Bunions Why & How

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Slide 1:

Bunions Michael E. Graham, DPM, FACFAS

What is What is a BUNION bunion?:

What is What is a BUNION bunion?

Latin word meaning “enlargement” it was applied to a bursa that has had chronic irritation. Associated with tarsal or metatarsal articulation. :

Latin word meaning “enlargement” it was applied to a bursa that has had chronic irritation. Associated with tarsal or metatarsal articulation. A Manual for the practice of surgery, Thomas Bryant, Henry C Lea Publisher, Phila , 1879, p. 140

Slide 4:

The inflamed bursa is a fluid filled sac that acts like a cushion. The most common location for an enlargement of this cushion is on the side of the foot near the big toe.

Slide 5:

Now most people only associate a bunion with the big toe joint.

Why do we get bunions?:

Why do we get bunions?

It could be traumatically induced.:

It could be traumatically induced.

It could be congenital:

It could be congenital

The most common reason is simply due to a faulty foot structure.:

The most common reason is simply due to a faulty foot structure.

There is an internal flaw with the support system of the feet.:

There is an internal flaw with the support system of the feet.

High heel shoes make a bunion deformity worse…:

High heel shoes make a bunion deformity worse…

…but there first has to be a pre-existing internal predisposing factor.:

…but there first has to be a pre-existing internal predisposing factor.

Let’s:

Let’s

Let’s dig a little deeper:

Let’s dig a little deeper

What are the involved structures?:

What are the involved structures?

First, there is the big toe (hallux). It has 2 bones.:

First, there is the big toe (hallux). It has 2 bones.

Then there is the first metatarsal bone.:

Then there is the first metatarsal bone.

The 1st Metatarsophalangeal joint (1st MPJ) is where the base of the big toe joins the end of the 1st metatarsal.:

The 1 st Metatarsophalangeal joint (1 st MPJ) is where the base of the big toe joins the end of the 1 st metatarsal.

Also, there are 2 accessory bones called the sesamoids.:

Also, there are 2 accessory bones called the sesamoids. Fibular sesamoid Tibial sesamoid

Finally and very importantly there is the medial cuneiform.:

Finally and very importantly there is the medial cuneiform.

The medial cuneiform is a very important bone.:

The medial cuneiform is a very important bone.

The medial cuneiform should provide a very stable connection/foundation to the first metatarsal bone.:

The medial cuneiform should provide a very stable connection/foundation to the first metatarsal bone.

There should only be 1 to 2 degrees of motion of the first metatarsal on the medial cuneiform.:

There should only be 1 to 2 degrees of motion of the first metatarsal on the medial cuneiform.

Individuals who develop bunions have instability of first metatarsal cuneiform joint.:

Individuals who develop bunions have instability of first metatarsal cuneiform joint.

The 1st metatarsocuneiform joint is stable in these feet and no bunion deformity is present.:

The 1 st metatarsocuneiform joint is stable in these feet and no bunion deformity is present. These feet have a flat stable foundation for the 1 st metatarsal

In order to identify abnormal you first have to know what IS normal.:

In order to identify abnormal you first have to know what IS normal. Normal Abnormal

If the foundation isn’t stable at the base of the 1st metatarsal bone then it will follow the direction of the abnormal tilt.:

If the foundation isn’t stable at the base of the 1 st metatarsal bone then it will follow the direction of the abnormal tilt.

When the 1st metatarsal drifts away from the 2nd metatarsal this is called metatarsus primus varus.:

When the 1 st metatarsal drifts away from the 2 nd metatarsal this is called metatarsus primus varus .

When the big toe turns outward this is called hallux abductovalgus (HAV):

When the big toe turns outward this is called hallux abductovalgus (HAV)

It’s pretty rare to have a HAV deformity without a large metatarsus primus varus deformity.:

It’s pretty rare to have a HAV deformity without a large metatarsus primus varus deformity.

The metatarsal bone drifts inward and the big toe will turn out to compensate.:

The metatarsal bone drifts inward and the big toe will turn out to compensate. “For every action, there is a reaction”

That’s because these 2 deformities contribute to the formation of the other.:

That’s because these 2 deformities contribute to the formation of the other.

This complex deformity is hallux abductovalgus with metatarsus primus varus.:

This complex deformity is hallux abductovalgus with metatarsus primus varus.

Recap A bunion is mainly due to instability of the first metatarsal at it’s connection to the medial cuneiform. :

Recap A bunion is mainly due to instability of the first metatarsal at it’s connection to the medial cuneiform.

If this connection was stable than it would it not deform no matter how strong the forces acting on it. The toe would still be straight and therefore a bunion deformity could not occur.:

If this connection was stable than it would it not deform no matter how strong the forces acting on it. The toe would still be straight and therefore a bunion deformity could not occur.

Let’s think about the progression of this deformity.:

Let’s think about the progression of this deformity.

There are more contributing factors to the formation of bunions.:

There are more contributing factors to the formation of bunions.

First let’s discuss involved anatomy.:

First let’s discuss involved anatomy. Bones – osseous structures Ligaments – connection bone to bone for added stability. Tendons – connect a muscle to bone to stabilize or move one bone on another. Joint - juncture where 2 bones meet.

6 Tendon Forces acting on the 1st MPJ:

6 Tendon Forces acting on the 1 st MPJ Proximal Forces Extensor Hallucis Longus Extensor Hallucis Brevis Flexor Hallucis Longus Flexor Hallucis Brevis Abductor Hallucis brevis Adductor Hallucis Brevis Distal Forces

If the big toe and 1st metatarsal joint are aligned then the forces will normally act on the 1st metatarsal.:

If the big toe and 1 st metatarsal joint are aligned then the forces will normally act on the 1 st metatarsal.

However, if there is an abnormal alignment of the 1st MPJ then the normal tendon forces act abnormally on the 1st MPJ contributing to a progression of this deformity.:

However, if there is an abnormal alignment of the 1 st MPJ then the normal tendon forces act abnormally on the 1 st MPJ contributing to a progression of this deformity.

Then there is “ground reaction” force.:

Then there is “ground reaction” force.

This is the force from the ground pushing up on the first metatarsal.:

This is the force from the ground pushing up on the first metatarsal.

To reiterate, if the 1st metatarsal bone is stable it is able to handle these forces with no problem. :

To reiterate, if the 1 st metatarsal bone is stable it is able to handle these forces with no problem.

However, if there is instability it will lead to a complex bunion deformity.:

However, if there is instability it will lead to a complex bunion deformity.

Recap:

Recap There is an inherent bony instability Tendons acting on the 1 st MPJ are contributing to the problem. The forces from the ground adding to the deformity.

So what is responsible for the formation of this unstable architecture?:

So what is responsible for the formation of this unstable architecture?

Well, the main underlying cause begins at the back of the foot...:

Well, the main underlying cause begins at the back of the foot...

…with the ankle bone.:

…with the ankle bone.

Ankle bone = Talus:

Ankle bone = Talus

The talus is supposed to sit on top of the heel bone (calcaneus).:

The talus is supposed to sit on top of the heel bone (calcaneus).

It is connected to the hind-foot via four different articulations :

It is connected to the hind-foot via four different articulations 1 2 3 4

If the talus partially dislocates off the heel bone it falls forward.:

If the talus partially dislocates off the heel bone it falls forward.

The leading edge of the talus:

The leading edge of the talus

The leading edge of the talus:

The leading edge of the talus should only be slightly in front of

Slide 56:

the leading edge of the calcaneus.

This leads to a chain reaction affecting the rest of the foot.:

This leads to a chain reaction affecting the rest of the foot.

This leads to the “Domino Effect”.:

This leads to the “Domino Effect”.

Need more proof:

Need more proof

Slide 60:

The stability of the hind-foot controls the stability of the mid-foot.

Slide 61:

The stability of the mid-foot controls the stability of the forefoot.

Slide 62:

The stability of the hind-foot controls the stability of the mid-foot and ultimately the stability of the forefoot.

Talar displacement on the hindfoot bones is a MAJOR factor in the formation of bunion deformities. :

Talar displacement on the hindfoot bones is a MAJOR factor in the formation of bunion deformities.

Bunions are CHRONIC PROGRESSIVE DEFORMITIES:

Bunions are CHRONIC PROGRESSIVE DEFORMITIES

Bunions will not go away on their own!:

Bunions will not go away on their own!

Conservative Options:

Conservative Options Good Luck

Slide 67:

When the metatarsal bone is cut and shifted, the true root of the problem is not fixed. Is this really “fixed”

A perfectly straight metatarsal bone was “bent” to “correct” it. :

A perfectly straight metatarsal bone was “bent” to “correct” it.

Failure or Reoccurrence:

Failure or Reoccurrence Until the underlying faulty mechanics are addressed this deformity will come back. We can put on a new tire, but until we balance the wheel, it will again wear-out.

Faulty foot mechanics with and without TaloTarsal Stabilization with HyProCure :

Faulty foot mechanics with and without TaloTarsal Stabilization with HyProCure

Same patient:

Same patient

One of the first things to do is to stabilize the hindfoot.:

One of the first things to do is to stabilize the hindfoot.

Hindfoot instability leads to…:

Hindfoot instability leads to…

Mid-foot weakness, leads to loss of stability to the 1st metatarsocuneiform joint.:

Mid-foot weakness, leads to loss of stability to the 1 st metatarsocuneiform joint.

The ground pushes up on the 1st metatarsal :

The ground pushes up on the 1 st metatarsal

Slide 80:

Hind foot forces Tendon forces Ground reaction forces

Eventually transforms a mild deformity:

Eventually transforms a mild deformity

Into a severe deformity.:

Into a severe deformity.

In order to eliminate this complex disorder…:

In order to eliminate this complex disorder…

…you must first address the underlying cause.:

…you must first address the underlying cause.

www.hyprocure.com :

www. hyprocure .com View our on-line training www.hyprocuredoctors.com “Changing Lives, One Step at a Time” For more information about bunions and an internal preventative treatment option please visit: