Understanding Bunions: What Causes Them, How They Progress, and What You Can Do

By Dr. Christopher R.D. Menke, DPM, FACFAS — Double Board-Certified Foot & Ankle Surgeon, Founder of 26 Apothecary

Understanding Bunions: What Causes Them, How They Progress, and What You Can Do

The most common misconception about bunions is that they are caused by shoes. Shoes absolutely worsen bunions and accelerate their progression. But the underlying structural vulnerability — the first metatarsal’s tendency to drift medially — is inherited. The genetic predisposition determines whether it happens. The mechanical environment determines how fast and how severely.

Dr. Christopher R.D. Menke, DPM, FACFAS — double board-certified in foot surgery and rearfoot and ankle reconstruction, founder of 26 Apothecary — explains bunion anatomy, causes, and the conservative care sequence for early-stage deformity.

What a Bunion Actually Is

What is a bunion?

A bunion — hallux valgus — is a structural deformity of the first metatarsophalangeal joint in which the first metatarsal drifts medially while the hallux drifts laterally. The visible bony prominence on the medial side of the foot is not an extra bone — it is the metatarsal head becoming prominent as the bone migrates out of its normal alignment. The deformity is driven by an instability at the first tarsometatarsal joint that allows the metatarsal to rotate and drift medially. This instability is largely genetic in origin.

How Bunions Progress

Bunion progression is typically gradual over years to decades. As the first metatarsal drifts medially, it transfers mechanical load from the first ray to the lesser metatarsals, creating a cascade of downstream effects including metatarsalgia, callus formation, and eventually stress fracture in some cases. The hallux, pushed laterally, begins to crowd and push against the second toe, which over time can cause hammertoe deformity. In advanced cases, the second toe crosses over the top of the hallux — a crossover toe deformity that significantly limits footwear options and function.

What Conservative Care Actually Does in Early Stages

Early conservative care cannot reverse hallux valgus, but it can meaningfully slow progression and reduce symptoms during the years before surgery becomes necessary. Footwear modification — a wide toe box that eliminates lateral compression — removes the primary environmental accelerant of progression. A bunion brace that applies medial corrective force to the hallux during rest counteracts the lateral drift. Orthotics that control the subtalar pronation contributing to first metatarsal instability address one of the biomechanical drivers of deformity progression. A toe separator reduces the interdigital irritation between the first and second toe.

When to See a Foot and Ankle Specialist

• Any visible bunion that is causing pain, limiting shoe wear, or showing signs of progression
• Second toe deformity or crowding developing adjacent to the bunion
• Significant functional limitation — difficulty walking, running, or maintaining daily activity level
• Any desire to understand surgical options and timing — early evaluation allows better planning than waiting until the deformity is advanced

Frequently Asked Questions

At what age do bunions typically develop?

Bunions can develop at any age. Most people develop symptomatic bunions in the fourth through sixth decades, though the structural tendency may have been present for years before becoming symptomatic. Family history is the strongest predictor of bunion development.

Are bunions more common in women?

Yes — hallux valgus is significantly more common in women than men, with most studies showing a ratio of approximately 3 to 1. This reflects both genetic factors — women tend to have greater ligamentous laxity — and footwear factors, as narrower and higher-heeled footwear is more commonly worn by women.

Will my bunion definitely get worse over time?

Not necessarily. Some bunions remain stable at mild severity for years with appropriate footwear and conservative management. The rate of progression is influenced by the underlying instability of the first tarsometatarsal joint, the footwear environment, activity level, and body weight. Regular monitoring by a podiatrist allows tracking of progression and appropriate timing of intervention.

About the Author

Dr. Christopher R.D. Menke, DPM, FACFAS is a double board-certified foot and ankle surgeon — board-certified in both foot surgery and rearfoot and ankle reconstruction. He completed his podiatric medical training at Temple University School of Podiatric Medicine in 2005 and his residency at Northlake Medical Center and DeKalb Medical in Georgia, completing in 2008. He is the founder of 26 Foot and Ankle and 26 Apothecary, and the founder of Surgeons of Service, a Georgia-based humanitarian surgical nonprofit. Every product in the 26 Apothecary catalog was selected through the same clinical lens Dr. Menke applies in the exam room and the operating room.