What should be done about a bunion, or when should it be corrected?

My opinions on this matter have changed over time. For many years my answers to this question was a compact “if it doesn’t bother you, leave it alone”. This answer possesses a certain kind of folksy, intuitive wisdom, and was usually well accepted by patients. I believed it myself… I felt that I was saving many patients from unnecessary intervention. However, this viewpoint was to simplistic, and did not address the reality that a great deal of internal damage can take place before some bunions become symptomatic (painful).

A significant portion of the patients with severe deformity eventually become symptomatic due to the internal loss of cartilage. Despite the fact that they made every necessary shoe compromise. However, correcting this type of bunion is not so easy. Not only because the deformity is more challenging, but because the cartilage is eroded, worn away. Cartilage is one of those tissues in the body that we are granted, only so much, for life. And when it’s gone, it’s gone. Oh sure there are methods that I can use to try and revitalize what’s left, transplant it, replace it with man made, but there is no substitute for having your own.

So now I’m getting to the meat of my answer. On x-ray of some painless and relatively mild bunions, one can see a loss of thickness of the joint space. Sometimes the the entire joint space becomes narrowed (joint space narrowing), while other times narrowing occurs only in one side of the joint space, and the other side remains a normal thickness.

We refer to this as “loss of joint space congruity” or “joint space asymmetry”. It means that one side of the joint is wearing out faster than the other. It is these painless bunions that need to be corrected earlier, before the pain starts. When this type of bunion starts hurting, it is late in the game, and it is hard to fix. I can realign the joint and it will look better, but it will take exceptional measures, or fusion of the joint, to stop it from hurting.

Why does cartilage wear out unevenly?

The short answer is; the joints were designed so the bones will touch and glide against each other in a very specific pattern. Once this contact pattern is lost, the wear of the cartilage becomes uneven.

Consider the front-wheel alignment of your car. When the alignment is correct and the tread makes even contact with the road, the tire wears well and you get lots of miles out of it. If the wheel alignment is incorrect, perhaps one edge of the tire makes firmer contact with the pavement. The tread on the heavy contact side will wear away faster, and you will rapidly need a new tire. The moral of this is, fix the alignment of your bunion joint before you need to retire it (eh… bad pun).