Jill Ferrari is a Health and Care Professions (HCPC) registered podiatrist and has worked in NHS and private practice since 1988. She is a senior lecturer at the University of East London and teaches on the undergraduate degree course in Podiatry, which is the only podiatry course in London.
Jill specialises in foot mechanics with a particular interest in paediatric foot conditions, working with the rheumatology team at Great Ormond Street Hospital. She was awarded a PhD in 2004 which researched into the female predominance of hallux valgus (bunions) in children and adults and she has numerous of publications in professional journals.
Do children get bunions?
Yes, one study found that around 1 in 40 children will develop bunions and the majority of these are girls. Typically the condition is seen to develop at around 10-11 years of age. The condition in young people appears to be related to a specific bony alignments of the first metatarsal, increased joint flexibility and tight calf muscles. The condition is not usually related to the pronated (flat) foot type such as is typically seen in adults.
Why is the condition so common in females?
The fact that females are more affected than males at all ages would suggest that there is something different about the foot structure between males and females. We know that females are more flexible than males and this might be one factor, since hyper-mobility (ligament laxity) is recognised as a cause of bunions. There is also some evidence that females have more rounded joint surfaces than males, making the female foot joints possibly more prone to drift out of position when abnormal forces act on the foot. Sexual dimorphism in leg and foot bones is recognised in primate bones as well!
Can I avoid getting bunions?
Despite recognising the foot structures that are seen frequently with bunions, we cannot predict who will develop bunions even when there is a positive family history. We feel that footwear with a high heel or that puts increased pressure on the toes may cause the deformity to occur more quickly if worn for extended periods. Activities such as ballet also exacerbate the occurrence of bunions, since the forefoot is overloaded (and is often very flexible). Climbing is also known to increase the deformity due to the pressure and positioning of the toes and the tight footwear used. We do not know if other sporting activities, such as a forefoot-strike running style, will speed the development of bunions. If you think you have a bunion developing it is good to seek the advice of an MSK specialist podiatrist to discuss ways to reduce abnormal forces acting at the 1st toe joint.
What treatment is the most successful?
Very little good quality research has been undertaken on conservative treatments to guide clinicians on the most effective non-surgical technique. Studies on splinting, toe wedges, exercises and manipulation, for example, have all shown an improvement in pain or deformity, but they have all been small studies, conducted over only a few weeks and the long term outcome, even at one year, is often not reported. Despite this, on the NHS, patients frequently have to try a period of conservative treatment before being considered for surgery. One good study has shown that the outcome for surgery at one year was better than the comparative groups of orthoses (which did reduce pain for the first six months) and the no treatment comparison. For surgery the osteotomies, which involve realigning the first metatarsal, provide the greatest correction of the deformity and these types of procedures are the most frequently used by surgeons. However, each surgeon will tailor the operations to suit the age of the patient, the degree of deformity and other factors that they might feel are related, such as the metatarsal length or joint instability.
Despite getting good surgical outcomes, the research studies have suggested that patients are not always satisfied with the outcome of the operation and this might be due to limitations in walking that remain or difficulty in wearing certain styles of shoes. Therefore it is important to discuss with the surgeon the results that you would like to achieve so that you are aware of what is possible or not, prior to the procedure. Always check that your surgeon has a special interest in foot and ankle surgery – so is a member of the British Orthopaedic Foot and Ankle Society (orthopaedic surgeons) or is a Podiatric Surgeon.