Bunionette: cute or painful?

Conway McLean, DPM

Joe was a veteran contractor. He performed some heavy labor, and always dressed in the appropriate uniform, which naturally included steel toed work boots. Joe had always found them uncomfortable, but, of late, they had become significantly painful. He was experiencing a vague, dull pain along the outside of his foot, but couldn’t recall any kind of injury to the area. He took some ibuprofen and hoped it would go away.

Martha was a paralegal in an upscale office, with some high-profile clientele. Everyone dressed “well”, and we’re not talking business casual here. There was no “Friday jeans day.” She noted a certain ill-defined pressure to look good, really good, and for a woman, that meant high heels. Much to her dismay, several of her nicest shoes were growing distinctly uncomfortable when worn. She didn’t get to sit at a desk all day, but was up and down, walking quickly, hither and yon. Her inspections revealed a red, hot, swollen area at the outer edge of her feet. Could it be gout?

Nursing can be a strenuous, stressful profession. Sally found it to be so, with short-tempered, demanding physicians, some ill-mannered, unhappy patients, and lots of long shifts, all adding up to both emotional and physical rigors. She was a veteran and had long ago learned to shake off the psychological stresses, but the passing years were making the physical requirements more difficult.

And painful, especially to her feet. She had noted a developing bump located at the base of her little toe, with the toe itself apparently drifting gradually over towards the other toes. Initially, the prominence just looked a little unsightly, but it was growing larger, and more symptomatic. She had never worked in orthopedics, and had no idea what the cause could be, but a co-worker said she probably had a bone spur. Did this mean she had arthritis?

Any guesses as to what was causing these problems? Could it be a bunion? That is a common foot problem, but, as you may know, a bunion is a bump that develops on the inner side of the foot and is always at the base of the big toe. How could this be the same problem, since these people were all experiencing deformity and pain on the outside of the foot? But it would seem there are similarities, which include a progressive prominence, redness, as well as a drifting of the attached digit over towards the middle of the foot.

Time to dispel the mystery: the condition under discussion is commonly referred to as a tailor’s bunion. How did it come to be called this? What is the association? Apparently, tailors used to sit in such a fashion that there would be pressure to the outside of the foot, and the joint in the ball of the foot, at the base of the little toe, would become irritated and painful, eventually leading to some local swelling. ‘Voila,’ it came to look like this common deformity, resulting in the term.

My personal favorite appellation for this malady is a bunionette. It sounds like such a cute little deformity, something to be shown off to your girlfriends! (“Sally has such a darling little bunionette!”) It should be obvious how this term came to be: if a bigger bump on the inner edge of the foot is a bunion, a smaller one on the outer edge must be a reduced version. Medically-speaking, it’s actually quite a different problem. A bunionette is often a stable deformity, more of an inherited condition. (Once again, thank your parents!)

A standard bunion, scientifically called hallux valgus, is a progressive issue, affected greatly by foot function. This means the position of the prominent bone, the first metatarsal, is altered by how well supported the arch is. In contrast, a tailor’s bunion is less likely to deviate because of how the body is working mechanically. What does change over time is the swelling of the soft tissues, the degree of inflammation, the development of a bursa, all of which can worsen the pain from the region.

But foot and leg function does have an impact. The positioning of the foot can greatly alter how much shoe pressure this area receives. Think about it; if the arch rolls inward excessively, a motion termed pronation, the arch moves down, but the foot also swings outward (away from the mid-line of the body). Some shoes resist this abnormal pronatory motion better than others, but the most practical method of reducing this movement is with an arch support. The most effective way of lessening pronation is with a prescription device (to the uninitiated, termed foot orthotics).

Naturally, any bump can be protected from pressure with various types of padding. If inflammation has developed in the soft tissues over the side of the metatarsal, a cold laser treatment or a steroid injection can be very effective at reducing the pain, but these do nothing for a bone that is sticking out. A variety of surgical procedures have been developed to correct the deformity, obviating the need for padding or shoe gear modification. Depending on where the deformity lies determines what kind of procedure is used.

Although the bone work performed will ultimately decide how effective the surgery is in the long run, the technique used to “approach” the site will have a major effect on the recovery. More trauma produced during the operation equates to more swelling and pain afterward. When a longer incision is utilized, the risk of infection rises. The concept behind minimally invasive surgical techniques, where the work required is performed through very small incisions, is to reduce this risk and speed recovery time. Special instrumentation is required for this kind of approach, especially the use of fluoroscopy, which is real-time x-ray imaging. This allows the surgeon to have x-ray vision, like the old ads for “x-ray spex.”

More technically demanding, minimally invasive techniques are being developed for a great number of surgical procedures, and not just in the feet, but throughout the body. With a tailor bunion deformity, sometimes the metatarsal bone is cut so that the head of the bone can be moved away from the side of the foot. If minimally invasive methods are used, this still doesn’t have to mean significant pain after the operation, and minimal recovery time is associated. A roomy but protective shoe or boot is used, but no crutches, casts, or walkers are required for normal healing.

There are various nuances to this problem, so naturally there are variations in care required. Is the painful bump on the outside of your foot a bump of bone, or just an inflamed joint capsule? Is it a spur of bone that has developed, or a bursa that is causing pain? If some simple home measures have not taken care of the problem, a structural abnormality may be responsible. Nothing wrong with trying some treatments on your own, but recurrent or lasting pain indicates something more is required. With a proper diagnosis, resolution of your foot pain is just a visit away. Relief from your cute little bunionette!

Editor’s note: Dr. Conway McLean is a podiatric physician now practicing foot and ankle medicine in the Upper Peninsula, having assumed the practice of Dr. Ken Tabor. McLean has lectured internationally on surgery and wound care, and is board certified in both, with a sub-specialty in foot orthotic therapy. Dr. McLean welcomes questions, comments and suggestions at drcmclean@penmed.com.