Podiatric surgery: foot operations, who performs them and how referral works

Foot problems are treated by several professions, and podiatric surgery is the part of that picture that people find hardest to place. It is the surgical treatment of conditions of the foot and, in some centres, the ankle, and it is carried out by podiatrists who have completed additional postgraduate surgical training. The Health and Care Professions Council regulates chiropodists and podiatrists and records podiatric surgery as one of the annotations that can appear against a podiatrist's entry on the register, alongside independent prescribing.

The other main group is orthopaedic foot and ankle surgeons, who are doctors with specialist surgical training in bones and joints. The two groups often work in the same departments. As a broad generalisation, podiatric surgeons tend to carry out forefoot and soft-tissue procedures under local anaesthetic, while orthopaedic foot and ankle surgeons also manage complex deformity, arthritis of the ankle and hindfoot, major trauma and reconstructive work. Both depend on podiatrists, physiotherapists, orthotists and nurses for assessment, footwear and rehabilitation.

Because the title can be unfamiliar, it is reasonable to ask a surgeon what their registration and training are, how many of the operations you are considering they perform, and how they manage complications.

Most foot surgery is elective and follows a trial of non-surgical treatment. Common problems include:

• Bunions (hallux valgus), where the big toe angles towards the others and a bony lump forms at its base. The NHS describes the main symptoms as hard lumps on the sides of the feet, sometimes with swollen or red skin and pain that is worse in shoes.

• Hallux rigidus, a stiff and arthritic big toe joint that makes pushing off painful.

• Hammer toes, mallet toes and claw toes, where one or more of the smaller toes are bent at the middle or end joint and rub on footwear.

• Ingrown toenails, where the nail grows into the toe and causes pain, redness and sometimes infection.

• Morton's neuroma, a thickening of tissue around a nerve between the toes that causes shooting, burning or stabbing pain, usually between the third and fourth toes according to the NHS.

• Painful lumps, corns and verrucas that have not responded to simpler treatment, and some persistent heel and plantar problems.

• Foot problems related to diabetes, where surgical procedures may be part of limb preservation under a specialist team.

A first assessment looks at the foot standing and walking, the shoes you wear, the circulation and nerve function and the history of the problem. Weight-bearing X-rays are the usual imaging for bunions and toe deformity, because the foot is photographed under load, and ultrasound or MRI is sometimes used for soft-tissue problems such as a neuroma. Pulses and circulation are checked in anyone with diabetes, smoking history or signs of poor blood supply, because they affect healing.

For bunions, the NHS says the most common operation is an osteotomy: the surgeon makes a small cut over the big toe, removes or scrapes away the bunion, straightens the toe bone and fixes it in place with metal screws or staples that are often left in permanently. It is usually done under general anaesthetic but sometimes under local, and most people go home the same day. Minimally invasive and percutaneous techniques use very small incisions, although the evidence on long-term differences between techniques is still developing and it is reasonable to ask a surgeon why they favour one method.

Smaller procedures include partial or total nail avulsion for ingrown toenails, typically with a chemical applied to the nail bed to prevent regrowth, straightening or fusing a toe joint for hammer toes, and removing or decompressing the nerve for Morton's neuroma. Steroid or alcohol injections are sometimes tried first for neuroma, according to the NHS.

Foot surgery looks small but the foot carries the whole body weight, so recovery needs patience. Following bunion surgery, the NHS says you will usually need to rest with the foot raised for at least 2 weeks, avoid driving for 6 to 8 weeks, stay off work for 2 to 12 weeks and avoid sports for 3 to 6 months. The toes may be weaker or stiffer than before and may not be perfectly straight, and the foot may still be painful. Swelling can persist for several months.

Surgeons often provide a special post-operative shoe and dressing instructions, and some operations need a period of protected weight-bearing. Physiotherapy and footwear advice help the result. People are generally advised to discuss expectations frankly before surgery, because the goal is usually to reduce pain and allow comfortable footwear rather than to create a perfect-looking foot.

NHS routes vary by area. For bunions, ingrown toenails and Morton's neuroma the NHS says you might be able to refer yourself directly to a podiatrist without seeing a GP, and the practice, website or integrated care board can say what exists locally. A GP may refer for surgery if a bunion is very painful or is having a big effect on life. The NHS also notes that referral to a podiatrist is not available to everyone and waiting times can be long.

Privately, a person can usually see a podiatric or orthopaedic foot surgeon directly. Ask for a written plan, the total cost including follow-up, what happens if a further procedure is needed, and where aftercare takes place. Because insurers and hospitals differ in how they list foot surgeons, check the HCPC register for podiatrists and the GMC register for doctors.

• Which non-surgical treatments have I tried, and is there anything else worth trying first, such as footwear change, orthoses or injection?

• What exactly will be done, under what anaesthetic, and will I need to stay overnight?

• How long until I can drive, work, exercise and wear normal shoes?

• What are the risks, including infection, stiffness, numbness, recurrence and the need for further surgery?

• Ask for the NHS advice to be followed if you have diabetes: the NHS says foot problems can be more serious in diabetes and you should see a GP if you have a bunion or ingrown toenail.

• Get urgent help from NHS 111 or a GP for a hot, swollen, pus-filled toe or fever, and call 999 or go to A&E for sudden severe pain with a pale, cold or numb foot.