Bunions Disease: A Comprehensive Overview

Introduction

Bunions, medically known as hallux valgus, represent one of the most common deformities of the foot, affecting millions of people worldwide, especially adults and the elderly.

What is a Bunion?

A bunion is a bony bump that forms at the base of the big toe, where the first metatarsal bone meets the proximal phalanx of the big toe. The condition is characterised by a lateral deviation of the big toe towards the second toe, accompanied by the protrusion of the first metatarsal head. Over time, this leads to a visible enlargement on the side of the foot, commonly known as a bunion. The term “bunion” is derived from the Latin word bunionem, meaning “turnip,” due to the swelling’s resemblance to this root vegetable.

Epidemiology

Bunions are prevalent across different populations but are more commonly seen in women than men. Epidemiological studies estimate that up to 23% of adults aged 18-65 and 35% of people over 65 years of age have some degree of hallux valgus. The higher prevalence in females is often attributed to footwear choices and genetic predisposition. In India, the exact prevalence is not well-documented, but urban populations, where western-style footwear is more common, report higher rates.

Pathophysiology

Bunions develop due to a complex interplay of anatomical, biomechanical, and environmental factors. The primary event is the lateral deviation of the big toe (hallux) and medial deviation of the first metatarsal bone. This misalignment causes the joint capsule, tendons, and ligaments to stretch and become imbalanced, further exacerbating the deformity.

Over time, the constant pressure and friction from footwear, combined with underlying biomechanical abnormalities (such as flat feet or excessive pronation), lead to inflammation, pain, and the characteristic swelling on the side of the foot. In severe cases, the deformity may progress to subluxation or dislocation of the metatarsophalangeal joint, and the second toe may also become involved.

Causes and Risk Factors

The development of bunions is multifactorial. The main causes and risk factors include:

• Genetic Predisposition: A family history of bunions significantly increases the risk, as certain foot shapes and joint laxity can be inherited.
• Footwear: Shoes with a narrow toe box, high heels, or poorly fitting footwear contribute to the formation and progression of bunions. This is particularly significant in urban Indian women who frequently wear such footwear for professional or social reasons.
• Biomechanical Abnormalities: Flat feet (pes planus), excessive pronation, and abnormal gait patterns can place additional stress on the big toe joint.
• Occupational Factors: Jobs that require prolonged standing or walking, especially in restrictive footwear, increase the risk.
• Arthritis: Inflammatory conditions like rheumatoid arthritis can weaken the structures supporting the toe joint.
• Trauma: Previous injuries to the foot can alter biomechanics, leading to bunion formation.
• Age and Gender: Bunions are more common with increasing age and in women, possibly due to hormonal influences and footwear choices.

Clinical Presentation: Signs and Symptoms

The primary symptom of a bunion is a visible, bony bump on the side of the foot at the base of the big toe. However, the clinical presentation may vary based on the severity of the deformity and the duration of the condition. Common signs and symptoms include:

• Pain or tenderness at the bunion site, especially after prolonged walking or standing
• Swelling, redness, or inflammation around the joint
• Restricted movement of the big toe
• Calluses or corns where the first and second toes overlap
• Altered gait or difficulty wearing shoes
• Progressive deviation of the big toe towards the second toe
• In advanced cases, involvement of the second toe with hammer toe or claw toe deformities

The pain associated with bunions can be intermittent or persistent and often worsens with footwear that compresses the forefoot.

Diagnosis

Diagnosis of bunions is primarily clinical, based on a detailed history and physical examination. Key diagnostic steps include:

1. History: The doctor will enquire about the onset, duration, and progression of symptoms, family history, occupational risks, and footwear habits.
2. Physical Examination: Inspection reveals the characteristic bump, toe deviation, and any associated calluses. Palpation may elicit tenderness and swelling.
3. Range of Motion: Assessment of the mobility of the metatarsophalangeal joint and evaluation for stiffness or subluxation.
4. Radiological Imaging: X-rays of the foot are the gold standard for confirming the diagnosis and evaluating the severity. The radiograph shows the degree of lateral deviation of the big toe, medial deviation of the first metatarsal, and any associated arthritis or joint degeneration.
5. Other Tests: In rare cases, additional imaging (ultrasound or MRI) may be ordered to assess soft tissue involvement or rule out other causes of foot pain.

Classification of Bunions

Bunions can be classified based on the severity of the deformity, which is usually determined by the angle between the first metatarsal and the proximal phalanx (hallux valgus angle) on X-ray:

• Mild: Hallux valgus angle less than 20 degrees
• Moderate: Angle between 20 and 40 degrees
• Severe: Angle greater than 40 degrees, often with significant symptoms and secondary deformities

Differential Diagnosis

Other conditions can mimic the appearance or symptoms of bunions, making differential diagnosis important. These include:

• Gout (especially if there is acute redness and swelling)
• Rheumatoid arthritis
• Osteoarthritis
• Infection or cellulitis
• Other toe deformities (hammer toe, claw toe)

Treatment Options

Treatment of bunions depends on the severity of the deformity, the degree of pain and disability, and the patient’s functional needs. The goal is to relieve symptoms, slow progression, and restore foot function. Treatment approaches are broadly classified into non-surgical (conservative) and surgical methods.

Non-Surgical Management

Conservative treatment is the first line for mild to moderate bunions, especially if the pain is manageable and the deformity is not severe. Common non-surgical options include:

• Footwear Modification: Wearing wide, comfortable shoes with a spacious toe box helps reduce pressure on the bunion. Avoiding high heels and pointed shoes is strongly recommended.
• Padding and Orthotics: Bunion pads or cushions can provide temporary relief. Custom-made orthotic devices may correct abnormal foot mechanics and distribute pressure more evenly.
• Medications: Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or paracetamol can help control pain and inflammation.
• Ice Application: Applying ice packs to the bunion for 15-20 minutes several times a day can reduce swelling and discomfort.
• Physical Therapy: Stretching and strengthening exercises for the foot and toes may improve joint mobility and muscle balance.
• Night Splints: These devices keep the big toe in a straighter position during sleep and may slow progression in some cases.

It is important to note that conservative management does not correct the deformity but can provide significant symptom relief and improve quality of life.

Surgical Management

Surgery is considered when conservative measures fail, and the bunion causes significant pain, functional limitation, or deformity. There are over 100 different surgical techniques described for bunion correction. The choice of procedure depends on the severity of the deformity, patient age, activity level, and presence of arthritis or other foot abnormalities. Common surgical procedures include:

• Osteotomy: The most common surgical approach, involving cutting and realigning the bones of the big toe and/or first metatarsal.
• Exostectomy: Removal of the bony prominence without realigning the joint. Usually combined with soft tissue balancing.
• Arthrodesis: Fusion of the metatarsophalangeal joint, reserved for severe cases or those with arthritis.
• Resection Arthroplasty: Removal of a portion of the joint, often performed in elderly patients with low functional demands.

Postoperative recovery varies depending on the procedure but typically involves a period of immobilisation, followed by gradual weight-bearing and physiotherapy. Most patients can return to normal activities within 6-12 weeks after surgery, but complete recovery may take several months.

Complications

Both the disease process and its treatment can lead to complications. Common complications associated with bunions include:

• Progression of Deformity: If left untreated, bunions can worsen, leading to further deformity and involvement of other toes.
• Chronic Pain: Persistent pain may occur, especially in severe or long-standing cases.
• Joint Stiffness: Limited movement of the big toe can impair walking and balance.
• Secondary Toe Deformities: Hammer toe, claw toe, or mallet toe can develop due to altered foot mechanics.
• Calluses and Corns: Increased pressure on adjacent toes can lead to painful skin lesions.
• Post-Surgical Complications: These may include infection, recurrence of the bunion, nerve injury, delayed bone healing, or overcorrection (hallux varus).

Prognosis

With appropriate management, most patients experience significant relief from symptoms and can maintain an active lifestyle. The prognosis depends on the severity of the deformity, the timeliness of intervention, and adherence to preventive measures. Surgical correction, when indicated, has a high success rate, but recurrence can occur if risk factors (such as inappropriate footwear) are not addressed.

Prevention

Prevention of bunions is particularly important for individuals with a family history or other risk factors. Key preventive measures include:

• Choose Proper Footwear: Select shoes that are wide, comfortable, and have ample room for the toes. Avoid tight, pointed, or high-heeled shoes for prolonged periods.
• Maintain Healthy Weight: Excess body weight increases pressure on the feet and can contribute to deformity.
• Regular Foot Exercises: Stretching and strengthening exercises for the foot muscles can help maintain joint alignment.
• Monitor Foot Health: Regular self-examination and early consultation with a healthcare provider at the first sign of a bunion can prevent progression.
• Manage Underlying Conditions: Control of arthritis, diabetes, or other chronic diseases can reduce the risk of foot complications.

Living with Bunions: Tips and Lifestyle Modifications

Living with bunions requires a combination of medical management and lifestyle changes. Some practical tips include:

• Wear shoes with adjustable straps or laces for a customised fit
• Use silicone toe spacers or bunion shields to reduce friction
• Soak feet in warm water to relieve soreness after a long day
• Maintain good foot hygiene to prevent infections
• Consult a podiatrist or orthopaedic surgeon for periodic evaluation
• Participate in low-impact exercises like swimming or cycling that reduce foot strain

Nursing Care of Patients with Bunions (Hallux Valgus)

Due to the tongue’s rich vascularity and proximity to the airway, prompt and effective nursing care is essential to prevent complications, promote healing, and ensure patient comfort.

Initial Assessment and Emergency Management

Immediate assessment is crucial in any burn injury to the tongue due to the risk of airway compromise and rapid swelling.

1. Airway Assessment: Monitor for signs of airway obstruction such as stridor, hoarseness, difficulty in speaking, drooling, or respiratory distress. Be prepared for emergency airway management if necessary.
2. Breathing and Circulation: Assess respiratory rate, oxygen saturation, pulse rate, and blood pressure. Provide supplemental oxygen if indicated.
3. History Taking: Gather information regarding the cause, time of injury, and any associated symptoms (e.g., difficulty in swallowing, pain intensity, presence of blisters or bleeding).
4. Pain Assessment: Use age-appropriate pain scales to assess pain severity and location.

Nursing Interventions

Pain Management

Pain is often severe with tongue burns. Nursing actions include:

• Administering prescribed analgesics, such as paracetamol or non-steroidal anti-inflammatory drugs (NSAIDs). In severe cases, opioids may be used under strict monitoring.
• Encouraging the use of cold compresses or sucking on ice chips (if not contraindicated) to provide local relief.
• Advising the patient to avoid hot, spicy, or acidic foods and beverages that may aggravate pain.

Airway Protection and Monitoring

Due to the risk of swelling, continuous monitoring is essential:

• Observe for changes in voice, increased drooling, or signs of respiratory distress.
• Raise the head of the bed to 30-45 degrees to reduce oedema.
• Prepare emergency airway equipment (suction, tracheostomy set) in case of sudden airway compromise.

Oral Hygiene and Infection Prevention

The oral cavity is prone to bacterial colonisation and infection following burns:

• Instruct the patient to rinse the mouth with prescribed antiseptic solutions, such as chlorhexidine, as tolerated.
• Maintain meticulous oral hygiene using a soft-bristled toothbrush or gauze swabs if brushing is not possible.
• Monitor for signs of infection: increased redness, pus, foul odour, or fever.
• Administer antibiotics only if prescribed for secondary infection.

Nutrition and Hydration

Burns to the tongue can make eating and drinking painful, risking dehydration and malnutrition:

• Encourage small, frequent sips of cool water or oral rehydration solutions.
• Offer soft, bland, non-irritating foods such as curd, porridge, mashed potatoes, custard, or khichdi.
• Avoid foods with rough textures, extreme temperatures, or strong flavours.
• Monitor fluid intake and output, and report any signs of dehydration (dry mouth, reduced urine output, sunken eyes).
• In severe cases, consult with a dietitian and consider alternative feeding methods (e.g., nasogastric tube) if oral intake is inadequate.

Communication Support

Tongue burns can impair speech, causing frustration or anxiety:

• Provide alternative means of communication such as writing pads, gesture-based communication, or mobile apps.
• Encourage family involvement to help interpret the patient’s needs.
• Offer psychological support and reassurance.

Patient and Family Education

Education is vital to promote healing and prevent recurrence:

• Explain the importance of adhering to prescribed medications and oral care routines.
• Instruct on recognising warning signs that require immediate medical attention, such as difficulty in breathing, worsening pain, or signs of infection.
• Advise on safe food and drink temperatures, especially for children and the elderly.
• Discuss the importance of electrical safety and safe storage of chemicals at home.

Monitoring and Documentation

Ongoing monitoring is essential for early detection of complications and evaluation of healing:

• Record initial assessment findings, interventions provided, and patient’s response.
• Document any changes in pain level, oral mucosa appearance, airway status, and nutritional intake.
• Report and escalate any signs of deterioration promptly.

Complications to Watch For

Potential complications of tongue burns include:

• Airway obstruction due to oedema or tissue necrosis
• Secondary infection leading to abscess formation or sepsis
• Malnutrition and dehydration from inadequate oral intake
• Speech difficulties or long-term scarring in severe cases

Prompt recognition and intervention can significantly improve outcomes.

Multidisciplinary Collaboration

Coordinate with other healthcare professionals for comprehensive care:

• Consult ENT specialists or maxillofacial surgeons for severe or non-healing burns.
• Involve dietitians for nutritional assessment and planning.
• Refer to speech therapists if long-term speech difficulties are anticipated.
• Engage psychologists or counsellors for emotional support as needed.

Evaluation

• Pain is reduced to a tolerable level as reported by the patient.
• Patient demonstrates improved mobility and independence in daily activities.
• Skin over the bunion remains intact and free from infection or ulceration.
• Patient verbalises understanding of self-care practices and preventive measures.

REFERENCES

1. American Academy of Orthopaedic Surgeons. Bunions. https://orthoinfo.aaos.org/en/diseases–conditions/bunions/. .
2. Merck Manual, Consumer Version. Bunion. https://www.merckmanuals.com/home/bone,-joint,-and-muscle-disorders/foot-problems/bunion.
3. Aebischer AS, Duff S. Bunions: A review of management. Aust J Gen Pract. 2020 Nov;49(11):720-723. doi: 10.31128/AJGP-07-20-5541. PMID: 33123707.
4. MayoClinic Staff. (2014, February 11). Bunions
   http://www.mayoclinic.org/diseases-conditions/bunions/home/ovc-20262028
5. The American College of Foot and Ankle Surgeons. Bunions. https://www.foothealthfacts.org/conditions/bunions.
6. Cai Y, Song Y, He M, et al. Global prevalence and incidence of hallux valgus: a systematic review and meta-analysis. J Foot Ankle Res. 2023;16(1):63.
7. Chou LB, ed. Hallux valgus. In: Orthopaedic Knowledge Update: Foot and Ankle 6. American Academy of Orthopaedic Surgeons; 2020.
8. Kharazmi AS, Okhovatian F, Baghban AA, Mosallanezhad Z, Kojidi MM, Azimi H. Effects of dry needling on symptomatic hallux valgus: a randomized single blind clinical trial. J Bodyw Mov Ther. 2020;24(3):246-251.

Stories are the threads that bind us; through them, we understand each other, grow, and heal.

JOHN NOORD

Connect with “Nurses Lab Editorial Team”

I hope you found this information helpful. Do you have any questions or comments? Kindly write in comments section. Subscribe the Blog with your email so you can stay updated on upcoming events and the latest articles.