A bunion, also called hallux valgus, is a common and often painful foot condition characterized by a noticeable bump at the base of the big toe. The big toe points toward the other toes and may overlap with the second toe, causing crowding or irritation. Bunions can cause swelling and redness over the joint and may make it painful to walk or wear shoes, in particular narrow or tight-fitting shoes. A bunion may occur on one or both feet at the same time.

Approximately 23% of adults between the ages of 18 and 65, and about 36% of those over 65, are affected by this condition. Bunions are more common in women than in men. The condition is associated with wearing high heels and narrow-toed shoes. Bunions can occur in children, though this is relatively uncommon.

While bunions can be painful and, in some cases, debilitating, effective treatments are available, including over-the-counter bunion pads and toe separators, wearing wide-toed shoes, and surgery.

A bunion is a deformity in which the first metatarsal bone (one of the long foot bones leading to the big toe) shifts toward the inside of the foot while the big toe itself angles toward the second toe (the toe next to the big toe), creating a visible and sometimes painful bump at the base of the big toe. The medical term for the condition is hallux valgus where “hallux” refers to the big toe, and “valgus” indicates that the big toe is angled outward, away from the body’s midline.

This shift happens at the first metatarsophalangeal (MTP) joint, where the first metatarsal bone and the first bone of the toe come together. The end of the first metatarsal protrudes at the base of the big toe creating a bony bump there. This bump can press and rub against shoes, causing the bump to become inflamed and tender. The misaligned bones can alter joint mechanics, and the big toe may press against or overlap the second toe, which can result in irritation and cause hammer toe (an abnormal bending in the middle joint of a toe, causing it to resemble a hammer) in the second toe or other toes. Other conditions are associated with a bunion, such as Morton’s neuroma, a painful nerve condition near the toes, as well as pain in the ball of the foot, known as metatarsalgia.

Once a bunion develops, it can worsen over time. As the condition progresses, people typically experience more frequent, intense, and longer-lasting pain. The misalignment of bones can also progress over time, increasing the angle between the foot and toe, causing the bony bump to become more noticeable.

The exact cause of bunions is still not completely understood. Research has identified multiple possible contributing factors, including abnormal foot mechanics and/or anatomy, genetic predispositions (an increased risk of developing bunions due to gene variations), and inflammatory conditions such as rheumatoid arthritis.

Shoes with a narrow toe box, including tight-fitting shoes and high heels, that constrict the toes and forefoot are associated with bunions. However, they are probably not a principal cause of the condition but rather make preexisting abnormal foot mechanics or anatomy worse.

In some cases, bunions develop as a result of an injury to the bones of the forefoot.

Risk factors for bunions include:

• Being female
• Family history of bunions
• Age (more commonly develops in older individuals)
• Wearing high-heeled or narrow-toed shoes
• Certain foot and ankle deformities
• Conditions associated with loose ligaments (generalized ligamentous laxity), such as:
  • Rheumatoid arthritis
  • Marfan syndrome (a genetic disorder that affects connective tissue)
  • Ehlers-Danlos syndrome (a group of conditions that affect connective tissue)

People with bunions typically have a noticeable, bony bump on the side of the foot at the base of the big toe. The big toe may lean or point toward the smaller toes.

Symptoms of bunions may include:

• Pain in the joint at the base of the big toe and/or in the smaller toes
  • May be an aching pain, though pain may be sharp while walking
  • Pain may worsen when wearing high heels or narrow-toed footwear
• Calluses on the outside edge of the big toe, the inside of the second toe where it overlaps and rubs against the big toe, and/or the ball of the foot
• Redness and swelling at the joint at the base of the big toe
• Burning or tingling pain, or numbness in the big toe (due to compression of a nerve in the toe)

Sometimes, people do not have any symptoms, while in other cases, symptoms can be severe.

To diagnose bunions, your doctor will ask you about your medical history and perform a physical exam. In most cases, this provides enough information for a diagnosis. In most cases, however, imaging tests are helpful to determine the severity of the bunion, which can affect prognosis and treatment.

Your doctor will ask you about your symptoms such as whether you are experiencing pain and whether pain occurs when wearing certain shoes or during certain activities. The doctor may also ask if you have a family history of bunions. During the physical exam, your doctor will examine your toes and feet while you are standing and seated, evaluate the range of motion in the big toes, and assess the location of any pain you are feeling. The doctor may also ask you to walk to assess your gait to check for a limp or other signs that may be indicative of a bunion.

Your doctor may also order a foot X-ray to evaluate the alignment of the bones of the big toe and to assess joint damage. X-ray images can also help doctors plan surgery.

Conservative Treatments

People who have just developed bunions or have bunions that do not cause pain are typically treated with conservative measures. These treatments can help reduce and relieve symptoms. They include:

• Choice of footwear. Wear shoes with a wide toe box. Avoid wearing high-heeled and tight shoes.
• Bunion pads and toe spacers. Bunion pads can cushion and protect the affected area of the big toe. Toe spacers are devices that fit between toes—typically the big toe and the neighboring toe—to keep them separated from one another. Bunion pads and toe spacers can be purchased over the counter at drugstores. These devices do not “correct” the bunion but rather reduce the symptoms of pain and skin irritation.
• Orthoses (devices worn on the foot or in a shoe). Splints, braces and arch support devices may provide support and improve alignment of the big toe temporarily.
• Medications. Over-the-counter pain medications such as nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen can help alleviate pain. Prescription pain medications and/or corticosteroid injections may also be used to help reduce pain and inflammation.
• Physical therapy. Stretching, strengthening, and mobilization exercises may reduce pain caused by bunions.
• Ice. Applying ice may help reduce inflammation.

Surgical Treatment

If symptoms do not adequately improve with conservative treatment, surgery may be an option. Several different surgical procedures are used to treat bunions, and they may involve cutting and realigning bones, shortening or lengthening tendons or ligaments, removing the bony bump at the base of the toe, and fusing the bones that form a joint in the toe or foot, immobilizing it while straightening. It may take several months to fully recover from bunion surgery.

Your surgeon will determine the best procedure for you based on a number of factors including the degree of bone deformity, whether you have arthritis in the toe, your age, and activity level.

People with bunions may be at increased risk for related conditions, including:

• First MTP joint bursitis (inflammation of a bursa, a fluid-filled sac that helps cushion a joint)
• Deformities in the toes next to the big toe, including hammer toe
• Osteoarthritis (arthritis caused by the breakdown of cartilage in a joint) in the joint at the base of the big toe
• Pain on the ball of the foot (metatarsalgia)
• Chronic pain
• Morton’s neuroma

In general, the outlook for people with bunions is good, though it may vary depending on the degree of the deformity.

Without treatment, the condition can progress, often leading to more frequent and severe symptoms (though some people may not develop symptoms, even as the condition progresses).

Conservative treatments such as a change in footwear or the use of bunion pads or toe spacers may relieve symptoms. However, conservative treatment does not correct the underlying bone deformity and may not prevent the condition from progressing. When nonsurgical treatment options do not sufficiently improve symptoms, surgical treatment may be necessary. It can correct the deformity, reduce symptoms, and improve function of the affected foot. The majority of people who undergo surgery are satisfied with the outcome. In some cases, however, bunions recur after surgical treatment.

“At Yale, we have a team of specialists who work together to provide the best treatments for all different kinds of bunions," says Sean Peden, MD, a Yale Medicine orthopaedic surgeon who specializes in foot and ankle conditions. "We offer the most cutting-edge, minimally invasive surgeries for bunions, which allows patients to recover faster with less pain, scarring, and risk for infection. At the same time, we are the best place to handle the more complicated bunions, especially revisions (surgeries done to correct problems or complications from a previous surgical procedure), as we are a center for referrals of complications after surgery done elsewhere," says Dr. Peden.