Can You Select A Bunion Procedure Based Solely On Clinical Evaluation?

Molly Judge DPM FACFAS

I was talking with some colleagues of mine recently and we were reviewing bunion surgery, the most common of the elective procedures that we perform. During this conversation, one more experienced colleague said he really does not even need X-rays as he can tell from the clinical evaluation what procedure is going to work out best for the patient. At this point in his career, he feels that getting X-rays is now simply an issue of medicolegal documentation rather than a tool for measuring angles and procedure selection. Most of the others at the table seemed to agree with his philosophy.

I would like to test this colleague’s theory that radiographs really are not necessary for most cases of bunion deformity by asking the readers what procedure they would select based solely upon the clinical evaluation and medical history of the patient presented below as well as the above clinical photos.

A 51-year-old male complains of “bump pain” on the sides of his feet with the left foot worse than the right. He claims the process has been present for years and seems to be getting much worse over the past five years. He denies trauma.

The patient has served as a strength trainer for the past 20 years at a state university so he has been very active and physically fit over the years. The patient recently retired and now drives a truck for pocket change. I asked him if he thinks his pain is in the bump or in the joint. “The big toe has never really moved that much,” he said. “It is the bump that makes it unbearable in shoe gear. If the bump were gone, I would be satisfied.”

He describes the pain as a deep aching sensation when he is off the foot and a sharp, stabbing sensation when he is weight bearing. The intensity of the pain is 5/10 walking into the office but the patient says it can be 10/10 if he is trying to do prolonged weightbearing activity.

He has tried multiple forms of conservative therapy, including modified shoe gear, and oral anti-inflammatory agents such as ibuprofen without significant improvement. The patient is presenting now because the pain has gotten significantly worse over the most recent years and since he is retired, he feels he is in a position to get this addressed. He thinks he would be happy if the bump were simply removed from the left foot.

The patient’s past medical history is benign. He is not taking any medication and has no allergies. His surgical history consists of a tonsillectomy and adenoidectomy in childhood. The patient is single, denies tobacco history and drinks alcohol on very rare social occasions. He denies illicit drug use. A review of his systems is unremarkable.

What The Clinical Exam Revealed

The clinical examination reveals a grossly enlarged prominence about the medial aspect of the first metatarsal of the left foot. Tenderness is evident with manipulation. The hallux is not reducible in the transverse plane despite applying pressure to the medial aspect of the first metatarsal head.

In terms of range of motion, the first metatarsophalangeal joint (MPJ) has 0 degrees of dorsiflexion and 10 degrees of plantarflexion with pain. There is no crepitation with manipulation but this is tempered by the fact that the joint really is not very mobile. The remainder of the MPJs have a smooth range of motion without crepitation and the digits have full ability to bear weight.

The LisFranc’s joint, midtarsal, subtalar and ankle joints also have a smooth range of motion without pain or crepitation. Specifically, there is no evidence of hypermobility or ligamentous laxity within the first metatarsocuneiform joint bilaterally. Localized palpation of the medial eminence is very tender with a firm hypertrophic feel. The right foot has a similar medial eminence prominence that is much smaller as is evident in the above clinical pictures. The range of motion in the right first MPJ consists of 30 degrees of dorsiflexion and 20 degrees of plantarflexion. Otherwise the exam for the right lower extremity is exactly the same as the left extremity.

The patient’s pedal pulses are easily palpable and the capillary fill time is less than three seconds in toes one through five. There is no warmth or erythema within the foot or ankle and hair growth is evident throughout both extremities. In regard to the neurological exam, the epicritic sensorium is grossly intact and is equal bilaterally. There are no motor sensory defects.

The muscle strength about the left first MPJ (extensor hallucis longus/flexor hallucis longus/flexor hallucis brevis) is diminished due to pain at the first MPJ. Otherwise, the intrinsic and extrinsic muscles about the foot and ankle appear to be within normal limits without evidence of atrophy.

What Procedure Would You Choose?

I am interested in my readers’ thoughts on what the procedure of choice should be based upon this clinical appearance and clinical findings. I will give you the radiographic visuals after I get a consensus on the proposed procedure. In this exercise, I simply wish to exercise the idea of basing procedure selection solely upon the clinical evaluation and medical history of the patient. I can give you the consensus in the next blog. I am happy to provide further clinical information as desired but I have given you the overall gist of things here.


When I read "0 degrees dorsiflexion", I cannot agree that PE alone will suffice. The procedure would range from cheilectomy to fusion. Radiographs and intra-op findings would dictate the degree of DJD and how much the IM angle is actually contributing to that giant medial eminence. So, not to be a wet blanket, but its hard to play along when I see there is no dorsiflexion. Note that the right great toe has a huge medial eminence and is actually almost rectus with the rest of the foot! My guess would be: This pt. actually has an almost normal IM despite the large eminence, and is in need of an implant vs. fusion.

I would offer him additional conservative treatment modalities (Morton extension, corticsteroids). In terms of surgery, a first MPJ arthrodesis is clearly the most indicatated operation. A Youngswick + chielectomy could be discussed, but he would need a fundamental understanding that an arthrodesis would likely be necessary at some point... and he's a better surgical candidate now that he will be in the future. Radiographs are definitely essential in my opinion. You cannot accurately evaluate metatarsal length parabola, arthritic changes, or the possibility of bone cysts or even neoplasms with a clinical exam. What would you do in the OR if you had had not take xrays, boarded the fusion, and then discovered a massive cyst in the first met head? Fixation and procedure planning in hallux valgus are certainly assisted by radiograph evaluation. Also, as was mentioned in the article, it's a moot point since standards of care and medicolegal concerns dictate that xray eval will always remain part of the pre-op bunion workup.


from the clinical data and lack of 1st mtp proper joint rom, is remarkable of djd stage 3. classic o/a, JJOCC, so rx will def be implant for me considering 51 is still a workforce member. back to the question i agree with one of the bloggers def x-ray will be useful in case o/p or cyst are present, met parabola, shortening of met etc will be vital for decision makin.

I am encouraged by the near unanimous response regarding the need for radiographic evaluation. Now you can see why I was so struck by a colleague who seemed a little on the arrogant side regarding over confidence in predicting procedure selection even without the benefit of radiographic evaluation. I am happy to post those radiographs for you in full detail. When these views are available will be determined by the staff of podiatry today. Thus far you all seem to be on the right track and all we need now is to know whether anyone would like further studies performed once the radiographs are reviewed. Radiographs will be posted as soon as P.T. will allow. Thank you in advance for following this blog. I am happy to see so many clear thinking surgeons out there. Cheers! Molly

I'm not sure why you wouldn't get a radiograph. We should all of our available tools to evaluate and manage our patients. This case does not represent a run of the mill bunion presentation as it seems there are multiple issues not necessarily isolated to a "straight" bunion procedure. With the right eye radiographs can provide a tremendous amount of information pertaining to selection of surgical procedures even when things seem simple. Get an X-Ray. You may be surprised what you end up gleaning from it.

Would not feel comfortable doing any such soft tissue or osseous procedure without seeing radiographs to 1) rule out other DDx's and 2) plan the surgery.....sorry

I wanted to thank all of you for sharing your thoughts on Dr. Judge's blog. Her next blog will feature the radiographs for the patient discussed above. Look for her next blog to debut on the Website in mid-May. Thanks again for your interest. Sincerely, Jeff A. Hall Executive Editor Podiatry Today

Greeting to all April readers and thank you so much for your comments. Just to recap, the point of this discussion was to explore the comment made to me by a colleague who believes that in their extensive experience with the bunion deformity and surgery that radiographs are really not that critical. This IS NOT MY OPINION HOWEVER. I present a case in this blog to explore YOUR confidence in suggesting management for a case without radiographs. A resounding comment from the audience is that radiographs are ALWAYS necessary in surgical planning and I couldn't agree with you more. For next months blog the x-rays will finally be posted and you will have the opportunity to expand the preoperative work up or make your surgical plan then. Once again thank you for your time and consideration on this point and thank you for reinforcing that IT'S NOT JUST ME . Enjoy your weekend. Molly

It would be irresponsible to choose a procedure without radiographs, period. My feelings tend to go the other way actually. I think it is wrong to place too much emphasis on the radiograph alone. Basing a procedure choice primarily on a couple of angles we measure or "eyeball" is not something that would probably be advocated a surgeon with some degree of experience.

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