Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Bunion

bunion in français (France)

Related Terms

  • Hallux Abducto Valgus
  • Hallux Valgus

Differential Diagnosis

Specialists

  • Orthopedic (Orthopaedic) Surgeon

Comorbid Conditions

Factors Influencing Duration

Disability after surgery could be lengthened by advanced age, poor nutrition, or surgical complications such as poor healing, infection of tissue, infection of the bone (osteomyelitis), injury to nerves (reflex sympathetic dystrophy), or tissue necrosis.

Medical Codes

ICD-9-CM:
727.1 - Bunion
735.0 - Hallux Valgus (Acquired)

Overview

© Reed Group
A bunion is a bony deformity of the foot affecting the joint between the foot and big toe (hallux); it appears as a “bump” on the bone at the base of the big toe. Anatomically it is described as a bony enlargement of the medial eminence at the base of the first metatarsal. Bunions develop over time when the big toe shifts toward the second toe, affecting alignment of the bones and producing the characteristic bump on the metatarsal head at the base of the big toe. Shoe pressure irritates the misaligned portion of the metatarsal head, causing the deformity to enlarge over time. The soft-tissue sac (bursa) between the tendon or muscle and the enlarged bone may become inflamed (bursitis). Arthritis of the big toe joint may also develop, limiting mobility (hallux limitus or hallux rigidus).

Bunions may be asymptomatic or may become painful, swollen, and tender. Although footwear does not cause bunion formation, poorly fitting shoes can exacerbate pre-existing biomechanical instability of the foot. Biomechanical instability has many causes, including trauma and anatomical variations such as “flat foot,” excessive pronation, hypermobility, or a short first metatarsal. Problems with the hips, knees, and ankles can also contribute to bunion formation.

The joint at the base of the fifth metatarsal can also become enlarged (tailor’s bunion), although it is less common.

Incidence and Prevalence: Bunions are 2 to 4 times more common in women than in men (Frank). Bunions occur in 3% of the population aged 15 to 30 years, in 9% of the population aged 31 to 60 years, and in 16% of the population older than 60 years (Frank).

Source: Medical Disability Advisor



Causation and Known Risk Factors

The risk of developing bunions increases in genetically predisposed individuals. It is greater in individuals with flat feet, arthritis, and faulty biomechanical foot structure. Foot injuries, congenital deformities, neuromuscular disorders (e.g., cerebral palsy, multiple sclerosis), and occupations that involve extra foot stress from prolonged periods of standing or walking (e.g., waiting tables, factory work, athletics, dancing) may also increase the risk of bunion development.

Source: Medical Disability Advisor



Diagnosis

History: Individuals may complain of a painful, bony enlargement on the inside (medial side) of the joint at the base of the big toe. They may report feeling greater pain when shoes are worn. The pain may be intermittent or persistent, mild or severe. Other individuals may report a bony enlargement with no associated pain.

Physical exam: Examination of the foot may reveal irritated skin, swelling, and tenderness around the joint at the base of the big toe. The big toe may be pointing toward the second toe or growing over or under the second toe. The individual may experience pain when the bunion is touched or when the joint between the metatarsal bone and the toe is moved. Other signs and symptoms may include thickening of the skin at the base of the big toe, corns and calluses caused by overlapping first and second toes, and restricted motion of the big toe. A thorough examination of the feet, ankles, knees, and hips is important in determining the factors contributing to bunion formation. Those factors will determine the appropriate treatment plan.

Tests: Observation is usually all that is needed to identify a bunion. However, weight-bearing x-rays may be ordered to reveal the nature of the bony deformity, extent of joint damage, and angular relationship between the first and second metatarsals (intermetatarsal angle). Weight-bearing x-rays must be taken before any surgery is planned. Blood and urine tests may be performed to rule out other diseases such as rheumatoid arthritis, diabetes, collagen vascular diseases, and gout.

Source: Medical Disability Advisor



Treatment

Nonpainful (asymptomatic) bunions require no treatment. Small and mildly painful bunions are managed by changing the type of footwear to roomier, more comfortable shoes that have a larger toe box (no less than 0.5 cm smaller than the forefoot) (Laughlin). If the joint has sufficient flexibility, padded shoe inserts (orthotics) can be used to correct foot alignment, relieve pressure, and shield the bony enlargement from irritation. The heating effect of ultrasound therapy or whirlpool baths can relieve bunion pain temporarily. The painful bursitis associated with bunions can be treated conservatively with rest, ice, and medications such as nonsteroidal anti-inflammatory drugs (NSAIDs). Corticosteroid injections may also be needed to help relieve an inflamed bursa.

Surgery to correct the underlying bone deformity may be indicated for bunions that do not respond to conservative treatment. Surgery is recommended if a bunion causes severe pain or if there is neuritis/nerve entrapment, the great toe overlaps/underlaps the second toe, or ulceration is present. Contraindications to surgery include active infection and extensive peripheral vascular disease.

More than 100 different surgical procedures have been described for bunions, and over a dozen are in common use today. The Silver procedure involves simple removal of the enlarged bump. Osteotomy procedures involve cutting and repositioning the big toe bone (proximal phalanx; Akin procedure), or the first metatarsal bone at the portion closest to the toe (distal portion or metatarsal head; Mitchell, Austin, Hohmann, Wilson procedures), or the portion closest to the midfoot (proximal portion or metatarsal base; Loison-Balascescu, Mau procedures). If arthritis of the metatarsophalangeal joint is present, removal (Keller procedure) or fusion (McKeever procedure) of the joint is often necessary. Most osteotomy procedures require internal fixation and immobilization.

Source: Medical Disability Advisor



ACOEM

ACOEM's Practice Guidelines, the gold standard in effective medical treatment of occupational injuries and illnesses, are provided in this section to complement the disability duration guidelines.*
 
Ankle and Foot Disorders
 
* The relationship between the MDGuidelines (MDA) content and ACOEM's guidelines is approximate and does not always link identical diagnoses. The user should consult the diagnostic codes in both guidelines, as well as the clinical descriptions, before assuming an equivalence.

Source: ACOEM Practice Guidelines



Prognosis

Symptomatic relief of bunions with conservative treatment is usually effective even when the underlying deformity is not corrected. However, bunions are progressive and do not go away; without treatment, they will become worse with time. Early treatment of a small bunion with corticosteroid injection may relieve the symptoms. Surgery may be necessary for large bunions to achieve relief of symptoms. To prevent a recurrence of symptoms, individuals should wear roomier, more comfortable shoes after recovery.

Source: Medical Disability Advisor



Complications

Untreated bunions may continue to worsen. Degenerative arthritis may develop in the metatarsophalangeal joint of the big toe, causing pain and stiffness.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Individuals undergoing conservative treatment who spend a substantial portion of an 8-hour workday standing or walking may need to increase the number of hours of seated work.

If surgery is performed, weight-bearing activity is usually restricted for 2 weeks. Some types of surgery require longer periods of restriction, up to 6 to 8 weeks depending on the type of surgery performed. The individual will need to elevate the foot periodically throughout the day and may have to use a walker, crutches, or wheelchair. Driving is prohibited until normal shoes can be worn. Because the individual will probably be taking prescribed pain medication, drug policies must be reviewed.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Did individual experience symptoms such as a painful bony enlargement on the inside edge of the big toe?
  • Did the physical exam confirm the diagnosis of a bunion?
  • Were x-rays done to determine the nature of the bony deformity, extent of joint damage, and angular relationship between the first and second metatarsals (intermetatarsal angle)?
  • Were additional diagnostic studies done to rule out other conditions such as arthritis or gout?

Regarding treatment:

  • Did roomier, more comfortable shoes, placement of taping and toe spacers, or use of orthotics reduce discomfort?
  • Did the condition warrant surgical intervention (severe or worsening deformity, worsening pain)?
  • Would individual benefit from removal (Keller procedure) or fusion (McKeever procedure) of the joint?

Regarding prognosis:

  • Based on the treatment required, what was the expected recovery?
  • Was adequate time allotted for recovery? Did individual return to activity too soon?
  • Have follow-up x-rays been taken to rule out complications of the bunion surgery, including infection, osteomyelitis, nonunion, recurrence, and avascular necrosis?
  • Has reflex sympathetic dystrophy been ruled out?
  • Does individual have any underlying conditions such as vascular disease, obesity, or diabetes that may affect recovery and prognosis?

Source: Medical Disability Advisor



References

Cited

Frank, Crista J., and Dan E. Robinson. "Hallux Valgus." eMedicine. Eds. John S. Early, et al. 10 Sep. 2008. Medscape. 2 Dec. 2008 <http://emedicine.com/orthoped/TOPIC126.HTM>.

Laughlin, Richard T., et al. "Bunion." eMedicine. Eds. James K. DeOrio, et al. 30 Mar. 2007. Medscape. 2 Dec. 2008 <http://emedicine.com/orthoped/topic467.htm>.

General

"Bunions." FootPhysicians.com. 28 Jul. 2008. American College of Foot and Ankle Surgeons. 2 Dec. 2008 <www.footphysicians.com>.

Mayo Clinic Staff. "Bunions." MayoClinic.com. 25 Jan. 2007. Mayo Foundation for Medical Education and Research. 19 May 2005 <http://www.mayoclinic.com/invoke.cfm?id=DS00309>.

Source: Medical Disability Advisor






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