussing bunions, which are painful, bony lumps that can develop at the base of the big toes. Dr. Rahnama, what’s going on within a patient’s foot when a bunion forms?
Dr. Rahnama: So, as you very nicely said, a bunion is a large bump at the base of the great toe joint that forms. There are multiple reasons that can contribute to a bunion’s development. We think that, for the most part, the average patient that we see with bunions, it’s likely hereditary in nature. Most experts will agree that shoe gear and high heels and tight shoes - while they can exacerbate or make it more painful or symptomatic, they’re likely not the cause of why a bunion would form.
Host: Often, people think of older adults as most likely to develop bunions. Is that accurate?
Dr. Rahnama: Well, it’s true that by the time most people present for help and evaluation of their bunion, the bunion can become prominent and painful as early as the teen years. And, this is usually a condition called juvenile hallux valgus. These individuals are usually hypermobile or ligamentously lax, think of highly flexible people. So, to answer your question, no. The bunion can really affect people of all ages.
Host: Do patients usually know what’s going on with their foot, or are they surprised by the diagnosis when they come see you?
Dr. Rahnama: No, this is actually one of those things where usually people know exactly what is going on when they come and present to us. They’re really looking more so for an answer on what they can do about the pain and discomfort that they’re experiencing, more than wondering what’s going on. Pain is the number one thing at the base of the great toe joint. A lot of times it becomes red and hot and swollen, particularly after they do have to be in a pair of tight shoes. We see this a lot in females but certainly we do see it in our male patients as well. A lot of times, because of that bony prominence or protuberance that’s there, the body will produce a small bursa sac as a little cushioning or type-mechanism to help protect itself and so, that even, a lot of times, makes the bunion seem larger, more prominent than it actually is.
Host: Sort of like a blister?
Dr. Rahnama: Similar, but it’s more...it’s on the inside. It’s inflammatory tissue. The actual skin around the great toe joint can become thickened. So, these things can all contribute to the bunion becoming or appearing larger than it actually is.
Host: Could having a bunion indicate that something else is going on within the foot?
Dr. Rahnama: Absolutely. A lot of times, we can see that a bunion comes hand-in-hand with a larger orthopedic or foot and ankle deformity, such as a flat foot or a tightening or contracture of the heel cord, can contribute to the bunion’s formation as well.
Host: What are the most effective treatment options for bunions?
Dr. Rahnama: We can try things like toe spacers, shoe inserts, oral anti-inflammatories, topical anti-inflammatories to start, but none of these things will actually get rid of the bunion. They may just help with simply alleviating the pain that the patient is experiencing. The most definitive way to treat them is by surgically correcting them. But one thing I will add is that, at least my philosophy when it comes to bunions, is that I will try not to operate on a patient who’s telling me that the bunion’s not painful. So, we try to typically stay away from cosmetic foot surgery. That’s something that I will not do. If it’s not bothering you and it doesn’t hurt, my recommendation is to leave it alone.
Host: Is there any long-lasting ramifications for leaving a bunion untreated?
Dr. Rahnama: The biggest thing with that is that not having a symptomatic bunion fixed or repaired can do two things - the pain can become worse with time and the bunion can become worse with time. So, those are the two big things that I would caution patients when it comes to their bunion. The third thing is that, over time, the great toe joint can actually become arthritic. And so, if they wait too long, instead of having bunion corrective surgery, that they would have to have fusion of that great toe joint. And, while most patients do well with that, it would be great to avoid that with a lesser procedure, if possible.
Host: During or after treatment, what activity restrictions should patients expect?
Dr. Rahnama: Well, after surgery, depending on the type of bunion procedure that they’ve needed to have, some patients would be able to start weight-bearing, in a surgical boot, as soon as the day after surgery. In patients who have to undergo a slightly larger procedure because of how bad their bunion may be, they need to stay non-weight-bearing on the operative extremity, or foot, for a period of time, typically no more than 3 or 4 weeks.
Host: Is treatment typically “one and done,” or do bunions often return?
Dr. Rahnama: It depends on the type of treatment that they had. Bunions can certainly return after surgery but there are surgical procedures that we can choose so that it gives the patient the best chance at not having a recurrence of the deformity. Those procedure sometimes may take a little longer for the healing of the patient and they may require them to remain non-weight-bearing, or staying off of the foot, for maybe a few more weeks. But, in the long run, particularly if they’re younger, those juvenile hallux valgus patients, as an example that we talked about a little earlier, if we DO do the slightly larger procedure, it can avoid a recurrence as they get older, into their 40s, 50s.
Host: Could you describe a general bunion removal or a bunion treatment procedure?
Dr. Rahnama: So, if you look at a textbook on foot and ankle surgery, you can find over a hundred ways to surgically correct a bunion. The most common two procedures, I would say, are head procedures, is what we call them. It’s when we physically shave the bump down with the saw in the operating room and then we make small cuts in the bone and shift the bone over, and we typically fixate it with one or two screws. That is a smaller procedure. Patients are typically able to weight-bear almost immediately after surgery. But again, that is the smaller of the two procedures. But, if a patient has that done and they have a really severe bunion or if they’re very young, they’re always susceptible to having a recurrence. The slightly larger procedure is where we fuse the joint that is distoproximal, or towards the midfoot. Patients are a lot of times surprised to see that we want to go after an area of the foot that doesn’t appear to be symptomatic for them. But that joint is really where the root of the bunion is. And so, if we can correct the bunion at that level and fuse the joint end close to the midfoot, then straighten out the bone, then we avoid a recurrence.
Host: Can you recall a patient who had particularly bad bunions but was able to return to an active lifestyle?
Dr. Rahnama: I would say that, luckily, most of our patients who undergo bunion surgery are able to get back to not only the things they want to do, but also wearing the type of shoes that they want to wear without discomfort. Really, the aim of the surgery is to be able to help them have a better quality of life to begin with so that’s why we decide to proceed with it to begin with.
Host: Why should someone with bunions consult with the foot and ankle surgeons at MedStar Washington Hospital Center?
Dr. Rahnama: I think it’s really important for patients to be able to consult with a specialist who can help the patient choose the best procedure that’s right for them. And, I would say that we have a very highly skilled team of surgeons here, more than equipped to deal with patients and their foot and ankle needs.
Host: Thanks for joining us today, Dr. Rahnama.
Dr. Rahnama: Thank you so much for having me.
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