What is the condition called when there is a bony prominence on the internal lateral foot?

Bunionette (Tailor's Bunion): Diagnosis and Management

A bunionette, also known as tailor's bunion, is a painful bony prominence on the lateral aspect of the fifth metatarsal head that appears as a protuberance on the internal lateral foot. This condition can cause significant discomfort, particularly when wearing shoes that put pressure on the affected area.

Clinical Presentation and Diagnosis

Physical Examination

• Visible prominence on the lateral aspect of the fifth metatarsal head
• Tenderness to palpation over the prominence
• Possible erythema, swelling, and callus formation
• Pain exacerbated by tight-fitting shoes
• Possible varus deformity of the fifth toe

Imaging

• Weight-bearing radiographs (anteroposterior, lateral, and oblique views) are recommended as the first imaging study 1
• Radiographs may show:
  • Lateral prominence of the fifth metatarsal head
  • Widened 4-5 intermetatarsal angle
  • Varus deformity of the fifth metatarsophalangeal joint

Differential Diagnosis

• Plantar fasciitis with associated heel spur
• Stress fracture of the fifth metatarsal
• Diabetic foot complications (in patients with diabetes)
• Peripheral neuropathy
• Achilles tendinopathy

Management Algorithm

First-Line Treatment (Conservative Management)

1. Footwear Modifications:

   • Wider shoes to reduce pressure on the prominence 1
   • Open-backed shoes to reduce pressure on painful areas 2
   • Avoid tight shoes and those with rough edges 1

2. Orthotic Devices:

   • Over-the-counter or custom insoles to redistribute pressure 1
   • Padding techniques to protect the prominence 3
   • Toe spacers for associated neuromas 1

3. Pain Management:

   • NSAIDs (oral or topical) for pain and inflammation 1
   • Acetaminophen as an alternative for those who cannot take NSAIDs 1
   • Cryotherapy (ice applied through wet towel for 10 minutes) 1

4. Activity Modification:

   • Relative rest
   • Stretching exercises for the foot and ankle 1
   • Strengthening of intrinsic foot muscles 1

Second-Line Treatment (If No Improvement After 6-8 Weeks)

1. Referral to Podiatric Foot and Ankle Surgeon 2
2. Additional Conservative Measures:
   • Custom orthotic devices
   • Immobilization with cast or fixed-ankle walker-type device 2
   • Night splinting to maintain dorsiflexion during sleep 1

Surgical Management (For Refractory Cases)

Surgical approach depends on the type of deformity:

1. Simple Lateral Eminence Resection:

   • Appropriate only in rare situations 3
   • High risk of recurrence or overresection 3

2. Distal Chevron-type Osteotomy:

   • For patients with lateral bow to the fifth metatarsal 3
   • Recommended if medial translation of the head for one-third of the width produces normal 4-5 intermetatarsal angle 4

3. Diaphyseal Osteotomy:

   • For widened 4-5 intermetatarsal angle 3

4. Proximal Osteotomy:

   • Able to correct most deformities 4
   • Recommended for larger deformities 5

5. Minimally Invasive Techniques:

   • Percutaneous resection of lateral exostosis
   • Osteotomy without internal fixation using burrs 6
   • Comparable outcomes to standard procedures with advantages of minimally invasive surgery 6

Special Considerations for Diabetic Patients

For patients with diabetes, additional precautions are necessary:

• Regular foot examinations to identify high-risk conditions 2
• Assessment for peripheral arterial disease and neuropathy 1
• Probe-to-bone test if there is an open wound to rule out osteomyelitis 2
• Daily foot inspection and proper foot care 1
• Appropriate footwear at all times (shoes 1-2 cm longer than foot with adequate width) 1

Follow-up and Monitoring

• Regular assessment every 4-6 weeks to evaluate response to treatment 1
• Monitor for proper technique with stretching exercises
• Assess footwear compliance and orthotic fit
• Consider additional imaging if symptoms persist despite appropriate treatment

Common Pitfalls to Avoid

• Failing to assess biomechanical factors contributing to foot pain 1
• Not considering systemic conditions that may contribute to foot pain 1
• Overlooking the possibility of infection in patients with diabetes 1
• Relying solely on the presence of a bony prominence for diagnosis 1

With appropriate conservative management, approximately 90% of patients with bunionette deformity can experience significant symptom improvement 1. Surgical intervention should be reserved for cases that fail to respond to conservative measures.