Joey Wahler (Host): There are very common, often painful conditions. We're discussing bunions. Our guest is Dr. Stuart Saunders, an orthopedic surgeon. This is Meaningful Medicine, a Novant Health podcast, bringing you access to leading doctors who answer questions they wish you would ask. From routine care to rare conditions, our physicians offer tips to navigate medical decisions and build a healthier future. Thanks so much for joining us. I'm Joey Wahler. Hi there, Dr. Saunders. Welcome.

Stuart Saunders, MD: Hi there. Thank you for having me.

Host: Great to have you aboard. Appreciate the time. So first, just about all of us, I think, have heard the word bunion. But for those who may be unfamiliar, in a nutshell, what exactly is one, and how does it develop in the foot? What causes it?

Stuart Saunders, MD: Sure. So, it's a painful bump or prominence at the base of your big toe that slowly develops over time as the soft tissues around that joint loosen up and cause that toe to kind of turn towards your second toe.

Host: So, it's just the big toe then?

Stuart Saunders, MD: Yes, sir.

Host: I did not know that. All right. I learned something already, and we're just seconds in here. Excellent. So, bunions apparently are far more common in women than men. Do we know why that is?

Stuart Saunders, MD: Well, some of the beliefs to it being more common in women is due to shoe wear, in terms of they're more common to wear narrow shoes, also higher heels, because the literature has shown that anything more than a two-and-a-quarter inch heel puts increased pressure on your foot and can increase your rate of causing a bunion. Most men don't wear high heels.

Host: Interesting. So, it's a difference in footwear, and you led me beautifully there into my next question, namely, how much does our footwear in general contribute to developing bunions or avoiding them?

Stuart Saunders, MD: So, it contributes a fair amount, especially with tighter shoes, shoes that don't conform to your feet. Anything that puts increased pressure or squeezes that portion of the foot increases your risk of developing those bunions to occur. Also, anything that has a higher heel will put increased pressure on the ball of your foot, and that can also contribute. So, that's why we usually recommend that patients wear wider shoes in terms of a wider toe box, more conforming, less of a heel, to try to prevent these from developing.

Host: Gotcha. So to be clear, Doc, are high heels and tighter shoes just making the problem worse or are they actually helping to cause a bunion in the first place?

Stuart Saunders, MD: A little bit of both. That's one of the things that we try to educate patients when we start to see that bunions have developed, that if they continue to wear tighter shoes, narrow shoes, higher heels, it's going to cause the progression of the bunion to go faster than if they did not wear those sorts of shoes.

Bunions aren't just strictly related to shoe wear. There are some of it's hereditary, in terms of someone else in the family may have had them, passed them down. You may have had prior injuries, things like that, that could have contributed to the development also.

Host: Yeah. And so, to pick up on that point, we've covered footwear, but you mentioned genetics there. Just how much of a factor is that if your parents or someone closely related has had bunion issues, how much more likely might you be to get it?

Stuart Saunders, MD: There's a higher likelihood that it can be passed down within your family. You probably have an aunt or a grandmother or mother or something of that nature who's had them. Sometimes fathers, uncles have them. They just usually don't complain about them or worry about them as much.

Host: So if you're having a big family get-together and you're on the younger side, Doc, you may want to look around, especially if it's summer and people have their toes exposed, and you might be able to get a look at your future, huh?

Stuart Saunders, MD: You sure can. Yes, sir.

Host: So besides genetics and shoes, any other risk factors here that people should be aware of?

Stuart Saunders, MD: Sure. So, there are some other risk factors for developing these bunions. Some of them have to do with your foot shape, your foot mechanics. Not to get super technical, but patients who have flatter feet or lower arches, they put different stresses through their feet and the balls of their feet, which can cause these to happen. People who have more looseness to their joints can also cause this to happen just because those tissues aren't as tight. People as well with inflammatory arthritis like rheumatoid or lupus are also at increased risk of developing bunions, as well as people in the sports world who have had prior turf toe injuries or that's where they've damaged ligaments specifically to that big toe joint can also be predisposed to bunions.

Host: Gotcha. Let me ask you one more thing about footwear. You touched earlier on the width of a foot. If you have a wider foot, I know I do, and so I can speak from experience that sometimes wider shoes, sneakers can be harder to find. Fortunately, I have not had bunions, but am I more prone to getting one perhaps if I start wearing a shoe that's too narrow?

Stuart Saunders, MD: Potentially on how tight and conforming the material of the shoe is, if you have wider feet, it can be harder to find because you have a narrow heel and a wider foot. And so, you want to find a shoe that fits appropriately, and also conforms to your foot. But yes, if you over time start wearing just more narrow and constrictive shoes, it can potentially develop. And so, that's where you may want to, you know, go to a place that has more shoe options, things of that nature to make sure you find the right fit.

Host: Gotcha. I'm going to ask you about treatment here in a moment for bunions, but one more before that. Are bunions typically purely cosmetic at first, just bumpy looking, et cetera, or should people even with mild symptoms consider seeing a specialist? Where's the line when you know it's time to see someone professionally?

Stuart Saunders, MD: It really depends on your age and how much symptoms you're having. Some patients have very small bunions but they're very symptomatic, they're very painful. Some people have very large bunions and they aren't as symptomatic for them. Some people develop bunions in their adolescence or early teenage years. And so, it's just a matter of kind of how bad it's bothering you. And it's never a bad idea to always come in and get checked out so we get more information on how to slow down the progression moving forwards.

Host: Absolutely. Now, in terms of treatment, there's surgical and non-surgical. Let's start with the latter first. What conservative treatments, if you will, do you recommend before considering surgery? And how effective are they?

Stuart Saunders, MD: So in terms of effectiveness, once a bunion starts, it will progress. We just can't know how quickly it will progress. So, all these conservative treatments are more preventative to try to slow down the progression. And with that, that is making adjustments to your shoe wear, which we've already touched on. You can wear bunion spacers in your shoes to prevent how much pressure that big toe is putting on your second toe. You can do taping or strapping for comfort. I will say the devices that they sell online that say that they can realign or put you in a brace for your bunion, those are not effective. They do straighten the toe while they're on. But then, once you take it off, the toe will just drift back over. And so, that's a little bit of an advertising or misadvertisement in terms of bunion correction with that aspect of it.

Host: All right. Great warning and advice indeed there. So when surgery is needed, how do you determine if a patient qualifies for that, and what kind of a procedure are we talking about?

Stuart Saunders, MD: Sure. So first off, we determine how much pain they're having and how much it's affecting their daily activities. Those are the big points that we look at and talk with the each patient on a patient-by-patient basis. The other things that we look for too is if they're starting to develop associated deformities of the adjacent toes, or they're starting to transfer their pressure or pain to different areas of their forefoot, that's where we'll, you know, talk to them more about potentially doing surgery because we know that it's progressing at that point.

Host: In that case, what kind of a procedure are we talking about?

Stuart Saunders, MD: Sure. And then, we're looking at doing procedures to correct the bunion, either through soft tissue balancing or rebalancing, as well as bony work called osteotomies. You can do those either through open procedures where we make a large open incision, or there are also newer procedures called minimally invasive or MIS surgery, where you're able to correct the surgery through smaller incisions.

Host: I'm going to ask you more about that in just a sec. But first, to go back to something you mentioned a moment ago, you said if you have a bunion and it gets progressively worse, it can affect the adjacent toes. So, how important is it because of that alone to get it addressed in a timely fashion?

Stuart Saunders, MD: We take it a case-by-case basis. Some patients we try to get to the surgery beforehand so that those hammer toes and things like that don't develop. It also depends on what age and stage you are at life. Some patients come in and, you know, they don't want to have surgery, so they talk to us about things that they can do to, you know, prevent their progression or things that they can do with shoe wear to, you know, decrease their pain or live with other deformities that have developed.

Host: And then, you mentioned a moment ago minimally invasive bunion surgery. And so, what are the basic advantages there over the more traditional open surgery?

Stuart Saunders, MD: Sure. So with the minimally invasive surgery, it's through smaller incisions. Usually, it's three to four little poke hole incisions, which theoretically should reduce your pain as well as swelling and potentially increase your recovery time and greatly reduce how much restricted weight bearing you have to be after surgery.

Host: And what kind of a recovery are we looking at in terms of time and physically what people can expect?

Stuart Saunders, MD: So with any bunion surgery, we say it's going to take you three to six months to fully become comfortable on your foot again. In terms of with open surgery, you usually are more limited in terms of your weight bearing at first, usually for a minimum of six weeks, versus the MIS surgery where, usually, you may be able to walk right away afterwards.

On more average, we're seeing that patients are limited weight bearing for closer to anywhere from two to four weeks, and then allowed to start kind of ramping up their recovery at that point

Host: And then, in summary here, Doctor, what's your overall message, generally speaking, to those joining us about the prospect of successfully addressing their bunion issue if they have one? Naturally, every case is different, but in general.

Stuart Saunders, MD: The biggest thing would just be if you have questions, seek a provider that you feel comfortable with to be able to answer those questions about how to best manage your bunion moving forwards.

Host: And then, you would say there's a pretty good chance that in some form or fashion their bunion can be addressed in a positive manner, yes?

Stuart Saunders, MD: Yes, sir. Either with or without surgery. You know, of course, no surgery is 100% guarantee. But the goal of surgery is to be able to get you back pain-free to be able to do the things you want to do and not have to worry about the bunion still being painful for you.

Host: Absolutely. Well, folks, we trust you are now more familiar with bunions. Dr. Saunders, keep up all your great work. Thanks so much again.

Stuart Saunders, MD: Thank you.

Host: And to find a physician, please visit novanthealth.org. For more health and wellness information from our experts, please visit healthyheadlines.org. If you found this podcast helpful, please do share it on your social media. I'm Joey Wahler. Thanks again for being part of Meaningful Medicine, a Novant Health podcast.