Dr. Rania Habib (Host): The National Foot Health Assessment estimates approximately 18 million women and 4 million men report having bunions every year.  Welcome to BayCare HealthChat. I'm your host, Dr. Rania Habib.  Joining me today is Dr. Felipe Peterson, a board-certified podiatrist affiliated with BayCare. And he's here to share his knowledge on the diagnosis and treatment of bunions.

Dr. Felipe Peterson: Good afternoon. Thank you so much for having me, Dr. Habib.

Host: Bunions are one of the most common foot problems affecting people in the US. What is a bunion and could you describe the symptoms of a bunion deformity?

Dr. Felipe Peterson: Sure. A bunion, in layman's terms, is a bulging bump at the base of the big toe. However, it is due to a misalignment of the bones and the joints in your foot. And typically, some of the symptoms you'll see is swelling, redness, soreness around the big toe joint. And with time, you can also develop painful, thickened skin, corns, calluses. And this pain can become persistent even with walking, standing, exercising, or trying to get into certain shoes. And also, as it progresses, we also see restriction in motion of the big toe joint and certainly decreased activity or desired activities due to the progressive foot pain and deformity due to that bulge or trying to get in a certain shoe. Some patients, unfortunately, even feel very self-conscious about wearing open-toed shoes in public areas or arenas or events. And a bunion can often affect the patient's well-being, their daily activities of living, and their inability to fit into their desired shoe, and affecting their self-confidence.

Host: Now, you were talking about pain in the foot. Is it isolated to that big toe or do they tend to complain of pain throughout the entire foot?

Dr. Felipe Peterson: So usually, the pain in the early stages can certainly be very localized at the big toe joint. However, as the bunion deformity progresses, you also find that the patient sometimes has to alter the way that they walk, right? So, they'll find pain creeping up the foot, sometimes around the adjacent toes as it can rub and cause friction, and even sometimes in the midfoot and in the ankle. It definitely can become a problem that initiates at the big toe joint. And then, it can progress based on the severity of the bunion and how long the patient's had the bunion for as well.

Host: Now, I know you mentioned that the bunion is at the first metatarsal joint on the big toe. Are they ever found anywhere else on the foot?

Dr. Felipe Peterson: So, there is a such thing known as a tailor's bunion, which can demonstrate very similar finding. However, it's located on the joint of the pinky toe. And in that case, it can also have its different causes there. Sometimes it's just a bulge of the bone. And other times, it's the actual metatarsal bone itself, deviating away from the access, and sort of pushing out the skin and tenting out the skin and causing very similar findings and, typically, a large bump, a bulge, redness, painful thickened skin. It can also be located on the pinky toe joint, which has historically been known as a matter of fact as a so-called tailor’s bunionette, because it was first actually found in patients that usually sit crisscross and place a lot of pressure on their pinky toe joint of the fifth metatarsal head.

Host: It's so interesting. What are some causes of bunions?

Dr. Felipe Peterson: So, there are several theories and potential causes. However, the most likely ones would be genetics and an inherited foot type. You know, typically, when a patient comes to my office and they say, "Oh, I have this bunion and my mom and my grandma had a bunion," so it usually is an inherited thing.

In addition, poorly fitting shoes particularly our ladies in their stilettos. They look wonderful; however, they certainly do not necessarily cause, but they can greatly affect and accentuate and put that foot in such a position where a bunion has a greater disposition for being formed. In addition, trauma and previous injury can also cause a bunion. If a patient has been involved in some sort of a car accident, blunt trauma, dropping a very heavy object on their foot. And last but not least, systemic arthritis, rheumatoid, psoriatic, lupus, and definitely gout is known to be a very painful form to cause a bunion as well.

Host: Such a wide variety of causes. How is a bunion diagnosed?

Dr. Felipe Peterson: Clinically, you can certainly observe a bunion in relation to the position of that first metatarsal and that enlargement of that medial skin border, especially in relation to the second metatarsal. And you can sort of palpate that joint, if you would. And typically in the more advanced stages, which you will feel, there is some progression of arthritis as well. And that's the thing, if you let a bunion go too long, it can definitely start to get more pain due to the arthritis deformity. And there'll be clicking, catching and just progressive deformity.

However, the most objective way to clearly see the progression, the stage, the severity of a bunion would be to just get a plain film radiograph, just a plain X-ray. You can see how deviated the joint is, how spread apart the two metatarsals are between the first and the second. And very important to bear in mind, that a bunion does not just affect one plane of the body, meaning that in addition to the bones themselves being spread apart, the first metatarsal is also rotated. And because of that rotation, it could indicate the severity of the bunion. In addition, we will find that patients will have a very painful, thick callus on the bottom of their first big toe joint. So when a patient comes to me and they say, "Well, I have a callus underneath my toe joint, but what does that have to do with my bunion?" It has everything to do with the misalignment and the rotational deformity of the bunion itself. That's why when a patient asks me, "Well, can you just shave a bunion off?" It's not that simple, once again, because of the very intricate nature of how the metatarsals are set within the joint in the surrounding ligaments there that are supposed to hold that joint in place. That whole complex that's supposed to be very stable, it progressively gets weakened, you know, lax, destroyed, and there's an actual complete disjointed misalignment of the foot, including a rotational deformity.

Very rarely do I have to order CT scans or MRIs, perhaps in a more advanced case where I'm trying to look at the foot as a whole. But just looking at the bunion straightforward, a plain radiograph can give the typical podiatrist more than enough information to share with their patient to really get a good handle on the severity and the degree of the deformity.

Host: It's so fascinating that this seemingly small problem can cause so many issues within the big toe itself. So what happens if I recognize that I have a bunion, but then I do nothing about it?

Dr. Felipe Peterson: Well, what tends to happen is that a bunion is a progressive deformity, and what that means is that it's not a deformity that's going to just deviate a little bit and stay in place. It's going to get slowly worse over time. Some patients, it gets really worse within a small amount of time. And with time, the end-stage of every bunion is the dreaded, feared and hated by patients, the so-called crossover deformity. And in the crossover deformity, what happens is the big toe sort of slips underneath the second toe. And it's an uncomfortable situation. And typically, what happens is that there's calluses on the top of the second toe now. The calluses between the toes get worse.

So, to summarize, the bunion gets worse, but unfortunately, as I tend to see with my own patients, there's also progressive arthritis because of the misalignment of the joint where the cartilage are supposed to be easily gliding against each other. It's no longer in that position. And so, the cartilage tends to get worn on portions of the bone of the joint where it's not supposed to bear that great of a load. So, it's definitely a very insidious condition that can very slowly get worse with time.

Host: So, this is definitely something I, as a patient, would want to get treated. So, what are some treatment options for a bunion?

Dr. Felipe Peterson: Absolutely. For all my patients that come in my office, I always really like to emphasize the conservative treatment options first. And this includes a variety of different little shoe gear modifications, wearing supportive and rigid orthotics that could potentially help to stabilize some of the deforming forces. Pushing the joints in that bunion and helping to mitigate that. There's bunion pads, there's splints, there's oral anti-inflammatories, medicines such as Advil and ibuprofen. There's topical anti-inflammatories such as Voltaren. Or even sometimes patients that come in, they are severely and acutely in pain, we can also give them injections for pain as well. Typically, some sort of a steroid cocktail is what I do in my office here.

And once again, modifying the shoe gear to accommodate for the wide toe box is really key because again, as we said before, a bunion is not an isolated deformity. You know, it's going to affect usually the second toe, and typically it can also affect the fifth toe joint just because of the patient's overall foot type. So, I look at their foot, and I press my hand underneath their foot. And I show the patient what the foot is doing as if simulating the foot stepping on the ground. And what they'll see is just how wide their foot looks. And they're like, "Oh my god, does it really look that wide?" I said, "Yeah, you can't fit into a narrow heel for that reason." You know, that's why sometimes they come in wearing heels, they are in agony. So, shoes such as a New Balance, such as an Altra, for example. Of course, the challenge is, "Doctor, that's an orthopedic shoe, right?" So, that, that's why in those cases why also surgical correction would be a more permanent procedure when the procedure is chosen carefully for the right patient.

Host: So, if these conservative non-surgical options do not work, what is the next treatment option?

Dr. Felipe Peterson: Honestly, I like to take a step back. I like to look the patient right in the eye and I say, "What is your plan for your life? What are you trying to accomplish with your life? What stage of life are you in currently? Are you perhaps at a place where you're working full time, you're going to school, you're in pain, but you really don't have the time off to get the bunion fixed, but it's bothering you." There are other patients where they're in much pain and agony where they're saying, "Listen, this is making my life miserable. I cannot complete my daily activities of living. I'm in pain almost every day, and it's really keeping me from doing what I want to do, and I'm unhappy with it." You know, those are the patients that I really begin to discuss basically the surgical treatment options with them. And I'll discuss the variety of all the procedures available based on their deformity.

Once again, if it's a true typical bunion deformity, I don't necessarily order additional advanced imaging, unless the patient has rheumatoid or gout or lupus, there's something else I may be concerned about. But usually, we can come up with a surgical plan relatively quickly and straightforward by just looking at the X-ray and showing the patient what my concerns are, what my findings are, because the fascinating thing about bunions is that every single bunion is truly different, honestly. Every single one. There's no one-size-fits-all bunion approach for every patient. Just as everybody's life and anatomy and their situation is unique, so is the correction they require and how much time are they able to take off to get this taken care of.

Host: Could you describe the difference between open surgery and minimally invasive procedures?

Dr. Felipe Peterson: Absolutely. So for a very long time, well over 50, 70 years, I mean, we've been doing the so-called traditional open surgery. And what this entails is using a larger skin incision, which can range anywhere from 2 to 5 or 6 inches in order to really access the anatomy that is affected. And the outcomes do tend to be very good overall with using traditional open surgery. However, of course, there's a risk for scarring, stiffness, and in particular, if we're doing what's known in the medical literature as the typical distal chevron type of osteotomy, the medical literature does substantiate that there's a possibility of up to 24% recurrence with the traditional open techniques.

Host: Okay.

Dr. Felipe Peterson: And possibly not common, but sometimes even there's a possibility to have more pain after the procedure as well. It's uncommon, but I like to really have an honest conversation about all the things, all the benefits and risks involved. And that's traditionally the open surgery there is what that entails.

Now, the minimally invasive as to what you asked before, it's a procedure where it definitely uses a much smaller incision, it's definitely the claim to fame there, and it can use anywhere from a 1/8 to a 1/4-inch incision. And of course, the benefit of this is preservation of the soft tissue envelope. There's far less soft tissue disruption, which may certainly enable a quicker and less painful recovery. However, the only caveat with the minimally invasive option is that it's only suited to mild or moderate bunion deformities. And definitely, the patient's entire foot type, their structure and overall medical health definitely needs to be taken into consideration. It's a great option for the right patient, but it's definitely not for everybody, for the MIS procedure.

Host: Well, thank you so much for joining me today. Are there any other pearls of wisdom you would like to share with our audience about bunions?

Dr. Felipe Peterson: Absolutely. If you or a family member, if you have a history of foot deformities, of bunions, whether it's a typical bunion or even a tailor's bunion, I do recommend to get it checked out, get a preliminary exam, get some X-rays, see where you're at in this bunion journey. Because sometimes, just using the right shoe or the right orthotic can definitely help to mitigate and defray this progressive course of this bunion. You know, sometimes I see patients that are maybe 70 or 80 years old, and have a really severe bunion and really bad arthritis, well, maybe you were seen a long time ago, or the newer techniques are available, you can get away with a minimally invasive option and your arthritis and deformity would've not have been so bad. So, it definitely does not hurt just to get it checked out and see where you stand.

Host: Absolutely. And I think a pearl of wisdom that I took from you is your foot type might not fit a specific shoe. So, don't wedge your foot into that tiny little narrow shoe.

Dr. Felipe Peterson: No. Please don't do that, unless want to be in agonizing pain.

Host: Well, that wraps up this episode of BayCare HealthChat. Head on over to our website at BayCare.org for more information and to get connected with one of our providers. Please remember to subscribe, rate and review this podcast and all other BayCare podcasts. For more health tips and updates, follow us on your social channels. If you found this podcast informative, please share on your social media, and be sure to check out all other interesting podcasts in our library. This is Dr. Rania Habib wishing you well.