Hallux Valgus (Bunion)

Wider footwear, toe spacers, offloading pads and foot strengthening may reduce pain, although across the non-surgical treatments that have been tested the certainty of the evidence is low 1. Patients report this as worthwhile. None of it has been shown to correct the deformity: a few small studies report some reduction in the angle, but pain relief is more likely than a change in the angle 1.

We tell patients this at the assessment rather than after three months of treatment, because the decision about surgery should be made with accurate information about the alternative.

Before surgery: calf and foot strength, gait pattern, and getting the patient used to the post-operative footwear and crutch technique. It makes practical sense to learn these before the operation, although no randomised trial has yet tested exercise or other physical preparation before bunion surgery 2.

After surgery: protected weight bearing to the surgeon's protocol, swelling management, restoring big toe movement at the right time, and returning the push-off phase of walking. Stiffness of the big toe joint is a common late complaint, which is why its movement is restored deliberately rather than left to return on its own.

Hallux valgus tends to run in families 3. It is also more common in women and with age, and narrow-toed shoes are among the factors most clearly associated with it 4. Where the whole foot is pronating, treating only the toe may miss part of the mechanics driving it.

Footwear changes, toe spacers and strengthening may reduce pain and irritation, though the evidence is of low certainty 1. None of them has been shown to straighten the toe: the deformity is structural, and in trials a reduction in pain has been more likely than any change in the angle 1.

This is worth stating plainly because a great deal is sold on the opposite claim. If straightening is the goal, surgery is the only thing that achieves it, and the decision should be based on pain rather than on appearance.

For a painful bunion, the one randomised trial that compared all three favoured surgery at one year. In 209 adults with a painful bunion and a toe angle of 35 degrees or less, orthoses eased pain at six months, but at one year surgery had reduced pain more than either orthoses or waiting, and 83% of the surgery group felt improved, against 46% with orthoses and 24% on the waiting list 5. A 2024 Cochrane review rated this evidence as low certainty, because patients knew which treatment they had and only one trial has made the comparison; no trial has compared surgery with a sham operation 6.

It can. A 2021 meta-analysis of 23 studies with 2,914 patients put the pooled rate of recurrence at about one in four, with wide variation between studies 7. The factors most strongly linked to it were how large the toe angle still was after the operation and the position of the small sesamoid bones under the joint; a larger angle before surgery was also linked, less strongly 7. These are mainly surgical factors, set in the operating theatre rather than in rehabilitation, which is why rehabilitation after bunion surgery starts from the operation report and the surgeon's protocol.