Hallux valgus – bunion

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The word bunion is derived from the Latin word bunion, meaning turnip.


  1. Improper shoe wear.

  2. Almost exclusively seen in populations who wear shoes, it rarely occurs in unshod populations.

  3. There is a hereditary predisposition in some people.

  4. Male to female ratio is 1 to 15 as modern foot wear is the principle offender.

  5. Flat feet have a slightly increased tendency towards bunion deformities.

  6. Metatarsus Primus Varus, hyper-mobility in the joints.

  7. Heel cord contractures.

Goals of surgery:

  1. Correct bunion deformity.

  2. To achieve the most functional foot.

  3. Pain relief. If there is no pain, it is difficult to improve the situation.

Expectations after surgical correction:

  1. Some residual stiffness should be expected although relief of pain and deformity are the major goal.

  2. Approximately 1/3 of the patients pre-operatively can wear shoes they wanted, post-operatively, this increased to 2/3.

Conservative treatment:

  1. Soft leather shoe

  2. Wide toe box without stitching, soft sole.

  3. Modify shoe with stretching.

  4. Bunion pad, post or night splints.


Women’s Shoe Wear:

  • First sandal was made around 8000 B.C. and high heels were made around the 16th century.

  • Improper shoe wear is the primary cause of hammertoes, hallux valgus, bunions, bunionetts and corns.

A 1992 study showed that:

  • 66% had one foot larger than another.

  • 80% had significant pain.

  • 76% had one or more deformities of the foot, 54% bunions.

  • 88% had shoes smaller than the width of the foot by ½ inch.

  • The average foot-shoe size discrepancy was one quarter inch in women without pain.

In a recent study:

  • There was a large discrepancy between forefoot and heel width in women.

  • Heel width in shoes increases proportionately with forefoot width but anatomically the heel does not increase proportionately with forefoot width.

  • Larger feet therefore are more likely to have pain and deformities.

  • Therefore, a combination list is required for best fit and to avoid deformities.

  • Larger feet had more pain and deformities.

In a 15 year study by Dr. Coughlin:

  • 94% of bunion surgeries were performed in women. This peaked in the 4th, 5th, and 6th decade.

  • 87% of bunionette surgery was in women, 88% of neuroma surgery was in women and 87% of hammertoe surgery was in women.

  • High heels result in 50% more pressure on the ball of the foot and changes in the maximum pressure from the 2nd metatarsal head to the bunion area.

In a questionnaire by the Foot and Ankle Society:

  • Six pairs of shoes are bought per year on the average.

  • 60% of them are women paid between $50 and $200.

  • 50% are not satisfied wit comfort and fashion.


  • Fit to a weight bearing foot at the end of the day.

  • Toe box should not wrinkle with flexion.

  • Foot should not bulge over the welt.

  • Allow ½ inch from the largest toes to the end of the toe box.

  • Forefoot should not be crowded; the heel should be snug.

- The majority of women wear shoes that are too small, this causes pain and deformities.
Variations in design that affect comfort:
Toe Box Height:

High toe box provides more vertical room, i.e. more accommodation for the toes:

Receding toe box creates silhouette with long, slender look. Compromises toe space:

Toe Box Shape:
Rounded toe box provides more room for width of toes. Pointed box provides less.

Worse of both worlds: pointed and receding.


  1. Do not select shoes by the size marked inside the shoe. Judge the shoe by how it fits on your foot.

  2. Select a shoe that conforms as nearly as possible to the shape of your foot.

  3. Have your feet measured regularly. The size of your feet changes as your grow older.

  4. Have both feet measured. Most people have one foot larger than the other. Fit the larger foot.

  5. Fit at the end of the day when your feet are largest.

  6. Stand during the fitting process and check that there is adequate space (3/8 – 1/2 inch) for your longest toe at the end of your shoe.

  7. Make sure the ball of your foot fits snugly into the widest part (ball pocket) of the shoe.

  8. Do not purchase shoes that feel too tight, expecting them to “stretch to fit”.

  9. The heel should fit comfortable in the shoe with a minimum of slippage.

  10. Walk in the shoe to make sure it its and feels right.


ANAHEIM – Patients who go to an orthopaedic specialist for bunion surgery typically report significant improvement after just six months, according to a major multi-center study conducted by the American Orthopaedic Foot and Ankle Society (AOFAS).

The study asked 305 patients to evaluate factors such as foot pain and shoe comfort before surgery and at six months follow-up. Comparisons of preoperative and follow-up data confirmed what lead researcher David Thordarson, M.D., Los Angeles, expected to fine – that bunion surgery is highly effective when performed by an orthopaedic surgeon.

“The study demonstrated that at six months, patients had significantly better physical function, better overall foot and ankle function, greater shoe comfort and decreased pain,” said Dr. Thordarson, chairman of the Clinical Outcomes Committee. “Most importantly, patients say that they are happy with the results.”

Presented at the AOFAS Annual Winter Meeting, February 7th in Anaheim, California, the study is the first large-scale effort to evaluate patient perception of bunion surgery. AOFAS members from medical centers throughout the United States enrolled patients, each of whom completed a questionnaire before surgery to determine a baseline for later comparison.

Developed and tested for validity by the American Academy of Orthopaedic Surgeons and a task force of national musculoskeletal specialty societies, the MODEMS questionnaire gathered data on medical history, activity level, foot and ankle function, foot pain and shoe comfort, as well as demographic information.

At six months, patients again completed the questionnaire, and the results demonstrated significant improvement. The average score on the global foot and ankle scale, a measure foot and ankle function, improved from 75.8 to 90.7. Shoe comfort improved from 34.3 to 54.8. Scores for overall satisfaction – measured on a 1 to 5 scale, with 5 completely satisfied – increased from 1.6 to 3.4.

A common problem, especially among women in shoe-wearing populations of the world, a bunion is a bump or bony prominence that forms where the big toe joins the foot. Generally, bunions form due to a condition known as hallux valgus, a alignment of the big toe. Shoe pressure on this area can cause inflammation and pain.

Often, bunions can be treated without surgery. When surgery becomes necessary, there are a variety of procedures used to remove the bump and correct the underlying cause.

The AOFAS study represents “the largest pool of normative data ever compiled on the outcome of bunion surgery,” Dr. Thordarson said. “This will be the database, the landmark study that will guide future research.”

The AOFAS plans to gather data from patients again at 12 months and 24 months after surgery. Plans also call for breaking down results by the type of procedure performed, Dr. Thordardson said.

The leading medical organization for orthopaedists specializing in foot care, the AOFAS is dedicated to advancing research and educational objectives in orthopaedic foot and ankle medicine.

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