Treatment Options for Bunions
Initial management of bunions should focus on conservative measures including extra-depth or wide-toed shoes, NSAIDs for pain, and customized orthoses, with surgery reserved only for patients who fail conservative therapy and have persistent pain or recurrent ulcerations. 1, 2
Conservative Management (First-Line Treatment)
Footwear Modifications
- Extra-depth shoes are essential to accommodate the bony prominence and reduce friction 1
- Wide, soft-toed shoes or sandals should replace constrictive footwear 3
- Custom-molded shoes may be necessary for extreme bony deformities that cannot be accommodated with standard footwear 1, 4
Orthotic Interventions
- Customized pressure-relieving orthoses should be used for patients with increased plantar pressures 1
- Cushioning shoe inserts help redistribute pressure away from the bunion 4
- Toe spacers and splints/braces have evidence supporting their use, though they may not provide long-term relief 2
Medical Management
- NSAIDs are recommended for temporary pain relief and inflammation control 3, 2
- Daily foot inspection and proper skin care with moisturizers for dry, scaly skin 1
When Conservative Treatment Fails
Indications for Surgical Referral
Refer to an orthopaedic surgeon when: 2
- The patient has a painful prominence despite exhausting non-operative treatment
- There are recurrent ulcerations not amenable to conservative footwear therapy 1
- The patient is a suitable operative candidate
Important Surgical Considerations
- Cosmesis alone is NOT an indication for surgery 2
- Smoking is a relative contraindication; cessation is recommended before proceeding 2
- In pediatric or adolescent patients (juvenile bunion), surgery should be delayed until skeletal maturity 2
- Surgical reconstruction should only be performed by experienced surgeons who understand both the deformity complexities and the patient's overall health status 1
Special Population: Diabetic Patients
Risk Stratification
- Patients with loss of protective sensation or peripheral arterial disease require more frequent monitoring 1
- Bunions in diabetic patients increase risk for ulceration and potential amputation 1
Enhanced Monitoring
- Referral to foot care specialists is recommended for moderate to high-risk diabetic patients 1
- Patients should avoid self-care of ingrown nails and calluses that may develop secondary to bunion deformities 1
- Those with visual difficulties, physical constraints, or cognitive problems may need assistance from family members for proper foot care 1
Common Pitfalls to Avoid
- Do not proceed directly to surgery without adequate trial of conservative measures - most symptomatic bunions respond to non-operative management 2, 5
- Do not overlook the increased complication risk in diabetic patients - these patients require special attention and more aggressive monitoring 1
- Do not perform surgery for cosmetic reasons alone - pain and functional limitation are the primary indications 2
- Failing to address underlying biomechanical issues (such as excessive subtalar joint pronation) may lead to treatment failure 6