Foot and Ankle Problems

Overview

Self management and conservative treatment of foot and ankle problems

Before considering referral for foot or ankle problems please see the specific sections on the page below. Self- management and conservative management options in primary care include:

• Self care - the getUBetter app (Remedy BNSSG ICB) has self management advice on ankle injuries.
• MyJointHealth hub has some useful information on foot and ankle problems.
• Self care - the Sirona Leaflet Library has leaflets on general foot health and some other conditions including Achilles tendinopathy, Bunions, Plantar heel pain aswell as exercises for foot and ankle pain (to find these, click on MSK podiatry tab)
• First contact physiotherapists (embedded in most PCNs)

If initial conservative treatment in primary care is not helping or not appropriate then consider referral to Sirona MSK Foot & Ankle Service (managed referral pathway) where other conservative treatment options may be considered. Orthopaedic triage assessment with advanced practice skillsets (imaging/injection therapy), or onward referral to secondary care can also be provided.

Criteria Based Access for Forefoot Surgery

If referral for surgery is being considered then please see the Forefoot Surgery in Secondary Care Criteria Based Access Policy 

This policy includes criteria for surgery for conditions such as:

• Hallux Valgus (Bunions)
• Hallux Rigidus
• Hammer Toe
• Mallet Toe
• Claw Toe
• Plantar Fasciitis.

Referrals for surgery should not be made unless these criteria are met.

This policy does not cover referrals for mid foot or ankle problems. See relevant section below.

High Risk Feet should be referred for review without delay where clinically appropriate (see Red Flag section below for details).

When and where to refer

See the Sirona MSK Foot & Ankle Service page of Remedy for referral information.

Please provide details in your referral to evidence what conservative measures have been tried in primary care. If referring for conditions covered by the BNSSG Forefoot Surgery in Secondary Care Criteria Based Access Policy please include how criteria are met. If your referral does not provide enough information or if criteria are not met then it may be returned.

The Sirona Leaflet Library may help with conservative management.

Please note Spire will be closing down its Foot & Ankle Service to any new referrals with effect from 28^th February 2023

Red Flags

High Risk Feet should be referred for review without delay where clinically appropriate.

The following factors may indicate that the patient may have a high risk foot:

• previous/current ulceration
• previous amputation
• on renal replacement therapy
• neuropathy and non-critical limb ischaemia together
• neuropathy in combination with callus and/or deformity
• non-critical limb ischaemia in combination with callus and/or deformity
• spreading infection
• critical limb ischaemia
• gangrene
• suspicion of an acute Charcot arthropathy, or an unexplained hot, red, swollen foot with or without pain

Referrals should normally be submitted via the Vascular HOT clinic.

Metatarsalgia and Morton's neuroma

Clinical Knowledge summaries has information regarding diagnosis and management of Morton's neuroma/ Metataslagia.

Please note that USS can be requested for diagnostic purposes but direct referrals for USS guided injections will no longer be accepted other than on advice of a radiologist following an initial scan: Image Guided Steroid Injections

Referral

If no improvement or symptoms are worsening with conservative measures then consider referral using the criteria in the 'When and Where to Refer' section above.

Bunions

Clinical Knowledge summaries has information regarding diagnosis and management of Bunions.

Assess severity of symptoms. Treatment decision should be based on extent of deformity, severity of pain and functional impairment such as ability to wear normal closed shoes. 

Conservative management includes:

• wearing wide shoes with a low heel and soft sole

• holding an ice pack (or a bag of frozen peas wrapped in a tea towel) to the bunion for up to 5 minutes at a time

• trying bunion pads which can be purchased from pharmacies

• analgesics (paracetamol or ibuprofen)

See the Sirona Patient Leaflet on Bunions.

Referral

If no improvement or symptoms are worsening with conservative measures then consider referral using the criteria in the 'When and Where to Refer' section above.

Other toe deformities

Patient.info has advice on other Toe Deformities (claw toes, hammer toes and mallet toes) and Hallux Rigidus (degenerative arthropathy of the first metatarsophalangeal (MTP) joint).

Initial assessment should be in primary care.

Consider investigations if an underlying condition is suspected or prior to consideration of referral including:

• Plain X-ray
• Bloods - HbA1c, Rheumatoid factor
• Vascular studies if peripheral arterial disease is suspected.

Referral

If no improvement or symptoms are worsening with conservative measures then consider referral using the criteria in the 'When and Where to Refer' section above.

Plantar Fasciitis

Clinical Knowledge summaries has information regarding diagnosis and management of Plantar Fasciitis.

Conservative management includes:

• Analgesics (paracetamol or ibuprofen)
• Wearing shoes with good cushioning in the heels and good arch support.
• Losing weight if overweight.
• Avoiding exercising on a hard surface.
• RICE therapy
  • Rest – try to avoid putting weight on the heel. Do not exercise, instead try gently moving it from time to time to stop the area getting stiff.
  • Ice – put an ice pack or frozen vegetables, covered in a damp cloth, on it for 20 minutes every 2–3 hours.
  • Compression – wrap a bandage around the painful area. It should be tight enough to support it, but not so tight that it restricts the blood flow.
  • Elevate the foot to reduce swelling.
• Plantar fasciitis exercises - see the Versus Arthritis website or the Sirona Leaflet -  Heel pain - A Guide for Patients and GPs.

Usually patients have a symptomatic improvement after 6-12 weeks of initial treatment although it can take up to 18 months to fully recover.

Steroid injections for Plantar Fasciitis

Steroid injection in primary care can be undertaken but is not routinely recommended due to lack of long term evidence of efficacy and potential adverse outcomes.

Direct referrals for USS guided injections will no longer be accepted: Image Guided Steroid Injections

Referral

If no improvement or symptoms are worsening with conservative measures then consider referral using the criteria in the 'When and Where to Refer' section above.

Achilles Tendinopathy

Clinical Knowledge summaries has information regarding diagnosis and management of Achilles Tendinopathy.

Arrange admission or a same-day referral to orthopaedics (depending on local protocol) if Achilles tendon rupture is suspected.

Manage as appropriate any underlying causes, such as:

• Fluoroquinolone antibiotics — discontinue (discuss with microbiology if unsure regarding alternatives).
• Hypercholesterolemia.
• Diabetes mellitus

Do not inject corticosteroids into or around the tendon.

Advice on self- care is available on the Sirona Leaflet - Achilles Tendinopathy

Mid foot and ankle problems

Referrals for problems in the mid foot and ankle that may require surgery are not subject to the CBA policy. Referrals can be made to the MSK team. Referrers are advised that conservative management options should be considered and/or trialled before referral.

See FAQ section below for some further advice on management of more persistent ankle problems.

FAQs and Resources

Steve Hepple (Foot and Ankle Surgeon at NBT) has provided some information about FAQs .

Q: We have a lot of patients who suffer persistent pain following eversion or inversion ankle injuries, who have normal X-rays. They often do not seem amenable to physiotherapy. Is MRI the best investigation for post-injury pain and at what stage would you like to see these patients if they are not improving?

A: Post ankle sprain persistent symptoms are most commonly due to soft tissue impingement around the ligaments, ostochondral lesion, syndesmotic injury (high ankle sprain) or peroneal tendon problems although other diagnoses are possible and sometimes the sprain can simply be slow to settle. With persistent significant symptoms beyond 3 months it is reasonable to investigate further. X-ray should be performed initially (if not already done)*. If normal then MRI is usually the next line investigation, although dynamic ultrasound may be necessary to pick up impingement or peroneal tendon problems. If there is abnormality on any of these investigations and/or symptoms are failing to settle beyond 3 months referral is recommended.

*Local pathways would suggest a physio referral or MSK referral initially to consider further investigations as GPs may not be trained in ordering or interpreting MRI findings.

Q: Avascular necrosis of ankle bones post-surgery is probably the most severe and persistent problem I have seen in my foot and ankle patients. Is there any good post-op advice you can give patients to give them the best chances of good bone healing?

A: Avascular necrosis of bones in the foot and ankle is a rare condition that can occur spontaneously or after surgery. Non-union or delayed union is more common after surgery. After surgery patients should carefully follow the post-operative instructions given to them. Smoking is known to decrease bone healing and can increase the risk of non-union by up to 16 times. Patients should therefore stop smoking prior to undertaking major hind foot fusion and should be encouraged not to use NSAIDs if possible as they also slow bone healing.

getUBetter App

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.