Introduction

Our feet often change as we get older. Sometimes the big toe starts leaning in towards the other toes and then the joint at the base of the big toe sticks out more, forming a visible bump.

Known as a bunion (medical term: hallux valgus), this is more likely to happen in women. It is one of the most common foot deformities. Many people have a bunion with only mild symptoms, or no symptoms at all. But bunions can also lead to pain and sore areas.

Wearing suitable shoes can relieve the symptoms. Surgery is the only treatment that can get rid of bunions, though.

At a glance

• A bunion is a type of foot deformity: The big toe leans in towards the other toes, and a bump appears on the joint at the base of the big toe.
• This can lead to problems.
• The possible causes include weak tendons and ligaments in your foot, together with shoes that are too tight.
• Wearing comfortable shoes and strengthening the muscles in your feet can help to prevent and relieve symptoms.
• Surgery is an option for painful bunions.

Symptoms

In people who have a bunion, the foot bone leading up to the big toe (the first metatarsal bone) gradually moves sideways towards the other foot. As a result, the front of the foot becomes wider and the joint at the base of the big toe bulges out. The big toe leans in towards the other toes, sometimes deforming them too. Bunions can be painful, but not all of them are – even if they are very big.

The pain is usually felt in the toes, on the bulging big toe joint or under the ball of the foot. The big toe joint mainly hurts when you wear shoes that are too tight. If the bulge is very big, it might even hurt when wearing loose-fitting shoes. Bunions can sometimes damage nerves in the big toe, leading to numbness. The skin on the sole of the foot often becomes thick and hard. The big toe joint may be red and swollen, and sometimes inflamed too. It also becomes harder to move the big toe. Hammer toes or claw toes might develop as well. If that happens, the other toes are bent in the middle or push against each other. Corns often form on the affected toes.

Bunions can increase the likelihood of osteoarthritis in the joint at the base of the big toe, leading to chronic pain. They can also make you unsteady on your feet, increasing the risk of falls.

Causes and risk factors

Several factors can lead to a bunion.

Contrary to popular belief, tight shoes aren’t the main cause: They can increase the risk of bunions and make the problem worse – especially shoes with high heels and pointed toes. But some people regularly wear tight shoes and never get bunions. And others nearly always wear comfortable shoes that are wide enough, but develop a bunion anyway.

Some people are more likely to have bunions because of their genes, perhaps because their tendons and ligaments are weaker. Joint diseases like rheumatoid arthritis can increase the risk too. Other risk factors include a short Achilles' tendon and short calf muscles. But bunions can also develop as a result of having a splayfoot or flatfoot.

Prevalence and outlook

Although it's not possible to say for sure how many people have a bunion, it's estimated that about 1 in 5 have one to some degree. Bunions are far more common in women than in men – probably because women often have weaker tendons and ligaments in their feet and are more likely to wear tight shoes with high heels. Bunions are also more common over the age of 40.

In many people, bunions never cause any real problems. In others, the foot continues to change, the pain gets worse and they have trouble walking.

Diagnosis

To determine whether foot problems are being caused by a bunion, the doctor will check whether the joint at the base of the big toe is sticking out, look at the position of the toes in relation to each other, and see how well they can move. He or she will look at the position of your legs, too. The examination is done while you're standing, walking and sitting. The doctor will also look at the skin on your foot, check for signs of osteoarthritis, and ask about your symptoms and any limitations in daily life. To get a clearer diagnosis, the foot is x-rayed in a standing position.

Bunions can vary a lot in severity. The severity is determined based on the angle between the big toe and the foot bone leading up to it (the first metatarsal bone).

The difference between a “normal” big toe joint and a bunion isn’t always clear. Many people have a mild bunion that never causes any problems.

Prevention

To prevent bunions, experts recommend wearing comfortable, flat shoes. If there’s enough room for the front of the foot, there’s less pressure on the toes and the ball of the foot. Other advice includes walking barefoot a lot in order to strengthen the foot muscles and allow the feet and toes to be in their natural position. Some doctors recommend using orthopedic shoe inserts (insoles).

But there’s not a lot of research on how well these things can prevent bunions.

Treatment

Bunions only need to be treated if they're causing problems. The most suitable treatment will depend on a number of factors, including the symptoms, the type of deformity, and whether the person has other medical conditions such as rheumatoid arthritis, diabetes or vascular (blood vessel) disease.

There are various conservative (non-surgical) treatments that aim to relieve the symptoms of bunions:

• Splints: These toe-spacers or toe-supports are used to keep the big toe in a normal position. The aim is to relieve the symptoms and slow down the progression of the bunion – although it’s not clear whether they really do this. They can’t correct the misalignment. Splints are typically worn at night.
• Well-fitting shoes: People are advised to wear flat shoes with enough room for all the toes. If the toes or big toe joint hurt, a bunion pad can be used. If the middle part of the foot hurts, the toes can be supported with the help of shoe inserts or special shoes. Experts also recommend walking barefoot a lot.
• Physical therapy: Special exercises can be done to try to strengthen and stretch the foot muscles.
• Painkillers: These may include non-steroidal anti-inflammatory drugs (NSAIDs) like diclofenac or ibuprofen, in the form of tablets or a gel. Due to the potential side effects, tablets should only be used over a short period of time.

Only a few studies have looked into the effects of these measures. The results of these studies suggest that things like physical therapy, wearing well-fitting shoes and using splints do not relieve the symptoms effectively.

If the symptoms are severe and no other treatment helps, surgery can provide relief. Surgery is the only way to treat the cause of the symptoms, by correcting the misalignment. But there’s no guarantee that surgery will make the symptoms go away completely, and it can lead to complications.

Further information

When people are ill or need medical advice, they usually go to see their family doctor first. Information about health care in Germany can help you to navigate the German healthcare system and find a suitable doctor. You can use this list of questions to prepare for your appointment.

Sources

• Cai Y, Song Y, He M et al. Global prevalence and incidence of hallux valgus: a systematic review and meta-analysis. J Foot Ankle Res 2023; 16(1): 63. [PMC free article: PMC10510234] [PubMed: 37726760]
• Hollander K, Heidt C, Van der Zwaard BC et al. Long-Term Effects of Habitual Barefoot Running and Walking: A Systematic Review. Med Sci Sport Exer 2017; 49(4): 752-762. [PubMed: 27801744]
• Hurn SE, Matthews BG, Munteanu SE, Menz HB. Effectiveness of non-surgical interventions for hallux valgus: a systematic review and meta-analysis. Arthritis Care Res (Hoboken) 2022; 74(10): 1676-1688. [PubMed: 33768721]
• Klugarova J, Hood V, Bath-Hextall F et al. Effectiveness of surgery for adults with hallux valgus deformity: a systematic review. JBI Database System Rev Implement Rep 2017; 15(6): 1671-1710. [PubMed: 28628523]
• Wülker N, Mittag F. The treatment of hallux valgus. Dtsch Arztebl Int 2012; 109(49): 857-867; quiz 868. [PMC free article: PMC3528062] [PubMed: 23267411]
• Zirngibl B, Grifka J, Baier C, Götz J. Hallux valgus: Ätiologie, diagnostische und therapeutische Prinzipien [Hallux valgus: Etiology, diagnosis, and therapeutic principles]. Orthopade 2017; 46(3): 283-296. [PubMed: 28251259]

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