Bunions
Bunions - Summary
A bunion is a prominent first metatarsal head, sometimes associated with bursitis, which may be inflamed and can occasionally ulcerate.
Bunions are caused by an abnormal deviation of the big toe towards the midline of the foot.
The exact cause and prevalence of bunions is unknown; however, there is often a significant family history of bunion deformity. Ill-fitting footwear is considered to be one of the major causes, with women being more often affected than men.
Complications of bunions include:
Arthritis in the big toe joint and deformity of the second toe.
Pressure in shoes.
Displacement of the second toe by the big toe, due to severe deformity.
Managing a bunion should include:
Establishing the reason for consultation (symptom relief or skin trauma).
Assessment of severity and effect on lifestyle.
Assessment of the degree of deformity: mild, moderate, or severe (weight-bearing X-rays are not done in primary care).
Assessment for degenerative joint disease (which may develop in people with long-standing or severe bunions).
Assessment for coexisting osteoarthritis (more likely in people with long-standing or severe bunions).
Ruling out alternative diagnoses, such as gout or sesamoiditis.
Enquiring about a medical history of diabetes, vascular disease, or neuropathy.
Assessment of footwear, including questions about what types of shoes are normally worn and whether there has been any recent change in footwear.
Enquiring about treatments that have already been tried, such as bunion pads.
Offering paracetamol or ibuprofen for pain relief.
People presenting with bunions should be advised that:
They should wear low-heeled, wide shoes (preferably with laces or adjustable straps).
Bunions are progressive. Non-surgical treatments (e.g. medication, bunion pads, orthoses) may relieve symptoms but do not limit progression.
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 (e.g. infection, joint stiffness, bunion recurrence, damage to the nerves, and long-term pain).
They should wear sensible, wide-fitting, low-heeled shoes for 6 months or more after surgery.
Referral should be arranged:
To diabetic care services if the person has diabetes.
For orthopaedic or podiatric surgery consultation if: self-care advice and analgesia have been tried and symptoms are not improving; the person has difficulty obtaining suitable shoes; the person has recurrent ulcers; or infection is present.
Have I got the right topic?
This CKS topic covers the assessment, management, and referral of adults with bunions in primary care.
This CKS topic does not cover the management of bunions in children, tailor's bunion (bunionette), or diabetic foot disease.
There is a separate CKS topic on Diabetes - type 2.
The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary health care.
How up-to-date is this topic?
How up-to-date is this topic?
Changes
September 2012 — reviewed. A literature search was conducted in September 2012 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of the topic. No changes to clinical recommendations have been made.
Previous changes
February 2010 — minor update to the Definition section. Issued in February 2010.
July to October 2008 — this is a new CKS topic. The evidence-base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.
Update
New evidence
Evidence-based guidelines
No new evidence-based guidelines since 1 September 2012.
HTAs (Health Technology Assessments)
No new HTAs since 1 September 2012.
Economic appraisals
No new economic appraisals relevant to England since 1 September 2012.
Systematic reviews and meta-analyses
No new systematic review or meta-analysis since 1 September 2012.
Primary evidence
No new randomized controlled trials published in the major journals since 1 September 2012.
New policies
No new national policies or guidelines since 1 September 2012.
New safety alerts
No new safety alerts since 1 September 2012.
Changes in product availability
No changes in product availability since 1 September 2012.
Goals and outcome measures
Goals
Making an accurate diagnosis
Making an accurate assessment (e.g. severity of the bunion)
Appropriate treatment in primary care settings
Appropriate referral to secondary care or other specialist service
Providing appropriate advice to patients
Background information
Definition
What is it?
A bunion is a prominent first metatarsal head, sometimes associated with bursitis, which may be inflamed and occasionally ulcerate. Bunions can cause pain when walking or wearing shoes [Merck, 2003; Vanore et al, 2003; Ferrari, 2009].
An abductus angle (the angle formed between the metatarsal and abducted hallux) greater than 15 degrees is considered abnormal [Ferrari et al, 2004].
Not all people with bunions are symptomatic [Vanore et al, 2003].
Causes and prevalence
What are the causes and the prevalence?
Bunions are caused by an abnormal deviation of the big toe (hallux) towards the midline of the foot (hallux valgus) [Ferrari et al, 2004].
There is usually an associated drift of the first metatarsal away from the second metatarsal. This leads to splaying of the forefoot and enlargement of the first metatarsal head, which can become painful and inflamed.
The exact cause and prevalence of bunions is unknown; however, there is often a significant family history of bunion deformity [Vanore et al, 2003]. Ill-fitting footwear is considered to be one of the major causes, with women being more often affected (up to one-third) than men [Dawson et al, 2002; Ferrari et al, 2004].
Complications
What are the complications?
Bunions are usually progressive, and the deformity can cause secondary problems, such as arthritis in the big toe joint and deformity of the second toe [Vanore et al, 2003]. They typically cause pressure problems in shoes because of the altered foot shape. With severe deformity, the big toe may displace the second toe.
Management
Management
Scenario: Bunions
Scenario: Bunions
Assessment
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
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.
Management
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
Additional information
See the CKS topic on NSAIDs - prescribing issues for more information on nonsteroidal anti-inflammatory drugs.
Basis for recommendation
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).
Referral
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
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].
Evidence
Evidence
Supporting evidence
Orthosis and night splints
Evidence on orthosis and night splints
One small trial found that, compared with no treatment, people using orthoses were more likely to say they were better off than they were 1 year ago. There is no good-quality evidence that night splints or orthoses (devices, usually plastic, worn in shoes to provide control of the foot position) correct the hallux valgus angle or reduce pain associated with bunions.
A Cochrane systematic review (search date: March 2003) assessed 21 randomized controlled trials of interventions (e.g. surgery, night splints, orthoses) used to correct hallux valgus [Ferrari et al, 2004]. The methodological quality of the trials was generally poor, and sample sizes were small.
Only three trials (n = 332) were found that evaluated conservative treatments (orthoses and night splints) versus no treatment. There was no evidence of a difference in outcomes (pain and correction of the hallux valgus angle) between treatment and no treatment:
Global assessment:
One trial (n = 28) 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) [Torkki et al, 2001].
Pain:
In one small trial (n = 28), no significant difference was detected between the number of people remaining in pain when prescribed night splints and those who received no treatment (OR 2.20, 95% CI 0.47 to 10.35) [Juriansz, 1996].
A second, larger, trial (n = 209) found no evidence of a difference in pain scores reported on a visual analogue scale in people receiving orthoses and those receiving no treatment (mean difference 0, 95% CI –8.19 to +8.19) [Torkki et al, 2001].
Correction of hallux valgus angle:
One small RCT (n = 28) found no evidence that night splints corrected the hallux valgus angle compared with no treatment (mean difference 0.30 degrees, 95% CI –3.40 to +4.00) [Juriansz, 1996].
A second, larger, RCT (n = 122) that assessed orthoses compared with no treatment in children showed evidence of a difference in hallux valgus angle in favour of the no treatment group (mean difference 2.56 degrees, 95% CI 0.40 to 4.72). The hallux valgus angle in both the treatment and control groups deteriorated, and the deterioration was greater in the group treated with orthoses [Kilmartin et al, 1994].
Search strategy
Scope of search
A literature search was conducted for guidelines and systematic reviews on the primary care management of bunions.
Search dates
June 2008 – September 2012
Key search terms
Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline and these were adapted for other databases. Further details are available on request.
exp Hallux Valgus/, (hallux ADJ valgus).tw., (hallux ADJ abductovalgus).tw., bunion$.tw.
Table 1. Key to search terms.| Search commands | Explanation |
|---|---|
| / | indicates a MeSh subject heading with all subheadings selected |
| .tw | indicates a search for a term in the title or abstract |
| exp | indicates that the MeSH subject heading was exploded to include the narrower, more specific terms beneath it in the MeSH tree |
| $ | indicates that the search term was truncated (e.g. wart$ searches for wart and warts) |
Topic specific literature search sources
American College of Foot and Ankle Surgeons
American Association of Colleges of Podiatric Medicine
American Podiatric Medical Association
Council on Podiatric Medical Education
Society of Chiropodists and Podiatrists
British Orthopaedic Foot and Ankle Society
American Orthopaedic Foot and Ankle Society
Sources of guidelines
National Institute for Health and Clinical Excellence (NICE)
Scottish Intercollegiate Guidelines Network (SIGN)
Royal College of General Practitioners
National Guidelines Clearinghouse
Guidelines International Network
NHS Scotland National Patient Pathways
Agency for Healthcare Research and Quality
Institute for Clinical Systems Improvement
National Health and Medical Research Council (Australia)
Royal Australian College of General Practitioners
British Columbia Medical Association
University of Michigan Medical School
Michigan Quality Improvement Consortium
National Resource for Infection Control
UK Ambulance Service Clinical Practice Guidelines
RefHELP NHS Lothian Referral Guidelines
Medline (with guideline filter)
Driver and Vehicle Licensing Agency
NHS Health at Work (occupational health practice)
Sources of systematic reviews and meta-analyses
Systematic reviews
Protocols
Database of Abstracts of Reviews of Effects
Medline (with systematic review filter)
EMBASE (with systematic review filter)
Sources of health technology assessments and economic appraisals
NIHR Health Technology Assessment programme
NHS Economic Evaluations
Health Technology Assessments
Canadian Agency for Drugs and Technologies in Health
International Network of Agencies for Health Technology Assessment
Sources of randomized controlled trials
Central Register of Controlled Trials
Medline (with randomized controlled trial filter)
EMBASE (with randomized controlled trial filter)
Sources of evidence based reviews and evidence summaries
Central Services Agency COMPASS Therapeutic Notes
Sources of national policy
Health Management Information Consortium (HMIC)
Patient experiences
Patient.co.uk - Patient Support Groups
Sources of medicines information
The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.
British National Formulary (BNF)
electronic Medicines Compendium (eMC)
European Medicines Agency (EMEA)
References
Dawson, J., Thorogood, M., Marks, S.A. et al. (2002) The prevalence of foot problems in older women: a cause for concern. Journal of Public Health Medicine 24(2), 77-84. [Abstract] [Free Full-text]
Easley, M.E. and Trnka, H.J. (2007) Current concepts review: hallux valgus part 1: pathomechanics, clinical assessment, and nonoperative management. Foot & Ankle International 28(5), 654-659.
Ferrari, J. (2006) Critical review: the assessment and conservative treatment of hallux valgus deformity in healthy adults. British Journal of Podiatry 9(4), 104-108.
Ferrari, J. (2009) Bunions. Clincial Evidence..BMJ Publishing Ltd.www.clinicalevidence.com [Free Full-text]
Ferrari, J., Higgins, J.P.T. and Prior, T.D. (2004) Interventions for treating hallux valgus (abductovalgus) and bunions (Cochrane Review) [Withdrawn]. The Cochrane Library.Issue 1.John Wiley & Sons, Ltd.www.thecochranelibrary.com [Free Full-text]
Juriansz, A.M. (1996) Conservative treatment of hallux valgus: a randomised controlled clinical trial of a hallux valgus night splint. Journal of British Podiatric Medicine 51, 119.
Kilmartin, T.E., Barrington, R.L. and Wallace, W.A. (1994) A controlled prospective trial of a foot orthosis for juvenile hallux valgus. Journal of Bone and Joint Surgery British Volume 76(2), 210-214. [Abstract] [Free Full-text]
Merck (2003) Hallux valgus and bunion. Merck Manual of Medical Information..Merck.www.merck.com
NHS Scotland (2005) Musculoskeletal - foot and ankle patient pathway. ..NHS Scotland.www.pathways.scot.nhs.uk [Free Full-text]
Torkki, M., Malmivaara, A., Seitsalo, S. et al. (2001) Surgery vs orthosis vs watchful waiting for hallux valgus: a randomized controlled trial. Journal of the American Medical Association 285(19), 2474-2480. [Abstract] [Free Full-text]
Vanore, J.V., Christensen, J.C., Kravitz, S.R. et al. (2003) Diagnosis and treatment of first metatarsophalangeal joint disorders. Section 1: hallux valgus. Journal of Foot and Ankle Surgery 42(3), 112-123. [Free Full-text]