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Bunion Brother

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Does your bunion hurt? And hurt enough you're inclined to do something about it? An assortment of approaches can help.

Treatment for a bunion can vary from wearing dynamically-corrective sandals to more conservative, ample-toe-box shoes, to a change of diet, to cortisone injection, to physical therapy to ultimately surgery -- if the other options aren't having you feel the love of your feet again.

Quite honestly, I've found wearing bunion pads to be a waste of time, so-called yoga toes detrimental and night-time splints to be ineffective.

As far as surgery goes, not all bunion deformities are the same. Some can be fixed by just sculpting the "bump," while others do require cutting the bone and possibly doing joint remodeling. However, it can be a painfully-enduring process, and a little-known fact, often not shared before a surgical procedure, is that a significant number of people are not happy after bunion surgery. (1)

The key that I have found over the years in working to alleviate bunion pain symptoms is working with people, not film images, meaning gaining a gestalt of what has built the bunion. Even if I'm shown X-rays that incline me toward thinking about osteotomy (cutting and resetting bone) to achieve alignment, many times a less-radical alternative procedure can be done to obtain both pain relief and create better body symmetry. (I've even found some level of pain remediation and alignment correction using an amputee "phantom limb pain alleviation technique" I used in the Air Force called mirror therapy.) (2)

Mirror therapy tricks the brain into believing the amputated limb is still present. It apparently reduces the overall interference the brain generates in typical central pattern generation rehearsal to move a non-existing limb that many amputees experience until the "field of energy/morphic resonance" learns to compensate. Though, a note of experiential caution: This only seems to have an effect if a bunion is on one foot (and a mirror is positioned to reflect the other foot's properly-aligned toes).

Remember, bunions most often result when weakened muscles and ligaments holding the first metatarsal in place allow it to shift away from the second metatarsal. At the same time, the big toe will shift the other direction, toward the second toe, causing an imbalance in the joint. Pressure from shoes or the ground on the protruding end of the first metatarsal cause the characteristic bump on the side of the foot at the big toe joint. Bunion deformities are progressive and can lead to arthritis.

Of course, when you opt for alternative procedures, there are trade offs. Example: Is your bunion pain simply from the large bump on the side of the foot (your big toe does not hurt when it moves up and down)? If so, in my practice that is known as "bump pain."

Now, a film might show the metatarsal bone could be snapped and moved over as well as having the "bump" removed. But, in most cases, if you're more concerned about pain relief and not as much about the cosmetic appearance of the foot afterward, you and your health care professional might decide to just remove the bump without surgically altering bone.

End result: You no longer have pain, but when you look at the foot there may still be some deviation of the big toe and the foot may be slightly wider than your other foot. These asymmetrical features can be systematically addressed with a prescribed series of tai chi-like balance enhancing movements and being conscious of footwear choices and gait mechanics.

Nether-region pain

If the bulk of pain is on the bottom of your foot, then any surgical correction has to have as its goal elevation of the metatarsal bone and not necessarily decreasing the space between the fourth and fifth metatarsal heads.

Most cases of pain underneath are largely due to either: a severely-prominent fifth metatarsal head, thus putting more pressure on the walking surface; a lack of plantar fat underneath the metatarsal head, thus causing a lack of cushioning for the metatarsal; or an inflamed bursitis underneath the metatarsal head.

The order in which I come at this:

1) Padding (to take pressure off the metatarsal head.
2) If there is a chronic, inflamed bursitis, I highly encourage reducing dairy intake and increasing turmeric and ginger.
3) Instead of an osteotomy, I might recommend a client take a closer look at a simply condylectomy -- a shaving away of the bottom of the metatarsal head in an effort to decrease the pressure exerted by the bone on the walking surface.

A condylectomy is a much simpler procedure than an osteotomy, with a lot quicker healing time and no threat of non-union of the osteotomy, since an osteotomy is not being performed. I've seen clients misdiagnosed with plantar fasciitis receive gratifying pain relief after a condylectomy has been done (usually within days).

Another alternative first

Traditionally, the surgical treatment of hallux valgus (bunion) has been either by osteotomy bunionectomy -- cutting through the first metatarsal and repositioning it -- or by fusing the first metatarsal base to the first cunieform and the second metatarsal base, known as a Lapidus procedure. Both treatments require a long recovery period.

A procedure that requires no cutting of the bone and can be repeated if a bunion returns is
called the Tightrope or Mini Tightrope. It consists of drilling four 1.1-millimeter holes through the first and second metatarsals, and two sets of fiberwire are passed through the openings and anchored on either side. The wire is tightened to pull the first metatarsal inward and aligns the big toe. Finally, the wire is anchored on each end by a tiny button to keep it from slipping. A surgeon uses X-ray guidance to ensure the desired alignment, allowing a level of correction not possible with osteotomy or fusion. Walking with a boot brace is possible immediately after surgery and rehabilitation is generally 6-8 weeks.

Remember, the foot is art and science in motion. Leonardo da Vinci captured the essence of the strength and vulnerabilities of our feet when he wrote, "The human foot is a masterpiece of engineering and a work of art." It's the main reason you may want multiple opinions and to seriously consider alternatives to foot surgery. Once you tinker with a masterpiece, it is never the same.

References:

(1) A review of bunion surgeries shows that up to 33 percent of people who have surgery for bunions are disappointed in the result despite pain being reduced and the toe being straighter. The reasons are not clear. Some reasons for being disappointed in the surgery results could be that a person has to alter wear of certain shoe types (such as high heels) after surgery, or that the joint has less functional motion compared to the other foot. Ferrari J (2008). Bunions: http://www.clinicalevidence.com.

(2) http://mhsquadrupleaimchallenge.challenge.gov/submissions/13235-mirror-therapy-for-phantom-limb-pain-treatment-in-military-amputees

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