How to prevent bunions, treat them and when to resort to surgery

Bunions — those ugly and sometimes painful bumps on your foot — are a common affliction; 1 in 3 Americans has them. They can hurt year-round, but in the fall and winter, with colder weather and holiday gatherings, people typically switch to closed, restrictive shoes making bunions feel even more painful.

Bunions take time to develop and usually result from genetics, faulty foot mechanics and — for women in particular — unwise shoe choices.

“For most people, bunions are heredity plus lifestyle,” says Nicholas DiNubile, a Philadelphia-area orthopedic surgeon and spokesman for the American Academy of Orthopaedic Surgeons. “They are a self-inflicted wound.”

A bunion is an enlargement of bone or tissue around the joint at the base of the big toe. It makes the big toe bend toward — and often overlap — the other toes. When this happens, the toes of the foot are forced sideways. Instead of facing forward, the way they’re supposed to, they point at an angle to the right or left, depending on the foot. Also called a hallux valgus, a bunion can cause the adjacent toes to contract. The toe next to the big toe often becomes claw-like, forming a hammertoe.

While the majority of bunion sufferers are adults, some conditions — such as cerebral palsy and Down syndrome — increase a child’s risk for developing them. Also, young ballet dancers are vulnerable if they get up “en pointe,” that is, on the tips of their toes, before their bones are fully fused, or if they are constantly in a position where they are pointing their feet excessively outward, experts say.

Bunions make shopping for shoes frustrating, since many people with bunions need footwear that’s wide in the forefoot and narrow in the heel. But shoe-hunting is not the worst of it: Bunions can become chronically swollen and painful. When the pain becomes unbearable, surgery may be the only option.

Bunions come from having a flat foot — a low, flexible arch — which is heritable. “We look at our parents and grandparents for how we got our height, weight, eye and hair color, but not how we got our foot structure,” says Sheldon Laps, a podiatrist in Washington. “Also, we abuse our feet with bad shoes, especially women, with pointy toes, high heels and shoes with no support or stability.”

The calf muscles tighten when women squeeze their feet into high-heeled shoes with narrow, pointed toes, causing them to overpronate, that is, to overly roll their ankle inward. Athletes with flat feet do the same during workouts. This fosters bunion development. “Bunions result from the way the body accommodates the flexible flatfoot,” Laps says. “The leg muscles and tendons that attach along the inner side of the foot end up working overtime to support the flat arch.”

Also “the big toe area takes up about 50 percent of the pressure when walking or running,” DiNubile says. “It’s a high stress area, which is why you are exacerbating the stress when you get into a high heel.”

Some people with bunions have no problems. Others experience unrelenting misery.

Cary Craig, 65, a retired veterinary anesthesiologist in Esparto, Calif., has been plagued with bunions and other foot problems for more than 40 years. “They would flare up frequently getting swollen, red and painful, not just to run or walk, but even to touch,” says the longtime runner and triathlete. She struggled to find shoes. “I took scissors and razor blades to most of my shoes” cutting holes in them to make more room for the bunions, she said, adding: “Shoe choices are better these days.”

She had surgery on her right foot in 2010 to remove the bunion and to repair other foot problems. Recovery was long and painful. “It was a full year and lots of physical therapy before I felt like I had made the right decision,” she says. “The bunion on the operated foot is mostly gone now. However, the post-op experience was so awful, I have opted to live with the bunion and flaws in my other foot rather than go through the surgery a second time.”

But Eileen Rogers Orfalea, 65, a D.C.-area Realtor, has bunions on both feet that never bother her. “I come by them honestly from my mother and grandmother, but they don’t hurt,” she says. “Most of the time, I wear comfortable, flat shoes. It can be hard sometimes if I have to get dressed up, but I can always find a pair that’s the right shape and fit. I don’t ever wear narrow pointy shoes — and fortunately I don’t have to.”

To help prevent bunions — or to keep them from growing worse, here are some suggestions from experts:

Go shopping 30 minutes after a workout, or at the end of the day. That’s when your feet are the widest. “Most people get swelling as the day goes on,” DiNubile says. “They also are wider during the summer months. That’s a good time to make sure the shoe fits correctly.”

Also, shoe size changes — often increasing — as we age, because the arch drops, lengthening the foot, and ligaments loosen, widening the forefoot, according to experts.

“It’s something women do all the time,” DiNubile says. “If they don’t have your size, move to another shoe — or sneaker. Most sneakers all have wide sizes.”

Do you run or play other sports? Make sure your athletic shoes have a wide toe box, arch support and well-cushioned heel.

This will reduce friction against your shoe and help prevent pain. You can buy these pads in any drugstore.

These can help prevent the toes from starting to overlap.

Change your shoes midday, if you can, to another — preferably more comfortable — pair, which can vary the stresses on your foot muscles. If you must wear high heels, don’t keep them on longer than three hours at a time. If you have a desk at work, kick off your shoes underneath for a spell. Women often travel in sneakers and switch to their dress shoes in the office, which is a good idea, DiNubile says.

“Find a good, old-fashioned shoemaker,” DiNubile says. “Many of them still exist. They can stretch out the front and break the shoe in for you. Don’t try to break the shoe in yourself. You never win that battle because your foot takes a beating in the meantime.”

These are custom-made shoe inserts that correct for the body’s mechanical imbalances and help reduce overpronation. Many insurance plans cover them. Medicare does not, unless you need them for diabetes-related foot disease. They can be expensive. Laps charges patients who lack coverage $500 for a pair. You also can find over-the-counter orthotics that cost less. Laps recommends Superfeet, available in running stores and online.

Stretch your Achilles’ tendon to counter the stresses on your forefoot. Calf stretches are important for women who wear high-heeled shoes. Try some toe-strengthening exercises such as big-toe pulls: Sit with your feet flat on the floor, wrap a towel or belt around your big toe, and pull it toward you while pushing against it with your foot — hold for five seconds and repeat 10 times.

Surgery usually involves shaving the bump and breaking and realigning the big-toe bone closer to the second toe. The bone is then secured with a screw or an absorbable pin. It takes about 10 to 12 weeks for the bone to completely heal, Laps says. Younger patients, especially children, will heal in 6 to 8 weeks, while older people — especially those 65 to 70 — take longer, from 12 to 16 weeks. “I generally don’t allow my patients to return to sports until the X-ray demonstrates complete bony union, which is 10 to 14 weeks, again depending on the age of the patient,” he says.

Laps also discourages having both feet done together. “Some patients want it because they don’t want to have anesthesia twice, but I try not to do it,” he says. “You’re breaking a bone — why would you elect to have both feet broken at the same time?”

Also keep in mind that bunions can come back. At least one study suggests a recurrence rate of nearly 25 percent. “It’s one of the reasons you want a surgeon who does lots of these and has high success rates,” DiNubile says. And if you want to prevent a recurrence, it’s important to follow some of the steps above — especially wearing shoes that won’t promote bunions, experts say.

Consider surgery only when the pain becomes unbearable, experts say. “I don’t tell patients when they need it, they tell me,” Laps says. “It’s usually when they have pain — with or without the shoe on — or can’t walk or run without pain. They think about their feet all the time. People whose jobs require standing up all day can’t work. These are the patients willing to put up with months of recovery.”

DiNubile agrees. “Always operate on the shoe before you operate on the foot,” he says.

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