What are the treatment options for a bunion?

Treatment of Bunions

Initial management of symptomatic bunions should be conservative with accommodative footwear, NSAIDs, orthotics, and toe spacers, reserving surgical referral for patients with persistent painful prominence after exhausting non-operative options. 1

Conservative Management (First-Line Treatment)

Footwear Modifications

• Wide, accommodative shoes with adequate toe box space are the cornerstone of bunion management 1
• Avoid narrow, pointed, or high-heeled shoes that compress the forefoot and exacerbate deformity 1

Pharmacological Options

• NSAIDs provide evidence-based pain relief and inflammation reduction 1
• Use the lowest effective dose for the shortest duration to minimize gastrointestinal and cardiovascular risks 1

Orthotic Devices and Bracing

• Orthotics, splints/braces, and toe spacers have demonstrated efficacy in symptom management 1
• These interventions may not provide long-term relief but can delay or avoid surgical intervention 1
• Orthotics are particularly useful when bunion symptoms result from excessive subtalar joint pronation 2

Exercise-Based Interventions

• Foot muscle strengthening exercises may reduce bunion-related pain and improve mobility 3
• Weak intrinsic foot muscles may contribute to bunion-related pain and functional limitations 3
• Strengthening programs can be implemented as adjunctive conservative therapy 3

Indications for Surgical Referral

When to Refer to Orthopedic Surgery

• Persistent painful prominence despite exhausting conservative treatment options 1
• Patient must be a suitable operative candidate with realistic expectations 1
• Cosmesis alone is NOT an indication for surgery 1

Special Populations Requiring Modified Approach

Pediatric/Adolescent Patients (Juvenile Bunion)

• Surgery should be delayed until skeletal maturity is achieved 1
• Early intervention risks recurrence and growth disturbance 1

Athletes with Bunions

• Many athletes have compensated bunions with congruous joints requiring minimal treatment 4
• Surgery becomes necessary when the bunion rapidly progresses, sesamoids sublux, and the joint becomes incongruous 4

Smokers

• Smoking is a relative contraindication to bunion surgery 1
• Smoking cessation is strongly recommended before considering operative management 1
• Continued smoking increases risk of wound complications and non-union 1

Surgical Considerations

Surgical Options (When Conservative Management Fails)

• Multiple surgical techniques exist including distal osteotomies, diaphyseal osteotomies, proximal osteotomies, and resection procedures 2
• Distal osteotomy is recommended when medial translation of the metatarsal head by one-third of the shaft width produces a normal fourth-fifth intermetatarsal angle 2
• Proximal osteotomy should be performed for larger deformities 2

Recurrence Risk

• Up to 15% of bunions return after surgical correction 3
• Revision surgery may be considered if recurrence is due to under-correction or inappropriate initial procedure selection 2
• Resection should be considered as a final salvage procedure for recurrent deformity 2

Common Pitfalls to Avoid

• Never proceed to surgery based on cosmetic concerns alone—pain and functional limitation must be present 1
• Do not operate on juvenile bunions before skeletal maturity—this leads to high recurrence rates 1
• Avoid surgical intervention in active smokers without cessation counseling—wound healing complications are significantly increased 1
• Do not bypass conservative management—accommodative footwear and orthotics should always be attempted first 1
• Recognize that conservative measures may not provide permanent correction but can effectively manage symptoms and delay surgery 1