What are the treatment options for hallux valgus (bunion)?

From the Guidelines

Treatment of bunions should begin with conservative measures, prioritizing properly fitting shoes with a wide toe box and low heels to reduce pressure on the bunion, as recommended by the most recent guidelines 1.

Conservative Management

Conservative management of bunions involves several key strategies:

• Wearing properly fitting shoes with a wide toe box and low heels to reduce pressure on the bunion
• Using over-the-counter pain relievers like acetaminophen or ibuprofen to manage pain and inflammation
• Applying ice packs for 15-20 minutes several times daily to reduce swelling
• Utilizing bunion pads, toe spacers, or custom orthotic inserts to provide cushioning and realignment
• Engaging in physical therapy exercises that strengthen toe muscles and improve joint mobility, such as toe stretches and picking up marbles with your toes

Surgical Intervention

For severe cases where conservative treatments fail, surgery (bunionectomy) may be necessary to realign the joint and remove excess bone, as supported by the highest quality study available 1. The bunion develops when the big toe joint (metatarsophalangeal joint) becomes misaligned, causing the toe to angle inward while the joint protrudes outward. This misalignment often results from inherited foot structure, though tight footwear can exacerbate the condition. Early intervention with proper footwear and supportive devices can prevent progression and reduce the need for surgical intervention.

Footwear Recommendations

General footwear recommendations for individuals with bunions include:

• A broad and square toe box
• Laces with three or four eyes per side
• Padded tongue
• Quality lightweight materials
• Sufficient size to accommodate a cushioned insole, as outlined in the guidelines 1 Use of custom therapeutic footwear can help reduce the risk of future foot ulcers in high-risk patients, particularly those with bony deformities, including Charcot foot, who cannot be accommodated with commercial therapeutic footwear 1.

From the Research

Non-Operative Treatment

• Initial treatment of symptomatic bunions should be non-operative 2
• Accommodative footwear is important in the treatment of bunions 2
• There is evidence supporting the use of:
  • Nonsteroidal anti-inflammatory drugs 2
  • Orthotics 2
  • Splints/braces 2
  • Toe spacers 2
• Conservative measures emphasize the adequate accommodation of the forefoot within the toe box of the shoe and the even distribution of plantar pressures by various metatarsal pads or bars and soft insoles 3

Operative Treatment

• Referral to an orthopaedic surgeon is recommended if the patient has a painful prominence, has exhausted non-operative treatment and is a suitable operative candidate 2
• Cosmesis alone is not an indication for operative management 2
• Smoking is a relative contraindication to surgery, and cessation is recommended 2
• Numerous surgical procedures have been developed, including:
  • Soft tissue realignment procedures 3
  • Bony realignment procedures 3
  • Combined bony and soft tissue realignment procedures (ie, osteotomy) 3
  • Bony and joint resection 3
  • Arthrodesis techniques 3
  • Silastic joint replacement techniques 3

Postoperative Pain Management

• Multimodal analgesia with acetaminophen and/or nonsteroidal anti-inflammatory drugs is recommended for the treatment of postoperative pain 4
• An intravenous fixed-dose combination of ibuprofen and acetaminophen has been shown to be effective in reducing postoperative pain after bunionectomy 4
• The use of an intravenous fixed-dose combination of ibuprofen and acetaminophen resulted in reduced opioid usage rates compared to monotherapy with either ibuprofen or acetaminophen alone 4