Bunions or hallux valgus

What are bunions or hallux valgus?

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Hallux valgus or bunion is a progressive and complex deformity that affects the forefoot. The most obvious signs are the deviation of the big toe and bone protuberance at the articulation of the first toe. The deviation of the first toe towards the second toe, along with the bone growth on the outside of the foot, causes the joint swelling, pain and may lead to other deformities such as hammer or claw toes.

Bunions occur almost exclusively in people who wear shoes, so it is very rare to find it in populations were accustomed to walking barefoot.
The growth of the deformity occurs gradually throughout life, although in some cases can evolve faster.

According to the Manchester scale, the bunion deformity or hallux valgus can be classified into four grades. The slightest deformity corresponds to grade 2. Moderate deformities correspond to grade 3, and the most severe are classified as grade 4. Grade 1 is when there is no deformity.

Also, there are other ways of classifying the hallux valgus (depending on the angles of the foot), but for practicality for the patient, the Manchester classification is a simple and practical system.

This deformity is recommended to treat it in time because the more severe it gets it can involve other toes and surgical treatments are more complex and may not have the expected results.

bunion normal

What if I have bunions?

If you have bunions, go ahead and consult a foot specialist, as time will only exacerbate the problem. The specialist must perform a complete exam of the foot which should include X-rays. These will establish the degree of bunion deformity and other deformities that may be present.

What shoes are recommended to wear?

As a general rule, the foot must fit comfortably in the shoes, always avoiding overcrowding the toes. Shoes should be comfortable, wide in the toe area, and most importantly they must have a firm grip on the middle of the foot.

In the case of women, a study at the University of Navarra found that the heel of the shoe should not exceed 5 centimeters in height. This does not mean that high heels can never be used.

The sole of the shoe should be thick whenever possible, as this absorbs the impact when walking while protecting the foot at the same time.

In the summer, sandals can be used for walking short distances.

What can I take for pain?

There are pain medications such as paracetamol or metamizole type (Nolotil) that provide pain relief.

When having bursitis or swelling, one could also take a nonsteroidal antiinflammatory drug (NSAID) such as ibuprofen or dexketoprofen. Always remember to consults your doctor before taking any medication.

What is the incidence of bunions?

Bunion or hallux valgus is the most common problem in orthopaedic and podiatric surgery.

The bunion is 7-9 times more common in women than in men. One study found that in women (Nguyen et al.2010), the incidence of bunions increases with the use of high heels and a low body mass index. However, in men, hallux valgus was found more commonly in men with high body mass index and flat feet.

What can be done if I am 30 years old with bunions?

The highest incidence of bunions occurs during the third decade (Coughling & Jones, 2007) of life. At age 30, if you have this deformity, you should consult with a foot specialist to evaluate your options. Depending on the degree of deformity there are several treatment options. At initial stages, you should follow the recommendations of San Roman Clinic. However, when having a large deformity or persistent pain, the only option is a surgical procedure.

What can be done if I am 40 years old with bunions?

From the age 40 onwards, it is the time when patients with bunions should seek a definitive solution to their problem. It is an excellent time to see a foot surgery specialist to assess the different surgical options depending upon the degree of deformity and foot type (planus or valgus foot for example)

What can be done if I am 50 years old with bunions?

If you are 50 years old with bunions, surgery is still the best option. Walking is very important to have a quality of life.

What is minimally invasive surgery?

What type of anesthesia is used if an operation is required?

Why do bunions grow?

The enlargement of this deformity is due to a combination of factors. One of these factors is the continuous pressure and friction of the shoe on the bone protrusion.

Other factors affecting growth are the foot type (planus or valgus), hypermobility or abnormal shortening of the first metatarsal bone, trauma, inflammatory diseases such as rheumatoid arthritis and finally footwear with a narrow tip and high heel shoes are essential factors that contribute towards the deformity.

Why do bunions hurt?

Pain mainly occurs by the pressure of shoe on the deformity. Sometimes the pain is constant due to nerve entrapment as it passes through the area.

Why do bunions or hallux valgus occur?

Hallux valgus is composed of the medial deviation (out) of the first metatarsal, the lateral deviation of the big toe or hallux, and the bone protuberance of the first metatarsal head. When the big toe or “hallux” deviates, it is called abducto valgus.
The origin of the bunion is multifactorial, i.e., which is due to many causes.

Genetic causes: despite being in a continuous study, we can say that bunions are transmitted from one generation to the next, but sometimes a generation is skipped. Up to 83% (Coughling & Jones, 2007) of patients suffering bunions have a family history.

The inherited defect is autosomal dominant (Biciuto, 2014), it is an alteration in the foot structure, which can be of the soft tissue or the bone or both. This produces an imbalance in the biomechanics of the foot that predisposes the development of the deformity. These alterations may be for example a long first metatarsal, a curved joint of the first toe or hypermobility of the first ray. This does not mean that all inherited alterations lead to the development of bunions.

Footwear: footwear plays a critical role in the development of bunions since as mentioned earlier, bunions do not occur in people that wear no shoes. High heels and narrow tip shoes influence their formation. Footwear that oppresses and hoards toes accelerates bunion growth and deformity of the toes. Also, tight shoes, cause pressure on the bony protuberance and even nerve entrapment.

For this reason, the bunion is up to 7-9 times more common in women than in men. Studies have shown that up to 34% of bunions (Coughling & Jones, 2007) are caused by very narrow shoes and shoes dictated by the wearer´s profession.

Profession: Studies have shown that certain professions that require the use of inadequate footwear or inappropriate use of the feet to perform their duties can also contribute to their formation.

Age: Deformity usually increases gradually with age. Patients seeking professional help are more often over 40 years of age.

Trauma: Patients who have suffered an accident or some type of injury to the foot that has affected the bone, joint, soft tissue and even dislocations or sprains, can result in hallux valgus.

Associated Diseases: Deformities such as flat or arch foot, hypermobility and lengthening of the first metatarsal, excessive pronation, hyperelasticity, and inflammatory diseases such as rheumatoid arthritis, gout and psoriasis are common causes of bunions and deformities to the toes.

Where do bunions appear?

The deformity appears in the joint of the big toe. When the appearance of the deformity is in the fifth toe, it is known as Tailor´s Bunion.

Where do  bunions hurt?

bunions hurtPain occurs mainly in the deformity itself, in the joint of the toe or under the foot. It is important to remember that bunions often cause other deformities such as hammertoes.

Where to buy a  bunion corrector?

The so called “bunion correctors” are devices that try to correct the deviation of the big toe and protect it from rubbing against the shoe. However, while these”correctors” may relieve pain caused by the deformity or even temporarily and minimally correct the deviation of the big toe, in no case will remove the bunion or correct the deviation of the big toe.

For this reason, we must remember that the only solution for bunions is surgery. Minimally invasive foot surgery allows correction of bunions and hammertoes through an incision of 5 mm, with little pain, rapid recovery, fewer complications and allows the patient to walk out unaided after the surgery.

Where and how must  Percutaneous Minimally Invasive surgery to the  foot be done ?

Who operates bunions?

This operation is performed by podiatrists and other medical specialists. Today, there are specialists dedicated exclusively to foot surgery. You must remember that surgery is an art.  In addition to knowledge and science, it requires a lot of experience to get a good result. For this reason, foot surgery should be performed by surgeons with extensive experience in this field.

When do bunions appear?

They may appear at any time. Initially, as a small deformity, on the outside of the toe joint. This deformity may be asymptomatic or painful.

How long have we known bunions?

The oldest bunion (Isidro & Margosa, 2017) known belongs to a mummy from ancient Egypt, about 2100 BC. It is very rare to find bunions in archaeological remains as these deformities are predominant in societies that wear shoes every day.

When can I can drive or work if I have Percutaneous  Minimal Incision Surgery on my feet?

How to prevent?

To prevent the formation of bunions, you should seek an initial assessment of a foot specialist when the first signs occur.  X rays of the foot along with a biomechanical gait analysis to detect any alteration in the tread, imbalances, foot type and hyper pressure points will be taken.  All this will help to establish the type of deformity, and if necessary,  customised shoe inserts will be made to stabilise pressures on the foot and to slow  the progression of bunions.

The use of high heels and tight tip shoewear should be avoided so that the toes are not squashed and also not to put too much pressure in the area of the bunion. Footwear must accommodate and hold the foot correctly. The shoe sole should be thick, platform type. Finally,  you can do rehabilitation exercises to strengthen the muscles of the foot and reduce overpronation.

The San Roman Clinic has made a series of recommendations based on the experience of over 35 years treating bunions.

How to correct or heal without surgery?

Unfortunately, bunions cannot be corrected or removed without surgery. Orthotics can be used to stabilize the joint of the first toe or even a silicone separator to align the first toe a little, but in no case,  it will be fully corrected without surgical intervention.

´Laser surgery´ is a term that was first used in the 80s about minimally invasive surgery or percutaneous foot surgery. The laser is not used in any bunion operation, however, it is defined as being laser technique when the correction is done through incisions of a few millimeters with much faster recovery and minimal pain.

What are the symptoms of bunions?

Bunions in early stages are usually asymptomatic, meaning that the patient has no symptoms at all. With the passage of time,  it increases in size and the big toe diverts also affecting the other toes.

The main symptoms are as follows:

Pain and swelling: the main symptom is pain that occurs on the outside of the first toe. The joint swells and reddens causing pain that can be incapacitating. The bone deformity swells with the friction of the shoe causing painful bursitis (accumulation of inflammatory fluid). These symptoms worsen when walking or standing for extended periods.

Calluses and painful blisters: the deviation of the big toe toward the second cause deformities in the toes which in turn produce calluses both on the toes and the sole. These can cause metatarsalgia which is pain in the middle of the sole. Also, the bunion area may show calluses produced by rubbing or pressure.

Pain caused by stiffening of the big toe: bunion deformity is often associated with some degree of osteoarthritis. Rigidity produces limitation of movement of the big toe and this, in turn, can cause pain, tenderness and numbness especially when wearing high heel footwear.

In general, all these symptoms can temporarily improve with the recommendations we described in another section. However, over time and as it evolves, these measures will cease to be effective. Therefore, it is important to remember that the best and only treatment for bunions is surgery.

What are the complications of not treating hallux valgus?

Bunion: as described at the beginning of the text, the bunion is the bulge or bump that forms on the outside of the joint of the big toe. Is often painful due to the pressure exerted by the shoes narrow tip and high heels. Sometimes it can hurt even without shoes as a result of the inflammation and nerve entrapment that occurs in the area of the deformity. With the passage of time, this deformity continues to increase in size and can make the use of everyday footwear impossible, producing increased pain and lack of instability in the foot support.

Deformities in the other toes claw and hammer toes are usually associated with bunion deformity. The deviation of the big toe toward the other toes induces continuous pressure which is aggravated by the use of high-heeled and narrow tip shoes. Over time, your toes are raised and bent to accommodate the deformity of the big toe. The toe deformities are usually, claw, hammer and gooseneck. Often, the patient comes to the specialist foot surgeon presenting not only the bunion but also deformities to other toes.

For this reason, it is very important to treat the deformity as soon as possible to avoid the associated deformities that can occur in other parts of the foot such as claw and hammer toe in particular.
Claw toes: toe deformity associated with hallux valgus affects soft tissue, mainly muscles and tendons. In hammertoes, it causes an abnormal flexion of the toe joints. This deformity resembles the claws that some animals have.

Hammertoes: deformity is also known as mallet toe due to the bending of the toe, like a hammer or mallet. Anatomically, an extension of the proximal toe (metatarsophalangeal joint) and a bending of the end of the toe (distal interphalangeal joint) occurs.

What is the postoperative period of this surgery?

Bunion Diagnosis

  • Diagnosis of a bunion is initially visual as the bulge or deformation of the first joint of the big toe is apparent. Very important to have an individualized and accurate diagnosis of the severity of the bunion to assess the surgical option and future outcome of such intervention.
  • To establish an accurate diagnosis, the specialist foot surgeon  should   carry out the following:
  • A complete physical examination with particular attention to the lower limbs. The surgical specialist should assess the type of foot, joints, flexibility or rigidity degree, state of skin, nails, pressure areas and associated toe deformities.
  • Patient´s history:  The specialist foot surgeon must perform a complete anamnesis with the symptoms the patient presents. Likewise, gather any family history of hallux valgus, diseases such as rheumatoid arthritis, psoriasis, gout, etc. Risk factors such as hypertension, diabetes, arrhythmias etc.  and previous trauma of the foot. It is also important to know of any previous surgery the patient may have had, profession, age, allergies and factors that may have initiated the development of bunions such as the use of inappropriate footwear.
  • Radiology tests: The specialist foot surgeon should assess foot x-rays in different projections (anteroposterior, lateral and oblique) and load whenever possible. The radiology study provides information as to the degree of deformity (different angles of the foot, as well as the size and composition of bone, are measured), foot type (cavus, flat or valgus) and toe deformities such as claw or hammer.
  • Biomechanical Study of the tread with plantar pressures analysis: These studies require a computerised platform that analyses and measures each cm2 of the foot during a  stride. This allows the study of the distribution of loads when walking, foot type and body balance centre.  These measurements are essential and should take into account for evaluation.
  • Blood tests: before any intervention, it is necessary to know if the patient has any actual inflammatory / infectious process, the condition of the liver, kidney and blood clotting of the patient. All these parameters must be taken before any surgical procedure consideration. Patients being treated with anticoagulant medication such as SINTROM or other new generation anticoagulants must inform the specialist foot surgeon so that the type of treatment can be changed for  3-6.
  • Vascular Dopper of the lower limbs:  A study with vascular doppler to measure blood flow in the major arteries and veins in the legs and in the feet in particular. This study is more important in older people or anyone with signs or symptoms of vascular insufficiency.


In older patients or patients with associated conditions, the minimally invasive surgery can be performed to correct the deformity.

In early stages, you can apply the recommendations indicated above. When these measures fail or are insufficient, then, surgery is the only solution.

There are over 200 techniques to operate bunions, but unfortunately, there is not a single method that works for every deformity. For this reason, it is essential to perform a thorough preliminary study to assess the best surgical option.

In general, the procedures used to operate the hallux valgus are the following:

  • Correct the deviation of the hallux (toe) removing the deformity.
  • Realign the long bone (metatarsal) in between the big toe and the back part of the foot and thus correcting the angle of the first toe.
  • Elongation and transposition of tendons.

Although there are many ways to intervene bunions, minimally invasive or percutaneous foot surgery has overall more benefits and lower risks.

Consult your physician if minimally invasive or percutaneous foot surgery may be an option for you. The benefits of this technique are:

  • Low postoperative pain.
  • Minimum limitation because the patient walks out of the surgery unaided
  • Early Recovery, 1-5 weeks depending on the procedure performed.
  • Outpatient surgery, no hospitalisation is required.
  • Local anaesthesia, therefore avoiding the potential complications of spinal or general anaesthesia.
  • Excellent long-term results if performed by experienced professionals.

To prevent new deformity, the patient should wear suitable shoes the rest of their life.

Always remember to inquire to your foot specialist, what will be the outcome of the foot after the surgery? What is the surgeon going to do? And what are the complications of the procedure?

Recommendations to alleviate the pain of bunions:

Bunions in early stages are usually painless, however, as the deformity increases, the pain worsens. For this reason, medical and podiatry team San Roman Clinic has the following recommendations:

  1. Footwear: when bunions cause pain or deformity is large, should avoid narrow tip shoes and high heels. Shoes should be comfortable, wide on the part of the finger, and very importantly,must have a proper grip on the back foot.is advisable avoid both completely flat footwear as high heels.
  2. Interdigital silicone: your foot specialist or podiatrist can make you an interdigital separator to place between first and second finger. This Reduces the pressure the big toe on the other fingers.
  3. Local Cold: can be applied by local cold nights as a “gel pack” or even a bag of frozen peas dorsum of the foot. This Reduce inflammation and pain.not forget place a something between the skin and the cold and avoid possible burns.
  4. Medication: If no known drug allergies are present, you may take a nonsteroidal anti-inflammatory (NSAIDs) medication such as Ibuprofen orally. Remember to consult  your doctor and foot specialist before taking any drugs.
  5. Postural measures: it is advisable to avoid postures that acerbate pain, such as standing for long periods of time.
  6. Physiotherapy: physiotherapy in these cases is limited to reduce oedema (inflammation) and mobility exercises of the toes. This has the aim of reducing the stiffness that often presents the big toe.

Can both feet be operated at once?

Is minimally invasive surgery performed with laser?

Can all bunions  and claw toes be operated with minimal invasive surgery?

Do bunions have salt deposits?

No, the deformity is an abnormal bone growth, there are not salt deposits. In patients with gout, the deformity may contain urate salts. We can also read many home remedies for removal without surgery. While all these natural treatments can improve symptoms for some patients, we must emphasise that there is no scientific evidence that they work and to correct the deformity, surgery is the only option.

Are bunions bad / dangerous?

The deformity is not dangerous

Are bunions contagious?

They are not contagious because there are not caused by any microorganisms. However, bunions have a  hereditary genetic component. For this reason, when you have a member of your family that suffers from this deformity, it is likely that you will develop them in the future. It is therefore critical to take good care of the foot, using comfortable shoes, which support the foot,  wear shoes with thick soles and where toes are not piled up. For more information, go to section on recommendations in the San Román Clinic.

Are all bunions operable?

In general all bunions are operable but not all patients can be operated with the same technique. Older patients or patients with associated diseases are usually not good candidates for open or aggressive techniques. For these patients, less invasive techniques such as percutaneous or minimally invasive surgery can be a good choice since they eliminate the deformity with fewer complications.

There are more than 200 surgical techniques for  the correction of hallux valgus. These  techniques can be mainly grouped into acting on soft tissue techniques that require osteotomies (bone fractures nails, needles or plates), percutaneous or minimally invasive techniques and finally, techniques that combine elements of each. For more information read the section on treatments

Are bunions caused by osteoarthritis ?

The deformity is often associated with osteoarthritis. Hallux rigidus is the limitation of the joint of the toe caused by severe osteoarthritis just fusing  the joint.

Bunion with 13 years, 16 years, 17 years, 19 years, 20 years or 22 years? It is possible atearly age, whatdo in that case?

If possible. You should consult a foot specialist for evaluation and conservative treatment initially.

Can bunions be cured with homeopathy?

No scientific studies that support this currently exist.

Can bunions have pus?

If, when you have a wound or infected callus in the deformity. should see your doctor to treat the infection and then to foot specialist

Do bunion surgery ever come back?

If the operation is performed with the appropriate technique for deformity, the likelihood of a return to be less developed. After surgery are advised follow a series of recommendations to be played again no deformity.

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  2. ISIDRO, A. and MALGOSA, A., 2017. Oldest Mummified Case of Hallux Valgus from Ancient Egypt. Journal of the American Podiatric Medical Association, 107(3), pp. 261-263.
  3. NGUYEN, U.-.DT, HILLSTROM, HJ, LI, W., DUFOUR, AB, KIEL, DP, PROCTER-GRAY, E., GAGNON, MM and HANNAN, MT, 2010. Factors associated with hallux valgus in a population-based study of older women and men: the MOBILIZE Boston Study. Osteoarthritis and Cartilage, 18(1), pp. 41.
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