Bunion
Julie Adkins and Jill C. Cash
Definition
A.A bunion is a bony enlargement at the base of the great toe.
Incidence
A.Approximately nine out of ten bunions occur in women. Nine out of ten women wear shoes that are too small and/or too tight, and/or are too narrow.
Pathogenesis
A.The bony prominence and abnormal angle at the base of the great toe gets larger, and the skin over it may be red and tender, causing pain when wearing any type of shoe. The great toe may angle toward the second toe or move all the way under it, causing the skin under the foot to become thicker and more painful. This may force the second toe out of alignment and overlap the third toe. The pain may become chronic.
Predisposing Factors
A.Wearing shoes too small and/or too narrow for the feet.
B.Wearing heels higher than 1¼ inches.
Common Complaints
A.Pain in the great toe at rest and with walking/movement.
B.Difficulty wearing shoes.
C.Great toe looks deformed due to hallux valgus deformity.
Other Signs and Symptoms
A.Metatarsophalangeal (MTP) joint is tender and enlarged.
B.Patient cannot walk normally due to pain.
C.It hurts to bend the toe.
Potential Complications
A.Acute arthritic pain.
Subjective Data
A.Ask the patient what activity brought about or preceded the episode of pain.
B.Ask the patient to describe the pain; note duration of pain and impairment of activity.
C.Inquire regarding any limited range of motion (ROM) of toe/toes.
D.Ask the patient if there is any evidence of sores, calluses, or open areas of skin.
E.Ask the patient what treatments have been used and what makes the pain better or worse.
F.Ask the patient to list all medications currently being taken, including over-the-counter (OTC) preparations.
Physical Examination
A.Vital signs: Temperature, pulse, respirations, and blood pressure:
B.Inspect:
1.Inspect the MTP joint for tenderness and enlargement.
2.Inspect skin for skin irritations, open sores, drainage, and calluses.
3.Evaluate ROM of MTP joint, plantar flexion, and dorsiflexion.
4.Evaluate for other toe involvement.
C.Palpate:
1.Palpate the MTP joint for tenderness.
2.Palpate peripheral pulses in legs.
3.Check passive ROM for rigidity and crepitation and degree of pain on movement.
Diagnostic Tests
A.None. Advanced cases are easily diagnosed by inspection and exam.
B.X-rays may be used to confirm the diagnosis and to assess for inflammation and joint changes.
Differential Diagnoses
A.Bunion.
B.Morton’s neuroma.
C.Bursitis.
Plan
A.General interventions:
1.Recommend the use of a bunion shield.
2.Advise using ice over the side and top of the toe for comfort and elevation.
3.Encourage performing stretching exercises of extensor and flexor tendons.
4.Moderate cases (4–6 weeks) may require an nonsteroidal anti-inflammatory drug (NSAID) for pain relief, dependent on renal function of the patient. They may require a local intra-articular injection for pain/inflammation relief.
5.Chronic cases (8–10 weeks) may require a referral to an orthopedist or podiatrist.
B.Patient teaching:
1.Educate the patient on the most common cause (tight-fitting shoes). Encourage the patient to wear widetoed shoes.
2.Educate the patient on use of a cotton or rubber spacer to be worn between first and second toe.
C.Pharmaceutical therapy:
1.NSAIDs may be taken in moderate cases, dependent on patient history of gastrointestinal or renal disorders.
2.Further adjuvant therapy may be considered for chronic conditions/severe pain.
Follow-Up
A.Follow-up is determined by the patient’s needs and by whether complications are present. All treatments, including surgery, are palliative.
Consultation/Referral
A.Orthopedist or podiatrist referral for chronic cases; possible bunionectomy.
B.Physical therapy for stretching exercises of the extensor and flexor tendons before deformity becomes permanent.
C.All treatments, including surgery, are palliative.
Individual Considerations
A.Geriatrics:
1.Use precautionary measures when using NSAID therapy in the geriatric population because of possible gastrointestinal or renal disorders.
2.Taping has been an effective therapy for improving bunions (hallux valgus) in adults; however, research indicated that taping for correcting hallux valgus angulation in geriatrics had a negative acute effect and impaired balance when walking up/down stairs.
3.Hallux valgus increases fall risk in the geriatric population. Research indicated that moderate-severe deformity and bunion-related pain impair physical function and balance independent of knee and hip arthritis. Consider discussing surgical interventions for these patients and review fall safety measures in the home, activities of daily living (ADLs), traveling aspects, and areas the patients frequently visit.
4.Corrective surgery for the geriatric population has potential risks: deep vein thrombosis, pulmonary embolism, and infection. Bunion surgery requires cast immobilization, which increases risks for clotting. Pre-op education must include therapeutic interventions such as anticoagulant therapy (long/short-term), modifications for non-weight-bearing ADLs and exercises, and professionally monitored physical therapy (after recovery) when returning to consistent weight-bearing activities. Surgery is usually not an option for patients that are ≥80 years old, or have uncontrolled diabetes, a history of systemic cancers, or uncontrolled gout.