What can I prescribe for a patient with bunion pain?

From the Guidelines

For bunion pain, I recommend starting with conservative treatments before considering surgical options, prioritizing over-the-counter NSAIDs like ibuprofen (400-800mg three times daily with food) or naproxen (500mg twice daily) to reduce pain and inflammation, as supported by recent guidelines 1.

Conservative Treatments

• Begin with over-the-counter NSAIDs like ibuprofen (400-800mg three times daily with food) or naproxen (500mg twice daily) to reduce pain and inflammation.
• Topical NSAIDs such as diclofenac gel 1% applied to the affected area 3-4 times daily can also provide relief with fewer systemic side effects.
• Recommend proper footwear with a wide toe box and low heels to reduce pressure on the bunion.
• Custom orthotics or over-the-counter bunion pads can help redistribute pressure away from the painful area.
• Ice application for 15-20 minutes several times daily can reduce inflammation, especially after prolonged standing or walking.
• Physical therapy exercises to maintain joint mobility and strengthen surrounding muscles may be beneficial.

Referral to Specialist

If conservative measures fail after 4-6 weeks, consider referral to a podiatrist or orthopedic surgeon for evaluation and possible surgical intervention. These treatments work by reducing inflammation at the first metatarsophalangeal joint where bunions form, decreasing mechanical pressure on the deformity, and maintaining proper joint alignment to prevent further progression, as suggested by studies 1.

Key Considerations

• The most recent and highest quality study 1 emphasizes the importance of a multidisciplinary approach to managing bunion pain, including patient education, lifestyle modifications, and pharmacological interventions.
• Other studies 1 provide additional guidance on the management of chronic pain, including the use of non-opioid analgesics, antidepressants, anticonvulsants, and skeletal muscle relaxants.
• The American College of Physicians and the American Pain Society recommend a stepped-care approach to managing chronic pain, starting with non-pharmacological interventions and progressing to pharmacological treatments as needed 1.

From the FDA Drug Label

Naproxen has been studied in patients with rheumatoid arthritis, osteoarthritis, juvenile arthritis, ankylosing spondylitis, tendonitis and bursitis, and acute gout Improvement in patients treated for rheumatoid arthritis was demonstrated by a reduction in joint swelling, a reduction in duration of morning stiffness, a reduction in disease activity as assessed by both the investigator and patient, and by increased mobility as demonstrated by a reduction in walking time In patients with osteoarthritis, the therapeutic action of naproxen has been shown by a reduction in joint pain or tenderness, an increase in range of motion in knee joints, increased mobility as demonstrated by a reduction in walking time, and improvement in capacity to perform activities of daily living impaired by the disease

Naproxen can be prescribed for a patient with bunion pain, as it has been shown to be effective in reducing joint pain and inflammation in patients with osteoarthritis and other conditions.

• The dosage and duration of treatment should be determined by the healthcare provider, taking into account the patient's medical history and current condition.
• Patients should be monitored for potential side effects, such as gastrointestinal bleeding and renal toxicity.
• Naproxen should be used at the lowest effective dose for the shortest duration necessary to minimize the risk of adverse effects 2.

From the Research

Treatment Options for Bunion Pain

• Nonsteroidal anti-inflammatory drugs (NSAIDs) can be used to manage bunion pain, as evidenced by studies 3, 4
• Orthotics, splints/braces, and toe spacers may also provide relief, although they may not offer long-term solutions 3
• Accommodative footwear is an important aspect of non-operative treatment 3
• Muscle-strengthening exercises may help reduce pain and improve mobility in patients with bunions 5
• Analgesic adjuvants, such as pregabalin and naproxen sodium, have been shown to be effective in reducing postoperative pain following bunionectomy 4
• Nonopioid analgesics, including acetaminophen and NSAIDs, can be used to manage pain in patients with bunions 6

Medication Options

• Pregabalin has been shown to reduce PCA hydromorphone consumption and increase the time to first use of PCA hydromorphone postsurgery 4
• Naproxen sodium has been found to be effective in reducing pain and opioid consumption in patients with bunion pain 4
• Tramadol may be an alternative to musculoskeletal pain management in patients with moderate to moderately severe pain 6

Referral to Specialist

• 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 3