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The Bunion Conundrum

Updated: Mar 23, 2023

Runners are not known for having pretty feet. Certainly, none of us could or would make a living from being a foot model. We aren’t fielding calls from Dove, Venus, or flip flop companies not called “OOFOS”.

At any rate, one of the most common foot and toe issues I see is the bunion, or hallux valgus, as we properly call it in the medical field. A bunion is typically known as an abnormal alignment of the big toe joint, where the toe angles inward toward the middle of the foot, instead of straight ahead. These can form for many reasons, including footwear, genetics, biomechanics, and previous injury. Women are more likely to develop them than men, and this was previously thought due to the fact that women are more likely to wear high heels and tight-fitting shoes, which may compress the forefoot and toes. However, we also know that people with no history of high heel shoe wearing can also develop them (ahem, me). There is a paucity of research as to the biomechanics of why bunions form, but it is likely due to a combination of factors, including arch height/structure, ankle mobility, connective tissue strength/flexibility, and other joint disease. They can occur just in one foot or bilaterally - and bilateral bunions could be a good indication that genetics are at play.

Contrary to popular belief, bunions aren’t all bad and there are plenty of conservative options to treat them if they are a problem. Far too often I hear patients say that someone told them they would have to have surgery on their toe, and that just isn’t true.

Bunions are not always painful, and the degree of the bunion does not correlate with pain in the joint. However it is also possible that misalignment of the toe is changing how your foot, ankle, and leg functions while running and can possibly lead to pain in other areas, even as far up as the hip and low back.

Well, why is that?

The big toe plays a big role in power generation and the arch of the foot. Extension of the big toe causes the plantar fascia to tighten, creating important tension for force generation in the push off phase of gait. We get A LOT of power from the big toe, thus if we avoid using it, we are missing out! In the case of a bunion, the force is directed more toward the midline of the foot and over the second and third toes. We will also see concomitant pronation and collapse of the midfoot to accommodate this pattern. Avoidance of the big toe may also cause a rotation of the foot and lower leg, potentially translating into rotation all the way up the chain into the knee and hip. This is why correcting the mechanics is important even if the toe and joint is not painful.

Conservative management for bunions is totally possible and can be very effective. When I see either a painful big toe joint or that a bunion is significantly affecting someone’s running, I usually do the following (of course with individualization based on that person’s needs and goals):

1. Utilize toe spacers and toe spreaders

This of course depends on individual anatomy, but in general I will advise that people wear a toe spacer (there are many options on Amazon, I will link to my favorites below) as often as possible, which may mean deciding to wear shoes with a slightly wider toe box to accommodate. This can help with alignment of the toe and to strengthen the muscles in the direction that we want strengthened. Toe spreaders, which go in between each individual toe instead of just the big one, can also be useful for those with what I call a “crammed foot”, where all of the toes are close together (probably because they just love each other soooo much). The caveat with toe spreaders is that they oftentimes cannot be worn with shoes because they take up so much extra volume in the shoe. Sometimes they can also be uncomfortable to wear for long periods of time, so are best used in shorter periods, either walking around the house or when nonweightbearing. They can also be used during strength training workouts as well as a way to improve foot proprioception and muscle alignment.

2. Joint mobilization and dry needling

There are a few muscles in particular that are helpful in these conditions, and treating those muscles can help decrease pain and improve mobility of the joint. In particular, the Flexor Hallucis Longus, which flexes the big toe, can restrict movement when it is tight. A PT can assess the muscles and decide which ones need the most treatment and stretching. Joint mobilization is another technique that PT’s will use to help create joint space for the big toe and can be pain-relieving as well. A painful joint is often the result of abnormal wear of the joint with activities, so mobilizing it can help distribute the stress more evenly.

3. Optimizing shoe choice

A proper fitting and shape shoe can go a long way in improving discomfort caused by bunions. Things to look for in a shoe are: a wider toe box, rocker bottom (curved sole of the shoe - many nylon or carbon plate shoes and the brand HOKA are good places to start), and potentially a slightly stiffer upper to help control excessive side to side motion of the midfoot. Getting properly fitted and seeing a shoe expert at a local running store is essential, so I won’t say too much more here.

4. Strengthening the muscles of the foot and the big toe push off mechanism

I love the MOBO board for this. I wrote an entire blog about why I love the MOBO board, so if you have questions about this fantastic training and strengthening tool, give it a read. The MOBO board strengthens the muscles of the arch and big toe quite specifically, so it can help with improving the push-off mechanism we talked about earlier. These exercises should always be pain-free, so DO NOT force these exercises upon a painful joint.

5. Single leg stability exercises

Finally, we need to learn how to coordinate our newly strong foot muscles with our hip muscles. This involves taking everything we’ve learned about arch strength and control, and challenging our hip at the same time. Single leg deadlifts and squats are great for this, just make sure to focus on your foot throughout!

Don’t let bunions get in the way of what you love to do! There are so many non-surgical strategies to help.

Keep going, you got this!

Dr. Kacy Seynders, PT, DPT

Helpful links:

Previous blog about toe spreaders:


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