What are the appropriate management options for a middle-aged to elderly patient presenting with a bunion, considering their history of wearing poorly fitting shoes or certain medical conditions?

Management of Bunions in Middle-Aged to Elderly Patients

Initial management of symptomatic bunions should be non-operative, with accommodative footwear as the cornerstone of treatment, and surgery reserved only for patients with persistent pain who have failed conservative measures and are suitable operative candidates. 1

Conservative Management (First-Line Treatment)

Footwear Modifications

• Proper shoe fitting is essential: shoes should not be too tight or too loose, with the inside 1-2 cm longer than the foot, internal width equal to foot width at the metatarsophalangeal joints, and sufficient height for toes 2
• Fit should be evaluated with the patient standing, preferably at the end of the day when feet are most swollen 2
• Avoid shoes with rough edges, uneven seams, or tight construction 2
• For patients with significant deformity who cannot be accommodated with standard therapeutic footwear, custom-molded shoes may be necessary 2, 3

Medical Management

• NSAIDs are evidence-based for pain relief in symptomatic bunions 1
• Orthotics, splints/braces, and toe spacers have supporting evidence, though they may not provide long-term relief 1

Patient Education

• Daily foot inspection, including between toes 2
• Daily inspection and palpation of the inside of shoes 2
• Avoid barefoot walking indoors or outdoors 2
• Notify healthcare provider immediately if blisters, cuts, or sores develop 2

Professional Foot Care

• Regular treatment by a trained foot care specialist for callus and skin pathology 2
• Callus should be debrided with a scalpel by an experienced foot care professional, not by the patient 2, 3

When to Consider Surgical Referral

Refer to an orthopaedic surgeon when the patient has:

• Painful prominence that persists despite conservative treatment 1
• Exhausted non-operative management options 1
• Is a suitable operative candidate 1

Important Surgical Considerations

• Cosmesis alone is NOT an indication for surgery 1
• Smoking is a relative contraindication; cessation is recommended before surgery 1
• In pediatric or adolescent patients (juvenile bunion), surgery should be delayed until skeletal maturity 1
• Be aware that up to 15% of bunions may recur after surgery 4

Special Populations

Diabetic Patients

• Bunions (hallux valgus) represent a significant foot deformity that increases ulceration risk 5
• These patients require extra care when fitting footwear, particularly when neuropathy and/or ischemia are present 2
• Refer to therapeutic footwear specialists, as they are at moderate to high risk for foot ulcer development 5
• If deformities cause signs of abnormal loading (hyperemia, callus, ulceration), refer for special footwear construction including insoles and orthoses 2

Patients with Vascular Disease

• Assess pedal pulses and consider ankle-brachial index if pulses are diminished 2
• Extra caution needed with footwear fitting in patients with ischemia 2

Common Pitfalls to Avoid

• Do not use chemical agents or plasters to remove corns and calluses 2
• Avoid recommending surgery based solely on appearance 1
• Do not delay addressing footwear issues—ill-fitting shoes are the most frequent cause of foot complications, even in patients with vascular disease 2
• Standard off-the-shelf footwear will not adequately accommodate significant bunion deformities 3

Adjunctive Therapies

• Muscle-strengthening exercises may help reduce bunion-related pain and improve mobility 4
• For patients with persistent symptoms despite conservative care, minimally invasive surgical approaches have gained popularity with positive outcomes 6