How to Beat Bunions

As the holiday party season gets into full swing, many of us will be squeezing our poor feet into great-looking but uncomfortable strappy heels. Which brings up the rather unpleasant subject of those unsightly bumps at the joint of the big toe known as bunions. Often, they're just a cosmetic problem--especially when you want to show off your feet in sexy shoes. But sometimes bunions can cause so much pain that you have trouble walking. Either way, they're about as desirable as a lump of coal in your Christmas stocking.

According to some studies, up to half of adults over 50 have bunions. It's easy to see why. With each step, your foot takes the equivalent of 1.5 times your body weight. Throw off the balance just a little bit and you've got problems.That's why you see scores of bunion remedies advertised on the Web or in the back of women's magazines. (Yes, it's largely women who suffer from bunions, although researchers aren't sure why.) Some doctors also tout surgical procedures that claim to stop bunions without any side effects. If you're considering any of these products or treatments, this column's for you.

We were inspired to write about bunions after listening to Dr. Judith Baumhauer, chief of the Strong Foot and Ankle Institute at the University of Rochester School of Medicine and Dentistry, speak at a presentation sponsored by the American Academy of Orthopedic Surgeons (AAOS). Her passionate plea: "Don't be bamboozled into surgery or expensive treatment. It won't prevent problems and it may create new ones." In her clinic, Baumhauer sees what happens when bunion surgery goes wrong; she estimates that the vast majority of her patients come in for what she describes as "revision" procedures that attempt to correct earlier surgeries. "I am a little biased in that I do get a lot of complications," Baumhauer says. "But I think the operation is sold too hard."

She's equally vehement about the value of expensive orthotics--custom shoe inserts that are supposed to alleviate pain and even stop the progression of bunions. These products can cost hundreds of dollars, but Baumhauer says research shows that they aren't any more effective at ending soreness than much cheaper pads or inserts (usually $25 or less) that you can buy in the drugstore. And, Baumhauer says, there's no guarantee that inserts of any kind will stop bunions from getting worse.

Treating bunions has become big business with more and more patients seeking treatment each year. You might be tempted to blame the post-"Sex and the City" popularity of pointy stilettos for the problem, but doctors say that while ill-fitting shoes can aggravate bunions, they generally don't cause the problem. In fact, when anthropologist Margaret Mead studied a shoeless South Sea tribe, she found lots of bunions. These islanders probably developed bunions from the same unstable mechanics that give so many of us a bump: basically, the structure of your foot puts too much pressure on the joint at the front, which makes your big toe turn inward. The Latin name for this is hallux valgus (hallux for big toe, valgus for bent outward). With more than two dozen bones and joints, the foot is kind of like a Rubik's Cube, Baumhauer says. "If you screw up one little part of the cube, the whole thing is screwed up."

Bunions tend to run in families; you're especially vulnerable if you have flat feet. Although bunions can develop at almost any stage of life, women often first notice them when they're pregnant--perhaps because of the effect of hormonal changes on foot ligaments or because of the shift in the body's center of gravity.

Once you start developing a bunion, there's no way to predict whether it will progress to the point of causing pain, or even if it will progress at all. So if a doctor tells you that you need surgery immediately, be wary, Baumhauer says. "Nothing needs to be done stat," she says. "This isn't like appendicitis." Another red flag: doctors who want to operate on bunions that aren't causing pain. "It's all around pain, not around looks," Baumhauer says. And, she adds, it shouldn't be occasional pain, like once a month or even once a week. Surgery is justified only if you have pain most of the time. "If you can put on reasonable shoes and run and jump and play," she says, "don't have surgery."
One study, a 2004 review of bunion treatments by the nonprofit Cochrane Collaboration, found that as many as 33 percent of patients were dissatisfied after surgery. Baumhauer suspects that many of these patients might be unhappy not because of botched surgery, but because they weren't appropriate candidates for surgery in the first place. Their risks of scarring or nerve damage, for example, may have outweighed the benefits of a merely cosmetic improvement. "These complications are very hard to swallow if you didn't need the surgery to begin with," she says. With patients whose pain is debilitating, the satisfaction rate could be much higher, Baumhauer says. "Good surgeons will actually have pretty good results because they will have screened out all the people who don't need surgery," she says.

If your bunions are causing pain, Baumhauer advises seeing a fellowship-trained foot and ankle surgeon. A good surgeon should suggest first trying over-the-counter inserts along with shoes that are wide enough to accommodate the bunion. Anti-inflammatory medication can also help. If the pain persists, surgery would then be a reasonable next step. But Baumhauer says patients should always get a second opinion.

And to the many women suffering from bunions who are tempted to squeeze their feets into strappy shoes this season: good news. Ballet flats with rounded toes are in fashion. Substitute them for your stillettos during the holidays and you can keep your toes covered, and comfortable, and still look stylish.

To learn more about bunions and how to treat them, check out the web sites for The American Academy of Orthopaedic Surgeons and the American Orthopaedic Foot & Ankle Society.