Tuesday's Patient Question of the Week: How to deal with Bunion Surgery Complications?

Dear Dr. Blake,

I imagine you must get many of these emails.  I stumbled upon your blog by reference of an enthusiastic patient of yours.  Coincidentally, I live in the Bay Area.

I have a series of complications which has led from flare-up to constant chronic pain and immobility.  I have eliminated all exercise except swimming and lifting weights.  Walking and standing are hard; I used to be very active.  I have a slight build so my weight is not an issue.  I am just wondering how to proceed, how to find an expert, whether surgery is appropriate (I am scared of this as I have had 6 in all but I do not want this current condition to be my new norm).  My summary, if I may indulge you, is as follows:

Image of a bunion patient whose previous surgery had failed and the toe collapses towards the 2nd toe and off the big toe joint causing arthritic pain. 

After no luck with orthotics for painful bunions, in March 2002, I had my left foot worked on ( a bunionectomy).  In June, 2002, I had my right foot bunionectomy-same doctor- an orthopedic surgeon.  One outcome of that surgery is that the big toe bone has become shortened and my first metatarsal head is misaligned with the second and third.

The bunions came back five years later; in August 2007 and December 2007, I had my left then right foot done respectively, by different surgeons.   The surgery, shaving rather than cutting the bones, was much easier to recover from.

Dr Blake's comment: Bunion surgeries vary immensely, and typically the longer the post op course, and the more bone work done, the longer the bunion correction will hold. There are also so many factors like severity of pronation, width of foot, general ligamentous looseness, and bone structure to name a few that can help determine the longevity of these surgeries. Surgeons have their preference, but in discussing with them, see if you can determine why they choose a particular type for you. Definitely get a second opinion and do not mention what the first surgeon plans on doing. See if they are on the same page or miles apart. 

In 2011, I developed bone spurs and was diagnosed with hallus ridigus which amounted to a 40% loss of mobility in my foot due to arthritis so I had surgery on the bone spurs (by my big toe).  My left foot was worked on in August 2011. 

Dr Blake's comment: Surgery on any joint weakens the joint leading to gradual onset of potential problems in the future. This is typically very slow process, so it is unusual that arthritis set in after your second surgery. I am assuming that there was no mention of arthritis in the first and second surgeries. Something does not make sense, but you have what you have right now. Bone spur surgery on the big toe joint, AKA joint cleanout, AKA joint arthroplasty, AKA cheilectomy is definitely a very skilled procedure and needs some luck in going to work. I highly recommend this surgery over implant or fusion for Hallux Limitus since it works well normally (at least for many years). 

 The doctor also removed screws in my feet from the previous surgery and he shaved a “bunionette” off the right side of my left foot, so in August I had two parts of my foot worked on.  I was healing okay until I tripped about six weeks later and broke my middle toe on that same foot.  This set me back immensely.

My second bone spur surgery was in March, 2012 on my right foot.I was healing well, in general, and was running by fall of 2012 just a little.  I did lots of yoga until I injured my left foot in January 2013.  I took time off and by March, got a cortisone shot in my left foot.  I had had one in 2012 at some point for swelling.  I began physical therapy in March/April of 2013 and had been seeing my PT currently once every two weeks. I'm now upping it to once a week.

Current problems since June:  Metatarsalgia, sesamoiditis, arthritis, poor flexion in the ankle due to tight calves (and on my feet all day due to teaching), thin padding on the bottom of the feet and stressed metatarsal heads, minor pain from Taylor's bunion on right foot.  Left foot, overall, is much worse than right.  I tried a chiropractor this summer with no positive outcome.  I sometimes get acupuncture and massage.  I'm also wearing a metatarsal pad, mainly on my left foot (Jill's Gels) and am now trying toe stretchers.  I have rocker-bottom shoes and have been unsuccessful with new orthotics.

Another orthopod is recommending surgery to align the metatarsal heads.  I have a second opinion upcoming with another orthopod.  I am also considering a visit to the Mayo Foot/Ankle Clinic in Arizona.  I will do anything to  get my mobility back.  If you have any advice as to who to see or how to proceed, I would be so grateful.  I am very lost on this journey.

Best Regards and thank you for what you do.

Sara (name changed)

Dr Blake's response:

     Hey Sara, thank you so very much for your email. I will try to help you. Your journey is not unusual unfortunately for many patients that have bunions and probably some underlying arthritis. But, it has been alot of surgery for you. I would be cautious about more surgery at this point, since something must be amiss. Someone has to explain how you got to this point in so much pain. And then explain what can be done for it. Since your pain is so widespread across your left foot, you should be in a removable boot for 3 months to place that foot in the Immobilization Phase of Rehab. During that 3 months, get MRIs (if affordable) on both feet to see what is wrong. Have someone into orthotics figure out how to off weight sore areas. Daily ice both feet 3 times daily for 10-15 minutes to cool them down, and take NSAIDs. Try to analyze the % of pain from each area. When you present to the medical profession with these issues, it is overwhelming. Focus on one problem (the most problematic) if possible and get that well, then move on to lesser problems. See a pain specialist if you are having trouble with day to day activities, or if the present docs can not help with the pain. Pain causes more pain, and you can get into vicious cycles. Check the information on this blog on handling nerve pain. I hope this helps somewhat. Rich

Bunion Surgery Problems: Email Advice

Dr. Blake,

     I am one and a half year post bunion surgery of my right foot, and am having a very difficult time.  As soon as I was able to walk after surgery, I felt a tiny rub on the bottom of the foot, but just assumed it's normal after surgery, six month after, resumed normal activities, doing Zumba, Spinning, hiking, which may have contributed to the problem I am having now.  There was always a tingle, an ache, big toe area always stiff and frozen. I mentioned it at checkups, but the surgeon didn't seem to be concerned about it.

Dr Blake's comment: I am not sure if I would have told you anything different at this stage as long as your function seemed fine. Post surgery, bunion or any other surgery, surgeons expect 20% of the symptoms to just gradually work themselves out, as long as the pain level stays between 0-2. This is how you are presenting this at least. 

     Begining of June (6 weeks from the day of this email), the foot started feeling numb, and shooting pain along the big toe area. 

Dr Blake's comment: Now you are having nerve pain and this is quite disabling. Surgical joints are always the weakest link in the chain. They are the one most picked on. The present day does not have to have anything to do with the surgery, other than that this area is a weak spot for you. 

     Went to the Dr, ordered custom orthotics, not even x-ray, endured stabbing pain, was told to adjust the orthotics, still waiting for the appointment to see him.

Dr Blake's comment: So, what should of happened then and now? Creating a pain free environment needs to be accomplished with shoes, orthotics, removable boot, crutches, etc, and anti-inflammatory measures (minimum of 3 times daily 10 minute ice pack). During this time, the sometimes slow process of figuring out what is wrong with diagnostic injections, xrays, nerve conduction tests, low back evaluations, etc should be started. 

     I went to another surgeon, who took the time to watch me walk, x-rays, and said I have sesamoiditis. Pain and discomfort is nonstop, I can barely walk... my question is, what is the relation between bunion and sesamoiditis?

Dr Blake's comment: Your big toe joint, which was remolded to remove a bunion, has 2 bones called sesamoids under neath. You big toe joint is a weak link in your bio mechanics. There are so many scenarios of what is happening to you I could write a book chapter at least. The most obvious, because this is a fairly common problem, is that the bunion joint following surgery is continuing to get weaker. Perhaps some arthritic changes are occurring in the joint which is very common. Perhaps the surgery weakened that side of your foot enough that you are pronating more now and overloading the sesamoids. If there was a surgical complication, you would have been in pain a year ago as you went into normal activities. Perhaps this has nothing to do with the surgery (very common), and it just a new injury due to your activities. The reason you got the bunion is that your mechanics are weak in that area, and unless the surgeon did bone fusions to stabilize (highly unlikely), you are still weak there and could have just irritated the sesamoids.

The fact that something is rubbing right after surgery made me feel something went wrong with the surgery, but the second surgeon I saw said the surgery was fine from what he saw in the x-ray. I never felt the foot went back to normal, and now, I cannot even handle daily routines.

Dr Blake's comment: We tell our patients who have bunion surgery that we are not giving them a normal joint. But, we can hope we are giving them a better joint. You may indeed have a surgical complication that can not be seen on xray. Even seemingly minor collections of scar tissue in the wrong place, can give symptoms. My best guess, based on what you have told me, is that you have a predictably weaker big toe joint area that is susceptible to injury. I can not presently tie it to a problem with your surgery, so my recommendation is to work with the PT on creating that pain free environment, treat inflammation when found, definitely treat the part of your pain that is nerve related with treatments that help that. Get an MRI or neurological workup for possible nerve entrapment, or a diagnostic injection series to find out exactly what structure is painful. As you progress through those steps, you should predictably feel better and better. I hope this helps you some. Rich

Your blog is the best information I can find online, and I just don't know what to do. The new Dr. did send me to Physical Therapy.

Thank you so much for your time, I do hope to find answers from you.