What is the initial management for tailor's bunions or prominence at the base of the 5th metatarsal?

Initial Management of Tailor's Bunions

Conservative management with footwear modification is the first-line treatment for symptomatic tailor's bunions (bunionette deformity), as most cases respond well to non-surgical approaches. 1, 2

Conservative Treatment Approach

Footwear Modifications

• Recommend wide-toe box shoes that eliminate lateral pressure on the fifth metatarsal head prominence 1, 2
• Advise patients to avoid narrow, constrictive footwear that creates friction between the bony prominence and shoe 2
• For patients with bony deformities, extra wide or deep shoes should be prescribed 3
• Appropriately fitting footwear that cushions the feet and redistributes pressure is essential 3, 4

Padding and Pressure Relief

• Apply lateral padding over the bunionette prominence to reduce friction and inflammation 1, 5
• Use metatarsal pads placed behind the metatarsal heads to relieve focal pressure and transfer load more proximally 4
• Consider felted foam padding when other offloading devices are not available 4

Orthotic Interventions

• Prescribe custom or prefabricated orthotic devices if the bunionette results from excessive subtalar joint pronation 1, 6
• Orthotics help redistribute plantar pressures and address biomechanical abnormalities 4

Additional Conservative Measures

• Recommend regular calf-muscle stretching exercises to reduce tension on the forefoot 4
• Advise weight loss for overweight patients to decrease forefoot pressure 4
• Prescribe NSAIDs for pain management and inflammation control 4
• Consider corticosteroid injections for persistent pain in appropriate cases 4

When to Consider Imaging

Rule Out Fracture

• Apply Ottawa ankle rules if there is acute trauma: obtain radiographs if there is palpation pain at the base of the fifth metatarsal bone 3
• The Ottawa rules have 86-99% sensitivity and 97-99% negative predictive value for ruling out fractures 3

Surgical Planning

• Obtain weight-bearing anteroposterior, lateral, and oblique radiographs if conservative treatment fails after 2-3 months 4, 7
• Measure the fourth-fifth intermetatarsal angle to guide surgical decision-making if operative intervention becomes necessary 5, 6

Duration of Conservative Treatment

Continue conservative management for at least 2-3 months before considering surgical referral 4. Most symptomatic bunionettes respond to non-surgical treatment 1, 2, 5.

Special Considerations for Diabetic Patients

• Ensure meticulous attention to proper shoe fitting to prevent pressure sores and ulceration 3, 8
• Perform comprehensive foot examination including assessment for loss of protective sensation using 10-g monofilament testing 3
• Educate patients with neuropathy to perform daily visual foot inspection, as they cannot rely on pain sensation 3
• Consider custom-molded shoes for severe bony deformities that cannot be accommodated with commercial therapeutic footwear 3, 4

Common Pitfalls to Avoid

• Do not proceed directly to surgery without adequate trial of conservative measures - the vast majority of patients improve with shoe modification and padding 1, 2
• Avoid recommending conventional footwear when offloading devices are indicated 4
• Do not overlook biomechanical factors such as excessive pronation that may require orthotic correction 1, 6
• In diabetic patients with neuropathy, never assume absence of symptoms means absence of pathology - rely on objective examination 3