How to manage a tender bunion?

Management of Tender Bunions

Start with conservative management using proper footwear, NSAIDs for pain control, and orthotics to redistribute pressure—surgery should only be considered after exhausting these non-operative options in patients with persistent pain despite appropriate conservative treatment. 1, 2

Initial Conservative Approach

Footwear Modifications

• Prescribe extra-depth shoes to accommodate the medial prominence and reduce direct pressure on the bunion 1
• Advise patients to avoid narrow, pointed, or high-heeled shoes that compress the forefoot 2
• For severe deformities, custom-molded shoes may be necessary 1

Pain Management

• Use NSAIDs for acute pain relief and to reduce inflammation around the tender bunion 2
• Apply ice to the bunion after activities that aggravate symptoms 2

Pressure Redistribution

• Provide customized pressure-relieving orthoses for patients with increased plantar pressures under the metatarsal heads 1
• Consider toe spacers to reduce pressure between the first and second toes 2
• Splints or braces may provide symptomatic relief, though evidence for long-term benefit is limited 2

Skin Care and Monitoring

• Instruct patients on daily foot inspection, particularly checking for areas of redness or skin breakdown over the bunion 1
• Apply moisturizers for dry, scaly skin that may develop 1
• Patients should avoid self-treatment of calluses that commonly form over the bunion prominence 1

When Conservative Management Fails

Indications for Surgical Referral

• Refer to an orthopaedic or foot surgeon when the patient has persistent painful prominence despite 3-6 months of appropriate conservative treatment 2
• Recurrent ulcerations not amenable to conservative footwear therapy warrant surgical consideration 1
• Cosmesis alone is NOT an indication for surgery 2

Pre-Surgical Considerations

• Smoking is a relative contraindication—recommend cessation before proceeding with surgery 2
• Ensure the patient understands that surgery aims to relieve pain and improve function, not simply appearance 2
• Surgical reconstruction should be performed by experienced surgeons who understand both the deformity complexities and the patient's overall health status 1

Special Populations

Diabetic Patients with Bunions

• Risk stratification is essential—patients with loss of protective sensation or peripheral arterial disease require more frequent monitoring 1
• Bunions in diabetic patients significantly increase risk for ulceration and potential amputation 1
• Refer moderate to high-risk diabetic patients to foot care specialists 1

Pediatric/Adolescent Patients

• Delay surgery until skeletal maturity is reached in juvenile bunions 2
• Nearly all juvenile bunions have an elevated distal metatarsal articular angle (DMAA) and congruent joints, which differentiates them from adult bunions 3

Common Pitfalls to Avoid

• Do not proceed directly to surgery without exhausting conservative options—most patients can be managed non-operatively 2
• Avoid recommending surgery based solely on radiographic appearance or cosmetic concerns 2
• Do not neglect patient education about proper footwear, as this is the cornerstone of conservative management 1, 2
• Patients with visual difficulties, physical constraints, or cognitive problems may need family assistance for proper foot care 1