Good morning, and thank you for joining us. My name is Joan Williams.
I'm one of the foot and ankle surgeons in the Department of Orthopedic Surgery here at UCLA,
and I'm going to talk to you today a little bit about bunions and toe deformities.
If you have any questions during the
presentation, please feel free to
ask them using the hashtag #UCLAMDChat via Facebook or Twitter, and we'll try to get to those at the end of the session.
Okay, so we're going to talk briefly about what bunions and toe deformities are,
how to treat them if you have them, and if there's anything you can do to try to prevent them.
So, we will start with bunions.
The biggest question is, kind of, what is a bunion?
What it is in the orthopedic literature
is that the first metatarsal, or the bone on the inside of your foot starts moving more inward, and
as it does that, over time, the tissues and the capsule on that inside
start stretching out, and the big toe moves towards the outside, and
so what you see, as a patient, is usually a big bump on the inside of your big toe
or your foot that starts bothering you when you wear shoes or try to do activities.
So, this is kind of a little bit more complex diagram, but really, when I look at it, what's happening
is this bone here is moving that way, and
as this stretches out here, your big toe starts to move this way, and all the
soft tissues and structures on the inside of your foot start to tighten, and that's why it starts
becoming more and more rigidly moved over towards the outside of your foot, pressing on that second toe.
And that in and of itself can start causing problems with your second toe.
So, who gets these?
It's typically adults, although there are some people who get them
earlier as a child, and that's a little bit of a different beast, so we won't talk about that here today.
But you may start to notice a little bit of a deformity in your early 20s,
especially if you have anyone else in your family who had
bunions or other toe issues. It typically occurs in women more than men.
They're not really sure why. Sometimes, I think that's just because women often wear shoes that are not as
nice to our toes and feet as shoes that men can wear, and so that can sometimes
cause women to have symptoms earlier than men do.
And often its bilateral,
so that doesn't necessarily mean that if you have it on one foot that you're absolutely going to get on the other foot, or
that if it's really bad on one foot the other foot is going to be just as that,
but I would say most people
will notice at least some
deformity on both feet.
So, the biggest question is, why do they happen? And sadly, genetics is probably one of the biggest causes, so
unfortunately--
it tends to run in the females in your family, so--if your mom, or grandma, aunt,
someone else in your family had some pretty gnarly looking feet, there's a good chance you will too.
It has been shown in other studies that it occurs almost exclusively in populations that wear shoes,
so there is a thought that the types of shoes that we wear can contribute to this as well,
and as you can see in the diagram, when you have shoes that are really tight on those bones there,
it's kind of pushing everything together, so that in and of itself can start to stretch out those structures on the inside of your foot
like it does when that bone starts to shift. And shoes that are a little bit,
maybe less fun, or fashionable, but fit your foot a little bit better are a little bit kinder to those toes.
Also, people who are really flexible, or have what we call ligamentous laxity,
they tend to be people who those
capsule and soft tissue structures stretch a little bit more, so they're a little bit more prone to developing bunions and toe deformities.
If you have really tight calf muscles,
sometimes that can contribute to the deformity, and
people who have had strokes or
other sort of neuromuscular diseases where there's a little bit of muscle imbalance, that can also play role in this, and
there's a little bit of controversy over whether or not having flat feet contributes to this.
I don't want you to worry. If you do have flat feet, you are not destined to get bunions, but sometimes they go together.
So, the symptoms people get is you usually start having pain when you're wearing shoes, pretty much,
you know, most people I see, you say, "Well, it's fine
if I'm wearing sandals or flip-flops. When I try to put on tennis shoes or shoes for work,
then I start having pain," and usually the pain is on the inside, kind of over that bump.
Sometimes what happens is as that toe--as the bone moves out of the right
plane, you start putting more stress on the other bones in your foot,
so you can get calluses and pain under like your second and third toes
because they're buried more weight than they should be.
So the biggest question is how do you treat them?
There are
tons and tons of different bunion pads and bunion splints and over-the-counter type
devices that people will sell. I've seen hundreds of different types.
There's not one that's necessarily better than the other,
but there are a lot of devices that you can use, and basically what they're trying to do is hold the big toe over
so that it not pressing on the second toe,
give a little padding over that kind of bump on the inside so that it's not rubbing on shoes,
or kind of just cushion around that part of the foot.
All of those are fine.
I think the biggest struggle that people have with them is sometimes,
they don't fit in shoes,
and so then it becomes a little bit more challenging to find a
bunion splint or pad that you can wear and a shoe that it fits into and still go about your normal life.
The other easy thing to do is get shoes that have wider toe boxes.
If you have some really nice leather shoes that you really don't want to get rid of, sometimes you can take them to a cobbler
and get the leather stretched to make a little bit more room,
but if you can find shoes that fit your foot a little bit
more kindly and have a little bit of a softer sole, a lot of times that can take care of some of the pain, and
then if all of that fails, and you can't get on with your life because of the pain in your foot,
there is surgery, and I will tell you, if you talk to any foot and ankle surgeon, you're probably going to get
50 different types of surgeries that you could have for bunions.
So, we'll kind of go over those in a little bit here.
The types of surgeries vary. It depends. Not all bunions are the same. So, some people have a really big deformity, some people's
deformity is not as big, and
some people have arthritis that have the different joints that are involved, and so, depending on
where you fall in that spectrum kind of changes what the
physician you're seeing may recommend for surgery.
There are things that we call osteotomies, which means you cut the bone and kind of shift it over and realign it.
There's soft tissue procedures, where we're tightening capsules or releasing tendons and others, you know, the structures that got too tight.
There's fusions, and then probably most commonly you end up with a combination of those. I
think one of the worst things about bunion surgery is
that it does have a relatively high chance of--even if the surgery goes smoothly, these deformities can come back,
and there's about a 30% recurrence rate.
Just because it does come back doesn't mean it comes back to enough of a deformity that you need to have surgery again,
so I think only about a third of the 30%
actually need another surgery, but there is that chance, so.
Soft tissue procedures basically involve removing the bump, and I would say this is fairly rare unless
it's done in a child
or someone who has really low activity demands and just needs to be able to put their foot in the shoe.
These, like I was saying,
involve kind of tightening the structures on the inside that got stretched out and release the ones on the outside that got tight.
The soft tissue procedures alone have a fairly high rate of coming back, so, again, these are pretty uncommon.
Osteotomies are the one where you're cutting and shifting the bone, and
they have many different names, so some that you may have heard or had recommended to you would include like a Chevron,
or a scarf, or an Akin osteotomy, and what those are,
they all involve cutting the bone. They just involves cutting the bone at a different location.
So, depending on how bad your deformity is and how much correction is needed, that kind of depends on where
the surgeon would recommend cutting and shifting the bone.
Typically, after this type of surgery, you do have to be non-weight-bearing on that foot for a few weeks to let the bones heal.
Everyone's a little different, and it does vary a little bit based on what osteotomy you have, so
just be prepared that that may be something that gets recommended to you for your recovery period. And
fusions are
where, basically, we take out the cartilage that is in this joint, or this joint here, and
we put screws or plates and screws across that joint to fuse the bones together into one solid joint.
That's usually done if you have a really big deformity or if you have really bad arthritis at either of those joints,
and those almost definitely involve being off of your feet for
about six weeks after surgery in order to let the bones heal and unite.
And so this was just an x-ray, like I said, most often you'll have a combination of those, so this patient
had a fusion back at this joint. They also had an osteotomy here, where the bone was cut and shifted over, and
you can see the bump was removed, and so that capsule and everything on the inside was also tightened.
So they kind of have all three in that procedure.
All right, so moving on to the smaller toes. So, hammertoes, clawtoes, mallet toes. They're all kind of
similar, and they're all treated very similarly. The different names
are based off of which joint is flexed and which joint is extended, so
hammertoes are the most common, so I'll probably
refer to most of them as that, but clawtoes and mallet toes, just so you know, are treated very similarly.
These tend to happen more because if you have really tight calf muscles
and you're trying to pull your foot up, those
extensor tendons on the top of your foot can get a little bit tighter and start to be stronger than the
tendons on the bottom, which help pull the toes down.
Sometimes if you have neuropathy or other nerve issues that can happen,
again, people who have neuromuscular diseases or strokes where there's a muscle imbalance,
this is fairly common, meaning the extensors, again, are stronger than those
flexion tendons and tend to pull the toes up.
And then people with rheumatoid arthritis
are a little bit more prone to this
because that kind of chronic inflammation in the joints of these toes can stretch the capsule out over time and cause these deformities.
And then, again,
poor footwear is always a
culprit in these deformities.
So, the symptoms for this are very similar to the symptoms that people have with bunions. You can get
calluses and pain on the top of the toes where they're bent up, if they're rubbing on the shoes.
You can get pain at the tips of the toes because the tips of our toes aren't meant to be
sustaining that much pressure.
Sometimes the toenails can get involved and start being deformed.
You can have problems putting on shoes because your toes are pulled up so much, and you can get pain underneath
in kind of the ball of your foot because when the toes are pulled up,
the fat that's supposed to cushion the ball of our foot moves up with them,
and so then you're walking more on the bones rather than that nice cushion that we have.
So, treating these--very similar to treating bunions. Again,
there's millions and millions of different types of toes straps and toe tapes and toe spacers and
all of them work if you find one that works for you and fits in the shoes that you need to wear.
Again, you can get shoes that have a little bit of a wider or deeper toe box,
and then if all else fails, there is surgery.
So, the surgery you have for these kind of toe deformities depends on whether or not your
toes are fixed or flexible. So if you can passively stretch your toes to where they're straight again,
that's what we call flexible. In those, we can usually treat with things like tendon transfers and pinning and
more of kind of a soft tissue type of procedure. If
the toes are curled up and you can't get them straight,
that's what we call fixed deformity, and so usually, in order to get those straight,
we have to cut out a little piece of bone and usually put a screw or a pin in there,
and it kind of forms a fusion there,
and so afterwards you'll see a lot of people have this--where the pins are kind of sticking out the tips of the toes.
But the toes are nice and straight, little bit swollen.
So, in summary, these are very common things, and they can be very annoying, but
whether or not you have surgery just kind of depends on how badly it bothers you and how badly it interferes with
your daily life.
But if you try to wear shoes that fit your feet, well, you'll tend to have happier feet.
So, I think we have some questions.
Okay, um, first question is "Will wearing bunion splints fix my bunion?"
Sadly, no, there is not really any
splints or tape or pad that is going to move your toe back over to where it was initially.
The goal of the splints and the pads is to try to prevent the pain, and they can slow down the
deformity, you know--if you're keeping your toe kind of well aligned with those splints,
then you're less likely to have those soft tissues on the outside get tight sooner and the ones on the inside stretch out.
So it can kind of slow down that natural progression, and in that sense it may
fix it in the sense that you won't need surgery,
but there isn't anything that's going to put it back to normal
unless, I guess, you catch it really, really early and you're lucky.
And the second question we have is "Will waiting to have surgery make your feet worse?"
Not necessarily, you know--these deformities kind of vary based on why they're happening and your genetics, and
so a lot of times they tend to progress,
but they can progress really slowly, or they can be something that progresses rather quickly,
and there's not a great way to kind of predict where you're going to fall on that spectrum,
but the surgeries
don't change a whole lot whether you have them
right away or whether you wait a few years to see if it's actually going to bother you or become worse.
Usually what gets worse in that time period is just the pain that you have to deal with.
So, that's all we have for questions, but thank you very much for joining us, and
If there's anything we can, do just give us a call.