Bunion Management: Surgery or No?

Should I get a bunionectomy for my toe pain?

Bunions usually refer to the “bump” that is created via calcification at the metatarsophalangeal (MTP) joint in the foot — typically at the first or fifth toe. The cause of bunions can vary, from shoe type to gait mechanics. These calcifications can cause pain, reduce range of motion, and ultimately change the way we walk, squat, weight-bear and move.

Management of bunions can include conservative care (physical therapy), orthotics, and often surgery (bunionectomy). Making the best choice for managing bunions requires careful diagnostic work and proper adherence to a treatment plan. So how do you know if you should proceed with surgery or a conservative approach?

Most importantly, I emphasize that any decision surrounding surgery should be made in conjunction with the appropriate surgeon and healthcare team. Physical therapists are often part of that healthcare team, and as a PT I aim to provide data to inform the decision under this scope. It is ultimately your choice as the patient.

In order to truly decide if a possible surgical solution is best, you need to know the exact impact the bunion is having (or may have) on your overall quality of life and movement health. How painful is it, and how long does it take before the pain becomes unbearable? Is the trend worsening (bunion getting larger, tolerance before pain onset decreasing, etc), or is the level of resultant disability harmful to the rest of your health? Is your bunion negatively impacting your walking to the point it may cause other problems, such as ankle, knee, hip, or back pain?

These were the questions I asked my client, who was seeking advice on how to handle her own bunion at the first metatarsal. It was limiting her big toe extension and causing pain with weight-bearing. Additionally, I had been treating this client for other conditions and was aware she had a history of falls, which raises potential concerns with regard to balance performance. I suggested she consult with a podiatrist and recommended she have her gait precisely measured to determine the extent to which her bunion was impacting her walking performance. This would provide clarity on the likelihood of falls or other “upstream” injury at the ankle, knee, hip, or back.

Using combined and synchronized accelerometry and electromyographic data I was able to capture her joint positions and neuromuscular strategy in real time while she walked on her own back patio. Ultimately, we concluded she had enough range of motion in the big toe with minimal compromise at the knee and hip — and no major “favoring” of the limb or altered gait strategy — to advise surgery was not urgent. Additionally, impairments that were measured, such as delayed gluteal muscle activation and variations in cadence and step length, are treatable with conservative (non-surgical) techniques. She was able to share these objective, data-driven and confidence inspiring results with her podiatrist and a conservative plan of care was established to help manage her bunion going forward. This approach minimized the risk of either unnecessary surgery or the downplaying of a problem that could fester into worse outcomes. She also now has a template “reference gait” to measure against should she ever suspect the condition becomes worse later in life.

If you have a bunion and are concerned about what to do, consider reaching out for a consult and gait analysis