Treatment for Bunion and Metatarsophalangeal Joint Pain that is not responding to conservative care
Ross A. Hauser, MD
We see many patients at our clinic with various problems of the foot and feet. One problem is the problem of a bunion. If you are reading this article it is very likely that when you try to put on your shoes and socks, you are looking at a bony enlargement of the joint at the base of your big toe (the metatarsophalangeal or MTP joint). You play with and adjust your various splints and insoles trying to get that “just right” fit so you can comfortably walk. You may have been putting up with the pain for some time.
- Foot pain from toe instability.
- Bunions do not happen overnight – a bone spur is an evolutionary process.
- You have to do something with your bunion because now it is more than a problem of your toe.
- The surgery – non-surgery discussion.
- Realistic expectations of what conservative care can do for a bunion.
- Is physical therapy helpful for first metatarsophalangeal joint osteoarthritis?
- The surgical option – disappointing results because it is more than a problem of the big toe?
- “Surgical correction of the deformed segment itself could only correct skeletal alignment. However, does not solve functionally related problems that occur during walking.”
- Stiffness and range of motion problems persist after minimally invasive surgery.
- Prolotherapy for bunions.
- Lack of consensus on the efficacy of surgery and other conservative treatments.
- Patients reported a significant reduction in pain and stiffness.
There are many ways bunions can form and bunions can be treated. Here is what we hear from patients, many times after they had already visited the foot surgeon.
- I have had toe problems for a long time. My toes are beginning to point in all directions. I have corns and calluses. I need both feet done. My doctors do not want me to do both at the same time because it will make walking and rehab very difficult. One doctor does not think the bunionectomy (the surgeries to remove the bunions) will be effective long-term. I do not want the surgery. There was a woman in the podiatrists’ waiting room that told me she has had nothing but trouble since the surgery. She told me that she had to have a second surgery to fix the problems caused by the first surgery.
To be fair, some patients do very well with surgery. Some do not. We will explore this further below.
The challenges of treating bunion and metatarsophalangeal joint pain can be many. Medical researchers are continuing to study patient outcomes of the various forms of treatment they have received. In June 2022, La Trobe University researchers in Melbourne announced in the Journal of Foot and Ankle Research (8) that they are embarking on new research on the use of non-surgical treatments for hallux valgus. The authors reason: “Non-surgical management of hallux valgus may involve footwear advice or modification, foot orthoses, night splints, and physical therapies (manual therapy, taping or foot exercises). In podiatric clinical practice, these interventions are often combined in a multifaceted approach. However, there is limited evidence for the effectiveness of any of these interventions.”
Foot pain from toe instability
All joints in the body, when they become unstable or weak, will form bone spurs or bony overgrowths to prevent the joint from hyper-extending and causing more damage to itself. This is probably what is happening with your big toe. That bunion is there to protect the toe. A joint also forms this bony overgrowth to continue to be able to function as best it can in your body’s musculoskeletal community. In other words, the bony overgrowth helps the joint function enough so that the other joints do not have to assume an over compensatory role to keep balance in the body. For instance, your ankle making adjustments or your knee or your hip or your spine to favor your big toe.
In this video, Ross Hauser MD discusses a brief ultrasound examination that can show how your big toe pain is coming from toe joint instability. In this video, this is demonstrated by gently pulling on the toe to check for toe ligament damage and laxity or looseness.
Bunions do not happen overnight – a bone spur is an evolutionary process.
Unfortunately, over time, the bone spur itself becomes the problem as it continues to grow and impede function. This is when your ankle and knee and hip and spine do have to overcompensate. It is at this time toe joint replacement or toe fusion surgery is considered because your big toe is throwing everything out of alignment and above all, it is really painful. So that is how your bunion, initially trying to protect the function and stability of the toe, reached a point where it now became the problem.
Now we have presented the idea of how the bunion got there. Now we will tell you when it got there.
You did not wake up one morning and suddenly discover you have a bone abnormality, bunions do not form overnight. They are the continuing result of a big toe instability. Unfortunately, many people wait until the bunion becomes a big problem before they seek medical attention. If you keep putting off treatment for your toe problems that are causing the bunions, your situation will continuously degenerate.
You have to do something with your bunion because now it is more than a problem of your toe
A bunion is also referred to as hallux valgus in the medical community. The Latin name describes the problems of your big toe “hallux’, with a “valgus” a deformity that is pushing the toe away from the foot at the joint. See the x-ray to the left, or, as mentioned above, look down at your foot. Your own x-ray may be worse than our example.
Your big toe formed this bone not only to protect itself but also to provide support to the rest of the foot. If the big toe is not functioning, as we mentioned above, it can cause problems throughout the foot as the rest of the structure tries to overcompensate. In other words, the big toe is trying not to be a burden on the rest of the foot.
But your big toe did become a burden
The big toe has a big job to do in keeping balance among the foot and joints. If the big toe becomes a problem, it can cause gait abnormalities that can lead to ankle pain, Achilles tendon problems, plantar fasciitis, knee pain, hip pain, and lower back pain. These are situations that you may already be dealing with.
Please see our article You have a Gait Abnormality to understand the disruption one joint, such as a toe, can cause in your walking.
The surgery – non-surgery discussion
If you are reading this article it is very likely that you have graduated out of “conservative care options,” and need to explore something more aggressive for your toe problems. If you are like the many patients we have seen over the years with bunions and tailor bunions, or bunionette (a bunion on your little toe), you have already:
Changed your shoes or footwear type
You tried wider shoes, you stopped wearing high heels, the problem is the bunion is still there and it is painful.
You tried shoe inserts
You went down to the pharmacy or drug store and got yourself bunion cushions or pads. Many people buy the biggest pad they can get or use a sponge. This makes their foot pain worse in many instances because the pad or sponge is making for more pressure on the big toe and will cause pain. Even so, despite the pain, people sometimes continue to use these things because they think it will help. They will not help, they will make things worse.
For most patients, a bunion does not have to be treated surgically. It can be “managed” with conservative care. Below we will explain the difference between managed bunion care and regenerative medicine injections which can halt the progress of the bunion.
Realistic expectations of what conservative care can do for a bunion
Your doctors know that traditionally there are two routes that a person with bunion problems can take. Conservative care and pain and discomfort management, or surgery to shave down the bunion. There is a lot of research to suggest that neither of these routes is particularly effective. Later in this article, we will offer a third route. Regenerative medicine and the research that supports this line of treatment. Let’s look at some of the research.
This is what a team of hospital clinical researchers in Japan wrote in the Journal of Orthopaedic Science (1):
- “Nonoperative treatment using foot orthoses (shoe inserts or other types of brace or splint) decreased pain in patients with hallux valgus. The effect of treatment was maintained up to 2 years with a relatively high degree of patient satisfaction. However, treating physicians should inform patients to set realistic expectations and be aware that a limited degree of pain reduction is expected.”
Here we should note that at two years of wearing inserts and other appliances, the bunion pain was managed, but limited.
Here is a study from January 2019, it appears in the journal Foot and Ankle Surgery.(2) First, we want to comment on the opening two sentences:
- “Hallux valgus is a common diagnosis in orthopedics. Only a few studies have analyzed the effects of conservative therapy.”
- This is very true when researching Hallux valgus or bunions in the medical literature, very few studies discuss conservative therapy. There is a difference however between conservative care and regenerative medicine. Which we will discuss below. The great majority of research surrounds the challenges and outcomes of bunion surgery, which we all also get to.
Back to the research which comes from a team at the prestigious Hannover Medical School in Germany, the doctors at the Department for Foot and Ankle Surgery analyzed the effect of a dynamic hallux valgus splint.
They studied seventy patients with a hallux valgus who were treated using a dynamic splint or underwent no treatment. After a period of observation, they concluded wearing a dynamic hallux valgus splint does provide some pain relief in patients with symptomatic hallux valgus, but showed no effect on hallux valgus position.
Here again, the bunion pain was managed, but limited. A splint did not correct the toe deformity.
Is physical therapy helpful for first metatarsophalangeal joint osteoarthritis?
A March 2020 study from The University of Melbourne published in the Journal of Foot and Ankle Research (3) found that “Podiatrists and physical therapists use an array of assessment and treatment approaches for people with first metatarsophalangeal joint osteoarthritis, albeit there is limited evidence to support their clinical utility. Treatment strategies differ between professions, particularly with respect to medication, orthoses, and exercise. It is unclear whether these commonly-used strategies improve symptoms associated with first metatarsophalangeal joint osteoarthritis.”
The surgical option – disappointing results because it is more than a problem of the big toe?
“Surgical correction of the deformed segment itself could only correct skeletal alignment. However, does not solve functionally related problems that occur during walking.”
In this section, we are going to follow a progression of studies. Many people do benefit from bunion surgery. This section will explore the opinions of surgeons in presenting their realistic outlook on the success of bunion surgery.
In December 2016, doctors in the Czech republic published troubling finding on bunion surgery in the medical journal Clinical Biomechanics.(4)
Above we spoke about gait abnormalities and how the big toe or ankle, knee, hip, and back could impact how you walk. The point of having surgery for your bunion is to help correct this problem. The researchers in this study compared lower limb and pelvis movement during walking in patients with hallux valgus before and after surgery.
- Seventeen females with hallux valgus, who underwent first metatarsal osteotomy (bone shaving), constituted the experimental group.
- The results showed that after hallux valgus surgery:
- the walking speed decreased even more
- asymmetry in the hip and the pelvis movements in the frontal plane (present preoperatively) persisted after surgery. This is important because it leads to the study conclusion:
“hallux valgus deformity is not only a problem of the foot’s structure and function but also affects the entire lower limb and even the pelvis motion during walking. Surgical correction of the deformed segment itself could only correct skeletal alignment. However, does not solve functionally related problems that occur during walking that are probably related to the cause of the problem or with the learned aspect of motor behavior.”
In other words, the bunion surgery could only shave down the bone, it does NOT correct what caused the problem in the first place and a bunion may return
In other words, the bunion surgery could only shave down the bone, it does NOT correct what caused the problem in the first place. In this study, doctors found bunions can be caused by INSTABILITY in the entire lower limb and even the pelvis.
A paper in the April 2017 edition of the journal Arthroscopy Techniques (5) suggests that “the underlying reason for recurrence of hallux valgus deformity after bunion surgery is multifactorial and includes surgeon-based and patient-based factors as well as original components of deformity initially unaddressed at the index procedure.”
In other words, the surgeon did not address the problem causing the hallux valgus deformity and the patient is predisposed to factors of degenerative joint disease. In our opinion, these are the tell-tale signs of degenerative joint disease from joint instability from ligament weakness. Surgery does not address ligament weakness.
Stiffness and range of motion problems persist after minimally invasive surgery
In January 2019, a study published in the journal Foot and Ankle International (6) lead by surgeons at the University Hospital Basel, Switzerland addressed the problems of stiffness after open hallux valgus surgery which affects 7% to 38% of patients. They looked at Minimally invasive surgery and suggested:
- “Minimally invasive surgery (MIS) is thought to decrease this rate (of stiffness after surgery) by reducing soft tissue trauma. Minimally invasive surgery, now in its third generation, is advertised as delivering results superior to open surgery. However, no studies have reported stiffness or range of motion (ROM).
The surgeons of this study looked at 50 patients who received Open Scarf-Akin surgery and 48 received minimally invasive Chevron Akin (MICA) surgery.
Your doctor may have discussed these surgical options with you. In the Open Scarf-Akin surgery, the surgeons saw down the bunion, the remaining bone is then split into two halves and re-positioned into more natural alignment. Screws are then drilled into the bone to hold your “new” toe together. Recovery time suggested in 6 to 8 weeks. One of the reasons doctors look at minimally invasive surgery is to limit soft tissue damage. In this surgery, the ligaments that hold the bones of the toe together are “released.” The ligaments are damaged.
In the minimally invasive Chevron Akin, surgeons also re-position the bone, hold it in place with screws, and if needed shave down the bone if the deformity is causing the issue.
Back to the study, again people do benefit from this surgery, so let’s see what happened to these 98 patients.
- Six percent of patients continued with moderate stiffness. Three cases in both groups.
- Minimally invasive Chevron Akin patients showed toe extension increased by 10 degrees while it remained unchanged in the open surgery patients. However, both groups showed similar improvements in functionality scores, score, pain, and subjective foot value. (Patients noted improvements).
- (Almost 15% wound problems) Wound problems included delayed healing in 10% in open surgery patients and wound infections in 4% in minimally invasive patients.
- The rate of recurrence and other complications were comparable, except for reoperations, which were higher in minimally invasive patients (27% mainly for protruding screws) than in open surgery (8% mainly for stiffness).
- In minimally invasive patients, 14% were intra-operatively converted to open surgery. During the minimally invasive surgery, the doctors had to switch to open surgery for various reasons.
The surgeons of this study concluded that minimally invasive surgery showed no advantages over open surgery other than a shorter scar.
A June 2022 study published in the British journal of pain (9) offered an assessment of patient reported outcomes following hallux valgus and/or hallux rigidus surgery. The researchers assessment included: “Even when surgery is performed by an experienced surgeon, there remains a potential for patients to experience dissatisfaction and unfavorable outcomes.”
These unfavorable outcomes included continued physical limitations and “Patients experiencing problematic outcomes were functionally limited, had low mood and were unable to return to a normal life post-surgery. (Women) reported weight related issues and were limited in their footwear and clothing choices, negatively impacting on their self-esteem.
Prolotherapy for bunions
In this video, Ross Hauser, MD, explains and demonstrates the treatment for Prolotherapy for toe pain, instability, and bunions.
The treatment begins at 1:12.
In this video, a medical professional is being trained on the Prolotherapy technique by Dr. Hauser. Dr. Hauser is the one making the pointing gestures to guide the injections.
- Prolotherapy injections involve using a simple and safe base solution, dextrose as the primary proliferant (treatment), along with an anesthetic (such as procaine or lidocaine), that is given into and around the entire painful/injured area(s). Many injections are given during each treatment. Most treatments are provided every 4 to 6 weeks to allow time for the growth of new connective tissues. Dozens of research studies have documented Prolotherapy’s effectiveness in treating chronic joint pain.
- In this particular patient, they came in seeking treatment after already having a joint replacement to the left big toe joint. The joint replacement did not help this patient and had made things worse for them. Because the patient continued to have pain after the toe joint replacement, this gave us the clue that the pain was coming from the ligaments and ligament attachments surrounding the joint.
At 2:24 the right toe treatments show the comprehensive nature of this injection treatment.
- We recommend toe crunch exercises in most patients. This is discussed at the time of the treatment.
- If there is a valgus deformity, we may suggest “Yoga Toes,” or other toe separation or toe stretching apparatus.
- If sesamoid bone pain or sesamoiditis was present, we would have continued the treatment to address those concerns.
Lack of consensus on the efficacy of surgery and other conservative treatments
The patient in the video above came into our office after toe joint replacement. This is in agreement with research like that above, that due to a lack of consensus on the efficacy of surgery and other conservative treatments, patients are considering alternative methods, including Prolotherapy. MTP joint pain is difficult to manage, this study investigated Dextrose Prolotherapy injections in order to establish the efficacy of this treatment with a study group and, subsequently, with patients afflicted with several painful conditions.
Bunions are an overgrowth of bone at the first metatarsophalangeal joint caused by degenerative joint disease from joint instability from ligament weakness. When ligaments weaken, the bones move. This is visually evident because bunions are a result of a gross displacement of the bone. Bone movement due to ligament laxity causes the bones to hit each other. This hitting causes an overgrowth of bone, as an attempt to stabilize the joint.
In Caring Medical Research, published in the Foot & Ankle Online Journal (7) patients complaining of diffuse big toe pain were treated with Prolotherapy. In the days following the procedure, patients were allowed to return to normal non-strenuous activities. Patients were advised to avoid medications such as ibuprofen, which block the inflammatory process. However, we did approve of the use of acetaminophen-based analgesia. Patients returned for treatment every four weeks, depending on their schedule, completing from 3 – 6 treatments.
In this Danielle R. Steilen-Matias, MMS, PA-C describes treatment in a patient with “Turf Toe.”
This patient came in with “Turf Toe.” A common injury in football players, it is a sprain of the metatarsophalangeal joint. This usually occurs when their toe gets caught “on the turf,” and the toe hyperextends.
With Prolotherapy treatment, we want to stimulate repair in those ligaments that surround the joint capsules of the big toe. The patient tolerates the injections very well. The treatment is quickly given. It is a lot of shots so we can stimulate sufficient healing.
We ask patients to rest for 4 days and then they can start gradually as tolerated.
Patients reported a significant reduction in pain and stiffness
- After receiving injections, patients reported a significant reduction in pain and stiffness.
- Patients were asked to rate their pain levels on a scale of 0 to 10, with 0 being no pain and 10 being severe crippling pain.
- All 12 patients reported pain as a symptom. Thus, patients were asked to report pain levels before and after Prolotherapy in these three categories:
- 1) pain at rest,
- 2) pain with normal activities, and
- 3) pain with exercise.
- Concerning 1) pain at rest: prior to Prolotherapy treatment, pain measurement scores averaged 4.42./10. After Prolotherapy treatment, pain measurement scores averaged less than 1/100th. Only one patient reported a VAS pain level of 1, and all others reported zero.
- Concerning 2) pain with normal activities: prior to Prolotherapy treatment, pain measurement scores averaged 6.50.
- Five of 12 patients could walk less than fifty feet without pain; seven of 12 could not walk a half-mile without pain; and ten of 12 could not walk a full mile.
- After Prolotherapy, all but one patient reported no restrictions in walking any distance without pain, and a pain measurement average score of 1.17 was noted.
- Concerning 3) pain with exercise: prior to Prolotherapy, five of 12 patients reported being severely compromised (only 0 to 30 minutes possible) in their ability to exercise, and pain measurement score of 7.42.
- Of the twelve patients, two were totally compromised and unable to exercise; three were moderately (only 30 to 60 minutes possible).
- Over half of the patients were severely to totally compromised in their athletic abilities prior to treatment.
- After Prolotherapy, seven of 12 patients reported being able to exercise as much as they wanted without impediments and with satisfaction.
When comparing the three previous categories before and after Prolotherapy, all reached a statistically significant outcome.
Thus, this retrospective study, without a control group, demonstrates that Prolotherapy decreases pain and improves the quality of life for patients with metatarsophalangeal joint pain—unresolved by previous therapies, medications, and interventions.
As a result of Prolotherapy, eleven of 12 patients reported a greater than 75% improvement in the activities of daily living that continued to the end of the study. Of the two patients who were told they needed surgery, both felt sufficient pain relief with Prolotherapy to avoid surgery. After the study period, patients experienced an overall improvement in range of motion, ability to walk and exercise, as well as relief of stiffness and numbness/burning. Prolotherapy is superior at eliminating the pain of bunions but does not correct the deformity.
Questions about Bunions and Metatarsophalangeal Joint Pain? Get help and inflammation from our Caring Medical staff
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This article was updated June 17, 2022