Bunions: Tips on Conservative Care

                                                         Tips on Bunion Care

     So you or someone you love is developing a bunion, what to do? Bunions are sometimes classified Stage I (you begin to see a bump), Stage II (the toe starts to drift towards the 2nd toe), Stage III (the 1st and 2nd toes come together), and Stage IV (the 1st toe moves under the 2nd toe with great instability to the entire foot as seen in the photo above). The goal of bunion care is to keep it in Stage II. During Stage II the bunion is not getting worse quickly since its alignment with the metatarsal is not too bad relatively. Stage IV is a surgical bunion and there are many great surgeries available. These surgical corrections, however, have a 6 month to 1 year recovery period depending on what is done.

     Stage III can persist for 3 weeks or 30 years, and in general is a stable place for your overall foot stability. Once the 2nd toe begins to drift dorsally (towards the top of your shoe), Stage III can quickly become Stage IV. In Stage III, with the 1st and 2nd toes abutting, as you push off the ground at heel lift, the poor angle of the 1st toe pushes back on the metatarsal gradually increasing the bunion deformity over time.

   

Sometimes a Budin Splint is used in Stage 4 to improve the overall stability. The success is based on the ability of the splint to keep the second toe at the same plane as the first. Here is a failure of the splint where the 2nd toe is too high off the ground.

     So the goal in treatment is to get the bunion back into Stage II---its Happy Place, and keep it there. The bunion will not go away, but you may stabilize the joint, eliminating or at least postponing surgery for a long time. Bunion surgeries have not changed dramatically in the last 30 years like knee replacements, yet, the post operative care has greatly improved. I believe that avoiding/postponing surgery now, with the chance of never needing it, is worth the possibility of better results in the future. You will see this is my bias against immediate surgical procedures.

     However, that being said, if you are disabled by anything like a bunion, try 6 months of aggressive conservative treatment first. If your condition has not improved after this time period, proceed with surgical advice. Your disability must match up with the risks and recovery period for the operation. Get 2 or 3 opinions, be a smart consumer, bring a friend or loved one to the appointments, make a logical decision, and go for it.

    Stage II in bunion development is where, when you stand on the ground, and look at your toes, there is still a gap or separation between the 1st and 2nd toes. Medium gel toe spreaders from Silipos® http://www.silipos.com/ or separators between those two toes instantly put the bunion in stage II. You wear them in any enclosed shoe. You can now buy socks, like Injinji ® http://www.injinji.com/ , and bedroom slippers, like Vibram ® Five Fingers http://www.vibramfivefingers.com/ , that have individual compartments for each toe to wear around the house. Several years ago, YogaPro® came out with YogaToes http://www.yogapro.com/ . The product has 5 individual compartments and patients stretch their toes for 30 minutes 2 to 7 days a week when they are sitting down. I usually start patients at 5 minutes a day several times a week and they can slowly build up time. Some patients, especially with small toes, can not wear the product at all, or it must be modified. If you are in pain, do not wear the device (Good rule of thumb for most things). YogaToes are designed only to be used while sitting. Bed, Bath, & Beyond has an effective, but not as aggressive product, called Pampered Toes®. There is another YogaToes knockoff called Healthy Toes®. Another great product is Correct Toes where you can walk around with the toes in better alignment https://correcttoes.com/

Free standing Medium Gel Toe Separators, but I also like the Zenn Toe product that fits completely over the 2nd toe

Toe separator that attaches firmly to the 2nd toe

Yoga Toes

    If your bunion is red, start massaging it. The red inflamed tissue adds to the discomfort and fragileness in shoes. Use circular motion to try to get rid of unwanted inflammation with soft tissue swelling. Gradually push harder during the massage. Massage for 5 minutes several times a day for 2 weeks longer than you think you need. What do you massage with? Ice cube is used if the bunion is sore. If not sore, use massage oil, or any hydrating, lubricating, lotion or cream. It is the massage that moves out the bad stuff.

    Padding with 1/4" adhesive felt just proximal to the bunion (called proximal padding) instantly takes pressure off of the bunion and allows you to wear many shoes that would normally irritate. The padding can be purchased in many locations including http://www.mooremedical.com/ item #09229. You normally cut out a 1 inch square and place not over the bunion, but just behind towards the arch, but as close to the bunion as possible. Best to place it on your foot directly. You can experiment with size and shapes so it does something without showing. You should never place under the foot or on the big toe itself—that will make the bunion worse. Sometimes, you may want to put on top of the 1st metatarsal and the side as just described. Each pad can be used multiple times, so 1 roll can last almost a lifetime or be shared with other bunion sufferers you know or see in the gym.

Proximal Padding is only when wearing shoes that irritates the bunion area

    Another vital aspect to bunion care is strengthening of the intrinsic foot muscles. These are tiny, yet powerful muscles within your foot that weaken over time due to life stresses (the aging process, pain, bad foot mechanics, reliance on shoes and orthotic devices, etc.) Normally, I would send a patient to a physical therapist to learn these exercises properly.

    If you can not wait, start doing the flatfooted balancing exercises now. All strengthening exercises should be done for a maximum of three days a week. Foot and ankle exercises fatigue the leg so much that they should be mainly done in the evenings when you are home for good. Stand on one foot in a doorway. Put your hands at your side so that you can grab the door frame if needed. Very slightly bend your knee that you are standing on. With your eyes open, try to balance on each foot for one minute until this is easy. Then, gradually build up to two minutes at a time. Then, begin to close your eyes during the two minutes off and on until you can keep your eyes shut the entire 2 minutes. This easy task can take 1 month to 1 year to complete. The longer it takes, the more important it is for you to accomplish this tremendous strengthening exercise. Very important: do not push through any pain whether it is in your foot, ankle, knee, hip or back. This is really where a physical therapist can help making sure you are safe at what you are doing. You can always have a doctor write a prescription and send you to therapy for 4 sessions to learn a HEP (Home Exercise Program).

     In summary, bunion care should be started as soon as possible after making the diagnosis. Elements of treatment should include toe separators/spreaders, YogaToes or a knockoff version, proximal padding, possible socks and slippers with individual compartments, foot strengthening and massage. . Hope this was helpful. Of course, most of this advice is also used post-operatively to stabilize the strengthen the foot if it ever gets to that point.

Key Word: Bunion

Awesome Toes vs. Correct Toes: Let the Battle Begin to see which One is Better!!

If you are trying to prevent, or at least slow down, the development of bunions and hammertoes, these are 2 good products to use on some regular basis. I have attached my original post on conservative management of bunions and these should now be included. 

http://shop.yogabody.com/yoga-props/Awesome-Toes.html

https://www.correcttoes.com/

http://www.drblakeshealingsole.com/2012/07/how-to-conservatively-treat-bunions.html

The Importance of Toe Separators in Bunion Care

https://youtu.be/sjrAYX0rEms

Bunion Exercise to slow Progression

https://youtu.be/J3js0t8oOYc

Yoga Toes as Art!! Bunion Patients should Wear 30 Minutes Daily

http://www.drblakeshealingsole.com/2012/07/how-to-conservatively-treat-bunions.html

Help for bunions and hammertoes: Correct Toes

I have been looking for a product like Yoga Toes, that will be help to hammertoe and bunion patients, and that can be worn to walk in some shoes. One of my patients is wearing Correct Toes while walking in Keen (extra wide) athletic shoes. I hope it helps some of you. Rich

How to Conservatively Treat Bunions

                     How to Conservatively Treat Bunions

                                     Dr Rich Blake

 

      Bunions are normal bones in abnormal positions. The process of developing bunions is very slow, but some activities can speed up the formation. Shoes are blamed excessively, but are rarely the underlying cause.  Managing and slowing down the development of bunions can prove very helpful to some people. 

      And, let us say you have bunion pain. Pain can definitely bring you to the doctor for treatment, and surgery has to be in the back or front of your mind. But, is it bunion pain? It could be something else.  It is best to get your bunions professionally checked.  Patients can with conservative treatment, delay the need for surgery and sometimes prevent it. 

      So, you decide you have a bunion. Your mom and/or grand mom did, so it is in the genes. What to do?  There are many conservative treatments that I will try to summarize in this handout.  Typically if you consistently do three or four of these self care treatments, your bunions will be much less painful.  You want to avoid getting to Stage 4 Bunion Development as shown in the photo below.  Stage 4 is always a surgical problem because of how it negatively  effects the rest of your foot and your walking gait. 

Stage 4 Bunion

You have bunions and you want to avoid surgery for as long as possible, here are your common treatments.

1.     Toe Separators

Standard Medium Gel Toe Separators that can be purchased  from Silipos.

Toe Separators can be bought made of gel, foam and rubber. This image shows gel one that attaches to the second toe for more stability.  Avoid the toe separator that attaches the first and second toes together since it would make the first and second toes move together whereas they normally move separately.

     Medium gel toe separators for weight bearing with shoes is probably the most single important aspect of conservative treatment for bunions.  It is to be worn any time you are weight bearing to negate the gentle consistent push of the shoes on big toe towards the second toe. 

2.    Night Splints

     This night splint can be purchased from Footsmart.com and it is the best one I have seen.  You should wear a sock over it so that the Velcro does not catch on your bedding.  Over 50% of my patient feel that this is helpful when they first start their bunion care while they get use to some of the other treatments below.  Slowly it will have less effect as you loosen up the tissue between the first and second toes. 

3.    BUDIN SPLINT

     If the bunion is accompanied by a 2^nd hammertoe as in the Stage 4 bunion above, use a Budin Splint (also known as Single Loop Hammertoe Regulator) to get the 2^nd toe down.  You can also use Kinesiotape, Rocktape, or 3MNexcare Waterproof tape to hold down the 2nd toe. 

4.  YOGA TOES

You do not walk around with these as it could be dangerous. If you have trouble fitting between all your toes, cut out the partitions between some. It is the separation of the first and second toes that we are looking for. Also running the yoga toes under water can help lubricate the rubber to allow them to slip on your toes easier.

     Yoga toes are the second most important conservative treatment for bunions.  They are to be worn 30 minutes per day and not to be walked on or slept with. They produce a gentle stretch on the soft tissues to help pull the toes into  better position.  Many of my patients use the knock offs from Bed Bath and Beyond or Walgreens, called Healthy Toes or Pampered Toes. 

5.    STRENGTHEN INTRINSIC FOOT MUSCLES FOCUSING ON ABDUCTOR HALLUCIS  

     Metatarsal Doming is the best  exercise to begin strengthening the small muscles in your foot. While doing these exercises focus on moving the big toe downward and away from  the second toe. The Abductor Hallucis pulls the big toe away from the second. Some patients have great difficulty separating the first and second toes and must use toe separators, Theraband,  or bunion taping to place the big toe away from the second toe in order to start the exercise in the correct position.

6.     Bunion Taping

     Bunion taping placed daily can help train the toes to go in the right direction (or at least a better direction).  If your bunion is large (Stage 3 or 4 normally), consider a 3 month trial of bunion taping with Kinesiotape, Rocktape or 3M Nexcare  Waterproof Tape.

7.    Injinji SOCKS or Vibram FiveFinger Shoes

     Socks or shoes with individual compartments can be worn around the house or for short errands to strengthen your toes in the correct position. 

8.    Bunion Protection

 

    Use ¼” adhesive felt from www.mooremedical.com just behind the bunion towards the arch, not over the bunion.  This has probably given my patients the most pleasure since it greatly increases the amount of fashionable shoes they can wear.  Therefore, I would put this as the third most important conservative treatment step for bunion care. 

9.     Ice massage

     If your bunion is red, even if it is not painful, you have some low level inflammatory tissue at the bunion prominence.  This makes the bunion more fragile and more likely to get irritated with various shoes.  Introducing daily 5 minute ice massage by melting an ice cube over the bunion should be done until the skin over the bunion looks normal on a consistent basis.  You can speed up the process by ice massaging two or three times per day.  You can substitute good hydrating cream or lotion for the massage when the bunion is not painful.

Cyrocup which can be purchased online, is used here to reduce inflammation around the bunion.  Ice cube in a cloth towel works well.

I  also love massage oils or combinations of Aloe Vera and Vitamin E. 

10.   Biomechanical changes

     If you pronate and your bunion hurts with certain shoes, experiment with Hapads or other OTC arch supports like Sole to see if you get pain relief.  You can use custom orthotics if the force of pronation is too great to control with OTC devices. However, treating bunions with any insert is always a delicate balance between support and shoe crowding.

    Other biomechanical changes would be selecting shoes that are stable and with a wide enough toe box to accommodate the bunion.  You do not want to wear too loose of a shoe as it leads to instability and other problems.  Make sure you feel stable in any shoe your select. Make sure when you are selecting shoes that you feel that you rolled through the center of your foot and not through the big toe joint at push off. 

11.  Shoes with Good toe box Width

Here Dr Jane Denton, my partner for 31 years, goes through great lengths analyzing the proper fit of shoes.

     Select shoes that do not put too much pressure on the bunion area.

12.   SHOE SOFTENING

    If there are slight pressure problems in some of your shoes that are not relieved with the felt padding, try to have local shoe repair store stretch them.  They need to take them overnight to do a proper job. 

This photo just demonstrates the fact that a shoe repair store can soften the leather in any spot like for a bunion. Many of my patients buy their own ball and ring stretchers and leather softening spray to do this themselves.

 13.  HIGH HEELS

Most podiatrists feel that heels over 2 inches place too much pressure on the ball of the foot increasing the chance for bunions. If the above conservative treatments are used, and you use some common sense in terms of the fit, you should be able to wear sensible heels and not have problems

Saturday's Exercise of the Week: Bunion Joint Strengthening

As you begin your treatment to maintain your bunions in an attempt to avoid surgery, think about all the possible treatment choices you have available. 

My common checklist for my bunion patients includes: (and my blog is full of these tips)

A) Toe Separators

B) Yoga Toes

C) Digital Stretches and possible Night Splint

D) Shoe Selection (so as not to push too hard)

E) Padding to Off Weight the Bunion Area

F) Icing as needed

G) Abductor Hallucis Strengthening (this video shows the patient attempting to train the toe to pull down as straight as possible)

http://youtu.be/V487w7IM_2c

H) Taping occasionally

Bunions Self Care: A Video Discussing Non Surgical Options

I hope you enjoy this short video discussing the common treatments used in avoiding or preventing the need for bunion surgery. There are many posts in this blog discussing all of these points.

Bunion Pain or Not? That is the Question

Hi Dr. Blake, I emailed you about a year and a half ago about a sesamoid bone that I broke and then had removed after about a year of it not healing. Now I have another issue I would like to ask about.  On the other foot I think I may have a bunion forming, but I am not sure if that is what the problem is. At first I thought the other foot hurt because it had to work harder to make up for the first broken one. Now I am still having issues and tenderness in the ball of my foot, but I don't think my other foot is compensating now.  Since I found a lot of information about my first foot issue on your blog, that is the first place I decided to look now. I am wondering how to determine if I have a bunion or not. I have a painful area below the great toe and today it began to turn red. The great toe is not turning toward the other toes yet. Since I have been healing from my sesamoid injury I have begun to get back into martial arts and I am not sure if something like that, since it is a barefoot sport, would encourage this to come on.  Neither of my parents have had bunions and I am not sure of my grand parents, but much of the information says it is hereditary. I looked at the information you posted for the different items from Foot Smart, but I am not ready to buy them before I know for sure that is my issue. Can you give me a suggestion of where to find information about diagnosing this or if I need to visit my doctor for x-rays to decide. I appreciate all your information you have for us and for any help you could offer me. Thank you! Dr Blake's comment:       I attached my You Tube video on Bunion diagnosis. I hope it is helpful. Rich

San Francisco Giants and Bunions

Listen to the San Francisco Giants Post Season Highlights

http://soundcloud.com/dj-raw-b/sf-giants-2012-postseason

Hello,

I have started to notice the beginnings of bunions on both feet. I am a 30 year old female and I was curious to see if there were any preventative measures I could start so that they don't get worse. 

Thanks!

Dr Blake's comment: 

     Here is the link to my blog post that reviews that most common preventative measures for bunion deformities. Hope they are helpful to you. Rich

http://www.drblakeshealingsole.com/2012/07/how-to-conservatively-treat-bunions.html

Bunions: Toe Separators Are A Must!!

Dear Dr Blake:


When I was in your office on Wednesday, you expressed interest in my gel toe ring. Here’s the Amazon info on it:

"Gel Toe Spreader with Loop" Health and Beauty; $9.99 per foot     Sold by: FootSmart Best, Emma By the way, so far so good on my new orthotics. You can see on Emma's feet how the ring around the 2nd toe may prove very helpful when the toes are moving out of position to hold the toe separators in place. Some of my patients complain that the traditional toe separators move out of place, so this may be an excellent product for them.

Bunion Pain while Running

Hi Dr. Blake,

      I started running last year and have since participated in a couple half marathons.  My bunions are quite painful during these long runs.  I tried doing shorter distances with the toe spacers, but found that I was "gripping" the spacers afraid they would move around in my sock.  Is there something else I can do to ease the pain?  They get swollen a few miles in and unfortunately, I'm more of a toe striker which doesn't help.

Thanks,
Marjorie

Marjorie, Here is an item you can buy at Footsmart that may help you. Rich

http://www.footsmart.com/P-FootSmart-Bunion-Sleeve-with-Gel-40106.aspx

You can also get 1/4 inch adhesive felt from Moore Medical for proximal padding. Please see the blog. Rich

http://www.drblakeshealingsole.com/2010/04/toenail-clippings2bunion-care-101.html

http://www.mooremedical.com/Index.cfm?Ntk=all&No=0&Search=Search&Ns=Searchorder%7C0%7C&Ntx=mode+matchpartialmax&Ntt=adhesive+felt&x=24&y=9

Bunion Pain: Xray Evaluation of the Swollen Tissue which causes Pain

Xray Evaluation of a Typical Bunion with almost 3/8 th inch soft tissue swelling at the bunion prominence.

Stage 4 Bunion Deformity with Red Inflamed Tissue

Patients can come in with red hot inflamed bunions. They may be so sore that they want surgery soon (even yesterday!!). When I get Standing AP Foot X-rays I show them the amount of soft tissue swelling between the bone and joint. I try to get them to do 5 minutes ice massage twice daily and physical therapy to reduce the overall swelling. 50% reduction of swelling, especially the 50% that is inflamed tissue, is common to achieve sometimes even with just the ice massage over the period of 4 weeks. As the symptoms die down, the immediate urge to have surgery passes, and I think the patients who still need surgery will make better decisions. For a lot of patients, as the pain resolves, and the bump reduces, and they learn all of the other steps to avoid surgery (see previous posts), surgery can be put off indefinitely. 

Bunions: FootSmart Night Bunion Splint

dear dr blake - slowing i am putting your suggestions in place for my bunion(s).the orthodics seem to be working well. i went on the foot smart web site and am confused as to which splint for sleeping you suggest. do you suggest that i wear one a night for each bunion? could you advise which on to order as there are many options? 

here are the names:

footsmart bunion regulator

bunion toe straightener

footsmart gel toe spreader

foot smart bunion sleeve with gel 

toe spreading gel bunion shield

pro foot bunion comfort adjuster 

silipos digital toe cap with toe spreader 

toe alignment splint

wheaton bunion brace

fabrifoam bunion sling

toe hold alignment splint

thank you,

katherine

And my response:

Katherine, I am impressed with you. Here is the link. Try on both sides, but you need to wear with socks. Rich

http://www.amazon.com/FootSmart-Bunion-Regulator-Womens-9-11-5/dp/tags-on-product/B000KI44KE

This is great when it is hard to separate the first and second toes. What I mean by this is that relative to the less bunion foot, if it is harder to separate these two toes on the side with the worse bunion, it is good to get a splint for night time. The splint gently stretches the tissue between the first and second toes and helps the yoga toes and toe separators work better. 

Bunions: What the top covers on your orthotics should not look like!!

I am getting a lot of mileage out of these inserts for my blog since they tell a great story. Orthotic devices are used all the time for long term preventative care of bunions. If you look at the wear pattern of these insoles recently removed from the top of a pair of orthotics for refurbishing, you will see that there is way too much pressure under the first metatarsal. This pair of orthotics will not prevent bunions, they may speed up the formation of bunions. There is too much pressure under the first metatarsal which makes the bunion worse. Golden Rule of Foot: If you are designing a pair of orthotic devices to  slow down the development of bunions, you must shift the weight under the arch and into the center of the foot. We have to say that the majority of the weight on this pair  is on the first metatarsal which is not good for bunion care. A redesign of the orthotics is in order. Also, this brings up the point of when to refurbish the orthotic devices. I believe that once a year ideally, the patient should relinquish their orthotics for several days for analysis of the wear pattern on the top covers and posts, and then for refurbishing. As a patient, you should make sure you tell the office that you want the doctor/therapist to look at the wear patterns, before refurbishing is done (normally by a technician). 

Bunion Pain: Ball and Ringer Stretcher to the Rescue

FootFitter Bunion Stretcher Ball & Ring, Cast Iron

http://www.amazon.com/FootFitter-Bunion-Stretcher-Ball-Ring/dp/B000POHTOG

This is a great product that the podiatrists in my office have been using for years. It can not only be used for bunion areas to produce a gentle stretch, but for other pressure spots also. My patient Lynda last Thursday reminded me that she purchased this several years ago and has been stretching her shoes to alleviate the pressure around her bunions every since. You want to go easy so it may take a few nights. If you push too hard, the bump produced can be cosmetically unappealing.

Bunion Pain: Or Is It?

Many patients present to my office with painful bunions hoping to avoid surgery. Or, even worse, having had surgery only to find out they still have significant pain. Bunions themselves only hurt due to pressure against a shoe from the bump that is produced.



Bunion on the right foot may develop pain from the bump.

Patients with bunions can present with sesamoiditis (two bones under the big toe joint), first metatarsal joint capsulitis (inflammation of the joint), hallux limitus (some joint tightness with possible arthritis), and hallux rigidus (definite arthritic joint). The treatment of bunions alone is different from bunions with sesamoiditis, bunions with capsulitis, bunions with hallux limitus, and bunions with hallux rigidus. I hope the video helps the patient with a bunion ask better questions of the doctor (ie Is this a bunion with hallux limitus?). I hope they also understand that a bunion needs specific treatments and the other causes of pain around the big toe joint each need specific treatments separate from the bunion.

Bunions: 4 Stages of Development

Here the 4 stages of bunion development are discussed. The emphasis is on stabilizing the bunion in Stage 2 for as long as possible. In most cases, rapid increase in the size of the bunion does not occur until Stage 3 due to the retrograde forces on the bunion as the big toe pushes off the ground in a misaligned position. The vital importance of simple, perhaps too simple for this high tech world, toe separators can not be emphasized enough.

Taping with Kinesiotape for Bunions

Bunions produce instability in the foot that can lead to pain in the foot, ankle, knee, hip or back. They are a weak spot that need to be addressed, often times quite simply. What do we have at our disposal? Foot strengthening exercises, toe separators, foot orthotics, surgery, shoes, and taping. The video below will show you how to use taping of the big toe joint to stabilize a bunion. If you tape for a week, you may find some of your symptoms that you thought were separate from the bunion are actually related. I have links below to the foot strengthening exercises and toe separators.













http://www.drblakeshealingsole.com/2010/12/foot-strengthening-exercises-who-has.html

http://www.drblakeshealingsole.com/2010/04/toenail-clippings2bunion-care-101.html

http://www.drblakeshealingsole.com/2010/03/tips-on-bunion-care.html