Bunionette Pain – The Clinical Syndrome
Occurring less commonly than the common bunion, bunionette is a common cause of lateral foot pain. The term bunionette refers to a constellation of symptoms, including soft tissue swelling over the fifth metatarsophalangeal joint associated with abnormal angulation of the joint resulting in a prominent fifth metatarsal head with associated medial angulation. Bunionette is also known as tailor’s bunion. This deformity is analogous to the hallux valgus deformity and occurs more commonly in women. The development of an inflamed adventitious bursa may accompany bunionette formation and contribute to the patient’s pain. A corn overlying the fifth metatarsal head also is usually present. The most common cause of bunionette formation is the wearing of tight, narrow-toed shoes. High heels may exacerbate the problem.
What are the Symptoms of Bunionette Pain?
Most patients with bunionette complain of pain that is localized to the affected fifth metatarsophalangeal joint and the inability to get shoes to fit. Walking worsens the pain; rest and heat provide some relief. The pain is constant and characterized as aching; it may interfere with sleep. Some patients complain of a grating or popping sensation with use of the joint, and crepitus may be present on physical examination. Physical examination reveals soft tissue swelling over the fifth metatarsophalangeal joint associated with abnormal angulation of the joint resulting in a prominent fifth metatarsal head with associated medial angulation.
How is Bunionette Pain diagnosed?
Plain radiographs are indicated in all patients with bunionette pain. Based on the patient’s clinical presentation, additional tests, including complete blood cell count, erythrocyte sedimentation rate, and antinuclear antibody testing, may be indicated. Magnetic resonance imaging (MRI) and ultrasound imaging of the fifth metatarsophalangeal joint is indicated if joint instability, occult mass, or tumor is suspected.
The diagnosis of bunionette is usually obvious on clinical grounds alone. Complicating the care of a patient with a typical bunion deformity is the fact that bursitis and tendinitis of the foot and ankle frequently coexist with the bunion pain. Stress fractures of the metatarsals, phalanges, or sesamoid bones also may confuse the clinical diagnosis and require specific treatment.
Initial treatment of the pain and functional disability associated with bunionette deformity should include a combination of nonsteroidal antiinflammatory drugs (NSAIDs) or cyclooxygenase-2 (COX-2) inhibitors and physical therapy. Local application of heat and cold may be beneficial. Avoidance of repetitive activities that aggravate the symptoms and narrow-toed or high-heeled shoes combined with short-term immobilization of the affected toes also may provide relief. For patients who do not respond to these treatment modalities, an injection with a local anesthetic and steroid may be a reasonable next step. Ultrasound guidance may increase the accuracy of needle placement and decrease the incidence of needle-related complications.
Complications and Pitfalls
Failure to identify primary or metastatic tumor of the foot that is responsible for the patient’s pain may yield disastrous results. The major complication of the injection technique is infection. This complication should be exceedingly rare if strict aseptic technique is followed. Approximately 25% of patients report a transient increase in pain after this technique, and patients should be warned of this possibility.CLINICAL PEARLS
Pain from bunionette can be debilitating, and the deformity is cosmetically unacceptable for many patients. Injection of the bunionette with a local anesthetic and steroid is extremely effective in treating pain secondary to bunionette. Coexistent arthritis, bursitis, and tendinitis may contribute to bunionette pain and may require additional treatment with more localized injection of a local anesthetic and depot steroid.
Patients with bunionette should be advised to avoid tight, narrow-toed shoes. The use of physical modalities, including local heat and gentle range-of-motion exercises, should be introduced several days after the patient undergoes this injection technique for toe pain. Vigorous exercises should be avoided because they would exacerbate the patient’s symptoms. Simple analgesics and NSAIDs may be used concurrently with this injection technique.