Bunions

By Jay Goldstein, DPM, MS


Q. I have a bump along the inside of my big toe joint. I have been told it is a bunion. For a long time it stayed the same size and did not hurt. Now it seems to be getting larger. It turns red after a lang run, and is taking longer to go away. The pain is increasing, especially when I go downhill, and to a lesser extent when I go uphill. It is not as bad when I run on flat ground.

A. Many things occur when a bunion develops.

The majority of the "bump" along the inside of the big toe joint is made of bone. Some of the bump may be swelling of the tissues and/or joint (increased joint fluid). Part of the bump is new bone which has formed in response to shoe pressure. The majority of the bump is the original bone which is now more prominent because the bones which form the joint have drifted into a new (worse!) position.

As the first metatarsal (see diagram) shifts inward (increasing the bony prominance), the big toe drifts in the opposite direction, moving closer to the second toe. Unfortunately, since the forces around the big toe are stronger than those around the second toe, eventually the second toe is also likely to shift. The second toe may be forced to curl upward (causing a hammertoe), sideways (toward the third toe), or both.The movement of the second toe then begins to cause other problems.

WHY DOES IT HURT?

There are two smell bones under the fist metatarsal head called sesamoids. The sesamoid bones normally fit into grooves on the bottom of the metatarsal head.

When the other bones drift out of position, the sesamoids are usually also forced out of their grooves, which may cause pain on the bottom of the joint. The joint is composed of two bones (the first metatarsal and the big toe) which articulate (move) with each other. The ends of the bones are covered with cartilage, which enables the bones to slide along each other smoothly with very little resistance. When a joint is out of position for a long time, the cartilage erodes, which then causes pain within the joint during motion. Since Mother Nature does not replace this type of cartilage, its Potential loss should not be ignored. On the other hand, when bunions develop rapidly, joint pain may occur prior to erosion of the cartilage because of the malalignment of the joint (the two pieces of bone do not "fit together" properly).

As the bump has gotten larger, your shoe has started to rub more. The rubbing increases the number of bacteria within the tissues. As the bacteria increase, you are developing a mild form of an infection called cellulitis The rubbing increases when you run downhill because yuur foot tends to slide forward. In addition, when one runs downhill, the foot elongates more than at any other time, which increases the pressure from your shoe.

The abnormal alignment of the joint eventually causes discomfort during motion of the great toe, particularly upward motion. This would be one reason why you may have slightly more discomfort when you run uphill. In more extreme cases, bone spurs may develop along the top of the joint, which also can cause pain when the great toe moves upward.

TREATMENT

Treatment consists of one or more of the following:
  1. Xrays of the joint to evaluate the alignment and quality.
  2. Evaluation of your running shoes and street shoes to determine proper fit and style.
  3. If the redness is more extreme and does not seem to be resolving rapidly, antibiotics may be needed (unusual).
  4. If the formation of the bunion is related to your foot and leg structure, and your gait, rather than primarily ill fitting shoes, foot orthases may also be needed.
  5. Surgery may be needed if the alignment is too abnormal, if surrounding bone spurs are interfering with motion and/or if significant cartilage has eroded.

Dr. Goldstein is an Oregon Road Runners Club member and has been running for 31 years. He is Board Certified in Podiatric Surgery, Podiatric Orthopedics, and in Podiatric Medicine.


Copyrighted by Jay Goldstein who reserves all rights to republication.