I have recently read one of those online health articles that begins with a scientific revelation and ends, after a decent interval for astonishment, with a half-price pair of shoes. Its subject was bunions. Its hero was Dr Bernhard Zipfel of the University of the Witwatersrand. Its villain was the pointed shoe. Its conclusion was that a Swedish company had solved a problem which the medical profession, being apparently too stupid or too corrupt to notice the shape of a human foot, preferred to treat with expensive surgery.

The article was admirably definite. In 2018, it said, Zipfel and his colleagues examined 2,300 people divided among four populations: lifelong wearers of Western shoes, people who adopted shoes in adulthood, people who had never worn shoes, and historical skeletons from before the invention of modern footwear. Among the lifelong barefoot population, the prevalence of bunions was precisely zero. Genetics, age, sex and body weight had all been controlled for. Zipfel supposedly concluded that a bunion was a “modern, shoe-induced deformity”.

It is a splendid story. The difficulty is that the study does not appear to exist.

Zipfel is real. He is a palaeoanthropologist and former podiatrist at Witwatersrand, and he has published interesting work on the human foot. But his own publication record contains no such 2018 study. What it does contain is a 2007 paper with Lee Berger called “Shod versus unshod: The emergence of forefoot pathology in modern humans?” That paper compared skeletal remains from several periods and found more forefoot pathology in the habitually shod groups. It gives some support to the common-sense belief that footwear affects the foot. It was not a controlled experiment on 2,300 living people, and it did not prove that heredity was irrelevant.

The distinction matters. A useful piece of evidence has been passed through the advertising machine and emerged as revelation. Dates have moved, populations have multiplied, qualifications have vanished and an impressively quotable conclusion has appeared. By the time the reader reaches the purchase button, an archaeological comparison has become the last word in clinical medicine.

The rest of the article is made by the same method. A genuine study of 57 runners is described as a trial of people with chronic foot pain who changed shoes for twelve weeks and experienced a 61 per cent reduction in pain. The actual study lasted eight weeks. It compared walking in minimalist shoes with foot-strengthening exercises and a control condition. It found increases in foot-muscle size and strength. It did not recruit 57 bunion sufferers, and the abstract reports neither the advertised 61 per cent fall in pain nor a cure for bunions.

This does not mean that narrow shoes are innocent. It means that the truth is less theatrical and more useful.

A bunion, or hallux valgus, is not merely a lump of bone produced where a shoe has rubbed. The big toe turns towards the smaller toes while the first metatarsal moves in the opposite direction, making the joint at the base of the toe project at the side of the foot. The tendons, ligaments and small bones beneath the joint cease to pull in their former alignment. As the deformity progresses, the joint may become painful and inflamed; the second toe may be crowded or displaced; and walking or finding comfortable shoes may become difficult.

The lump can certainly be irritated by pressure from a shoe. It is also part of a structural deformity. This is why changing shoes may relieve pain without making an established bunion disappear. There is no shame in preferring a simple explanation, but the foot contains twenty-six bones and a tiresome quantity of connective tissue. It has not arranged itself for the convenience of an advertisement.

The best available evidence suggests that bunions result from an interaction between inherited susceptibility, the structure and movement of the foot, age, sex and mechanical pressure from footwear. A recent systematic review found evidence of familial aggregation alongside associations with first-ray instability, abnormal pronation, reduced activity of a muscle that helps control the big toe, and prolonged use of restrictive shoes. A separate meta-analysis of observational studies found that narrow-toed footwear was associated with greater odds of hallux valgus. Shoes matter, but they do not act upon identical feet.

The claim that bunions are not hereditary is especially difficult to sustain. In the Framingham Foot Study, researchers examined 1,370 members of 429 families and found hallux valgus to be highly heritable in the population studied. A Korean twin and family study estimated the heritability of hallux valgus at 0.51 and of the angle of deformity at 0.47.

Heritability does not mean destiny. It does not identify a single “bunion gene”, nor does it tell an individual woman that her toe will inevitably follow her mother’s. It means that genetic differences accounted for a substantial part of the variation within those particular populations. The inherited feature may be the shape of the metatarsal head, the looseness of ligaments, foot width, pronation or some combination of structural tendencies. Shoes can then aggravate the tendency.

This also explains why bunions often appear to run through the female line without being reducible either to female biology or to female fashion. Women have historically been expected to place their feet into narrower and more elevated shoes. They are also more likely to develop hallux valgus even after crude differences in footwear are considered. The two explanations are partners, not rivals. A vulnerable foot subjected to years of constriction is more likely to deform than a less vulnerable foot in the same shoe. A vulnerable foot given adequate room may remain comfortable for much longer.

None of this rescues the pointed shoe. There is something faintly mad about manufacturing footwear that narrows towards the front when the human foot normally widens there. Fashion has persuaded generations of women that a properly dressed foot should resemble the bow of a small yacht. High heels add another mechanical indignity by shifting load towards the forefoot. In the Framingham study, women’s past use of high heels was associated with increased odds of hallux valgus. The NHS advice is correspondingly unromantic: wear shoes of the correct size, leave enough room for the toes, and avoid high heels and pointed fronts.

For someone with a bunion, a wide toe box, low heel and soft sole may reduce compression and rubbing. Bunion pads can protect the projecting joint. Insoles, spacers and splints may help some people with pain or alignment while they are being worn. Ice and ordinary painkillers may settle a flare. Weight loss can reduce loading where excess weight is contributing to discomfort, though body weight does not provide a simple explanation for the deformity itself.

These measures are management, not magic. A review of shoe modification and orthoses concluded that suitable footwear should provide adequate length, a wide toe box, cushioning and a lower heel, but found no consensus that conservative treatment can correct the underlying deformity or halt its progression. A systematic review of orthoses found some evidence of improvement in angle and pain with particular devices, but the studies were limited and varied considerably.

Minimalist shoes deserve the same calm treatment. They can provide more room for the toes and may encourage the foot muscles to work differently. Trials suggest that walking or exercising in them can increase some measures of foot strength. A 2024 systematic review and meta-analysis found that minimalist footwear and foot exercises may improve strength and alter certain aspects of movement, but judged the certainty of much of the evidence low or very low.

They are therefore an option, not a sacrament. A wide toe box is usually sensible; an extremely thin, flexible and completely flat sole is not necessarily suitable for every painful, arthritic or unstable foot. Someone accustomed to conventional shoes may also need to change gradually. A person with diabetes, loss of sensation, poor circulation or an existing injury should be particularly wary of conducting an evolutionary experiment on his own feet without professional advice.

Once a bunion is established, surgery is the only treatment that can reliably correct the bony alignment. This does not mean that every bunion should be operated on. A painless bunion may require nothing more than accommodating footwear. Surgery is normally considered when pain is persistent, ordinary activities are restricted and conservative measures no longer provide enough relief. It is not a cosmetic tidying service.

The usual operation involves cutting and realigning bone, often fixing it with screws or staples. Recovery is measured in weeks and months rather than the interval between ordering miracle shoes and receiving the parcel. The NHS warns that the toe may remain stiff or painful, may not become perfectly straight, and that the bunion can recur. These are proper reasons to think carefully about surgery. They are not evidence that surgeons have conspired to suppress wide shoes.

Nor is recurrence invariably 30 per cent, as the advertisement claims. Rates depend on the severity of the deformity, the procedure used, the length of follow-up and what a study counts as recurrence. Some NHS patient information gives a figure of about one in ten; published surgical studies report a broader range. A percentage without a procedure, definition or follow-up period is not information. It is scenery.

The most distasteful part of the miracle-shoe article is not its enthusiasm for roomy footwear. On that point it is largely sensible. It is the conversion of sensible advice into a false choice. Either believe the commercial revelation or submit to a medical cartel interested only in appointments and operations. Either bunions are entirely caused by shoes or they are an inherited curse. Either minimalist footwear reverses the damage or nothing short of the knife can help.

Real medicine is rarely so obliging. Narrow shoes are a modifiable risk and an avoidable source of pain. Inherited anatomy is also real. Roomier footwear may make an enormous difference to comfort and may reduce a source of continuing mechanical stress, especially if adopted early. It will not normally rebuild a deformed joint. Splints and orthoses may help symptoms. Surgery can correct alignment, but brings costs and risks that should be weighed against the seriousness of those symptoms.

There is an excellent case for allowing toes enough room without inventing a South African experiment, three grateful pensioners and a warehouse that is always seventy-two hours from running empty. A shoe shaped like a foot is a good idea. It should not require a fairy tale.

And the lesson? Never believe anything you read on-line – not, that is, unless you see it here on the Libertarian Alliance Blog!