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Destined to a Life without Fashionable Footwear?
A Troubled Teen’s Search for Convenient Bunion Prevention
February 1, 2008
For as long as I can remember, my grandmothers have complained about their bunions. The bony red bumps on the insides of their feet caused them to special order shoes and cringe whenever they got pedicures. While it was a fate I hoped to avoid, it was also a fate that seemed very far away to a child.
As I got older, however, the bunion nightmare came closer and closer to reality for me. Until my father showed symptoms of a growing bunion, I had believed that they were only the worries of older women. I didn’t understand why my dad, a man who was an entire generation younger than my poor grandmothers, already showed signs for bunions.
Once my Dad bought his first foot brace, the lectures about bunions increased exponentially. He criticized every pair of shoes I put on my feet, including high heels, flats, flip-flops, and shoes that were too small for me. Claims of lack of arch support, narrow toe box, and unnatural positioning became part of weekly conversations with my paranoid father. He believed that bunions were a genetic problem that ran in the family, and that if I did not take early steps to prevent them, they would appear sooner and with much more pain than I expected. “It isn’t just a problem for old ladies,” he said.
I am curious to find out if sufficient research supports his fears for me and other young adults regarding development and prevention of bunions. Hopefully, I will be able to find effective solutions for prevention that do not require spending my youth in therapeutic shoes.
What are Bunions?
Most simply, bunions are painful, bony, red protrusions on the inside of the foot that cause the big toe to angle towards the other toes. Bunions result from a hallux valgus deformity on the metatarsophalangeal (MTP) joint of the big toe; “hallux” denotes the big toe and “valgus” explains its tendency to rotate inward towards the other toes. The protrusions themselves are actually bursae, or small fluid-filled sacs that provide cushioning between bones and tendons, and their redness is due to the swollenness that occurs when they form between the hallux and the first metatarsal bone (major bone in the big toe) at the MTP joint (Ayub, Yale, & Bibbo, 2005).
More Than Aesthetically Unpleasant, Also Painful
This pressure caused by the bursae at the MTP joint is responsible for most of the pain of a bunion. The bursae causes the hallux to rotate inward, which in turn causes the biomechanics of the foot to change. These changes cause the person to shift their weight laterally, and the weight shift results in increased pressure at the first metatarsal bone, therefore inducing pain (Ayub, Yale, & Bibbo, 2005).
Bunions tend to correlate with other foot deformities, most often hammertoes. Hammertoes occur when the second, third, or fourth toe is unnaturally elevated, which sometimes happens when the hallux rotates towards the second toe. Much of an individual’s foot pain would come mostly from the hammertoe and would be relieved once the bunion is treated (Ayub, Yale, & Bibbo, 2005).
Once a bunion forms, any outside pressure increases pain, and most often that pressure relates to footwear. The tighter the shoe, the more pain results from increased pressure on the bunion. Shoes with a wide toe box are the best solution for people with bunions, and if the deformity is bad enough, the shoes needed must be special ordered or stretched around the bunion area (Lander, 2007).
Causes: Environmental and Hereditary
Several factors contribute to bunion formation, though the causes vary with each individual. The most widely accepted and researched causes, though, are footwear and genetics (Lander, 2007).
According to Ms. Payne in her 2007 article, Women spend $3.5 billion annually in the United States for foot surgeries, and their footwear seems to provide several reasons why. Mayo Clinic warns about high heels, saying that they force your foot forward and “redistribut[e] your weight, creating unnatural pressure points and throwing your body's natural alignment out of whack.” Bunions are associated with an unnatural shift of natural balance, and studies have shown that older women with bunions are more likely to fall because of being off-balance (Menz, Morris, & Lord, 2006). High heels are responsible for creating harmful pressure in the same bones and ligaments that cause bunions, and the higher the heel, the exponentially more dangerous its effects; The American Society of Podiatric Sports Medicine explains that even a modest “three inch heel creates seven times more stress than a one inch heel.” Echoing this, the American Academy of Orthopedic Surgeons developed a rule of thumb that is rarely heeded: “no more than three hours in 3- inch heels,” (Payne 2007).
High heels are not the only kinds of shoe highly detrimental to women’s feet. Several of the trendiest shoes in stores today boast not only four or five inch heels, but also narrow tow boxes, pointed toes, and thin soles, all of which cause the shoes to be categorized in the “cruel variety” by the American Orthopedic Foot & Ankle Society. Flip-flops and flats seem to be the solution since they do not have a heel, but they too cause problems. Podiatrist Stephen Pribut insists that flip-flops bring his patients into the office, not out of it. The “flip-flop” noise made with each step results from repeatedly lifting the foot from the shoe and creates tension in the foot, thus worsening factors that lead to bunion development. Ballet flats are only really detrimental when worn for long periods of time; while they do not create more tension, they fail to provide necessary support, explains podiatrist Erika Schwartz (Payne 2007). Pointed toes cause the foot to be pushed into an unnatural v-shaped, foreshadowing the shape of the foot once bunions form (Schwartz 2001). Even when straying from high heels, women still manage to find shoes that harm their feet.
Genetics seem to be an integral factor also, as bunions seem to run in families (Ayub, Yale, & Bibbo, 2005). My father is still developing bunions, even though he never wears the harmful footwear that women wear. Podiatrist Dr. Jane Collins (2007) explains that since bunions form as a result of weakness in ligaments and muscles of the foot, they are thought to be a genetic predisposition. Some people with bunions pass on genes for weak foot muscles that allow bursa to form in their children more easily than in other children. It is unknown which gene or genes translate to the kinds of foot problems that lead to bunions, but there are indications that there is a genetic connection.
General Advice for Prevention
Advice generally relates to changing footwear habits since genetics, the other main contributor to bunion development, cannot be altered. General tips include expanding the toe box, such as stretching tight-fitting shoes, and using orthoses, or special splints, inside shoes to decrease pain (Ayub, Yale, & Bibbo, 2005).
Mayo Clinic offers useful, practical advice about footwear options for those who are susceptible to bunion development. Dr. Ellman, who specialized in podiatry work with women who continue to wish to wear fashionable shoes despite their bunion problems, explains that everything is in moderation. These women do not necessarily have to throw out their heels, but they should buy low heels, hopefully only one inch tall. Dr. Ellman advises to only wear them for special occasions or to wear walking shoes or sneakers while commuting and change into heels upon arrival; alternating shoe choice during the day is always better than wearing harmful shoes all day long. Many women unknowingly wear shoes that are too small for them, she says. Feet grow wider as women age, and they should compare the width of the shoe to the width of their foot, occasionally getting re-measured. Also, she claims most women do not know that a shoe is a good fit only if it extends a finger width past the longest toe. A “break-in period” is a shoe seller’s favorite phrase, but not one that women should believe to be healthy; a shoe should be comfortable starting from the moment you first try it on. Many women sacrifice too much for fashion, even when no one is looking. She advises to choose footwear wisely, and only to let fashion override your common sense when it really matters (http://www.mayoclinic.com/health/foot-problems/WO00114).
The Payne article echoes nearly identical advice, and it seems that podiatrists seems to agree about footwear habits and options. However, I have not found many scientific studies to reinforce their suggestions so the effects of these changes in footwear are fairly skeptical.
A More Convenient Option…Night-time Orthoses
When it comes to bunions and other feet problems, I tend to relate the situation to orthodontics. Since I had braces for five years, I received many lectures on re-shaping teeth and wearing retainers; now I see those lectures as being very similar to those about re-shaping the big toe and wearing splints. Take two people with different teeth growth patterns. Person A does not need braces because he was born with naturally aligned teeth, but Person B needs braces for 4 years. After the four years, Persons A and B both have equally straight smiles, but Person B requires a retainer to keep his teeth straight, while Person A does not because they were born with different genetic tendencies for tooth alignment. Still, over time, both persons have the tendency for their teeth to shift into poor alignment because of environmental factors.
In connection with feet and bunions, Person A is born without any genetic tendency for developing a bunion, while Person B is very susceptible. Person B develops problems faster than A and shows symptoms of a bunion faster. I think that they should be treated just as the two teeth patients were treated, in that Person A should avoid environmental factors that would lead to a bunion (like harmful footwear) and Person B should both avoid environmental factors and pursue correction and retention techniques. If there was some way to put “braces” on Person B’s foot and make it normal like Person A, then a way to keep it normal with some sort of foot “retainer,” then wouldn’t they end up like the teeth patients?
It turns out that I was not the only person with this idea in mind. Night braces are special kinds of orthoses that reposition the big toe and use time spent sleeping to repair foot damage and retain a healthy position. At FeelGoodStore.com, “Nighttime Bunion Regulators” are available for sale. They promise to “correct painful bunions without surgery” and provide “permanent relief.” The comfortable splint “repositions the big toe” and “stretches tight tendons and muscles while you sleep.” Sounds perfect. Is it?
Fact or Fiction: the Science Backing a Night Brace
First of all, I got suspicious when I read that the brace is “one size fits all.” For tooth retainers, every mouth is different and every tooth is a different size and shape, meaning that the retainer must be tailored specially for that person’s mouth. I know that the same is true for special earplugs, shoes, clothes, and anything that is supposed to fit the body well. Why should this foot brace be any different? Feet are all different sizes and the bones that need to be realigned are in different positions depending on the size and shape of the foot. Feet have varying arch, length, width, and many other characteristics, and I am not sure that a brace that “fits all” would be very effective.
Secondly, a study in London produced results that demonstrated that orthoses, including night braces, only improved the pain created by bunions, not the bunions themselves (Ferrari, Higgins, Prior, 2004). The study was fairly criticized, though, as one reviewer in the article argued that the study should have taken place over a longer span of time and should have included more emphasis on orthoses treatments (it had been primarily dedicated to researching the surgeries available).
Another study in Finland concluded that surgery was an effective method of correcting bunions, and that orthoses were only useful for providing temporary relief (Torkki, Malmivaara, etc., 2001). It argued that orthoses were indeed better than no treatment, unlike the results obtained from the London study, but that they should only be used for mild cases that require short-term relief.
I am wary to conclude too much from my research. I think it is wise to heed the general advice about footwear found on the Mayo Clinic website; it makes sense to me and seems to allow for moderation, which is what I wanted. I will probably not buy the night brace online, as tempted as I might be, because of the one-size-fits-all claim. The studies informed me as to what options are available for bunion problems, but I am not sure that they were really tailored to my needs for prevention instead of correction. There is still much unknown about foot disorders like bunions and their causes, and I think moderating environmental harm is the best step I can take before consulting a physician. I will hide my highest heels for a while and make sure my feet feel comfortable in shoes I try on at stores. And who knows, maybe the athletic look would suit me better: sweats, t-shirts, and good, supportive sneakers.
Asad Ayub, MD, Steven H. Yale, MD, and Christopher Bibbo, DO. “Common Foot Disorders.” Clin Med Res. 2005 May; 3(2): 116–119
Collins, Dr Jane (2007, March 3). Too young for bunions :[Final 3 Edition]. The Times,p. 9.
Retrieved February 7, 2008, from ProQuest Newsstand database. (Document ID: 1226392231).
Ferrari J, Higgins JP, Prior TD. (2004). Interventions for Treating Hallux Valgus
(abductovalgus) and Bunions. From Cochrane Database Syst. Rev. CD 000964.
Hylton B Menz, Meg E Morris, Stephen R Lord. (2006). Foot and Ankle Risk Factors for Falls in Older People: A Prospective Study. The Journals of Gerontology: Series A Biological sciences and medical sciences, 61A(8), 866-70. Retrieved February 3, 2008, from Health Module database. (Document ID: 1122855341).
Lander, Dr. Richard Bunion woes on the toes :[1 Edition]. (2007, September 26). Manawatu Standard,p. 0; 15. Retrieved February 7, 2008, from ProQuest Newsstand database. (Document ID: 1342681791).
Payne, January W. (2007, May 14). BALANCING ACT / Cruel shoes? / Podiatrists warn against
spike heels, pointy toes, ballet falts - even flip-flops :[2 STAR , 0 Edition]. Houston
Chronicle,p. 3. Retrieved February 5, 2008, from ProQuest Newsstand database. (Document
Schwartz, Susan (2001, August 17). Pointy-toed fashion victim teeters on brink of disaster. South China Morning Post,p. 5. Retrieved February 5, 2008, from ProQuest Newsstand database. (Document ID: 77914669).
Torkki, M, Malmivaara A, Seitsalo S, Hoikka V, Laippala P, Paavolainen P. (2001). Surgery vs orthosis vs watchful waiting for hallux valgus: a randomized controlled
trial. 2001 May 16;285(19):2474-80. Retrieved from JAMA.
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