2. Elevator Podiatrist - Bunion Deformities - Dr. Gene Pascarella
Dr. Gene Pascarella was featured on the Elevator Podiatrist podcast and offered insight into bunion deformities.
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Q&A Transcript
Joe Crosby (JC)
Welcome to the Elevator Podiatrist, the show where we ask common foot and ankle questions to top podiatrists from around the country. There’s no appointment or co-pay required for this one-on-one Q&A, only free advice from individuals who have devoted their lives to all things feet. I’m your host Joe Crosby and today I’ll be speaking with Dr. Gene Pascarella, podiatrist and founding partner at Foot & Ankle Associates of Florida.
Dr. Gene Pascarella (GP)
Hi Joe, thank you for having me today. I am Dr. Gene Pascarella. I am a podiatrist in Altamonte Springs, Florida. I’ve been in private practice for approximately 34 years. I’m board certified by the American Board of Podiatric Medicine, Foot and Ankle Surgery and Fellow of the American College of Foot and Ankle Surgeons, and over the past 34 years I have been performing bunionectomy procedures on a continual basis and probably have done close to 800 to 1,000 of these procedures over my career.
JC
Speaking of bunions, that’s actually our topic for today. We’ll be kind of diving in the world of bunions, and specifically bunion deformities; what causes them, how to treat them and really any other issues associated with bunions, so to start off, we’ll kind of start simple.
What is a bunion?
GP
A bunion is a lay term, which basically describes a deformity of the big toe joint where the big toe meets the foot and the big toe moves in the direction towards the second toe and because of a mechanical imbalance it pushes the metatarsal bone behind the big toe in an outward fashion and that bump on the inside of the foot typically becomes red, swollen and it makes it difficult to find shoes that people can wear and walk in comfortably.
JC
What are some of the primary causes of a bunion?
GP
Well one of the primary causes of bunions is hereditary. Most of the time we see these in females and there is a hereditary component there, but probably another reason for that is because of the types of shoes. Most women would wear more of a dressier shoe with a narrow forefoot. This causes pressure on that bunion deformity causing pain. It’s probably interesting to note that shoe gear typically is not a cause of the bunion deformity. It is a progressive deformity and it will slowly get worse throughout your life, but it’s mainly a hereditary problem caused by muscular imbalance of the joint between the big toe and the foot.
JC
I guess speaking more specifically on bunion deformities, now there’s the term bunion. For bunion deformities, is there a specific grouping of different deformities, and if so, what would those be? What would be the main variances between those different types of bunion deformities?
GP
Well there are several different types of bunion deformities. Like I said, bunion deformity is a lay term. The medical term for a bunion is halus abducto valgus deformity. That describes the deformity of the joint. A lot of people wrongly thing a bunion is just a growth of bone on the side of the foot. It’s actually an angular deformity of the joint, and when we’re talking about different types of bunions, there are mild, moderate and severe deformities that can occur, and the treatment options are definitely designed to meet the criteria of the bunion. In addition, when you evaluate a bunion deformity, sometimes there will be arthritis in the joint, between the big toe and the first metatarsal, where the big toe meets the foot. That’s also spoken about calmly as a bunion deformity, but in reality, some bunions are an arthritic problem that occurs in that joint, where their joint becomes very stiff and painful, so in addition to maybe having pain that’s on the outside of the foot over the bump, you can experience pain within the joint when the joint actually becomes arthritic.
JC
I guess the next thing to cover would be treatment options. I’m sure there are several. What would be the top categories of treatment options for a bunion? If you see someone coming into the office, what would be the most common treatment and then talk through some of the other ones that you’ve used in the past.
GP
There’s both conservative and surgical treatment options available for bunion deformities. Conservative treatment options are adjusting the shoe gear so the shoes are wide enough that they’re not causing pressure on the bone and the nerve that overlies the bone there. Anti-inflammatory medications. Some of these can be over-the-counter medications like Aleve and Advil. There can be pads that can be placed over the bunion that can protect it from the shoe. In the case where there’s arthritis in the joint, sometimes we’ll utilize cortisone injections into the joint. That’s not something you would want to do frequently, but it can provide relief, and that relief can be sometimes longer term, sometimes very temporary. There’s really no way to predict the relief you’re going to get from a cortisone injection until you try it. And then on the other hand, surgical options are designed to address the actual degree of deformity. So just in general terms, the more severe the bunion deformity, the more advanced the procedures are to correct the deformity. So some of the simpler procedures are just to remove the bump of bone and maybe a soft tissue realignment. Patients can get back into a shoe in 2 to 3 weeks following that procedure. For moderate type bunion deformities, those usually result in some sort of cutting of the metatarsal bone to realign the joint, and once those cuts are made there’s usually some sort of fixation that’s applied; most likely small screws. And then when we get into the more advanced bunionectomy procedures, we’re looking at more fusions of the joint back down into the base of the first metatarsal, more of the midfoot, where that allows us to address larger corrections. That type of procedure generally carries a longer recovery time and involves larger screws and plates. And then more specifically talking about bunions that do have an arthritic component to the joint, sometimes it’s just removal of the spur or if there’s a little piece of bone. Next going into joint replacement procedures and then followed by a fusion of the joint between the big toe and the first metatarsal.
JC
So I do a little thing on here called myth or fact. I did some research to see what the top myths related to bunion surgeries. One of the myths I found is that “bunions can reoccur after surgery.” So is that a myth or is that a fact that a bunion can reoccur after surgery?
GP
So given that the correct procedure is chosen at the onset, the chance of recurrence of a bunion is small but not 100% unlikely. So there is a chance that you could get a recurrence of the bunion. We don’t see it that often, but it can occur. Some procedures that I discussed are more predictable than others in terms of recurrence such as the fusion of the big toe joint. That’s a very stable procedure and the chance of a bunion coming back after that type of procedure is actually very very small. So to answer your question just in short. There is the possibility that the bunion can recur, however if the proper procedure is chosen it is not that likely.
You know the driving force certainly to considering having the bunion corrected would be pain, number 1, inability to find shoes that you can fit and wear in comfortably, and three, how it impacts your activities. Most people today like to be active and exercise, and when you find that you can’t walk or run or do the workout you want to do because the bunion hurts, then it’s time to fix. What is really not appropriate is if you have a bunion and you just don’t like the way it looks, but there’s no pain and it’s not giving you any problems to go forth and have a bunionectomy, so there has to be the right reasons to consider having a bunionectomy in the first place.
JC
I want to thank Dr. Pascarella for joining me today, and I want to thank you for listening to the Elevator Podiatrist.