Hallux valgus, often referred to as a bunion, is a deformity of the big toe. The metatarsal moves medially toward the midline and the toe itself tilts over towards the smaller toes and a bony prominence appears on the inside of the first metatarsophalangeal joint. There is not usually associated arthritis within the joint and the toe movements are on the whole, pain free. There will naturally be discomfort over the medial prominence which can be inflamed.

The majority of patients with hallux valgus are asymptomatic or, if minor intrusive symptoms are present, simple adjuncts improve the majority of patients and symptoms.

If a red flag is present, then a referral from primary care can be made to secondary care via DRSS.

These red flag referrals will be limited to patients with one of the following comorbidities:

• Infection
• Inflammatory arthritis and complex foot deformity
• Ulceration, or imminent risk of ulceration

X-ray of simple hallux valgus is not routinely recommended in primary care.

However, if it is felt that the diagnosis is unclear, a standing radiograph may assist.

An aggressive approach to footwear modification, wider fitting shoes, avoidance of narrow toe-box and high heels with supportive insoles and/or orthotics is the mainstay of treatment.

Often many patients when questioned more closely have not robustly addressed their footwear and when sign-posted to better fitting shoes, supportive insoles and rocker-bottom shoes, report significant improvement in symptoms.

Simple analgesics and topical anti-inflammatory preparations can help.

Simple over the counter low profile bunion pads may help as can a toe-spacer worn between the great and second toe.

Referral Criteria

If patients remain symptomatic with severe intrusive symptoms, despite committed attempts to modify footwear or lifestyle modification over a period of at least 12 months, then referral to a community assessment service will be considered.

Such a referral would need to establish that footwear modification has been attempted on more than one occasion and that the patient has symptoms that severely limit essential activities.

Essential activities include:

• Work activities e.g. inability to wear safety footwear
• Inability to walk essential distances e.g. work related or essential daily living
• Carer activities e.g. inability to care for a dependant due to major limitation
• loss or absence of an individual's capacity to meet personal, social or occupational demands.

Equally patients who fulfil the following may also be considered:

• Cross-over deformity of great and second toe
• Increasing associated problems with lesser toes
• Deformity in conjunction with a history of diabetes, rheumatoid or inflammatory arthritis

Referral Instructions

e-Referral Service Selection

• Specialty: Orthopaedics
• Clinic Type: Foot & Ankle
• Service: DRSS-Western-Orthopaedics Foot and Ankle-Devon ICB-15N

Referral Forms

DRSS Referral Form

Patient Information

Certain types of footwear may significantly improve symptoms including: Fitflop shoes and Fitflop boots (not flip-flops), Vionics footwear, Rocker-bottom leisure footwear e.g Wolky, Skechers, Birkenstock and Hotter shoes.

Gentle over-the-counter constructs can be found at most pharmacies and supermarkets and include bunion pads, toe-spacers, insoles such as Comfeet and Orthoheel.

MyHealth patient information

Pathway Group

This guideline has been signed off on behalf of the NHS Devon.

Publication date: May 2019