Bunions Painful?

Prolonged changes to normal foot patterns can lead to the formation of bony protrusions commonly known as bunions.

Typically caused by tight fitting footwear, a bunion can be an eyesore, although the real sore is experienced on the great toe and sometimes the fifth toe (Tailor's Bunion). For early stages, preventing the bunion from enlargement is important.

Prevention can be achieved with orthotics that relieves pressure on the bunion.
Orthotics may be semi-rigid to rigid to meet the accommodations each person needs who are suffering from bunions. Orthotics are devices worn in your shoes that provide correction to your feet, helping them to function more efficiently.

Prescription orthotics may help relieve your pain by realigning and stabilizing the bones in your feet, restoring your natural walking pattern. They will also help alleviate pain from rubbing, which often leads to enlargement of the protrusion.

Patients should be advised to wear comfortable shoes that help support their feet. Taking preventative measures in the initial stages of the bunion’s existence is a great way to slow its growth.

Be sure to come by and see Dr. Weaver about getting your custom orthotics today and stop the unsightly growth of your bunion. The key to better health could be right under your toes.

Bunion research focuses on patient quality of life

Lower extremity practitioners know the effect of hallux valgus on a patient’s quality of life starts with a frustrating inability to find fashionable shoes that fit—but evidence suggests it doesn’t end there. Pain, function, and self-image all play significant roles.

By Larry Hand

Recent studies have concluded that increasing severity of hallux valgus (HV) leads to a series of conditions or behaviors—increasing pain, decreasing functional ability, withdrawal from normal daily activities—that contribute directly to a progressive decline in health-related quality of life.

The chain reaction applies to men and women, but studies have shown that women are much more likely than men to develop HV and more likely to experience a drop in quality of life. And practitioners interviewed for this article said more and more younger people are being seen with juvenile-onset HV, a disorder that is most often inherited.

It’s logical to think that eliminating the deformity would necessarily reverse any downward quality of life trends. And recently published research does conclude that some surgical procedures are effective for correcting HV. What happens after surgery, however, can vary greatly, depending on the procedure done, the patient’s own tendency to stiffen after surgery, whether patients get physical therapy, and whether they comply with surgeons’ recovery instructions.

“The most common quality of life issue is they just can’t put on the kind of shoes they want to wear,” said Lowell Weil, Jr., DPM, of the Weil Foot and Ankle Institute in Des Plaines, IL. “A typical patient is a woman in her mid- to late-40s who has seen her bunion progressively get worse and she’s tried wider shoes, deeper shoes, and less-high-heeled shoes. While that works for a time, the shoes are becoming less and less comfortable because of the progressive pain. She could probably find an ugly orthopedic shoe that she could get into, but that just doesn’t work for her professionally or socially.”

As the bunion progresses, Weil continued, women start to become embarrassed by their feet.

“They don’t want to go barefooted. They don’t want to wear sandals or flip flops. It’s an ugly deformity to them, and some people even have concerns that the opposite sex find it unappealing,” he added.

Mounting evidence

In a study e-published ahead of print in November by Arthritis Care & Research, researchers at the Musculoskeletal Research Centre at LaTrobe University in Australia and Keele University in the U.K. concluded that a progressive reduction in both general and foot-specific health-related quality of life occurred in people with increasing severity of hallux valgus deformity, or greater HV angle. They analyzed the records of people aged 56 and older in a six-year follow-up of the North Staffordshire Osteoarthritis Project in the United Kingdom.

More than 36% of the study’s participants were affected by HV, which was more prevalent in females and older patients. However, after adjusting for age, sex, education, and body mass index, Medical Outcomes Study Short Form 36 (SF-36) quality of life scores decreased as HV severity increased. After the same adjustments, increasing HV severity also was linked to greater impairment on the pain and function subscales of the Manchester Foot Pain and Disability Index (MFPDI). The same type of association existed for bodily pain, general health, social function, reduced physical function, and mental health subscale scores after adjusting for pain in the back, hip, knee, and foot.

The researchers used survey questionnaires to obtain their self-reported data, and they used five validated line drawings that showed various degrees of HV, with angles ranging from 0° to 60°. They started with a population of more than 11,300 people registered with three general practices from the North Staffordshire Primary Care Research Consortium. The researchers reasoned that, since more than 95% of people are registered with a general practice in the UK, the registers provided a valid sampling population.

Almost 3600 people completed the first of two surveys three years after recruitment into the trial, and the second survey three years later returned about 2800 responses, for an adjusted 83.9% response rate. Those reporting HV were most likely to be female and older than others, and they generally had a lower body mass index and shorter stature. Just over 40% had unilateral HV and just under 60% had bilateral HV. Of the 2681 respondents who could be considered for foot deformity severity, just over 33% characterized their worst foot severity as a 30° angle or higher, while most (almost 45%) characterized their foot angle as at least 15°. Only 57 people said their angle was more than 60°.

An earlier study, published earlier in 2010 in Osteoarthritis & Cartilage, was the first study to assess quality of life’s association with HV and big toe pain in a general community population. (An association had previously been reported in small hospital-based studies.) Researchers at the University of Nottingham in the UK analyzed results of almost 3100 responses received from more than 13,600 questionnaires mailed to individuals registered with two general practices in Nottingham. They used the short version of the World Health Organization Quality of Life assessment instrument (WHOQOL-BREF).

They concluded that concurrent HV and big toe pain—but not HV alone—is associated with overall dissatisfaction with health and low scores on the WHOQOL-BREF physical, psychological, and social domains. They also compared the significance of the association to that of patients with severe knee and hip osteoarthritis who are in line to have joint replacement surgery.

Research involving such large numbers of people relates well to individual patients being seen by practitioners in the United States.

“Much of it has to do with the types of shoes people have to wear and their activity levels,” said Vincent Marino, DPM, a podiatrist who practices in San Francisco, Novato, and Sacramento, CA. “Many of our professional women [patients] who have to wear fashionable shoe types during the day usually suffer more and at an earlier stage than someone who can wear more comfortable shoes. It becomes frustrating because they are in pain a great deal and it becomes an issue with work requirements.”

Often, the pain causes a person to forego activities that, under normal circumstances, they would be doing on a daily basis.

“A lot of times patients will say they’re not able to do the things they normally do, or they have to curtail it; if they usually go out for an hour or two, now it’s just a half hour,” said Althea Powell, CPed, LPed, OST, who operates Powell Shoes in Vero Beach, FL. “We’ve had patients who said they were just unable to exercise. They can’t go for a walk even though the doctor says they need to walk for exercise.”

And the effects go well beyond middle-aged and older women. In an article published last year in the Journal of Foot and Ankle Research, researchers from the University of Queensland reported HV prevalence of 36% in elderly women and 16% in elderly men, 26.3% in adult women and 8.5% in adult men, and 15% in juvenile (under age 18) girls and 5.7% in juvenile boys.

“The unsightliness of the deformity has an effect on many teenage girls and young women. They’re hesitant to wear open-toed shoes because they perceive their foot as being ugly,” Marino said. “They come in because they want to wear some open-toed sandals without having people stare, and it has an effect on their psyche. It also affects the ability of men and women to exercise. They lose the ability to run comfortably and do some of the activities that they put in their everyday lifestyle to help control their stress levels. They stop running. They stop using the elliptical. They stop doing aerobic activities. Every time they put a shoe on, they’re in pain.”

Just getting into a properly sized shoe makes a big difference for even minor bunions, said Chad Brown, CPed, of Brown’s Enterprises, a specialty shoe retailer in St. Louis.

“But in more severe cases, hallux valgus deformity can be just as debilitating as someone who suffers from migraines,” he said. “You’re going through excruciating pain, and it affects everything from going to the grocery store to taking vacations with your family.”

Even professional basketball players are susceptible.

“One player who was a patient of mine probably wore a size 20 or 21 shoe and he had two different-sized feet,” said Dennis Janisse, CPed, president and CEO of National Pedorthic Services and a clinical assistant professor of physical medicine and rehabilitation at the Medical College of Wisconsin in Milwaukee. “I actually had to cast his feet for a high-end dress shoe company so that they could make a shoe over the cast. Because he had such a big-sized shoe, it was so hard for him to get footwear anyway. He was cramming that bigger foot into a smaller shoe, and he ended up with a significant deformity on the one foot and the other foot was fine.”

Wide range of treatments

Treatment for HV, most often a hereditary disorder, ranges from just trying to control the symptoms with proper shoes and orthotics to surgery, often considered a last resort.

“Unfortunately there’s not a lot that really works,” Weil said. “For somebody who is developing a bunion, there’s nothing you can do to arrest the progression. No mechanical device or change of shoe gear is going to prevent the progression of the problem. Basically you treat it with finding wider and deeper shoes that are more amenable to the deformity. You change activities to make it more comfortable. Shoes and orthotics may make it less painful—until it gets bad enough to have surgery.”

More than 130 procedures have been described for HV as far back as the early 1900s, but in the last 20 years, techniques have improved and have been refined based on technological advances in surgery in general, Weil said.

In 2000, a Cochrane Database Systematic Reviews article cited a consistently high (25% to 33%) rate of dissatisfaction among osteotomy patients postoperatively. However, recent publications have pointed to different, highly positive results. A June 2007 paper published in Quality of Life Research concluded that surgery improves the quality of life for HV patients in terms of bodily pain, vitality, and mental health. A study to be published in the March 2011 issue of Clinical Orthopaedics & Related Research cites improvements in AOFAS pain and function scores from 61.5 to 90.3 in patients who underwent a unilateral scarf osteotomy combined with distal soft tissue alignment at the Hospital for Special Surgery in New York City.

Still, opinions vary as to the effectiveness of surgical procedures, depending on who you ask. Some pedorthists and physical therapists still see patients postoperatively who may be predisposed to stiffness in joints or otherwise have not fared well after surgery for various reasons, including not complying with surgeons’ instructions. Marino, however, said noncompliance is not a significant problem in his San Francisco practice.

“I personally drill into their heads that I won’t operate unless they know what they have to do afterward. I tell them, ‘If you don’t listen, then we’ll just end up doing this again,’ ” he said.

Some results depend on the reason for the surgery in the beginning, and the expectations of the patients, particularly with regard to wearing stylish shoes.

“In our neighborhood, people have surgery based on what they can’t wear and the amount of deformity, which is a lousy reason to do it, quite frankly,” said Stephen Paulseth, PT, DPT, SCS, ATC, in private practice in Los Angeles, near Beverly Hills.

He recommends the use of orthotics before and after surgery, as needed.

“We always try to get the patient in before they consider surgery, to see if we can get them a little bit more mobility, get them in some calf/soleus exercises and calf stretching, and to use their flexor hallucis during push-off. They tend to allow their foot to deviate at push-off, which drives their first-toe into abduction,” he said.

Most of the patients seen by RobRoy Martin, PT, PhD, assistant professor of physical therapy at Duquesne University in Pittsburgh, PA, are postoperative patients.

“A lot of them have inappropriate preoperative expectations, thinking they can go back to the shoes they wore before they had surgery,” he said. “The really fashionable shoes are just so bad. I’ll trace their foot and then put the shoe on top of the trace and ask the patients, ‘how can you possibly jam your foot back into that?’ ”

Other people, he added, are simply prone to stiffness after surgery. He tries to counter that with aggressive joint stretching and mobilization exercises, and he recommends a good cross-training shoe that is sturdier and stiffer than a running shoe to maintain forefoot stability.

If a person’s job requires a higher fashion, therein lies the rub. Although most shoes that are wide enough and deep enough to accommodate HV are functional, Powell said, “They’re not pretty. It does not matter the age group, whether someone is in their 30s or 80s, they are looking for function as well as aesthetic.”

That said, the footwear options available for patients with HV today are much better than in the past, Janisse said.

“You’re not going to find a three-inch spike heel or anything like that that’s going to accommodate something like a significant deformity. But a lot of the footwear out there today is much more accommodating and is acceptable, unlike it was years ago,” he said.

Still, shoe manufacturers “definitely need to keep their efforts strong in making shoes that are more fashionable, even though they have made a lot of progress in the past 10 years,” said Brown in St. Louis.

And the shoes need to accommodate all ages, he added.

“The younger people don’t want to look like they’re wearing the same pair of shoes their mom or grandmother wore,” Brown said.

Beyond Bunionectomy: The Role of Physical Therapy

More and more surgeons are embracing the idea that physical therapy after bunion surgery can improve range of motion and other functional outcomes. But some practitioners still aren’t sure it’s right for everyone.

Most surgeons will tell you outcomes of hallux valgus surgery are very good, often quoting a 90% to 100% percent success rate. A survey-based study published in the December 2001 issue of Foot and Ankle International is typically cited as evidence.
But consensus is harder to come by in determining to what degree post-operative physical therapy contributes to functional outcomes. Some doctors send patients home with a self-administered exercise and self-massage routine and nothing more. Others prescribe an extensive, twice-weekly supervised physical therapy protocol that lasts from four to eight weeks on top of home-based exercises. To complicate matters, patients start PT at various times after surgery, depending on the rate of healing and the type of procedure.

Not all practitioners are ready to accept the idea that physical therapy, and not just surgical technique, can have a substantial impact on the success of hallux valgus procedures.

“Some physicians may think if they send a patient for physical therapy after surgery, it reflects poorly on their surgical procedure,” said Juan J. Rivera, DPM, a private practice podiatrist with the Ankle + Foot Center of Tampa Bay, who views physical therapy as complementary. “In actuality, you are helping your patient optimize their ultimate results and overall post-surgical experience.”

In the last year, two studies, one published and one presented at the American College of Foot and Ankle Surgeons’ annual meeting, have revived the debate. They suggest that post-operative physical therapy can significantly improve range of motion and weight bearing outcomes.

Enter new evidence
In the September 2009 issue of Physical Therapy, investigators from the Foot and Ankle Center in Vienna, Austria, analyzed 30 patients who underwent surgical correction of mild to moderate hallux valgus deformity, including 20 Austin osteotomies and 10 Scarf osteotomies. Prior to initiating the study, the researchers had observed that despite favorable clinical results, including pain relief, the ability to wear a wider variety of shoes, and the ability to participate in recreational activities, gait patterns did not spontaneously alter after surgery.
“We noticed that patients who underwent hallux valgus surgery didn’t use their great toe for push off, even though the deformity was corrected sufficiently,” said Reinhard Schuh, MD, a first-year resident in the department of orthopaedic surgery at Innsbruck Medical University and lead author of the study.

“To achieve bony union of the osteotomy, we had to avoid loading for four weeks,” Schuh said. “But we instructed patients to perform passive ROM exercises starting two days after surgery.”

At four weeks, patients began a comprehensive, 45-minute rehabilitation program once a week for four to six weeks. The standard protocol included elevation of the leg, lymphatic drainage, and activation of the muscle pump, and cryotherapy in the first session to reduce swelling. Other modalities, such as scar tissue massage, mobilization, manual therapy, soft tissue techniques, proprioceptive training for the lower leg, strengthening exercises, and gait training, were added progressively over the next four weeks.

Although the researchers did not use a control group, they found that at six months after surgery patients experienced significant improvements in first metatarsophalangeal joint range of motion and function. Weight bearing at the great toe and first metatarsal head, specifically related to maximum force levels and force-time integral, also improved significantly. Participants’ mean functional score on the American Orthopaedic Foot & Ankle Society forefoot scale improved from 60.7 out of 100 before surgery to 94.5 out of 100 at six months. By comparison, previous plantar pressure studies have documented a lack of weight bearing in the medial forefoot and first ray after hallux valgus surgery not followed by physical therapy.

Believe it or not
In the second study, which has been submitted for publication, researchers studied 55 patients who had undergone Scarf procedures at the Weil Foot and Ankle Institute in Des Plaines, IL. The large, 16-office practice in the Chicago area handles 500 bunion surgeries a year. According to Lowell Weil, Jr., DPM, MBA, senior investigator of the study, surgeons in his practice fall into two camps.

“The advent of screws and proper screw fixation eliminated the need for complete immobilization. Patients are able to return to activities and start physical therapy earlier, which has tremendous benefits. We developed physical therapy protocols for patients undergoing these types of procedures,” he said. “Despite that, some doctors in our practice weren’t prescribing physical therapy; they didn’t believe it made a difference.”

So Weil and a few colleagues set out to investigate. Their nonbelieving colleagues’ patients, who did not receive PT, served as a control group.
They studied 44 patients (65 feet) who underwent Scarf osteotomy procedures between 2006 and 2008, followed by a program of once- or twice-weekly physical therapy sessions. The 30 to 45 minute sessions continued for one to six weeks. Another group of 11 patients (14 feet) received no post-operative therapy.

Follow up occurred between November 2009 and January 2010. The physical therapy group significantly outperformed the control group on the Foot Function Index (FFI) and the ACFAS Universal Foot and Ankle Scoring System (see table).

Opinions about post-operative physical therapy in hallux valgus cases are as varied as surgical procedures. For PT proponents, like Michael Loshigian, DPM, a podiatric foot and ankle surgeon in private practice with the Metropolitan Foot Group in New York City, the benefits are indisputable.

“My own experience is fairly clear. Patients who have some sort of formal or informal physical therapy after hallux valgus surgery have better overall results and the progression of healing is more consistent and reliable,” Loshigian said.

Getting a head start
Loshigian, who performs these surgeries at least weekly, says the physical therapy protocol often begins shortly after surgery.

“In a joint fusion case, there should not be any attempt to move the joint, obviously. But in the majority of cases, we’re reorienting the MTP joint, restoring normal range of motion and alignment and function of that joint. In those cases, I have patients start their own range of motion exercises the day after surgery,” he said.

A primary objective is to prevent the soft tissue contracture and joint stiffening that can result from cutting and repositioning of bone.

“It’s easier to maintain good range of motion from the beginning than to attempt to restore it after it has been lost,” he said. “If we give those soft tissues an opportunity to tighten up, movement becomes difficult.”

Loshigian usually starts patients on formal twice-weekly physical therapy two to three weeks after surgery, once he removes the stitches. For most patients, the complete course of therapy lasts six to eight weeks.

At three or four weeks after surgery, patients can start weight bearing without the protection of a post-op shoe; at that point, Loshigian recommends strengthening the muscles and tendons that control the great toe along with continuing ROM exercises and techniques to reduce swelling. The final stage involves strengthening the lower legs and improving patterns of gait, agility, and balance.

Contributing factors
Rivera says many factors influence his decisions about the timing and course of therapy.

“Surgical procedures —MTP joint fusion, arthroplasty, chevron, opening base wedge, closing base wedge, first metatarsal-cuneiform joint fusion—all have various timeframes to stay offloaded, which can lead to disuse atrophy,” he said. “Many patients have such low pain tolerance, they need gait retraining to overcome post-operative pain and swelling and regain joint flexibility. Older patients need more help with loss of balance and proprioception.”

Another issue is the amount of time a patient with an operable deformity has postponed surgery; long delays can lead to compensatory gait patterns that are difficult to unlearn without additional physical therapy.

“A common example for me is the patient who undergoes hallux limitus correction surgery,” he said. “The biomechanical compensation for a painful arthritic great toe joint is to ambulate with the foot in an inverted position. Post surgery, the patient continues to ambulate in that position out of habit, delaying the healing of the foot.”

Not for everyone
Donald R. Bohay, MD, a professor of orthopedic surgery at Michigan State University who is also in private practice at Orthopaedic Associates of Michigan in Grand Rapids, views hallux valgus surgery and its aftermath from a slightly different perspective.

“I’m a believer in physical therapy that can help your patient get better faster,” Bohay said. “But I don’t think we know for sure that the patient who gets physical therapy versus the patient who doesn’t is necessarily better after a year.”

Bohay, who favors tarsometatarsal arthrodesis with a modified McBride procedure, says that his patients wear a post-op splint for two weeks. They then wear a short leg cast with heel weight bearing for six weeks, followed by a weight bearing boot for two to four weeks.

Most of the surgeons interviewed for this article would prescribe supervised physical therapy for a procedure requiring so much healing time and immobilization. However, Bohay instructs most of his patients to do home-based range-of-motion exercises and soft self-massage with vitamin E oil to desensitize the foot. When he considers it necessary, he does prescribe formal physical therapy.

“You get a sense that some patients aren’t going to do the program. Those patients do well by going to PT,” he said. “Then there are patients who have a lot more done, who are very swollen, very stiff. For them, physical therapy helps reestablish control, range of motion, and desensitization.”

The therapist’s perspective
Despite the general consensus among surgeons that PT is a useful tool after bunion correction, at least in certain cases, physical therapists express frustration that surgeons don’t take full advantage of their expertise.

“It’s a misconception that physical therapy is cookie cutter,” said Clarke Brown, PT, DPT, OCS, ATC, who is in private practice in Rochester, NY, and president of the American Physical Therapy Association’s foot and ankle special interest group. “We study these procedures. We develop separate protocols for them, and adapt them for each patient.”

Physical therapy following bunion surgery, Brown said, should extend well above the ankle.

“The most challenging thing about feet is that they radically change what happens all the way up the kinetic chain. The good practitioner looks at the whole system, all the way up to the knee, the hip, and the back. We look at the range of motion in all the joints and the strength of the entire leg,” he said. “Most chronic bunion patients can’t effectively lift the bunion leg in side-lying. The hip muscles atrophy.”

Brown notes that the foot and ankle subspecialty in physical therapy is just developing. Even though it’s not something surgeons have clamored for, those who witness the benefits of specialized therapy are sold, he said.

“We found that the faster we started to move the patient’s foot and toes, the more quickly the swelling went down,” he said. “One podiatrist used to take his sutures out after two weeks. But when we moved aggressively, the incisions would sometimes open up. Now he takes the stitches out at 21 days, saying ‘I’ll leave these in longer so you guys can do more.’ The more we communicate with each other, the better.”

A proactive approach
Stephen Paulseth, PT, DPT, SCS, ATC, who runs a private practice in West Los Angeles, often sees patients who have complications or problems that he believes could have been avoided by introducing physical therapy earlier.

“If doctors would send their patients for prehab, they would be doing so much better,” said Paulseth, who preceded Brown as president of the foot and ankle SIG. “I sometimes see patients six weeks in who haven’t really done much. They’ve been told to ice, strengthen, and do some gentle motion, but they just can’t tolerate it.”

He believes proper therapy and patient training can reduce the progression of bunion surgeries.

“Calf length is number one. Inadequate dorsiflexion of the ankle leads to all kinds of distal forefoot issues, including hallux valgus. Patients should begin calf stretching as soon as possible, and they have to continue calf stretching after they’ve healed,” Paulseth said.

Surgeons contend that most patients who undergo hallux valgus surgeries are happy with the results.

“From my experience, the vast majority of patients who have gone through this procedure are very satisfied with the results and in retrospect would choose to undergo the same procedure again,” Loshigian said. “As for their initial post-op experience, the feedback I get from most patients is that it is less stressful and painful than they anticipated.”

In Brown’s estimation, that already good patient experience could be even better if the relationship between patient, doctor, and physical therapist were more collaborative.

“When patients do better quicker, the word of mouth is more positive for the doctor,” he said. “Everybody wins.”

August 2010 by Linda Weber