Are conventional explanations about “bunions” valid?

Hello Dr Driver-Jowitt. 

Thank you for suggesting I read your brochure about finding out more about foot problems on the internet. The first hit I found on Google just gave a quick overview of the different types of bunion surgery. The first they listed was for correcting the ligaments: Repair of the Tendons and Ligaments Around the Big Toe These tissues may be too tight on one side and too loose on the other, creating an imbalance that causes the big toe to drift toward the others. Often combined with an osteotomy, this procedure shortens the loose tissues and lengthens the tight ones.

(Name withheld by request)

Thank you for the enquiry. I am familiar with this paper, issued by the American Academy of Orthopaedic Surgery and co-developed by the American Orthopaedic Foot and Ankle Society. The Academy is a prestigious organization and it is disappointing that unsupported and irrational information is projected in this document. I am not aware that there is any evidence supporting the above suppositions. The comment about “tissues being too tight and too loose” is more an effect than a cause. Much of the paper discusses tight footwear as the causative factor, and the site says:” By far the most common cause of bunions is the prolonged wearing of poorly fitting shoes”.

As demonstrated in your case, the primary deformity is not the inward veer of the toe but the protrusion of the metatarsal away from the little toe. It is not possible for a tight shoe to cause the metatarsal to protrude outwards against the shoe.

The reality is that the deformity is zigzag, with the toe veering inward (towards the little toe) and the metatarsal veering outward (away from the little toe) and towards the shoe wall.

It is also improbable that your shoes were “too tight” when your deformity developed as a school-girl. Any shoe tight enough to produce a deformity, like any deforming force anywhere in the body, would be intolerably painful long before a permanent deformity could develop.

Many “Explanations” are not more than wild unsupported conjecture, without any validity or possibility of substantiation. Consider this suggestion by a surgeon discussing his “pain free” surgery in the online edition of a national newspaper.”Female hormones also soften this tissue, which is why women are prone to bunions”.

If this is the case why is a “bunion” often only on one side? Why do men and pre-adolescent girls get “bunions”? They don’t have “softening hormones”. This idea is simply fantasy.

More valid than the above “explanations” is the following statement by Drs Coughlin and Jones:” The…etiology of hallux valgus deformities…is a topic of great interest for all of us, but…is no closer to being defined now than in Morton’s era.” [Thomas George Morton 1835 -1903]

I notice that one of the corrections suggested is aimed at dividing the bone of the metatarsal (an “osteotomy“). If the deforming forces were caused by pressure from the shoe acting on the toe, what is the rationale for a surgically attack the metatarsal?

The “exostectomy” described is nonsensical to me. There is no “exostosis” (i.e. no abnormal outgrowth of bone). The prominence is the normal bone, which is made prominent by the angular deformity, as I demonstrated to you. To remove the structures as in the diagram is quite wrong: The very ligaments which prevent the angular veer, and prevent the deformity from increasing, are having their attachments to the shaft of the bones  removed, and are therefore rendered ineffective.

I am sceptical about the claim that: “Many studies have found that 85 to 90 percent of patients who undergo bunion surgery are satisfied with the results.” Notice also the contrary comment “In fact, you will have some shoe restrictions for the rest of your life.”

A more realistic and objective assessment of the outcome of “conventional” surgery for deformities of the forefoot is the following meta-analysis in the Cochrane Database Intervention for treating hallux valgus (abductovalgus) and bunions. Ferrarid, HigginsJP, Williams RL. This paper is not optimistic about the outcomes of conventional surgery as it is at present

I would like to discuss your management further when you x-rays are available.