Ray McClanahan, D.P.M
Bunions are a sometimes painful dislocation of the 1st metatarsophalangeal joint or 5th metatarsophalangeal joint that occurs primarily in shod or shoe-wearing populations. There have been many suggested causes of bunions, but the one cause that has been shown to be consistently reversible is the tapering toeboxes on most conventional footwear available to shoe wearing people. Tapering toeboxes have a long history of standard inclusion in most shoe models, including most athletic models. The unfortunate side effect of the tapered forefoot shape of our footwear is that it holds our toe bones and joints in an unnatural proximity to one another, forcing the great toe into the space that should be occupied by the second toe, to create the classical bunion deformity. The tailors bunion, on the outside of the foot, is created when the fifth toe is forced in under the fourth toe, and the head of the fifth metatarsal is forced into the outer aspect of the shoe, sometimes causing pain, swelling or bursa formation.
Unfortunately the taper of the toeboxes on most footwear available in America begins at the metatarsophalangeal joints, instead of at the ends of the toes, where the natural forefoot shape is at its widest. The only opportunity to see the natural shape of a human forefoot in America is in the newborn infant, or in the rare individual that grew up barefoot. Growing up without shoes keeps the shoe from pushing the great toe against the second toe, which is unnatural. The fifth toe is correspondingly not forced into the space occupied by the fourth toe, in the unshod state.
Growing up barefoot is a commonality in many parts of the world. These societies that don’t routinely wear shoes, rarely demonstrate the common forefoot deformities encountered in America, such as bunion, tailor’s bunion, and hammertoe deformity.
Hammertoes are another forefoot deformity that can take a walker out of their activity. Hammertoes generally represent a tendon imbalance in the toes caused by one of the toe tendons getting an advantage over another toe tendon. Most commonly, it is one or all of the long extensor tendons on the top of the foot that gets an advantage over one or all of the flexor tendons on the bottom of the foot, to cause the first joint in the toe to be elevated above the ground. Most shoe wearing people chronically alter the delicate balance that co-exists amongst the toe tendons whether they know it or not.
This occurs because most footwear has heel elevation and a feature called toespring, which holds the ends of the toes above the ground, in relation to the ball of the foot. These two features, coupled with the tapering toeboxes mentioned above, are responsible for the development of most hammertoe and bunion deformities. Hammertoes generally cause walkers to experience pain and dysfunction in three distinct areas: 1) On the top of the contracted joint, known as the proximal interphalangeal joint, due to callus buildup or bursa formation that occurs from the toe joint now rubbing against the top of the toebox of the shoe; 2) On the tip of the toe, since now there is an unnatural bend in the toe, which causes pressure on the end of the toe. This is a problem because the skin on the end of the toe is not as strong and resilient as the skin on the bottom of the toe; 3) Under the ball of the foot. When a toe becomes hammered, also termed contracted, it unfortunately puts downward pressure on the metatarsal bone, causing pain, swelling, and sometimes callus formation.
Although these following preventative tips may be able to reverse a painful bunion or hammertoe deformity, they are more effective when applied to young people, and are less effective the longer a person has progressed with their bunion or hammertoe deformity. This is because the joints in our bodies get used to the positions they are most frequently held in, and our feet are no different, with our 12 to 15 hours a day in restrictive footwear, with tapering toeboxes, heel elevation, and toespring.
If you wish to prevent or cure a bunion or hammertoe deformity naturally, you must be willing to view your footwear as health equipment, rather than as fashion statements. Even our walking and running shoes have tapering toeboxes, heel elevation and toespring, which encourage bunion and hammertoe formation, yet the market shows us that fashion and style rule most people’s agenda when it comes to buying footwear.
It is difficult to find a shoe that is widest at the ends of the toes, unless you are an infant. Somehow we believe it is okay to accommodate the natural forefoot shape of the youngest of our population, but progressively less so as we get older. Thus we end up with tapered shaped forefeet, and the resultant hammertoes and bunions.
If you have success finding a wide enough shoe to allow you to spread your great toe away from your second toe, with a toe spreader, or bunion splint, you may have success conservatively reversing a bunion deformity, or hammertoe deformity. To try to spread the great toe, away from the second toe, with a bunion splint, in a conventional style shoe with a tapered toebox, is certain to fail, due to the lack of sufficient room (sometimes referred to as volume) for the toes, already present in the forefoot of the shoe.
A good method for guaranteeing that you will have enough room for your toes in a pair of shoes is to remove the sock liners that come with shoes and stand on them to ensure that there is enough room for all of your toes to lay flat on top of the liner.
Unfortunately, most walking footwear is too narrow in the toebox for the average walker’s toes, and consequently most walker’s great toes and fifth toes will go over the liner when the toes are spread. This is unfortunate, since optimum walking can only occur if the toes are spread.
Range of motion exercises and manipulation of bunions and hammertoes into the correct joint positions, enhances reversal of these deformities. This can be done by a therapist, yoga instructor or physician, and then taught to be done at home as part of a regular wellness program. These methods are only successful if the walker does not wear footwear that maintains the deformed joint positions, which includes many walking models.
Nearly one million surgical bunion corrections occur yearly in America. This is largely due to the inability to find footwear that does not have a tapering toebox.
Plainly put, most toe deformities are caused by footwear. If you wish to avoid bunions or hammertoes, or work towards reversing them, please choose footwear that has a low heel, and is wide enough in the toebox to spread your toes. Your podiatrist or therapist can help with the manipulation exercises.
Wishing all of you a healthy walking experience!