This article was featured in the Wall Street Journal on January 22, 2013
Young People Also Weigh Surgery To Relieve Ugly, Painful Bunions by Sumathi Reddy
Grandma isn’t the only one with bunions.
Just 26 years old, Kacey Barker, of Haverhill, Mass., found herself with a painful joint jutting out from the base of her left big toe. “Mine got progressively worse over the years,” she says. “With all the sports and wear and tear…anything and everything was bothering it.”
Ms. Barker a couple of years ago had to stop her athletic activities, including running, field hockey and softball. The pain became unbearable after a marathon-length charity walk in the fall, and she finally decided to have surgery to correct the toe’s misaligned bone. Six weeks later, Ms. Barker, who manages funding for research grants, is still wearing a surgical boot to walk and is looking at another six weeks to fully recover. Her longer-term goal: rocking the dance floor pain-free at her wedding in September.
“A lot of my friends thought bunions are for women who are old or who wear high-heeled shoes for decades,” says Ms. Barker, who says she tends toward supportive, sensible shoes.
An estimated 23% of adult Americans suffer from bunions, including more than two-thirds of people over the age of 65, according to a review of studies published in 2010 in the Journal of Foot and Ankle Research. More than half of women get bunions, and women are nine times as likely as men to have the problem, according to the American Academy of Orthopaedic Surgeons. Some doctors say the growing popularity of high heels and pointy-toed shoes, including among very young women, has helped increase the incidence of bunions.
Although genetics plays a role in determining who develops one, motion and pressure, often caused by ill-fitting shoes, can trigger a bunion to form.
“There’s a misconception that shoes cause the bunion. Shoes aggravate it and make it symptomatic,” says Michael Trepal, a professor of surgery at the New York College of Podiatric Medicine. Usually, “it starts to occur in the early phases of young adulthood, and as time goes on, it progresses,” he says.
Doctors typically recommend nonsurgical remedies as a first recourse. This can include a different kind of padding in shoes, orthotic insoles and ensuring that you’re wearing a shoe that is wide enough and not too high, says Gary Pichney, a surgical podiatrist at the Institute for Foot & Ankle Reconstruction at Mercy Medical Center in Baltimore. While such approaches can reduce discomfort and may prevent a bunion from getting worse, they don’t correct the condition. Dr. Pichney says about half of his patients end up opting to do surgery.
Dr. Gary A. Pichney/Mercy Medical Center
Genetics and pressure from shoes can cause the big toe’s metatarsal bone to shift position, creating a bunion, left. In this case, a surgeon removed a section of bone and inserted a locking plate and screws to reposition the bone and hold it in place, right.
So what exactly is a bunion? It isn’t an overgrowth of a bone, as many people think. Dr. Trepal explains that the foot contains five metatarsal bones, one behind each of the toes. In a healthy foot those bones are roughly parallel. A bunion is formed when the big-toe joint, or the metatarsophalangeal, becomes misaligned, causing an enlargement of the bone or tissue around it that appears as a bump.
The big toe often drifts toward the second toe and can affect the position of the other toes. The severity of the big toe’s misalignment is what surgeons rely on to decide on the type of surgical approach to take.
There are many different types of surgeries to correct bunions, depending on the nature and severity of the problem. The most frequent procedure to correct the angular deformity is an osteotomy, or a bone cut at either the front, middle or back portion of the first metatarsal bone. The more severe the bunion the farther from the joint the cut is made.
Ms. Barker, after years of living with bunion pain, went to see James Ioli, chief of podiatry at Boston’s Brigham and Women’s Hospital, who last month performed a common type of osteotomy on her left foot called a chevron. This procedure involves cutting the front portion of the first metatarsal in a V-shape, moving the bone and holding the sections together with a fixation device, such as screws.
“It’s definitely not something to take lightly,” Ms. Barker says. “But for me I’m excited to just be able to get back into a normal routine.”
Most bunion surgeries take between six and 12 weeks for recovery, and often include time on crutches and in surgical shoes or boots, doctors say. One of the simplest procedures, with a relatively short recovery time, is called an exostectomy, in which the bump on the head of the first metatarsal is thinned or shaved off with a surgical saw. The procedure is usually only used in cases where there is no angular deformity or drifting of the big toe, doctors say.
The most serious bunions are treated with a joint-fusion surgical procedure known as a lapidus bunionectomy, in which the first metatarsal and the next bone back, a cuneiform, are fused together. In the process, the patient loses use of a joint that isn’t considered essential.
Some people choose bunion surgery mainly for cosmetic reasons, which many doctors advise against. “I don’t know if it’s because people are paying more attention to their feet now,” says Neal Blitz, chief of foot surgery at Bronx-Lebanon Hospital Center. Dr. Blitz also has a private practice in Manhattan where he performs what he calls a bunionplasty, which take a cosmetic approach to correcting bunions. “People want their feet to look good and they want them to be sexier.”
Dr. Blitz created a plating system about a year ago that he says allows patients to put weight on the foot soon after surgery. The technique involves inserting a titanium surgical implant and six screws into the foot to hold the bone into proper position.
Claudia Ngo, 22, received a bunionplasty from Dr. Blitz in July. “It’s always something that’s been really embarrassing,” Ms. Ngo, of Bethesda, Md., says of her bunions. “I always tried to hide, wearing socks and shoes around my friends or a blanket on the couch. In college I would wear heels…so they actually got bigger.”
The first podiatrist Ms. Ngo saw advised against surgery, saying she should only do it if she suffered from a lot of pain, not for cosmetic reasons. Pain usually came only after wearing heels for a long time or working out but not on a daily basis, says Ms. Ngo, an auditor.
After going to see Dr. Blitz, she received bunion surgery on her right foot and was able to walk with a special surgical shoe right away. “After four weeks I was wearing regular shoes,” she says. “Now I’m really happy with my results, it looks perfect,” says Ms. Ngo, who is hoping to do the same procedure on her left foot later this year.
Most experts advise patients after bunion surgery to be careful what shoes they wear to avoid a recurrence of the problem. Bunions come back between about 5% and 20% of the time. Generally the more aggressive the surgical procedure the less chance a bunion will recur, experts say.
Meghan Morrison, a 27-year-old graduate student in Nashville, Tenn., is sticking so far with nonsurgical treatments for her bunions. She avoids high heels and looks for wide shoes, mostly flats with padding and boots for maximum comfort.
But, she says, if the bunions get much worse, she might have surgery. “I don’t want my feet to end up looking insane and horrific,” she says. “And if it ever got to a point where I just couldn’t walk or be active I definitely would do it.”
Write to Sumathi Reddy at firstname.lastname@example.org