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Bunions - Management
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How should I assess someone with bunions?

  • Establish the reason for consultation. The person may:
    • Require symptomatic relief only.
    • Have difficulty in fitting into footwear (resulting in skin trauma).
    • Have no symptoms but dislike the look of their foot or the type of footwear that must be worn to accommodate the foot.
  • Assess for severity:
    • Ask about the location and duration of pain and the presence of paraesthesia (not all people with bunions are symptomatic).
    • Ask how the symptoms are affecting the person's lifestyle.
  • Assess the degree of deformity: mild, moderate, or severe (weight-bearing X-rays are not done in primary care).
  • Assess for degenerative joint disease (which may develop in people with long-standing or severe bunions).
    • Assess for coexisting osteoarthritis (more likely in people with long-standing or severe bunions).
  • Rule out alternative diagnoses, such as gout or sesamoiditis.
  • Enquire about a medical history of diabetes, vascular disease, or neuropathy.
  • Assess footwear, and ask what types of shoes are normally worn and whether there has been any recent change in footwear.
  • Enquire about treatments that have already been tried, such as bunion pads or over-the-counter analgesics.
Basis for recommendation
  • These recommendations are based on practical advice, two reviews [Ferrari, 2006; Easley and Trnka, 2007], and a guideline on the diagnosis and treatment of bunions [Vanore et al, 2003].
  • Establishing the reason for consultation at assessment is important so that the clinician can decide whether successful treatment can be provided [Ferrari, 2006]. Significant deformities may be asymptomatic, and reassurance and advice on footwear may be all that is required [Vanore et al, 2003].
  • People with diabetes require specialist management. For more information, see the CKS topic on Diabetes type 2.

How should I manage bunions?

  • Advise people presenting with bunions that:
    • They should wear low-heeled, wide shoes.
      • It is preferable for the shoe to have laces or an adjustable strap.
      • If they also have osteoarthritis of the foot, this is another good reason not to wear tightly fitting shoes.
    • Bunions are progressive.
    • Non-surgical treatments (e.g. medication, bunion pads, orthoses) may relieve symptoms but do not limit progression.
  • Advise the person that referral for bunion surgery is indicated only for pain and is not routinely performed for cosmetic purposes.
    • Surgery can be done under local or general anaesthetic and is usually done as a day case.
    • Bunion surgery may help relieve pain and improve the alignment of the toe in the majority of people (85%–90%); however, there is no guarantee that the foot will be perfectly straight or pain-free after surgery.
    • Some people (less than 10%) may have complications after bunion surgery (infection, joint stiffness, transfer pain [pain under the ball of the foot], bunion recurrence, damage to the nerves, and continued long-term pain).
    • The person will need to wear sensible, wide-fitting, low-heeled shoes for 6 months or more after surgery.
  • If the person is symptomatic:
    • Prescribe oral analgesia (e.g. paracetamol or a nonsteroidal anti-inflammatory drug, such as ibuprofen).
    • Advise self-care treatments for symptomatic relief, such as bunion pads (available over-the-counter) or ice packs.
    • Consider referral for an orthosis.
    • Symptomatic treatment is most effective when there is inflammation or when the symptoms are of short duration.
  • If the person has diabetes, refer to diabetic foot care services.
Additional information
Basis for recommendation
  • These recommendations are based on practical advice, two reviews [Ferrari, 2006; Easley and Trnka, 2007], and a guideline from the American College of Foot and Ankle Surgeons on the diagnosis and treatment of bunions [Vanore et al, 2003].
  • Analgesics:
    • CKS found no trials assessing the efficacy of paracetamol or nonsteroidal anti-inflammatory drugs for bunions; however, they are widely recommended [Vanore et al, 2003; NHS Scotland, 2005].
  • Self-care treatments:
    • Self-care treatments, such as bunion pads and ice packs, have not been evaluated in good-quality randomized controlled trials [Ferrari, 2006]. However, they are widely recommended because it is thought that some people may gain symptomatic relief [Vanore et al, 2003].
  • Night splints or orthoses:
    • There is no good-quality evidence that night splints or orthoses (devices worn in shoes to provide control of the foot position) correct the hallux valgus angle or reduce pain associated with bunions.
    • One small trial found that, compared with people using an orthosis, people not given an orthosis were more likely to say that they were no better off than they were 1 year previously (OR 0.38, 95% CI 0.18 to 0.78).

When should I refer?

  • Refer for orthopaedic or podiatric surgery consultation if:
    • Self-care advice and analgesia have been tried and symptoms are not improving:
      • Pain should be the primary indication for surgery. It is not usually indicated for cosmetic concerns.
    • The person has difficulty obtaining suitable shoes.
    • The person has recurrent ulcers.
    • Infection is present.
  • Refer to diabetic care services if the person has diabetes.
Basis for recommendation
  • These referral guidelines are based on practical advice and guidelines from the Musculoskeletal – foot and ankle pathway developed by the Centre for Change and Innovation for NHS Scotland [NHS Scotland, 2005].
  • Surgery is not indicated for cosmetic concerns because of the recovery time and potential for complications associated with bunion surgery [Easley and Trnka, 2007].

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