Background & Etiology (Cause)
There are 28 bones in the foot, and over 30 joints. The bones in the front of the foot, the toes, are called the phalanges. The big toe (great toe) can become angled inward at the metatarsalphalangeal joint toward the other toes. A bump will form on outer edge of the big toe, which is referred to as a bunion. This condition is also referred to as “Hallux Valgus.” Common complaints include pain and redness from abnormal rubbing and wear along the toe because it is angled incorrectly. In addition to joint pain, a fluid-filled sac may develop, at the base of the toe.
Bunions typically occur more often in women, have a large genetic component and can sometimes run in families. The genetic component is related to the alignment of tendons, ligaments and the supportive structures of the first metatarsal. Wearing narrow-toed shoes, or having an underlying bone abnormality will exacerbate these conditions.
- Wearing narrow-toed shoes, particularly women’s high heeled shoes
- Genetic component effecting bones and tendons of the foot
- Arthritis, or other conditions that affect the big toe joint
- Bone abnormalities
When a bunion forms, extra bone and a fluid-filled sac may develop at the base of the big toe. Other symptoms include:
- A visible deformity in the angle of the big toe
- A bony bump on the outside of the big toe
- Red, calloused skin along the outer edge of the big toe
- Pain at the big toe joint, that often gets worse when wearing shoes
A physician can diagnose a bunion with a visual analysis of the foot. If needed, an X-ray can confirm an abnormal angle of the big toe and the rest of the foot. The first line of treatment for a bunion is to wear wide fitting, comfortable shoes with felt or foam pads that cushion the bug toe against the edge of the shoe. If a bunion is causing severe pain or a deformity that makes activities like walking difficult, surgery to correct the condition may be necessary.
A bunionectomy is the surgical procedure used to address the dysfunction of a bunion. There are different approaches to this procedure but the goals are the following:
• Remove any boney enlargement
• Realign the first metatarsal and great toe relative to the other toes
• Address and arthritic and cartilaginous changes
Once cleared by the physician, a physical therapy program should be initiated post-surgery to aid in healing and recover full motion of the toe joint.
Physical therapy interventions
Goals for physical therapy post-surgery of the big toe include optimal loading and restoration of normal tissue relationships to improve motion, strength and the ability to perform functional activities of daily living.
- Manual Therapeutic Technique (MTT): hands on care including soft tissue massage, and joint mobilization by a physical therapist to modulate pain and reduce any soft tissue or tendon irritation and restore normal joint mechanics and range of motion.
- Therapeutic Exercises (TE) including exercises to improve strength and performance of the foot bones and surrounding muscles.
- Neuromuscular Reeducation (NMR) to restore stability, begin retraining the lower extremity, improve proximal joint stability and improve movement technique and mechanics (for example: jumping, running etc) in use of the involved lower extremity in daily activities.
- Modalities that can include the use of ultrasound, electrical stimulation, ice, cold and laser to decrease pain, improve mobility and reduce inflammation of the toe and surrounding muscles and tendons.
- Home program development should include strengthening, stretching and stabilization exercises as well as instructions to help the person perform daily tasks and advance to the next functional level.
- The use of pain medications
- rest and ice are the first line of treatment for a bunion
- Surgical intervention may be required in more severe cases or when the injury affects the integrity of the joint.
Rate of recovery and the prognosis from a bunion will depend on a number of factors:
- Severity – Minor conditions do well with padding and alterations to daily footwear. Bunions that are more severe and require surgery or effect joint integrity take longer to heal. Patients may have residual motion and strength deficits.
- Age- Younger individuals recover faster and are less likely to have residual deficits. Younger individuals heal quicker, have better circulation, are stronger and usually have better pre-injury tissue integrity.
- Prior activity level plays an important role in post-injury recovery. Those who exercise regularly are stronger and more flexible, and generally have an easier and more complete recovery.
- Compliance- Patients that are committed to their rehabilitation program and are compliant with their home program are more successful in returning to full function.
- Recovery time can range from 6-8 weeks to three months following surgery.