Foot and Ankle Pathway

Indications for Same Day and Red Flag Referral

 Same Day referral to A&E
 Signs of septic arthritis - fever, chills, hot, swollen joint
 Inability to weight bear due to pain
 Suspected fracture, dislocation, or infection
 Achilles tendon rupture - Do the calf squeeze test and feel for a palpable tendon gap. Can the
patient perform a calf raise on the affected side?
 For patients fulfilling the need for x-ray under the Ottawa Ankle Rules, e.g. following an acute
ankle inversion injury
 Red Flag (suspected malignancy)
 Unexplained weight loss, night pain, non-mechanical pain, severe unremitting pain, Systemically
unwell and/or high inflammatory markers.
 History of or suspected malignancy, investigate and refer as appropriate

History:
 Age , occupation and hobbies
 Symptoms - pain location, foot and ankle range of motion, weakness, numbness or altered
sensation, giving way, locking, swelling
 Onset, mechanism of Injury
 Intensity, duration, aggravating and easing factors, night pain, effect on ADLs/work
Past medical history, systemic symptoms (fever, abdominal, cardiovascular symptoms), previous
treatments/surgery, medication, consider fitness for surgery and co-morbidities
Features suggesting an Inflammatory cause:
 Symptoms in other joints, sites - previous episodes (consider - Gout),
 If other peripheral joints or spine affected (consider sero-negative arthritis)
 Spontaneous ankle or foot joint effusion, no history of trauma - refer to rheumatology
Examination
 Observation – Expose knee and foot - Posture, lower limb alignment, foot position, deformity,
swelling
 Palpation - Local areas of pain, medial and lateral ligaments, ankle joint line, Achilles tendon
 Range of Movement - Active and passive; dorsiflexion, plantarflexion, inversion and eversion
 Functional tests i.e. heel raise, squat, instability tests
 Neurovascular assessment, pulses, sensation

Investigations to consider:
Radiographs - foot and ankle (AP and Lateral weight bearing and mortice view of ankle) - Consider in
those with:
• Significant injury, sensory or motor loss, rheumatological disease
• Painful foot deformity
• Foot and/or ankle joint effusion
• When symptomatic measures have been insufficient for patient’s symptoms

Blood Investigations: CRP, FBC, U&Es, LFTs, Uric Acid, Rheumatoid Factor, Anti-CCP.
Click on individual condition for primary care management and referral advice

Hindfoot Pain

Midfoot Pain

Forefoot Pain

Diabetic Foot

Orthopaedic Self-help Information Belfast Trust

 Hind-foot/Ankle Pain

Ankle Joint OA +/- impingement (anterior and/or posterior)

Pain and stiffness in ankle joint - Ask about locking, giving way or catching of the ankle.

Investigations - AP and Lateral weight bearing and mortice view of ankle.

Treatment – refer to core podiatry/physiotherapy. ROM exercises, strengthening, proprioception/gait

analysis, supportive footwear.

Steroid/LA injection can provide symptomatic improvement if pain main issue - after clear diagnosis
and management plan

Referral - If no improvement after core podiatry/physio, consider orthopaedic referral

Lateral ankle ligament sprain.

History – Mechanism of injury, bruising, site of pain, inability to weight bear

Investigations – Consider need for ankle x-ray using the Ottawa Ankle rules .

Treatment – PRICE as soon as possible following the injury; ROM exercises (e.g. alphabet exercises)
started within 24-48 hours, strengthening, supportive footwear.
Consider early referral to physiotherapy for rehabilitation, e.g. strength, mobility and proprioception
exercises.
Surgical management in acute ligament sprains is rarely indicated (Cochrane review).
If initial symptoms not settling within first 6 weeks, consider urgent referral to orthopaedics to exclude
pathology requiring further treatment 0 osteochondral defect, fractures, +/- ‘high ankle’ sprain
(syndesmosis injury).

Plantar Fasciitis –heel pain, typically worse with first few steps in the morning.
Windlass or Jack’s test – passive dorsiflexion of the 1st metatarsalphalangeal joint – quick and
highly specific test for the plantar fascia
X-ray – not indicated; calcaneal spurs generally not significant.

Conservative management is mainstay of treatment – advise weight loss; OTC heel raise; calf
and plantar fascia stretching exercises, 3 times/day for at least 3 minutes; golf ball massage;
appropriate analgesia prescription. Night splints.
Refer to core physio +/- podiatry if no improvement after 3/12.

Consider steroid injection for pain control in patients not responding to adequate and extended
conservative management. Be aware of potential adverse effects – fat atrophy/plantar fascia
rupture

Peroneal tendinopathy
Consider diagnosis in lateral ankle pain, posterior to lateral malleolus and distally to 5th MTT. Pain on
eversion. Possible swelling over lateral foot. Insidious or acute onset after activity.
Investigations – USS could be considered
Refer Podiatry/Physio - Orthotics /Footwear advice – neutral supportive footwear
Management - NSAIDs, analgesia. Decrease sporting activities in short term.
Refer to orthopaedics for operative management if tendon dislocating/subluxing
Achilles tendinopathy
Tenderness/swelling proximal to insertion of tendon to posterior calcaneus

Classically, combination of morning stiffness and pain. Pain eases with activity.
May be related to change of activity (e.g. increase in training volume and/or intensity), footwear
or orthotics

Important to differentiate between mid-portion and insertional Achilles tendinopathy.

If insertional Achilles tendinopathy, may be part of the presentation of rheumatoid arthritis or
spondyloarthropathy as with any enthesopathy.

Investigations - Consider ultrasound of Achilles tendon or X-Ray if insertional

Management - Simple padding and foot wear advice. Avoid low heeled footwear. Avoid boots or
sports shoes which may impinge on the painful area during activity.
Analgesia & NSAIDs as appropriate Off the shelf heel raises/ in shoe orthoses (From
Boots/PhysioMed) may be helpful while awaiting physio/podiatry assessment.

Physiotherapy referral
Stretching and eccentric calf raise programme. See http://www.ouh.nhs.uk/patient-
guide/leaflets/files/11924Ptendinopathy.pdf for an excellent patient information leaflet and
exercise advice

Refer podiatry for appropriate insoles

Steroid injections are not indicated

Secondary care referral - Usually not indicated. Surgery occasionally indicated if no response
to adequate physiotherapy (3-6 months).
There are some new injection therapies, e.g. high-volume saline/dextrose injections, +/-
extracorporeal shock wave therapy (ESWT) for Achilles tendinopathy and these may be
indicated for recalcitrant cases

Soft tissue mass (See red flags)

Assessment - Size, site, shape, change, pain, fluctuant, tansallumination

If red flags (solid, atypical features, change in size, significant pain - refer red flag
or same day to secondary care as appropriate.

Investigations – Usually none indicated - consider USS.

Treatment - If benign / painless – observe & reassure. Aspiration generally not indicated.

Referral - If no improvement and swelling causing impact on ADLs, e.g. footwear issues.

Self Help/Patient information –

Heel pain leaflet,
Achilles Tendinopathy
TA rupture diagnosis
 Midfoot Pain/Deformity

Flexible – (Passively correctable flat foot)

Look, feel move – site of pain

Treatment - If painless, observe & reassure

Advise on footwear and padding.

Referral – If painless or an acute change in their foot shape, refer to core podiatry for
assessment. Prior to referral do a weight-bearing x-ray of ankle with AP, oblique and
lateral views.

Rigid – (not correctable, OA/Tarsal coalition)

Look, feel move – site of pain
Investigations – Weight bearing X-ray AP foot and ankle, Oblique & Lateral Ankle
Treatment - Lifestyle factors – advise on weight loss and appropriate footwear. ROM
exercises, strengthening, supportive footwear. Core podiatry is a good source of advise.

Tibialis Posterior Tendon Dysfunction (TPD)

Medial foot pain with loss of medial longitudinal arch - Consider TBD
Investigation – Weight bearing AP/Lateral foot and ankle and oblique foot X-Rays
Acute presentation refer to orthopaedics urgently
Chronic presentation refer podiatry for orthotics
If non responsive refer orthopaedics for advanced splinting and investigation
 Forefoot

Big toe deformities (Hallux Valgus (Bunion) / Rigidus)

See BOA/NICE Guidelins On Painful Deformed Great Toe

HALLUX VALGUS – bony medial prominence

HALLUX RIGIDUS – bony dorsal prominence over 1st MTPJ
Lesser toe pain and forefoot pain due to overload.
Consider excluding gout.
History – Level of Disability
Investigations – Often none needed initially. If required, consider weight bearing X-ray AP & Lateral

Treatment – Advise on footwear and padding

Referral - If no improvement with conservative management. Core podiatry should be the first referral.
Only refer for surgical intervention if prepared to consider surgery and fit for surgery.

Lesser toe deformities

Bunionette = prominence of the fifth metatarsal bone at the base of the little toe.
Investigations – Generally not indicated
Treatment – Advise on footwear, padding and strapping of digit for analgesia.
A local steroid/LA injection for Metatarsalgia can provide short term pain control.
Referral - If no improvement consider referral to core podiatry

Causes of Metatarsalgia

Idiopathic
Tibialis posterior dysfunction
Digital deformity
Inflammatory Joint Disease
Morton’s Neuroma
Frieberg’s
Idiopathic Metatarsalgia
Produces general pain/discomfort under MT heads with no other cause (eg inflammatory,
toe deformity, Frieberg’s, TPD, Morton's Neuroma)

Investigations – often not indicated.

Management – footwear advice, (avoid heels and tight fitting shoes) PIL on choosing
footwear; Analgesia & NSAIDs as appropriate.

Consider inter-metatarsal steroid/local anaesthetic injection by appropriately trained staff

Consider referral to core podiatry if not settling.

Morton’s Neuroma
Due to swelling of the inter-digital nerve causing pain often to radiate into the toes – pins
and needles for example. Most commonly affects 3 rd and 4th toes. ‘There’s a pebble in
my shoe’.

Investigations – often a clinical diagnosis – positive Mulder’s click? If required to confirm

diagnosis – do an Ultrasound scan

Treatment – If benign / painless – observe & reassure. Advise on footwear and padding
to area.

A steroid/LA injection can often provide symptomatic improvement.

Referral - If no improvement with conservative management, consider input from core

podiatry.

Claw/Hammer/Mallet toe(s)
Toe deformity may be fixed or flexible/passively correctable at PIP and DIPJ.

Investigations - Consider need for X-ray

Advice - If passively correctable orthotics/metatarsal support may help. Commence slant board
stretches for calf musculature.

Management - Consider referral for Orthotics to core podiatry.

Self Help/Patient information

Bunion leaflet
Mortons Neuroma leaflet
 Diabetic Foot

• Diabetic patients presenting with foot and ankle pathology need specialist attention –
please refer to local guidelines (https://www.nice.org.uk/guidance/ng19/chapter/1-
recommendations)
• Diabetic patients generally get an annual foot review in primary care
• Foot problems are common in diabetics - 5% develop a foot ulcer in any year
• Foot problems often due to a combination of:
– Peripheral neuropathy causing reduced sensation in the foot
– Peripheral vascular disease causing pain and predisposition to ulceration.
• Encourage good foot hygiene in all diabetic patients
– Daily examination of the feet for problems
– Well-fitting shoes and hoisery
– Good hygiene and nail care
– Ensure diabetics are well-informed about their feet and the dangers associated with
procedures, e.g. corn removal
– If reduced mobility, methods to help with foot assessment/monitoring, e.g. mirrors.
• Advise patients about when to seek medical review
– Any colour change, swelling, breaks in skin or numbness?
• Try to avoid barefoot walking due to risk of unrecognised trauma
• If they develop any skin lesions then seek review either through the GP or podiatrist
• If anyone develops a new foot ulcer – arrange an urgent assessment (ideally within 24
hours) from the multidisciplinary specialist foot care team. Assess ischaemia using
Doppler if available in the surgery.
• Charcot’s joint – neuropathic foot damaged because of trauma secondary to loss of pain
sensation. If suspected, refer immediately to the footcare team for immobilisation and
long-term management.