Dear Gait Guys:

if treated when still a child can you change a bunion without surgery? I have a young kid, 12, with a bilateral forefoot varus and bilateral bunions, he has started to compensate even through his hip and core already which I have been working on but wondered if, by retraining the foot, tripod exercises, lumbricals, interossei, can we actually change his foot? And do you have any other ways that I might be able to attack this foot in order to change it?



Dear J

As we sure you are aware, bunions form from unopposed activity of the adductor hallicus. Normally, with an appropriate tripod, it serves to assist in forming the transverse and longitudinal arches of the foot during the stance phase of gait. When the 1st ray (in basic terms, the medial aspect of the foot) isn’t anchored, it acts unopposed and adducts the hallux instead, forming an abductovalgus deformity over time. This causes a medial shift of weight in the foot and the metatarsals to abduct to compensate for this. In other words, the big toe and medial tripod are supposed to be well anchored so that the lateral foot is pulled towards it. This forms the forefoot’s transverse arch. But when the medial tripod is not anchored, the lateral foot serves as the anchor and thus the big to is pulled towards that lateral anchor by the adductor hallucis muscle.

It is imperative that you restore function (and the ability) to fully descend the 1st ray (your child must relearn how to anchor that metatarsal head aspect of the tripod).  This is imperative for success.  We have a youtube video of a young child demonstrating how they learned this. You can often accomplish this with manual methods, mobilization, appropriate footwear and most importantly exercises to descend the 1st ray , particularly toe extensor exercises (both the EHB and the EHL which descend the head of the 1st). Sometimes, if the 1st ray is rigid and won’t descend, you will need to use an orthotic or a cork addition to their footbed with a Mortons toe extension to bring the ground up to the base of the 1st metatarsal.

It sounds like you are strengthening the core, which provides stability from above down. Pay close attention to the external rotators, as they will often be lengthened due to excessive internal rotation of the extremity.  But the key is restoring the skill, endurance and strength of those muscles that descend the head of the 1st metatarsal and that help reengage the medial tripod.

We hope this helps. PLease let us know

Ivo and Shawn