Bunion Pain: Medially on the Bump or Laterally in the Joint

This is an AP Foot Xray with highlighting of the big toe joint. The metatarsal head is rounded and the toe has slipped off the joint on the side of the 2nd toe. This is very painful. The soft tissue on the lateral side (2nd toe side) is pinched and causes pain called capsulitis. Treatment is partially accomplished with toe separators and bunion taping to straighten the toe. 

This same xray shows that the joint dislocation is measured at 4 mm. This patient was in for a 2nd opinion following failed bunion surgery. Failed from the standpoint that 3 years after the first bunion surgery, the bump is coming back and pain is settling into the joint with activity. 

In this xray the numbers do not mean anything. I wanted another way of showing that 4 mm  dislocation of the toe on the metatarsal head. This patient did great with toe separators to push the big toe medially back onto the top of the normal part of the joint. 

Bunion or Arthritis: An Important Decision to Make Before Bunion Surgery

Any workup for Bunions should include a Plantar Axial Xray. This gets the bottom of the big toe joint and can reveal interesting findings. Here the lateral (fibular) sesamoid is damaged with also lateral first metatarsal spur. 

The xrays for a bunion workup should be weight bearing. Here the lateral projection shows a dorsal spur seen in Hallux Limitus, not typically in bunions. Also noted is spur on the dorsal surface of the toe bone (proximal phalanx). These would have to be removed in bunion surgery, and not only increases the time of post operative physical therapy, but also lowers both the overall joint motion and pain free expectations. 

This AP Foot Xray shows breakdown of the lateral part of the joint. See how the joint space is wider (healthier) on one side of the joint, and narrower on the other side (where the arrow is). This means that the joint is arthritic. Bunion surgery without discussion of special attention to this area will be unsuccessful. This joint should be considered an arthritic joint (Hallux Limitus/Rigidus) not a bunion joint, and surgery should be done accordingly.