Bunions Dr. Scott Tafuri

Dr. Hendler: Hello and welcome to KP Health Cast. This is Peter Hendler and today’s guest is Dr. Scott Tafuri. Dr. Tafuri is a podiatrist and is board certified in Podiatric Surgery. He has been with Kaiser since 1992. Welcome Dr. Tafuri. Dr. Tafuri: Thank you Peter. Dr. Hendler: Today we’ll be discussing bunions. So the first question, what is a bunion? Dr. Tafuri: Peter, a bunion is actually the bump that some people have on their foot where the big toe meets the foot itself. This can be accompanied also by a movement of the big toe toward the second toe, and we call that hallux valgus. So when someone has a bunion, they have the bump and then they have the motion of the big toe moving toward the second toe. Dr. Hendler: Okay, and what causes bunions? Dr. Tafuri: Bunions are part hereditary and so if we take a peek at dad’s feet, mom’s feet, grandma, or someone else in the family, sometimes we’ll find that our feet look much like theirs, and if they have bunions, then it’s likely that we may develop them as well. So that’s the first component. It is really that we might be set up to have bunions form, and then over time they tend to get worse if we’re predisposed to them. Another cause of bunions, which is less likely but does happen, is secondary to an injury. Sometimes a severe injury will cause the large toe to move toward the second toe. That movement forces the bunion bone out to the side, and that’s why we see the bump that we commonly know as a bunion. Dr. Hendler: Okay, and are there other common causes of bunions? Dr. Tafuri: Sometimes accompanying arthritic conditions. We will see bunions form especially with rheumatoid arthritis where there is some lack of stability of the great toe joint, and we see that movement again of the large toe toward the second toe with the resultant bump on the side. Now, it’s commonly thought that shoes themselves are the main cause of bunions, and in my opinion they contribute to either accelerating the process, especially if they’re very pointy-toed shoes. If we look at a pair of high heels with very pointy toes and do a little exercise whereby you take your barefoot and trace it on a piece of paper and then set the shoe on top of the piece of paper, you’ll see that many times those shoes look like they should only be big enough to accommodate three of the toes, and you’ll see a lot of extra space, and so in order to get into that shoe the toes need to be crowded and the big toe needs to be forced toward the second toe. So there may be a component from the shoes, and we do see more symptoms related to the Page 1

shoes. So the question is whether they actually cause the bunion themselves or make us notice the bunion more because they start to hurt, and we start to look at our feet and say what’s going on. Dr. Hendler: That’s interesting because what I’ve always been told was that shoes shoes shoes, and although they’re important I didn’t realize that the hereditary aspect was also so important. So let’s move on and talk to how you treat bunions. Let’s talk about the non-surgical treatment. Dr. Tafuri: Well, first of all when we’re talking about treatment, of course treatment is necessary only if the bunions are painful, and there are really two types of pain that we want to look for. The first type of pain is what we call bump pain, and that’s mainly caused by the bump which we’ve called the bunion throughout this podcast, rubbing against the shoe where we see redness from irritation. Sometimes fluid will gather giving that area a spongy feel or a swollen look to it, and the bump pain is really pressure related, and we treat that nonsurgically by trying to remove the pressure. We can do that in several ways. We can do that by making sure that we have a wide enough shoe so that the shoe doesn’t rub on the bump or the bunion itself. We can also do that by wearing some sort of padding device. Commonly in the pharmacy we’ll see the foot aisle where there are many foot products and the doughnut-shaped pads or now they have the silicone rubber clear type of pads that can be placed over the bump area, and they form an interface between the bump which is essentially the bone and the very thin cushioning we have there which is just basically our skin and a little more tissue and then the hard shoe itself. So that’s generally how you would treat the bump part of it. For women wearing higher shoes or men wearing say western boots where they’re pointy, sometimes the shoe itself can be stretched. Some shoe repair stores have what we call a bunion stretcher, or sometimes it’s called a swan, that they can use to stretch a semicircle where the bunion is. It looks like the old time ice picks with the two handles except there’s a ball on one side and a ring on the other, sometimes termed a ball and ring stretcher so you may want to check with your shoe repair person to see if they can help you with that. So that’s essentially the treatment of the bump pain itself. The joint pain which is an aching type of pain which occurs mainly after we’ve been on our feet a lot, that’s an internal pain as where the bump pain is an externally positioned pain. The bump pain is due in a great part to the fact that the big toe joint, which is essentially a hinge, is kind of bent. So it’s like taking a bent hinge on a door and when you move the door, you hear the squeaking of the door knowing that the hinge isn’t really functioning properly. And this bending of the toe puts a lot of stress on the joint and on the ligaments in the joint and causes what we call this bump pain. Some people feel that by using arch supports, because bunions tend to many times associated with persons having flat feet, that this will help keep the great toe joint in a little bit better alignment and allow some of that bump pain to resolve. I found this to be the case sometimes, not all the time, but it certainly is something that can be tried to help that part of the pain. Dr. Hendler: Okay, um....two questions that brought up in my mind. One is if you’re going to use the padding for the bump and your shoe is already too tight and the padding takes up some room, obviously there’s even more things being crowded, and so I guess if

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you’re going to use the padding, you don’t want to do that before you have them try and stretch your shoes? Dr. Tafuri: Well, I think that’s a great question. We see some of the pads which are actually more of a cushion, and the pads that I want to more specifically refer to look more like a doughnut so they have a hole on the inside and they have a ring on the outside or like a tire. Dr. Hendler: I see. Dr. Tafuri: So the bump would be on the inside and what we’re doing is raising the level of the tissue around the bump to about the level of the bump to make it more of a flush contact with the shoe. Dr. Hendler: Oh I see. Yes, it almost stretches the shoe for you in a sense. It pushes the wall of the shoe further away from the bump. Dr. Tafuri: Exactly. Dr. Hendler: Okay. Another thing. You were talking about the arches and although this is slightly off the subject it is something that comes up often, and I wonder if you could say a word or two about the things that they sell in those aisles called metatarsal pads. Dr. Tafuri: Metatarsal pads are generally, although there are several varieties, referred to as kind of a teardrop-looking pad. That goes in the front part of the shoe, and they usually have a picture along with the pad display so you know where to place it and it tends to take pressure off of the ball of the foot. That would help with pain that accompanies a bunion many times which is what we call metatarsalgia which is pain along the rest of the ball of the foot. If there is that type of pain, sometimes these pads can be helpful. Dr. Hendler: And can you buy them at regular drugstores, or do you have to go to special places to get those? Dr. Tafuri: You know, it’s hit or miss in drug stores, but with the advent of a lot of the catalogs coming in the mail, I’ve seen many health-related catalogs that have them in there so I would recommend taking a peek in there and seeing if there’s something there that would be helpful. Dr. Hendler: And of course, there’s always the Internet to look on. Dr. Tafuri: Yeah.

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Dr. Hendler: Okay, well moving on then, sometimes this isn’t good enough and you need surgery so the next related question would be, when do you need surgery? How do you know if you need surgery? Dr. Tafuri: Well, first of all, as I mentioned earlier, we usually don’t treat bunions unless they’re painful, and just to touch on something briefly, I’m often asked can we prevent the occurrence or prevent the speed at which the bunion is forming. If it’s not painful now, can we stop it from becoming a problem? And some feel that by wearing arch supports on a consistent basis that this process can be slowed down because the flattening of the foot is part of the cause of why some bunions occur and we inherit our flat feet. But most people subscribe, I believe, to the fact that we can’t really prevent these from happening, and so once they do become to the point where treatment is necessary, that is where they’re painful and we have to go beyond the nonsurgical treatment because it’s been ineffective, then we really want to take a careful look as to weighing the level of the pain versus what kind of investment and time effort in postoperative pain that’s necessary to actually fix the bunion. Dr. Hendler: Alright, and then why don’t you tell us a little bit about what the surgery actually accomplishes, what it does. Dr. Tafuri: Most of the time the surgery required to fix a bunion, and I should mention that once a bunion becomes painful and discussion of surgery is ensuing, taking an x-ray to give a better look at what’s going on with the actual bones helps us determine what type of procedure is necessary, but generally the surgical procedure involves realigning the bones and tightening the ligaments in an attempt to #1, get rid of the bump which is causing the bump part of the pain, and #2, to realign that hinge that I was telling you about, straightening the bent hinge to remove as much or all of the joint pain that’s occurring. We tend to do this, as I said, by cutting the bone and sliding the bone in a way that pushes the bump back in. So if you look at your foot with a bunion and you just press on the bump and push it in toward the second toe, you’ll get a feel for what happens when the surgery is occurring. Also, we shave off the part of the bump that’s in that area; however, it’s commonly thought that that bump is actually a growth, and generally it may be somewhat of a growth but in essence it’s a normal bone being forced out the inside of the foot. So we generally, as I said, cut the bone, put it in position, hold it in place with either screws or pins or dissolving pins, although there’s a variety of types of what we call internal fixation for surgery and then tighten up the joint and close the skin. Surgery, depending on the complexity and the procedure chosen, can take anywhere from about 45 minutes or so to an hour and a half or a little bit longer actually operative time. We tend to do this under a local anesthesia with some sedative so that it’s very comfortable, and then the postoperative course after surgery is what takes a long time, and that’s what we have most of our discussion about with patients before surgery because we’re working against several things. #1, we usually involve cutting the bone and that has to be repaired and the foot has to be protected during the healing process. This is why we see people walking around with these rigid wooden shoes. We call them postoperative shoes, and they help protect the area. The second thing we’re fighting against is, and really the main thing, that gravity brings swelling downward so the fluid in our body in general as we

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walk around without any surgery wants to collect down in our feet and after surgery this is more so a problem, and this is what really prevents or prolongs the period of time after surgery to the point where someone can actually get shoes on. And so the smaller the shoe, the more time it will take after surgery to get that shoe on, and initially it may take upwards of two months, maybe longer, to get into a tennis shoe. And sometimes, I usually mention, upwards of six months to get back into a dress shoe, sometimes longer than that. There are some definite individual factors when it comes to swelling after foot surgery. Dr. Hendler: Okay, but two to six months would be a very reasonable range to expect. There could be obviously exceptions to that rule but that’s the ballpark. Dr. Tafuri: I’d say it’s probably average. Dr. Hendler: Alright. Now after you’ve had surgery and you’ve recovered and everything is fine, can the bunion recur? Dr. Tafuri: There is the possibility of recurrence. Sometimes it has to do with the hereditary factors that caused the bunion in the first place. The one positive side to the bone cutting and realigning procedures is that they tend to put the bone in a better position. It was very common in the early days of bunion surgery to just remove the bunion – the bump itself and not realign the bones. And in certain circumstances that’s an appropriate treatment even today. But we want to make sure that the treatment surgically is aimed at the clinical picture and the x-ray so that we do exactly what’s necessary to give the best chance of a good result with the least chance of a recurrence. But people who have very very flat and flexible feet can tend to have, it seems, recurrence a lot easier than people with say higher arch, more rigid feet. Dr. Hendler: Umm....you mentioned the early days of bunion surgery, and I’m thinking that people have had bunions since cavemen days probably, so I’m curious the early days of bunion surgery, are we talking hundreds of years ago or just decades ago or what? Dr. Tafuri: We’re talking about probably over 100 years ago. Maybe even a little sooner than that. Certainly not in the caveman days because we didn’t have shoes so that’s how cavemen got by without bunion surgery. But bunion surgery has been around for quite some time. Dr. Hendler: So since the 1800s probably. Dr. Tafuri: Probably late 1800s, early 1900s. Dr. Hendler: Okay. Well, are there any other thoughts that you’d like to tell our audience? Dr. Tafuri: When it comes to bunions, it’s important to try to minimize their effect by wearing appropriate shoe wear and start with nonsurgical types of treatment. There are

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many resources to get some idea of where to go with self treatment, and then of course if that’s not working, then you should seek help from your physician in that area or podiatrist in that area. Dr. Hendler: Okay. Thank you very much, and as far as the resources, you can always check with kp.org where we have various patient information including the Healthwise Handbook. I’d like to thank our audience for listening to this podcast today on bunions. KP Healthcast is created by the people at Kaiser Permanente in Fremont, Hayward, and Union City, California. These podcasts are for general information only. They’re not intended to be used as a substitute for medical advice given to you by your personal physician. If you or a family member have any of the conditions that we’ve discussed, we encourage you to discuss it with your personal physician as every case is different, and your physician is in the best position to know what’s good for you. You can find all of our podcasts on our home page at http://www.kphealthcast.org, and you can e-mail us at [email protected]. We’d love to hear from you. Check our home page regularly for new topics and, as usual, be on the lookout for new ways to THRIVE.

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