Bunions (hallux valgus):
Shoes, Insoles or Surgery?

1. What is a bunion (hallux valgus)?

With hallux valgus (bunion), the big toe drifts outwards at its base joint, towards the second toe. At the same time, the first metatarsal bone tilts towards the inner edge of the foot. This creates the typical bunion on the inner side of the forefoot — usually not a new bony growth, but mainly the protruding head of the metatarsal bone.^¹,²

Hallux valgus is the most common forefoot deformity. Estimates suggest that around one in five people worldwide has a bunion to some degree, rising to about one in three among people over 65. Women are affected far more often than men.^² In Germany, around 1.3 million people are treated for it every year.^³

Normal or in need of treatment? A slight slant of the big toe is normal. Whether treatment is needed depends less on how pronounced the deformity is than on the symptoms: some people never have pain despite a marked bunion, others do even with a small deviation.^² Without symptoms, treatment is generally not necessary.

2. Severity grades and associated deformities

Hallux valgus is measured on an X-ray taken while standing: the hallux valgus angle describes how far the big toe deviates, the intermetatarsal angle how far the first metatarsal bone splays away from the second. Since 2026, the updated guideline distinguishes only two grades of severity, because the earlier finer classification makes no difference to the choice of operation:^¹,⁴

A bunion rarely comes alone. Common associated problems include splayfoot, in which the forefoot widens, pain under the heads of the middle metatarsal bones (metatarsalgia), and hammer and claw toes, because the deviating big toe pushes the second toe out of place.^⁴

3. Symptoms and consequences

• Pressure pain over the bunion — especially in tight or stiff shoes, often with redness.
• Inflamed bursa (bursitis) — a soft, red, warm swelling over the bunion.
• Pain under the forefoot — because the big toe bears less weight, the middle metatarsal heads are overloaded; calluses and corns often form there.
• Changes to the smaller toes — the second toe ends up overlapping or underlapping, and hammer and claw toes rub inside the shoe.
• Trouble buying shoes — the forefoot becomes wider, and finding shoes that fit gets harder.

In the longer term, osteoarthritis can develop in the big toe joint, and chronic pain becomes more common. A pronounced bunion can also change the way you walk and increase the risk of falls — a point that matters especially in older age.^² The course varies widely: in some people the deformity stays stable for years, in others it progresses.^² You can find general information on painful joints under joint pain.

4. Causes and risk factors

Hallux valgus usually develops over years from a combination of predisposition, foot shape and strain:^²,³

• Family predisposition: according to the guideline, the most important cause. Often a mother, grandmother or siblings are affected too.^³
• Sex and age: women are affected far more often, and frequency increases from middle age onwards.^²
• Foot shape: splayfoot or flat feet with an inward-tilting heel, as well as a shortened Achilles tendon and tight calf muscles, favour the deformity.^²
• Lax connective tissue: weaker ligaments and tendons hold the big toe joint less stably.^²
• Joint diseases: inflammatory rheumatism (rheumatoid arthritis) damages the joint capsule and ligaments and often leads to marked forefoot deformities.^²
• Shoes: tight, pointed shoes with high heels increase the pressure on the bunion and the symptoms. According to current knowledge, however, they are not considered the sole cause.^²,³

5. Diagnosis: examination, X-rays, ruling out other causes

A bunion can usually be recognised at first glance. Treatment planning still requires a thorough examination, because the cause of the pain and the severity determine what makes sense.^¹,²,⁴

• Consultation: Where and when does it hurt, and in which shoes? What have you already tried? Do you have diabetes, rheumatism, gout or circulation problems, and which medicines do you take?
• Examination standing, walking and sitting: position of the big and smaller toes, foot shape, mobility and stability of the joints, pressure points and calluses.
• Circulation and sensation: foot pulses and sensitivity are checked — important before any operation and if you have diabetes.
• Weight-bearing X-rays: images of the foot taken while standing are the most important imaging. They are used to measure the angles and assess osteoarthritis or bone changes.^⁴
• Further tests: MRI, CT or blood tests (such as uric acid and inflammatory markers) only for specific questions.^⁴

Conditions to rule out are mainly hallux rigidus, a gout attack, inflammatory rheumatism and isolated bursitis. Bring a list of your medicines to the appointment, and ideally the shoes that hurt most — tips in our guide Preparing for a doctor’s appointment.

6. Shoes, insoles, splints: what they can do

The guideline recommends exhausting the non-surgical options first.^¹,³ An honest assessment is part of this: no conservative measure brings the big toe back into a straight position permanently. The aim is to reduce pressure and pain and keep the foot mobile.^²,³ The evidence on this is thin and partly contradictory.^²

7. Surgery: when, which procedure, what risks

Surgery is the only way to actually correct the deformity.^² According to the guideline, it is an option if severe symptoms, reduced quality of life or recurrent painful pressure points persist despite conservative measures.^³ Foot surgeons often sum it up briefly: no pain, no operation. Wanting to wear narrow high-heeled shoes again is not a reason for surgery.^⁴

Numerous comparative studies were evaluated for the 2026 guideline. The result: all common procedures clearly improve the deformity and satisfaction, and no single technique has been shown to be clearly superior. Open and minimally invasive procedures also do not differ substantially in outcome.^¹,³,⁴ What matters are the severity, the condition of the joint and the experience of the surgical team. Which procedure is an option for you is decided by your doctor together with you.

After the operation

Many operations are done as day surgery or with a short hospital stay. After joint-preserving corrections, you are often allowed to put weight on the foot early on in a special forefoot offloading shoe or post-operative shoe, which you wear for several weeks; after a fusion, the foot is often rested for longer.^⁴ Swelling can last for months, and normal shoes usually only fit again after a few weeks. The guideline stresses that recovery after surgery takes longer than many people expect.^³

Risks, honestly assessed

Surgery generally has a good outlook, but complications are not rare: depending on the procedure and follow-up period, the overall rate in studies is 10 to 30 per cent.^⁴ They include:

• Recurrence of the deformity in up to 10 to 15 per cent, and less often overcorrection with the toe pointing inwards.^⁴
• Persistent or new pain under the forefoot due to a change in how weight is distributed.^⁴
• Failure of the bone to heal (non-union), more common after fusions, in smokers and with vitamin D deficiency.^⁴
• Wound healing problems and infections, nerve irritation with numbness in the toe, and rarely thrombosis.^⁴ More on poor wound healing.

8. Painkillers and medication around surgery

Painkillers for bunion pain

Anti-inflammatory painkillers (NSAIDs) such as ibuprofen or diclofenac relieve pain and bursa irritation. As tablets, they should ideally be used only for a short time; a gel works locally and puts less strain on the body.^² According to the summary of product characteristics, NSAIDs can cause gastrointestinal bleeding, strain the kidneys and raise blood pressure. Oral diclofenac must not be taken with heart failure from NYHA class II, coronary heart disease, peripheral arterial disease or after a stroke.^⁵ More in our guide Painkillers compared.

• With blood thinners, aspirin, cortisone or certain antidepressants: increased risk of stomach bleeding; stomach protection may be sensible — see Stomach problems caused by medicines.^⁵
• With blood pressure medicines and diuretics: NSAIDs can weaken their effect and, together with them, strain the kidneys.^⁵
• In older age: the risk of side effects rises; duration and dose deserve particularly careful review.

Around the operation

For the anaesthesia and pre-operative consultation, the hospital needs your complete list of medicines. Whether and for how long blood thinners are paused is decided individually by your doctor — more in our guide Medicines before an operation. Whether you receive thrombosis injections such as enoxaparin after the procedure depends on your personal risk and on how limited your mobility is.^⁴,⁶ For the pain afterwards, ibuprofen, metamizole or paracetamol are usually prescribed on a fixed schedule for a few days. When taking metamizole: have fever, a sore throat or inflammation in the mouth checked by a doctor immediately, because in very rare cases the white blood cells can drop sharply.

9. Special cases: teenagers, diabetes, rheumatism

Bunions in teenagers

If a bunion appears as early as adolescence, a family predisposition is almost always behind it. The focus is on suitable shoes and foot exercises. Surgery is generally postponed until growth is complete — unless the symptoms are severe.

Diabetes and nerve damage

With diabetes, a bunion can be more dangerous than in healthy people: if sensation in the feet is reduced, pressure points go unnoticed and can turn into ulcers that heal poorly. Daily foot checks, pressure-relieving shoes and regular foot examinations matter more here than for anyone else. Before an operation, blood sugar control and circulation are checked carefully, because wound healing problems are more common.

Rheumatism

With inflammatory rheumatism, forefoot deformities are common and often pronounced. Surgery is coordinated with the rheumatology team — including the question of whether disease-modifying drugs such as methotrexate or biologics continue around the operation or are paused briefly. This decision is never made by the patient alone.

10. Everyday life with bunions

• Buy shoes in the afternoon — that is when your feet are at their widest. Look for a wide toe box, low heels and soft material over the bunion.
• Walk barefoot where you can — on grass or sand it strengthens the foot muscles.^² This does not apply if you have diabetes with reduced sensation: then shoes protect you from injuries you might not notice.
• Short foot exercises — spread your toes, grab a towel with your toes, stretch your calves. This does not replace treatment, but it can feel good.
• Do not cut corns yourself — especially not if you have diabetes or take blood thinners. This belongs in the hands of a podiatrist.
• Apply pain gel correctly — thinly on the painful area, then wash your hands; tips in our guide Applying ointments and creams correctly.
• Do not drive too soon after surgery — with a post-operative shoe on your right foot, safe braking is hardly possible, and strong painkillers can impair your ability to drive; see Medicines and driving.

Well prepared for foot surgery — with brite

A medication plan for your pre-operative consultation, reminders for painkillers and thrombosis injections. Free.

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