July 2013

Patient Perspective: Bunionectomy recovery is more than just healing

9_FA_patient_perspBy Karen Bakar

I can’t recall exactly when the bunion on my left foot started causing discomfort, but it was probably when I was about 40. I waited some time to get a referral to a podiatrist, and when I finally saw one, life with two kids and a full-time job stalled my pursuit of treatment for another three and half years.

The podiatrist diagnosed moderate hallux valgus–not the worst case scenario, but I was definitely a good candidate for surgery. He explained that, while the procedure would correct the problem, the decision to go that route was ultimately up to me, based on my willingness to tolerate the discomfort of doing nothing.

I knew people who had gone through the procedure, and their accounts of severe pain in the immediate aftermath, as well as weeks of inconvenience scared me off, so I opted to first try managing my pain with new footwear. My shoe budget expanded, and I found salvation in several pairs of clogs and other more sensible, but expensive, styles. Even so, eventually the moderate discomfort I was experiencing turned to excruciating pain that often kept me awake at night and disrupted my workouts.

On my next visit to the podiatrist, in June 2012, I was intent on scheduling a date for surgery. Anticipating about a month of major life disruption, I targeted January 2013 for the procedure, when the craziness of Thanksgiving and Christmas would be behind me, work would be reasonably slow, and family and travel commitments were minimal.

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Healing the bone

Figure 1. The soft boot worn immediately after surgery.

Figure 1. The soft boot worn immediately after surgery.

On January 9, my podiatrist performed a bunionectomy with distal osteotomy. He prepared me well for the surgery and reviewed milestones and expectations for the first two months. As he described it, this period is about healing the bone. The progression is predictable–from five days with absolutely no pressure on the foot, to the resumption of modified activities in six to eight weeks. Nearly five months postsurgery, I’ve learned that “healing the bone” is only one part of the full recovery.

The initial pain was not as severe as I had expected based on my friends’ accounts, and I never felt the need to fill the Vicodin prescription the nurses gave me. I think my podiatrist’s advice was sound–to let the local anesthetic wear off, and then evaluate the pain level. In my case, over-the-counter relief was sufficient.

I found that during the first few critical days it was important to have lined up help. Friends had arranged meal deliveries every night for the first week, a lifesaver given my inability to get out of bed without crutches. Having a husband who works at home and kids old enough to be somewhat self-sufficient certainly didn’t hurt. The relatively manageable level of pain continued to surprise me, though knowing how fragile my foot was, I was petrified that someone would bump it or that I’d accidentally step on it. One wrong move could send the pain meter off the charts and me back to the operating room!

My biggest concern was sleeping, when things beyond my control could come into play–the dog could jump on the bed and onto my foot, I could get up in the middle of the night and forget I had just had foot surgery (thankfully, that never happened), or I could make involuntary movements while sleeping that might jostle my foot. I wore the soft boot the podiatrist gave me for moderate protection, and had to sleep on my back for several weeks with my foot elevated and outside the heavy covers. It didn’t make for a great night’s sleep, but it worked well enough.

Getting back into a routine

After four weeks, I returned to work, mainly sitting at a computer. I’m fortunate to have great health benefits, so I was able to maximize disability leave. I arranged parking inside my building during the first two weeks of my return, and, with swelling still an issue, I brought a pillow to prop up my foot. I also had my podiatrist provide me with a medical certificate so I could apply for a disabled parking placard from the State of California.

The walking boot I started using five days postsurgery was unattractive and clunky, but did the job and sure beat crutches. Because it didn’t go far past my ankle, it allowed me to walk with a somewhat normal gait. Wearing a flat but elevated shoe on the other foot helped keep my hips aligned and minimized the limp. I found that Dansko clogs were almost the perfect height (1.5-in heel) to match the boot’s elevation.

Once out of the walking boot, a little less than six weeks after surgery, it was time to venture into real footwear. (Even today, more than six months postsurgery, shoe selection is a bit of trial and error and one of the more unexpected frustrations of my recovery.) The podiatrist suggested soft tennis shoes as a first step, but I found the laces were too constricting, and I couldn’t fit the sneaker onto my foot. The best postsurgery shoes, for me, were shearling Ugg boots. Assuming the boot is not too snug to begin with, there’s generally enough room to accommodate some swelling. The soft, flexible material and internal padding were so comfortable I almost forgot I had just had foot surgery.

Figure 2. Examples of shoes the author still was unable to wear five months after surgery because they cut across the incision area.

Figure 2. Examples of shoes the author still was unable to wear five months after surgery because they cut across the incision area.

By two months, I still hadn’t started working out even though my podiatrist said I could begin exercising after four weeks. Exercise means different things to different people, so when doctors have that discussion with patients, it’s wise to be specific about the types of exercise the patient enjoys and what their goals and expectations are.

My particular routine involves aerobic classes, yoga, and dance. All of these require a high degree of toe flexibility, and are thus harder to resume than activities with little to no strain on the toe, such as swimming or riding a bike. I waited three months after the surgery to resume working out, and even then, began at a modified level and pace. It took a good four months to ramp up to my preferred routine. Five months after surgery, I’m enjoying these activities with a lot less pain than I had presurgery; however, I’m not yet pain-free, and I continue to notice the difference in flexibility between my two feet.

Bumps in the road

By the two-month mark, the danger of complications related to the bone healing had passed, and up to that point, my recovery was pretty much textbook.

Figure 3. The author’s active lifestyle requires a high degree of toe flexibility.

Figure 3. The author’s active lifestyle requires a high degree of toe flexibility.

Swelling and moderate pain continued to be issues, however, something I hadn’t expected at this stage of the game. I knew the recovery would be difficult, but I didn’t realize how prolonged it would be. Everything I had focused on up to this point was about healing the bone and keeping it safe. The milestones my doctor outlined so clearly were easy to define, and I understood exactly what I needed to do.

After the eight-week mark, though, as I was transitioning into normal activity levels, I realized my recovery would depend as much on me as it would on my doctor. The podiatrist had guided me successfully through the precarious first few weeks of healing, and while follow-up visits were still on the calendar, the homestretch to recovery–including the ability to do my normal workouts and wear halfway attractive shoes–would involve more time, effort, and some unexpected bumps in the road.

One day at work, two months after surgery, I noticed my foot had become unusually swollen and was turning a disturbing shade of purple. My calf started to throb unbearably with what could only be described as a warm sensation. I had developed a blood clot, and if a coworker hadn’t suggested the possibility, it never would have occurred to me. Sufficiently alarmed by my colleague’s observation, I did some amateur research and discovered that I had almost every symptom and risk factor one could have for deep vein thrombosis (DVT).

Blood clots: Rare but risky

Surgery is a general risk factor for DVT, but the condition is not common after a bunionectomy. Statistics about the risk of clotting after this procedure are hard to come by, and according to my hematologist, bunionectomy is not the type of high-risk procedure that typically causes clotting.

Figure 4. Physical therapy helped significantly improve forefoot range of motion in the operated foot.

Figure 4. Physical therapy helped significantly improve forefoot range of motion in the operated foot.

Nevertheless, my surgical history combined with the facts that I was taking oral contraceptives, had been on a recent flight, and had been relatively immobile for so long after the surgery, seemed to have created a perfect storm. It’s unlikely the surgery caused the blood clot, but I’m convinced it played a role.

Doctors performing bunionectomies might do well to warn patients, especially women on birth control, about the possibility of DVT, despite the low risk. I might have opted not to fly when I did. I might have been more conscious of staying mobile, elevating my foot more frequently, and staying better hydrated to minimize the risk of DVT. I certainly would have stopped taking oral contraceptives, the most significant risk factor.

Recovery after healing

Five months after surgery, I’m on track to what I hope and expect will be a full recovery. Even though my foot has technically been healed for months, it’s not 100% recovered. I still experience minor swelling around the incision, and that keeps me from wearing about a third of my shoes–the ones that have the least flexibility and that cut across the surgical site. “Thickness or puffiness” is how my podiatrist describes this swelling, and I usually notice it at the end of the day, especially with tighter-fitting shoes. He explained that the bunionectomy procedure itself results in trauma to the toe joint capsule and surrounding soft tissue. Compared with bones, soft tissue is slow to remodel, which is why full recovery extends beyond the initial healing.

Figure 5. The additional forefoot flexibility has helped the author get back to favorite activities like yoga.

Figure 5. The additional forefoot flexibility has helped the author get back to favorite activities like yoga.

Toe joint mobility wasn’t something my podiatrist and I discussed in great detail during those early appointments, but it is a helpful conversation to have, if not early on, at least after the first critical six to eight weeks have passed. In my last and final appointment with my podiatrist, he explained that by six months, the flexibility in my toe should be “good to very good,” and that by a year, things should finally “look and feel normal.”

In my case, a month of physical therapy to mobilize the joint capsule has helped me regain some of that lost flexibility. My podiatrist did not initially discuss therapy as part of the longer-term recovery strategy, but I requested the referral because I was afraid that, without it, my foot would forever be stiff and inflexible, an unwelcome scenario given my level of activity.

My podiatrist and I were impressed with the results. After four visits, supported by a handful of home exercises to force greater joint mobility and break up scar tissue, I’ve achieved measurable improvement. From the first therapy session to the last, the flexion of my toe increased from 10° to 30°, and the extension from 52° to 70°.

Would it be enough for a ballerina on pointe shoes? Probably not, but for me, it’s what I need to finally kick up my heels and do the things I’m used to doing.

Karen Bakar is a freelance writer in the San Francisco Bay Area.

18 Responses to Patient Perspective: Bunionectomy recovery is more than just healing

  1. Julie says:

    This was helpful for me to read. I just finished my 3rd week post bunion and hammertoe surgery. I have to remind myself that every day is better than the day before and stop looking at how long the road is ahead of me. I’m someone that never stops moving, that has been the biggest challenge for me. I’m assuming you didn’t have the hammertoe issue. I have a metal pin through my second toe into my foot. I get it removed in 2 days, I can’t wait and yet dread it too. I have a permanent screw in my big toe. I’ve documented every step with pics for anyone who wants to know what to expect. A pic is worth a thousand words for sure.

  2. Jennifer Spiegel says:

    I loved your article on your bunionectomy! I am in my 4th week and everything you said is what I’m experiencing. I know someone who was driving at three weeks after her surgery. I don’t know if it’s different because I also had hammertoe surgery in my two smallest toes, but I couldn’t drive right now if I wanted to. My bones are healing well, but my foot is so sore and still swells up. It was nice to hear that other people are having similar exoeriences. The sitting with my foot up is getting boring! I go back to work next week and get two weeks of desk work. I hope that will be enough! Again, thanks for sharing your experience. I feel better about mine.

  3. Linda Petrakis says:

    Julie, I am just reading this a year and a half after you wrote it. I am three weeks out from my bunion and hammer toe surgery. I had the pin and stitches removed at two week’s post surgery. I too was looking forward to getting the pin out, although dreading it. A day or two after the removal of the pin and stitches I started having severe pain, unlike any I had previously had. Doctor had me come back in for an ex ray and a blood count to rule out infection. Both tests came back ok and he told me sometimes the nerves become irritated after surgery. I think it was the removal of the pin that set it off. I had to refill my pain pills and double up on the dosage to get through it. Today is the second full day without pain pills. See the doctor next week which will be 4 weeks from surgery. I would love to hear from you about your recovery experience.

  4. Ellen Oster says:

    Thank you for this article. I am realizing , 6 weeks out from my big toe surgery, that it may be several months to full recovery. I had thought I may be able to ski this winter, but the thought of getting in to ski boot even 2,months from now, is excruciating. Will be working on flexibility.

  5. Lorraine says:

    Thanks for sharing this informational piece. Two weeks tomorrow post bunionectomy for me. I felt very little pain after surgery and have been able to walk very carefully and for short trips between rooms in my home on my heel and side with the boot given to me by my doctor. Your advice for physical therapy is something I will also follow.

  6. Lucie says:

    Thanks for this, it made me feel more hopeful that I might get back to normal soon. I am 7 weeks in recovery – wondering how long it was before you were able to do yoga again? I really miss it, but can’t imagine my feet coping with it any time soon 🙁 Also if you had any tips as to what kind of shoes you found comfiest (trainers?) would be much appreciated.

    all the best.

  7. Nici says:

    Physical therapy (early) to regain toe flexion, joint mobility, balance, strength and improve gait after years of walking improperly are key in my opinion. I had Cartiva in September on my left big toe and went back this week to do the bunion on the right. The PT made all the difference to fast recovery and gave me a good start after the recent bunionectomy surgery has healed enough to begin again. I will start seated toe flexion as soon as the dressings are off!

  8. Nicole Yackulic says:

    Very helpful! I’m 3 months post op and starting to become frustrated and worried I’m not healing like I should be. Physio therapy has helped me tremendously as well, and i plan on continuing. I just need to find those perfect comfy shoes!!!
    Sigh of relief!

  9. Ruby says:

    Thank you for writing this article, it has eased my fears about getting surgery for my increasingly painful right foot. If you don’t mind, I have a couple of questions. What type of surgery did you get? My surgeon is recommending a “Lapidus Fusion.” I have a moderate bunion and a hypermobile big toe. It is also causing neuromas along my smaller toes. In addition, I have longer second toe that gets stubbed when I go for long runs. I’ve only made up my mind about going through this (preferably in Jan18), so I may need to address those issues at the same time as well.

    I am also very active (run and hi intensity workouts 6x a week) and this has limited how far my runs can go. I had orthotics made, but they have stopped helping and I can’t wear them with normal shoes. Do you still have to wear orthotics in your sneakers after the surgery?

    I don’t know if you have to do the other foot, but I will have to get the left done as well. I’m trying to decide if I should do it 8-10 weeks after the first surgery or wait until the right foot is fully healed. On one hand, I want to maximize the healing of each foot as much as possible, but on the other hand, I want to start moving forward with both feet done behind me. What would you suggest?

    Again, thank you for posting your experience. I look forward to your response.

  10. Grey says:

    Appreciate the detail provided here. I am into my 9th week now. I’ve been taking short walks on my days off from work.
    kind of weird after being in that dang sandal for so long!
    I feel pretty good about my progress but, I am concerned that I may not be doing enough to exercise the toe area.
    Q.. How far along into your recovery were you when you started the physical therapy? I may write to my doc and ask for a referral.

    Thank you…well written!

    Grey Chapman

  11. Fiona Smith says:

    I had a bunionectomy and hammer toe pin put in 4 weeks ago today. The pin was taken out today which wasn’t pleasant but it didn’t take very long. I am now allowed to walk around indoors gently without my boot on but this seems much more painful than when I was walking around with the boot and practically pain free! I’m hoping that this will get better soon! I was told that the boot is only needed for another 2 weeks which is when I’ll go back to work. I haven’t tried to put a shoe on it yet!!

  12. Denise L Spacht says:

    Hi Karen, I realize your post is five years old, but I just came across it. I had bunion surgery three months ago, my metatarsal was only 70% healed as of two weeks ago, I just recently was able to get out of the boot again and start wearing shoes. My question for you is what type of physical therapy exercises did you do in order to achieve better range of motion in in your big toe. Any help you can give would be greatly appreciated, if you’re still out there.
    Thank you so much. Denise S.

  13. Hi Karen! This is a great article. I am 12 weeks post op and never imagined how the recovery would be. I had everything you mentioned here. When I went for a consult, all I heard was “sneakers 2 weeks post op”. Never did I think I would have to learn to walk again, that my toe would be so stiff, that I would not fit into any of my shoes! I too, insisted on physical therapy. That is my only hope of getting to do planks and yoga as actively as I did before the surgery. xo

  14. Deni says:

    I really wish I was lucky enough to not have a lot of pain with my bunionectomy. I had mine Nov 8th and it was terrible. I had no help though. I had to get up for my own ice packs and I had to make my own meals. I had some prepared ahead but i do have a young son in the house who eats too. It’s been 10 weeks and been in theropy 6 weeks. I’m still out of work because my job is in a automobile factory and there is no slowing down that line runs and the jobs are heavy. The walk to my job from my vehicle is a good 1/2 mile because the size of the lot and factory is huge. I see myself off at least 4 months. I just cant see how ppl think it wasnt painful. I think they are tell a fib. My recovery was worse than my recovery from a c section as far as pain. And I have a pretty good tolerance.

  15. Tracy says:

    Very informative and helpful article. I had bunion and hammertoe surgery on January 11th. I still have a temp wire on my second toe. That will be removed on 2 weeks. I was given a boot to wear 2-1/2 weeks after surgery and still keep foot wrapped in a compression wrap and second toe taped. I am able to take small walks without a crutch in the home but mainly get around with one crutch. Lately the pain is moderate to severe at night. I have been experiencing some burning and shooting pain in toes. I am scared that this will be permanent. Doc says it’s due to swelling and told me to continue to ice and keep elevated and take 600 milligrams of ibuprofen twice daily. I am very active and my job requires me to be on my feet all day long. I am not scheduled to return to work until April. I have also been doing toe stretching exercises in the big toe, but not toe with wire. Any advice or thoughts on this pain at night would be greatly appreciated. Thank you.

  16. Lesa says:

    Karen,
    Thanks for your article describing your experience with recovery. I am about 8 weeks post-op and still having swelling issues. I was worried that something was wrong although my dr assures me I’m on schedule. I, too, was unprepared for the length of recovery. I knew the first month would be there worst but didn’t think about the pain from swelling would last so long. Also like you I use dance and yoga for exercise and fun. So it’s killing me not being to dance daily but I’m trying to follow the rules. I’m hoping that by the end of the next month, I can return to partial workouts. Thanks for the suggestion of seeing a physical therapist to get back the mobility of my toe. It’s gotten better but still much to go.
    Sounds like it will be 6mo to a year for full recovery. Such a long time but I was in daily pain before so had to do it. But trying not to get down due to the lack of mobility.
    Thanks again.

  17. Leanne says:

    It’s been 7 weeks since my bunionectomy and hammer toe surgery. Oh yeah and a neuroma at the same time. I have permanent pins on my big toe and a permanent screw in my middle toe. After 7 weeks I still have no mobility in my big toe and tingling and burning on my middle toe. My foot looks like a small watermelon with all of the swelling. I’m still not driving or walking without a boot. I start therapy tomorrow. I need to be better in 4 more weeks. I’m a school teacher and I spent the entire summer not being able to walk.

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