Tailor's bunion, commonly known as bunionettes, are a prevalent foot disorder that often doesn't receive enough attention. These bunions are characterized by a unique structural change: the fifth metatarsal bone, which connects to the little toe, shifts outward away from the foot's midline, while the little toe itself angles inward towards the other toes. This condition owes its name to tailors, who historically developed it from their seated working posture, often with crossed feet. In simpler terms, a Tailor's bunion can be visualized as a protruding bump at the outer edge of the foot, at the base of the little toe.
From a medical standpoint, the outward shift of the fifth metatarsal bone is termed valgus deviation, and the inward angling of the little toe is known as varus deviation. This results in the foot forming a 'V' shape at the little toe's base, with the bunionette marking the point of this 'V'.
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Anatomy & Kinetic Chains
Anatomy of the Foot
Think of the foot as an engineering masterpiece with an incredibly complex design. The foot is a phenomenal mechanism, comprised of 26 bones, over 30 joints, and an elaborate meshwork of more than a hundred muscles, tendons, and ligaments. Functionally, it is divided into three main parts: the rearfoot, which includes the talus and calcaneus; the midfoot, hosting the navicular, cuboid, and three cuneiform bones; and the forefoot, consisting of the phalanges and metatarsals.
The Kinetic Chain and Tailor's Bunion
The kinetic chain within the foot represents a sophisticated and interconnected network of muscles, tendons, and joints that function in harmony to enable mobility and stability. The development of Tailor's bunion, a common foot deformity, is intimately tied to this complex interplay. Recognizing these intricate relationships' importance is integral to understanding and treating Tailor's bunion. Rather than viewing it as an isolated issue, effective care and treatment of Tailor's bunion require an insightful examination of underlying biomechanical and anatomical factors that contribute to the condition.
Muscles and Tendons:
Gastrocnemius and Soleus: Influence plantar flexion and heel alignment; improper alignment may contribute to Tailor's bunion through altered lateral foot pressure.
Tibialis Anterior: This muscle is responsible for dorsiflexion and inversion of the foot, and its role in controlling the medial arch may indirectly influence the lateral side of the foot. However, it's less directly related to the development of Tailor's bunion and other anatomical structures.
Peroneus Longus and Brevis: Essential for lateral foot stability; weakness can cause abnormal forces at the 5th MTP joint, a critical factor in Tailor's bunion development.
Tibialis Posterior: The Tibialis Posterior muscle plays a vital role in supporting the foot's medial arch, and its dysfunction can induce abnormal pressure on the fifth metatarsal, contributing to Tailor's bunion.
Flexor Digitorum Longus and Flexor Hallucis Longus: Influence toe flexion and push-off mechanics, alterations of which may further exacerbate the development of Tailor's bunion by affecting the alignment of the fifth toe.
Joint Mechanics:
Subtalar Joint: Dysfunctions in inversion and eversion can lead to abnormal lateral forces, contributing to Tailor's bunion.
Metatarsophalangeal Joints (MTP): The 5th MTP joint's malalignment or dysfunction directly correlates to Tailor's bunion formation.
The Fifth Metatarsophalangeal Joint
The fifth metatarsophalangeal joint (MTPJ) is a critical player in the formation of a Tailor's bunion. Positioned at the fifth digit's base, this joint is where the fifth metatarsal bone's head meets the proximal phalanx of the little toe. The MTPJs are synovial joints enabling mainly flexion and extension, with some sideways movement, and are crucial for keeping lateral balance and aiding in push-off during the propulsion phase of walking.
The Origin of a Tailor's Bunion
Tailor's bunions predominantly affect adults and are more prevalent in females. A complex interplay of biomechanical, anatomical, and lifestyle factors contributes to its development.
Footwear and Lifestyle
Footwear significantly influences foot biomechanics. Shoes that fit poorly or lack proper support can magnify biomechanical deviations and heighten the risk of Tailor's bunions. For example, shoes with a narrow toe box can coerce the toes into an unnatural posture, creating excessive pressure on the fifth metatarsophalangeal joint. Likewise, high-heeled shoes can redistribute the body's weight forward onto the forefoot, increasing pressure on the metatarsals. Coupled with the typically narrow and pointed design of high heels, this can aggravate the misalignment of the fifth metatarsal, hastening the emergence of a Tailor's bunion. As such, appropriate footwear becomes a crucial factor in managing and preventing this condition.
Genetic and Anatomical Factors
Genetic predispositions to specific foot shapes or mechanics, such as a wider forefoot or high arch (pes cavus), can create a vulnerability to Tailor's bunions.
Biomechanical Irregularities
Over-Pronation: This biomechanical dysfunction can lead to an eversion force on the forefoot. Specifically, the abductor digiti minimi muscle may become overworked, initiating an abduction and lateral rotation of the fifth metatarsal, which results in the characteristic enlargement and outward projection of the fifth metatarsophalangeal joint.
Metatarsus Adductus: This congenital deformity may lead to the fifth metatarsal experiencing increased lateral pressure, particularly during the propulsion stage of gait, leading to the formation of a Tailor's bunion.
Forefoot Varus: The inward turning of the forefoot relative to the rearfoot can cause abnormal loading of the lateral side of the foot. This condition strains both the osseous structures, such as the fifth metatarsal head, and surrounding soft tissues, like the tendons of the peroneus longus and peroneus brevis muscles, which manage the eversion and stabilization of the foot. In individuals with forefoot varus, the inward positioning of the forefoot can lead to compensatory overpronation in an attempt to maintain balance and full ground contact. This overpronation may result in various problems and stresses in other parts of the foot and lower limb, potentially contributing to issues like Tailor's bunions.
Soft Tissue and Joint Restrictions
Peroneal Tendons: Dysfunction or tightness in these tendons can exert additional lateral forces on the fifth metatarsal, contributing to the development of the Tailor's bunion.
Ligamentous Changes: The collateral ligaments at the fifth metatarsophalangeal joint may become compromised due to increased pressures and contribute to the joint's enlargement.
Diagnosis
Patients afflicted with Tailor's bunions typically exhibit localized pain and inflammation on the foot's outer part, specifically over the fifth metatarsophalangeal joint. The protrusion can become tender and inflamed, especially after sporting tight or unsuitable footwear. Other symptoms might encompass redness, an apparent bulge on the foot's lateral side, callus formation resulting from friction over the bunion, and discomfort during walking or other physical endeavours.
Essential Examination and Palpation Observations
Physical examination is a cornerstone in identifying a Tailor's bunion. Healthcare professionals should scrutinize the foot for irregularities, inflammation, erythema, and callus formation. Palpating the fifth metatarsophalangeal joint might disclose a bony enlargement and sensitivity. Evaluating the patient's gait and foot biomechanics can yield crucial information about contributing elements. Other significant aspects of inspecting include the foot's overall alignment, the affected joint's range of motion, and the patient's choice of footwear.
Examination Demonstration
Effective Ankle and Foot Examination - Hello and welcome to our channel. In this video, we will be discussing an important aspect of physical examination - the ankle and foot examination. The ankle and foot are complex structures that are responsible for weight-bearing activities. It is important to perform a thorough examination to identify any abnormalities or injuries. Whether you're a healthcare professional or simply interested in learning more about this topic, we hope you find this video informative and helpful. So, let's get started!
Imagery
Although the diagnosis of a Tailor's bunion is principally clinical, radiographic imaging can corroborate the diagnosis and gauge the severity of the deformity. Weight-bearing anteroposterior and lateral foot radiographs can depict the deviation of the fifth metatarsal and enlargement of the metatarsal head. These images can also assist in pinpointing any associated conditions, such as osteoarthritis or bursitis.
Differential Diagnosis
While a Tailor's bunion is a frequent culprit of lateral foot pain, it's vital to acknowledge other potential symptom origins. These could include a fracture or sprain, gout, rheumatoid arthritis, bursitis, ganglion cyst, or even a foreign object. An alternative diagnosis could be an inflamed adventitious bursa, which can form over any bony prominence but isn't associated with a true bony enlargement. An all-encompassing clinical evaluation and, when required, appropriate imaging studies can distinguish a Tailor's bunion from these other conditions.
Manual Therapy
Musculoskeletal (MSK) practitioners, such as physiotherapists, osteopaths, Registered Massage Therapists and chiropractors, play an essential role in the conservative management of Tailor's bunions. Their role encompasses pain management, patient education, foot biomechanics optimization, and the implementation of preventive strategies. By using manual therapy techniques and exercise prescriptions, MSK practitioners can help alleviate symptoms, slow progression, and improve functional mobility.
Joint Mobilization: Mobilization of the fifth metatarsophalangeal joint and associated structures can help increase the range of motion and reduce pain. Gentle passive movements can be applied to the affected joint to improve its mobility.
Soft Tissue Work: This involves manual techniques such as massage, Motion Specific Release (MSR), and trigger point therapy aimed at relieving tension in the muscles and fascia of the foot. Additionally, stretching and strengthening exercises can be implemented to improve the balance of forces acting on the foot.
While manual therapy cannot reverse the bony deformity, it can effectively manage symptoms, improve foot function, and enhance quality of life. Studies indicate that manual therapy, in conjunction with appropriate footwear and orthotic advice, can reduce pain and improve gait mechanics in individuals with Tailor's bunions. As with all interventions, the benefits and risks should be thoroughly discussed with the patient before proceeding with treatment.
Manual therapy can be beneficial for patients experiencing pain, stiffness, and limited mobility due to Tailor's bunions. However, it's not suitable for all cases. Contraindications may include severe osteoarthritis, gout, infections, or significant vascular compromise of the foot.
Treatment Demonstrations
Video #1
In this first video, Dr. Abelson demonstrates treating structures that are often involved in Tailor's Bunion. Treatment starts at Time Stamp 00:33.
Video #2
In the second video, titled "Resolve Your Plantar Fasciitis," Dr. Abelson focuses on directly addressing the foot's structures. He highlights that many of these structures, which play a role in Plantar Fasciitis, are also implicated in both big-toe bunions and Tailor's bunions.
Treatment Frequency Recommendations
When performing manual therapy for a Tailor's bunion, some patients may experience initial relief or improvement within the first few sessions, especially in terms of pain and flexibility. However, structural and functional changes, such as the realignment of the toe, can take longer and may require consistent therapy combined with exercises and possibly orthotic interventions. The exact timeline for results can vary based on the severity of the condition, patient adherence to home exercises, and individual differences in healing. Regular assessments and feedback are essential to gauge progress and adjust the treatment plan as needed.
Initial Treatment Phase:
MSR Manual Therapy: 2 sessions per week for two to three weeks.
Home Exercises: Daily functional exercise programs as prescribed by the MSR practitioner.
Response Assessment:
Evaluate the patient's response to therapy during follow-up appointments, typically after two to three weeks of treatment.
Positive Response:
A positive response to manual therapy for the treatment of a Tailor's bunion would be a noticeable reduction in pain and discomfort, coupled with improved toe alignment and enhanced functional mobility during walking and other activities.
MSR Manual Therapy: Reduce to 1 session per week.
Home Exercises: Continue daily routines; adjust as necessary based on professional advice.
Persistent Symptoms:
MSR Manual Therapy: Maintain frequency of two weekly sessions, reassessing the treatment approach weekly.
Home Exercises: Re-evaluate and modify exercises under professional guidance, ensuring correct technique and adherence.
When performing manual therapy for a Tailor's bunion, treatment should continue as long as there's an improvement in symptoms and function. If progress is noted and functional goals aren't yet met, ongoing therapy can be beneficial. If there are no noticeable results, only marginal improvements, or if progress plateaus, then treatment should be reconsidered or halted.
You should transition to maintenance care once the patient has achieved consistent symptom relief and optimal functional levels, ensuring that the achieved progress is sustained and potential recurrences are minimized. All decisions should be based on regular assessments and patient feedback.
Maintenance Phase:
MSR Manual Therapy: Monthly sessions or as needed.
Home Exercises: Daily routines to maintain benefits and prevent symptom recurrence, with periodic reviews by healthcare professionals.
Exercise
Exercise serves a pivotal function in both managing and preventing Tailor's bunions. It enhances muscular strength, flexibility, and foot mechanics as a whole, mitigating symptoms and decelerating the condition's progression. Furthermore, consistent exercise aids in maintaining an ideal body weight, lessening excessive pressure on the foot and minimizing the likelihood of developing or exacerbating a Tailor's bunion.
Targeted Exercises to Enhance Function and Mitigate Symptoms.
Several exercises can assist in managing symptoms and refining the biomechanical function of the foot:
Toe Abduction and Adduction: The process of spreading the toes (abduction) and then bringing them back together (adduction) primarily engages the foot's dorsal and plantar interossei muscles. These muscles are in charge of separating and reuniting the toes, respectively. Fortifying these muscles aids in enhancing toe alignment and balance, positively affecting overall foot mechanics.
Toe Curls: Exercises involving toe curling chiefly strengthen the flexor digitorum longus and flexor digitorum brevis muscles, which are accountable for curling or flexing the toes. These exercises can boost the toes' gripping strength, provide stability, and uphold the foot's proper arch structure.
Ankle Circles: Rotations of the ankles are exercises that involve the muscles accountable for the movement of the ankle joint. These include the tibialis anterior, tibialis posterior, peroneus longus, and peroneus brevis muscles, in addition to the calf muscles (gastrocnemius and soleus). Executing ankle circles helps amplify these muscles' mobility, flexibility, and strength, refining foot and ankle function.
Calf and Toe Stretch: This exercise requires stretching the gastrocnemius and soleus muscles in the calf, the flexor hallucis longus, which flexes the big toe, and the flexor digitorum longus, which flexes the other four toes. Retaining the flexibility of these muscles aids in maintaining optimal foot and lower leg function, which is vital for correct foot mechanics.
Towel Scrunches: Scrunching a towel with the toes targets the intrinsic foot muscles, including the lumbricals, the flexor digitorum brevis, and the interossei muscles. These muscles fulfill key roles in maintaining balance and stability, supporting the foot's arches, and allowing precise control of toe movements. Strengthening them can result in improved balance and foot stability.
Exercise Demonstration
Exercise demonstrations start at Time Stamp 04:50. Each of the five exercises above is demonstrated in this video.
Orthotics and Taping
Alongside exercise, supplementary therapies like orthotics and taping can substantially manage Tailor's bunions. Orthotics can assist in rectifying biomechanical abnormalities and shifting pressure away from the bunion, reducing discomfort and inhibiting progression. Taping can be employed to keep the toe in a more typical position, decreasing tension on the surrounding tissues. It can also assist in providing feedback about foot position, enhancing proprioception and refining gait mechanics.
Tailor's Bunion Conclusion
Tailor's bunions, often called bunionettes, are a widespread foot issue where the fifth metatarsal bone sticks out, causing pain. Understanding the foot's complex structure and how movement affects it is key to tackling this problem. Treatment focuses on the whole body's movement and might include the right shoes, manual therapies like Motion Specific Release (MSR), joint mobilization, and exercises tailored to the individual. While we can't reverse the bone change, a well-rounded approach can greatly ease symptoms and improve quality of life, showing the importance of treating the whole person, not just the foot.
DR. BRIAN ABELSON, DC. - The Author
Dr. Abelson's approach to musculoskeletal health care reflects a deep commitment to evidence-based practices and continuous learning. In his work at Kinetic Health in Calgary, Alberta, he focuses on integrating the latest research with a compassionate understanding of each patient's unique needs. As the Motion Specific Release (MSR) Treatment Systems developer, he views his role as both a practitioner and an educator, dedicated to sharing knowledge and techniques that can benefit the wider healthcare community. His ongoing efforts in teaching and practice aim to contribute positively to the field of musculoskeletal health, with a constant emphasis on patient-centered care and the collective advancement of treatment methods.
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References
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Rothermel, S. D., & Brunet, M. E. (2000). Tailor’s bunion deformity caused by a pronated foot. Journal of the American Podiatric Medical Association, 90(6), 313–316. https://doi.org/10.7547/87507315-90-6-313
Menz, H. B., & Morris, M. E. (2005). Footwear Characteristics and Foot Problems in Older People. Gerontology, 51(5), 346–351. https://doi.org/10.1159/000086373
Mahadevan, D., Attwal, M., Bhatt, R., & Bhatia, M. (2011). The identification and management of bunionette deformity. The Foot, 21(3), 131–137. https://doi.org/10.1016/j.foot.2011.03.004
Cotchett, M. P., Munteanu, S. E., & Landorf, K. B. (2014). Effectiveness of trigger point dry needling for plantar heel pain: a randomized controlled trial. Physical Therapy, 94(8), 1083–1094. https://doi.org/10.2522/ptj.20120503
Munuera, P. V., Polo, J., & Rebollo, J. (2008). Length of the first metatarsal and hallux in feet with bunionette deformity. The Journal of Bone and Joint Surgery. British volume, 90-B(4), 493–499. https://doi.org/10.1302/0301-620X.90B4.20107
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