What is the treatment for bunions?
Bunions are bony lumps that form on the side of the feet. Bunions can be broadly classified into two: asymptomatic and symptomatic. The first one causes no pain but the second can be very uncomfortable.
The symptoms of bunions include:
- Hard lumps on the sides of the feet, by the big toes
- Hard, red or swollen skin over the lump
- Pain along the side or bottom of the feet (this is usually worse when wearing shoes and walking).
Doctors don’t know exactly what causes bunions, but things that can increase the risk of developing them include:
- Wearing ill-fitting shoes that adds a strain to the bones and muscles in the feet
- The way a person walks, for example if the foot rolls inwards
- Bunions can run in families
- Bunions are sometimes associated with conditions that affect the joints, such as rheumatoidarthritis, gout, stroke or a foot injury
- Being female may increase the risk due to tighter footwear being worn, wearing high heels, or because the structures that connect bones together in the feet (ligaments) are looser in women.
A GP or podiatrist can offer advice about:
- How to ease the symptoms, such as wearing wide shoes that don't squash the toes
- Items to buy or have specially made which may help to reduce bunion pain, such insoles (orthotics), toe spacers and toe supports (splints).
However, surgery is the only way to get rid of bunions so a GP may refer the patient to a surgeon if the bunions are very painful or are having a big effect on the patient's life.
Patient eligibility criteria
Surgery for asymptomatic bunions IS NOT routinely commissioned. If the patient has diagnosed diabetes and presents with an asymptomatic bunion the patient should be referred to a community foot health service.
Surgery for symptomatic bunions will be funded in the following circumstances:
- The patient has a confirmed diagnosis of a bunion, AND
- The patient has deteriorating symptoms*, AND
- ALL conservative measures** have failed after three months, AND
- The patient is experiencing persistent pain and disability due to the bunion, which is causing functional impairment***, AND
- The patient must be prepared to undergo surgery, understanding that they will be out of sedentary work for 2-6 weeks and physical work for 2-3 months and they will be unable to drive for 6-8 weeks (two weeks if left foot and driving automatic car), AND
- Weight bearing X-rays have been undertaken prior to surgery, AND
- The provider has adopted a shared decision making model, with defined treatment goals and has taken into account personal circumstances, with ALL alternatives discussed with the patient, AND
- The procedure will be undertaken by orthopaedic surgeons trained in foot and ankle surgery or Health and Care Professions Council registered podiatric surgeons (CCPST), integrated into a multi-disciplinary network.
* deteriorating symptoms are defined as moderate or severe pain AND functional impairment AND redness/soreness; OR bigger deformation, 2nd toe affected/lifting; OR callus under 2nd MTPJ.
** conservative measures are defined for the purposes of this policy as ensuring footwear is appropriate (low heels; wider fitting shoes; moulded shoes); AND the patient has been advised on and has trialled patient directed approach (bunion pads, over the counter analgesia, ice to relieve pain and inflammation orthotics); AND referral to podiatry for offloading orthotics has been exhausted; AND the patient has been provided with the patient leaflet.
*** functional impairment is defined as interfering with activities of daily living, i.e. sleeping; eating; walking.
Surgical correction of bunions using minimal access techniques IS NOT routinely commissioned in any circumstances due to limited information and the lack of long-term data about its effectiveness.
This means (for patients who DO NOT meet the above criteria) the CCG will ONLY fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG.
Advice and further guidance
- For more information, search for ‘bunions’ at www.nhs.uk
- Choosing Wisely UK is part of a global initiative aimed at improving conversations between patients and their doctors and nurses.
Or visit the following website:
- British Orthopaedic Foot & Ankle Society, British Orthopaedic Association (BOA), Royal College of British Orthopaedic Foot & Ankle Society, British Orthopaedic Association (BOA), Royal College of Surgeons of England (RCSEng) 2017. Commissioning Guide: Painful Deformed Great Toe in Adults
Treatment policy for patients covered by NHS Birmingham and Solihull CCG