MSK SERVICES PATHWAY - FOOT & ANKLE PATHOLOGY · • Swelling of the foot and ankle (caused by synovial fluidthat leaks out of the joint capsule) • Subluxation/deformity of the

MSK SERVICES PATHWAY - FOOT & ANKLE PATHOLOGY

• Septic arthritis• Dislocations • Tumours • Infections• Achilles tendon rupture

• Fractures• Inflammatoryconditions• Neurological lesion• Charcot foot

GPs to follow guidance offered within this pathway and where relevant refer using Ardens templates and within remit of CCG Restricted and Not Routinely funded policy.Patients requiring Podiatry referral will be referred to the Podiatry SPA.

RED FLAG

ASSESSMENT & DIAGNOSIS OF OTHER CONDITIONS

Diagnosis to monitor

History &Symptoms

Injury

Medical Professionals seeing patients with MSKcomplaintsinprimarycareshouldbetrained in assessing for alarming features and redflagsinallpatients.

Consider admission/urgent referral

Red Flags

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Hind/mid and forefoot OA

Ligaments/Sprains

Tendinopathies/Achilles Tendon

Plantar fasciitis

Mortons Neuroma

Hallux Valgus/Rigidus

Metatarsalgia

RED FLAG SCREENING: SPECIFIC FOR FOOT & ANKLE PATHOLOGYRed Flags/ sinister conditions that will alter management immediately

1. Primary or Metastatic Tumours2. Infection or Septic Arthritis3.Inflammatoryarthropathy4. Acute ankle/foot Fracture/Dislocation5. Achilles tendon rupture (acute)6. Charcot foot7. Acute drop foot8. Soft tissue mass

History & Symptoms

MedicalProfessionalsseeingpatientswithMSKcomplaintsinprimarycareshouldbetrainedinassessingforalarmingfeaturesandredflagsinallpatients.

CONSIDER ADMISSION/URGENT REFERRAL IF: History of, or suspected malignancy investigate and refer as appropriate.1. Symptoms suggestive of Tumours (primary or metastatic):• PMHofcancer-Bonymetsdevelopin2/3ofpatientswithcancer-Mostlyprostate,breast, kidney• Unexplained weight loss • Non-mechanical night pain • Deep,intensepain• Pain worse at night• Fever• Mass presence• Lymphadenopathy

Suspected Tumour Management: Refer urgently for specialist assessment in line with 2 week fast track cancer pathway (via Systm1 communication to GP) 2. Symptoms suggestive of Infection or Septic Arthritis:• Riskfactorsforsepsisinclude:ComorbiditiesofRA,orOA,prostheticjoint,low socioeconomiclevel,diabetic,alcoholism,previousintra-articularjointinfection,IVuse• Constant pain• Suddenonset,red,hot,pyrexiaorred-hotjoint• Highinflammatorymarkers• Systemicsymptoms• Fever,notalwayspresent

Suspected Infection/Septic Arthrits Management: Refer the patient urgently to A+E with accompanying letter.3.Symptomssuggestiveofaninflammatorycondition• Stiffness-earlymorningjointstiffnessover30minutes• Swelling-persistentswellingofonejointormore,especiallyifthehandsjointsareinvolved• Squeezingthejointsispainfulininflammatoryarthritis

Suspectedinflammatoryconditionmanagement:investigateviabloods/x-rayfootand ankle for clinical work-up and refer to Rheumatology (state in Systm1 task early inflammatorypathway–urgent).SeeRheumatologypathwayforfurtherdetails.4. Symptoms suggestive of Acute ankle/foot Fracture/Dislocations:• Trauma• Pathologicalfracture(OP,Paget’s,multiplemyeloma,PMHCa)• Neurovasculardeficit• Deformity• Muscle wasting• Unable/difficultiesweightbearing• Painafteralotoftraining/runninge.gstressfracture• Has risk factors for osteoporosis

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RED FLAG SCREENING: SPECIFIC FOR FOOT & ANKLE PATHOLOGYHistory & Symptoms

Suspected fracture/ dislocation management: acute fracture/dislocation should immediately attend A+E (with accompanying letter where possible) or fracture clinic with urgent x-ray, depending on clinician’s clinical judgement. Suspected pathological fractures should be referred for investigations to determine root cause via referral to appropriate services as a matter of urgency (GP, secondary care).If suspicion of a stress fracture where X-ray has shown no bony injury consider MRI. 5. Symptoms suggestive of Achilles tendon rupture• Oftenreportanaudiblesnaporpopduringsportorrunningactivity• Sudden,significantpaininthecalforbackoftheankle-thismaybedescribedasbeinghit byaracquetorkickedinthebackoftheleg. oApproximatelyathirdofpeoplewithtendonrupturedonotcomplainofpainaftertheacute painoftherupturehaseased.• Inabilitytowalkorcontinuetheprecipitatingactivity-alimpisoftenpresent. oInsomecases,thepersonmaybeabletowalkasplantarflexionofthefootinvolves musclesotherthanthoserelatedtotheAchilles.• Unabletocalfraise• Simmondstriad(angleofdeclination,palpation,andthecalfsqueezetest)tohelpexclude Achilles tendon rupture:• Positivesqueeze/Thompsontest-liepronewiththeirfeetovertheedgeoftheexamination couch.Gentlyandsequentiallysqueezethecalfmuscles-inacuteruptureoftheAchilles tendontheinjuredfootwilltypicallyremainintheneutralpositionwhenthecalfissqueezed• Palpabletendongap-Feelforagapinthetendon.Nogapmaybefeltintheacutephase (duetohaematoma)orinthechronicphase(duetoorganization).Bruisingmaybeseen.• Angleofdeclination-Lookforanabnormalangleofdeclination-ruptureoftheAchilles tendonmayleadtogreaterdorsiflexionoftheinjuredankleandfootcomparedtothe uninjuredlimb.• Beawarethatdiagnosisofchronicrupturemaybedifficult,because: oPainandswellinghaveoftensubsidedandthegapmayhavefilledwithfibroustissue. oThecalfsqueezetestmayproduceafalseresult. oCalfmusclesmaybewasted. oOthermusclesmayfacilitateplantarflexion.• Achillestendonruptureismissedbynon-specialistsinabout20%ofcases.• Promptdiagnosisisimportantbecausedelayintreatmentcanleadtopooreroutcomes includingdisability,morecomplicatedsurgery,andinabilitytoreturntosportingactivity

Ref- https://cks.nice.org.uk/achilles-tendinopathy#!diagnosissub:1 (2016)

Management of suspected Achilles rupture: refer to A&E if acute (with accompanying letter). These patients need to be seen as soon as possible following the rupture in case theyrequiresurgery–typicallywithin2-3daysbutcouldbeseenwithin6weeks).Iftheproblem is beyond 6/52 post rupture, refer patient to elective orthopaedics urgently.6. Symptoms suggestive of Charcot foot• Dislocationofthejoint• Heat-skinfeelingwarmeratthepointofinjury• Deep aching feeling• Insensitivityinthefootduetoneuropathy• Instabilityofthejoint• Redness• Strong pulse• Swellingofthefootandankle(causedbysynovialfluidthatleaksoutofthejointcapsule)• Subluxation/deformityofthefoot(misalignmentofthebonesthatformajoint)

Historyofdiabetes/peripheralneuropathyandthetriggerforCharcotfootcanbeasprainortwistedanklethatgoesunnoticedbecauseofreducedfeelingfromnervedamage.

https://cks.nice.org.uk/achilles-tendinopathy#!diagnosissub:1


RED FLAG SCREENING: SPECIFIC FOR FOOT & ANKLE PATHOLOGYHistory & Symptoms

Complications of Charcot footIncludecallusesandulcers,whichoccurwhenbonyprotrusionsrubinsidetheshoesandmaybecomeinfected.Boneinflammation(osteomyelitis)andinflammationofthejointmembranes(septicarthritis)alsomaydevelop.Septicarthritismaymanifestwithmalaiseandfever.Bloodvesselandnervecompressionmayoccurandoftendonotcausesymptomsduetothelossofsensationinthefoot.

Management of suspected Charcot’s foot: refer to diabetic clinic urgently.

ACUTE INJURE

CONSIDER ADMISSION/URGENT REFERRAL IF: • Recent trauma to the foot and or ankle• Painmayormaynotbepresent• Swelling• Muscles wasting• Reduced function• NewDeformity• Neurovasculardeficit• Unable/difficulttoweightbear• UnabletocalfraiseduetopossibleAchillestendonrupture

If suspect a fracture/dislocation/Achilles tendon rupture referral to A&E/fracture clinic.

If suspecting a malignant lesion then MRI within 2 weeks USS via sarcoma pathway.

If suspect malignant tumour refer to east midlands sarcoma clinic: www.eastmidlandssarcoma.org.uk/making-a-referral

DIAGNOSIS: HIND FOOT/MID FOOT JOINT OATYPE OFINFORMATION GUIDELINES

Background information

HIND FOOTConsider the possibility of ankle osteoarthritis as the cause of ankle pain if :-• 45oroverand• Hasactivity-relatedjointpain• Haseithernomorningjoint-relatedstiffnessormorningstiffnessthatlastsnolongerthan30 minutes• Beawarethatatypicalfeatures,suchasahistoryoftrauma,prolongedmorningjoint- relatedstiffness,rapidworseningofsymptomsorthepresenceofahotswollenjoint,may indicatealternativeoradditionaldiagnoses.Importantdifferentialdiagnosesincludegout, otherinflammatoryarthritides(forexample,rheumatoidarthritis),septicarthritisand malignancy(bonepain)• AlargerpercentageshowradiographicchangesthanhavesymptomsfromankleOA.

Co-existswithmanyco-morbidities:obesity,CVdisease,psychologicaldysfunction(lossofsocialrole,mentalhealth,‘feelingold’)

https://www.nice.org.uk/guidance/cg144/chapter/recommendations#diagnosis-2

http://www.eastmidlandssarcoma.org.uk/making-a-referral/



Subjective History

OA• Screenforredflags• Typicallyinolderpeopleoraftertraumainyoungerpeople• Symptomsofankleosteoarthritisareoftenepisodicorvariableinseverity,andslowtochange.• Use-relatedpain,oftenworsetowardstheendofthedayandrelievedbyrest• Morepersistentrestpainandnightpainmayoccurinadvancedosteoarthritis.• Painthatisworseonmovement• Lessspecificdescriptionofpain,vaguedullaching• Describestiffnessintheankleinthemorningorafterinactivitylasting30minutesorless.• Reduced function

Examination findings

• Physicalexaminationfindingsmayinclude: oDifficultywithwalking/weightbearing oStiffnessofjointbothactiveandpassively o Crepitus on ROM oPainfulorrestrictedmovement. oBonyenlargementaroundthejointmarginsandabsentormodesteffusion(without warmth). oJointlinetenderness.• Functionalassessment–activitytolerance,patient-specificlimitationsinfunctionevaluated (iewalkingdistance),mustincludegaitassessment.• Assessjointsaboveandbelow

Investigations • SuspectedAnkleOA-WeightbearingX-rayAPandlateralAnkle• Ifmod-severesymptomstomidfoot(e.g.talonavicularjoint)oranklejoints–referforMRI tohelpdifferentiatepathologyandwillhelpguidemanagement(suchasspecifictargetfor injection).• ThisisespeciallyrelevantifreferringthepatienttothecommunityclinicatAshfieldHWB Centre for a second opinion • Or• PodiatricsurgeryteamcanalsoofferUSguidedinjections-toconsiderthisasanadditional referral route• Considerbloodsifdiagnosisunclear– oBeawarethatatypicalfeatures,suchasahistoryoftrauma,prolongedmorningjoint- relatedstiffness,rapidworseningofsymptomsorthepresenceofahotswollenjoint,may indicatealternativeoradditionaldiagnoses.Importantdifferentialdiagnosesincludegout, otherinflammatoryarthritides(forexample,rheumatoidarthritis),septicarthritisand malignancy(bonepain).

Conservative management

• Assesstheseverityofpainandtheeffectofosteoarthritisontheindividual’sfunction,quality oflife,occupation,mood,relationships,andleisureactivities.• FormulateanindividualizedmanagementplaninpartnershipwiththepersonwithOA• Takeaccountofcomorbiditiesthatcompoundtheeffectofosteoarthritisortheriskofadverse effects from treatments• Takeintoaccounttheperson’sexpectations,needs,andanxieties.Agreeindividualisedself- managementstrategies.Ensurethatpositivebehaviouralchanges,suchasexercise,life stylemodifications,weightloss,useofsuitablefootwearandpacing,areappropriately targeted• Advisethepatienttherewillbegood/baddays.Totrylacedbootstosupportthefoot.Not usuallyprogressiveinnature




• The core treatmentstobeofferedtoeveryonewithosteoarthritisis: oEducation,advice,andaccesstoinformation oRangeofmovementandstrengtheningexercise,alongwithaerobicfitnesstraining oWeightlossifthepersonisoverweightorobese oAssistivedevices(forexample,walkingsticks)forpeoplewhohavespecificproblemswith activitiesofdailylivingorpoorbalance• Possibleadjunctstotheircoretreatmentsare: oConsiderareferraltoMSKpodiatryororthotics(forreasonssuchastocushionand supporttheareaofthefootwhichhasOAsuchastheforefoot/midfoot) oTheuseoflocalheatorcoldtherapy

Treatments not indicated• Acupuncturenotcurrentlyindicated• ElectrotherapynotindicatedexceptforTensforpainrelief• Nutraceuticals(glucosamineorchondroitinproducts)

Pharmacological managementCurrentlybeingreviewedbyNICEandtocurrentlyusethe2008guidelines.• Healthcare professionals should consider offering paracetamol for pain relief in addition to coretreatmentsregulardosingmayberequired.Paracetamoland/ortopicalnon-steroidal anti-inflammatorydrugs(NSAIDs)shouldbeconsideredaheadoforalNSAIDs,cyclo- oxygenase2(COX-2)inhibitorsoropioids.[2008]• IfparacetamolortopicalNSAIDsareinsufficientforpainreliefforpeoplewithosteoarthritis, thentheadditionofopioidanalgesicsshouldbeconsidered.Risksandbenefitsshouldbe considered,particularlyinolderpeople.[2008]

Followupandreviewperiodicallyaccordingtotheindividual’sneeds.

Referral on for podiatric surgery or Orthopaedic opinion

Ifnoimprovementafter6monthsofconservativemanagementincludingtheappropriatecoretreatmentsconsiderreferraltofootandanklespecialist(Orthopaedicorcommunitypodiatricsurgeon)(seecriteria).

Ifthepatientisstrugglingdespitetreatmentfromprimary-intermediatecaresettingsatanypoint,pleaseconsiderreferraltofootandanklespecialist.

ThefootandanklecommunityclinicatAHVcanbeusedforasecondopinioniftheclinicianisunsureonwhethersecondarycaremanagementisrequired.

Referraltoordiscussionwiththepodiatricsurgeoncanshouldalsobeconsideredasareferralrouteforsuitablepatients.

Imageguidedinjectionsmaybeconsidered-NotethatthiscannotberequestedasadiscussionpatientwithinthecommunityclinicsatAshfieldastheconsultantwouldliketomeetthepatientandgaininformedconsent.

Considerreferralforjointsurgeryforpeoplewithosteoarthritiswhoexperiencejointsymptoms(pain,stiffnessandreducedfunction)thathaveasubstantialimpactontheirqualityoflifeandarerefractorytonon-surgicaltreatment.[NICE2014]

Referforconsiderationofjointsurgerybeforethereisprolongedandestablishedfunctionallimitationandseverepain.[NICE2014]

Ref-NICE-Osteoarthritis:careandmanagement(2014),

NICEosteoarthritis(2008)



Referral on for podiatric surgery or Orthopaedic opinion

Surgical Treatment options

• Thesearetypicallyconsideredwhentherehasbeenafailuretoimprovewithconservative managementandthepatientiskeentoexploresurgicaloptionsviaashareddecision- makingprocess.

Surgical Treatment options for Ankle OA:

• TotalAnkleArthroplasty(TAA)andAnkleFusion(arthrodesis)areconsideredtheprimary surgicaltreatments.AnkleFusionisstillseenasthegoldstandardduetohigherrisksof failure/revisionrateTAA.• Theconsultantsurgeonwouldexplaintherisksofthesurgerytoensureaninformeddecision (localanaestheticrisks,nerveinjury,infection,DVT,pulmonaryembolism,swelling,scar tenderness,non-union,metalworkproblems,persistentpainsyndromeduetonerve irritation).• Limitations of Ankle Fusion can also include reduced normal ankle motion which can acceleratejointdegenerationatothersegments.(Lawtonetal2017).• Anklefusionisamajoroperationrequiringsignificantlylongrehabilitationperiod–thepatient isinplasterfor6/52,thenabootfor6/52andcantake6/12uptoayeartosignificantly benefitfromtheoperationintermsofimprovementstopainandfunction.

Ref - Lawton et al 2017Totalanklearthroplastyversusanklearthrodesis-acomparisonofoutcomesoverthelastdecade.JournalofOrthopaedicSurgeryandResearch.

DIAGNOSIS: MID FOOT - OATYPE OFINFORMATION GUIDELINES


SeeNICEguidelinesonOA.

Subjective history

• Subjectivesymptomsofstiffnessandpain.• Age:45yearsoldandabove• RiskFactorssuchashypertension,highBMIandtype2DM.


• Restrictionstopassiveandactivemovementsmidfoot• Positivesqueeze

Investigations • WeightbearingX-rayAP,Oblique&Lateral• IfsevereOAneedsMRItohelpdifferentiatewhichjointsareaffectedasthiswillguide treatment


• ROMandStrengtheningexercisesandconsiderphysiotherapy/podiatry(ifhavingproblems regainingmovement,strengthandfunctionafter6-12weeksself-help)• Weight reduction programme• Lifestylemodifications• Orthotics/supportivefootwear

Referral on for orthopaedic or podiatric surgery opinion

• IfsevereOAseenasmayconsiderultrasoundguidedinjections.• MRIhelpstoidentifyjointsrequiringUSGI.• Referralonfororthopaedicorcommunitypodiatricsurgeonopinion

http://www.arthritiscare.org.uk

http://www.arthritisresearchuk.org

http://www.nhs.uk

http://www.arma.uk.net

DIAGNOSIS: MUSCLE AND LIGAMENTS/SPRAIN/STRAINTYPE OFINFORMATION GUIDELINES


SPRAINS A stretch and/or tear of a ligament(astrongbandoftissuethatconnectstheendofonebonetoanother).Sprainsareclassifiedbyseverityas:• GradeI-mildstretchingoftheligamentcomplexwithoutjointinstability.• GradeII-partialruptureoftheligamentcomplexwithoutjointinstability.• GradeIII-completeruptureoftheligamentcomplexwithinstabilityofthejoint.Astrain(or‘pull’)isastretchand/ortearofmusclefibresand/ortendon(fibrouscordoftissuethatattachesmusclestobone). oStrainsareclassifiedbyseverityas: • First-degree(mild)strain-onlyafewmusclefibresarestretchedortorn.Althoughthe injuredmuscleistenderandpainful,ithasnormalstrengthbutpowermaybelimitedby pain. • Second-degree(moderate)strain-thereareseveralinjuredfibresandmoresevere musclepainandtenderness.Thereisalsomildswelling,noticeablelossofstrength,and sometimesavisiblebruise. • Third-degree(severe)strain-themuscletearsallthewaythrough,sometimesproducing a‘pop’sensationasthemuscleripsintotwoseparatepiecesorshearsawayfromits tendon.Thereisatotallossofmusclefunction,severepainandswelling,avisiblebruise, anddifficultybearingweight.Causes and risk factorsSprainsoccurasaresultofabnormalorexcessiveforcesappliedtoajoint.Strainsoccureitherbecauseamusclehasbeenstretchedbeyonditslimitsorithasbeenforcedtocontracttoostrongly. • The risk of strains and sprains is high in people who frequently participate in sport. Factorsthatincreasetheriskofinjuryduringsportsinclude: oThetypeofsport-forexample,contactsports(suchasfootball,hockey,andboxing)and sportsthatfeaturequickstarts(suchashurdling,longjump,andsprinting)increasethe risk of strains; oStrengthandflexibility-alackofregularexercisecanweakenmusclesandjoints,making themlessflexibleandhencemorepronetoinjury. oOverload-thiscancauseexcessivepressuretobeappliedtoparticularjointsor muscles,therebyincreasingtheriskofinjury. oWearinginappropriatefootwear-thiscanincreasetheriskfordevelopinganklesprains andstrains. oInadequatewarmupbeforeexercising,andcooldownafterexercising. oMusclefatigue-tiredmusclesarelesslikelytoprovideadequatesupportforthejoints.• Other risk factors for sprains and strains include: oSuddentrauma,forexample;afall,twist,orblowtothebody. oAnatomicalvariationsofthefootandankle(forexamplegeneralizedjointlaxityorflatfoot) -thesemaypredisposeapersontochronicinjury. oTypeofmuscle-somemuscletypesaremorepronetoinjurythanothers,forexample: • Morepennatemuscles(shortmusclefibresthatextendfromacentraltendon)havea greaterpercentageofelongationbeforefailurethanlesspennatemuscles. • Fast-twitchmusclefibresaremorepronetoinjuriesthanslow-twitchmusclefibres. • Muscle-tendonunitsthatspantwojoints,forexampletherectusfemoris(whichspansthe hipandkneejoints),aremorecommonlyinjured. oMedicalconditionsthatpredisposetofalls(forexampleepilepsyorbalancedisorders). oExcessivealcoholintakeandtheuseofdrugsthatcancausedrowsiness(forexample opioidanalgesics).




oBeingoverweightorobese-thiscanputpressureonthejointsandmuscles. oPrevioussprainorstrain.• Sprains and strains are common,especiallyinpeoplewhofrequentlyparticipateinsport andwhentherearepredisposingfactors. oAbout30-50%ofmusculoskeletalinjuriesthatpresentinprimarycarearetendonand ligamentinjuries,withankleinjurybeingthemostcommoninbothathletesandsedentary people. oCKSwasunabletofindspecificUKincidenceorprevalencedata;however,intheUS, musculoskeletalinjuriesaccountforabout2millioninjuriesperyearand20%ofallsports injuries.

Subjective history

• Symptoms of a sprain typically include: opainaroundtheaffectedjoint, otenderness, oswelling, obruising, ofunctionalloss(forexamplepainonweight-bearing), omechanicalinstability(ifthesprainissevere).• Symptomsofastraintypicallyinclude: omusclepain, ospasm, oweakness, oinflammation,and/orcramping. oLargehaematomascanoccurasaresultoftearingoftheintramuscularbloodvessels. oTheremaybeobviousswelling,althoughsmallhaematomasorthosedeepwithinthe musclearemoredifficulttodiagnoseclinically. oTheseverityofsymptomswilldependontheseverityoftheinjuryaswellasthetimesince theinjury.Forexample,itcantakeupto24hoursforthefullextentofbruisingtobecome apparent. oSymptomdurationofmorethanafewdayscansuggestmoresevereinjury. oAnypredisposingorriskfactors,suchasamedicalconditionorprevioussprainorstrain (enquireaboutthemanagementandoutcome). oAnycomplicatingfactors,suchasmedicationthatmayaffecttheinjury(forexample anticoagulants)oracomplicatingillness(forexampleneuropathy,bleedingdisorder,or historyofdeepveinthrombosis


Sprains:• painaroundtheaffectedjoint,• swelling,• bruisingifacute• functionalloss(forexamplepainonweight-bearing),• mechanicalinstability(ifthesprainissevere)–testssuchasAPdrawer,Talartiltcouldbe positive,butshouldnotbeusedinisolationtodiagnosesprains.• Squeezetest(ifpositiveitcouldindicatesyndesomoticsprains)Strain:• musclepain,• spasm• weakness• swelling• haematomamaybepresent


https://cks.nice.org.uk/sprains-and-strains#!backgroundsub:1



Investigations ANKLE X-RAYFollowinganankleinjury,ananklex-rayistypicallyonlyrequiredifthereispaininthemalleolar zone AND one of the following:-• Inabilitytobearweight(walkfoursteps)immediatelyaftertheinjuryandwhenexamined.• Bonetendernessalongthedistal6cmoftheposterioredgeofthefibulaortipofthelateral malleolus.• Bonetendernessalongthedistal6cmoftheposterioredgeofthetibiaortipofthemedial malleolus

(the reason for the ankle x-ray would be to check for underlying fracture – Ottawa Rules)

ANKLE MRITheAPP/consultantmayorderanankleMRIIfthereispersistentpainandgivingwayfollowingatraumaticinjury.Reasonswouldbetocheckforosteochondrallesionorsevereligamentdamagewhichmayrequirerepair.


• Offer analgesia for pain relief. oPrescribeparacetamoloratopicalnonsteroidalanti-inflammatorydrug(NSAID,suchas ibuprofengel). oCodeinecanbeusedasan‘addon’toparacetamol,ifnecessary. oConsiderprescribinganoralNSAID(forexampleibuprofenornaproxen)48hoursafterthe initialinjury,ifneeded. oFordetailedinformationonprescribingparacetamol,ibuprofen,andcodeine,seetheCKS topicsonAnalgesia-mild-to-moderatepainandNSAIDs-prescribingissues.• If acute Advise the person: o To manage their injury using the PRICE measures: oToavoidHARMinthefirst72hoursaftertheinjury: • Heat-forexamplehotbaths,saunas,andheatpacks. • Alcohol-increasesbleedingandswellinganddecreaseshealing. • Running-oranyotherformofexercisewhichmaycausefurtherdamage. • Massage-mayincreasebleedingandswelling.• Consider the need for immobilisation. o For sprains: • Ifsevere,ashortperiodofimmobilisationcanresultinquickerrecovery. • Forlessseveresprains,itisadvisablenottoimmobilisethejoint.Beginflexibility(range ofmotion)exercisesassoonastheycanbetoleratedwithoutexcessivepainandwhen ablestrengtheningandfunctionalexerciseso For strains: • Immobilisetheinjuredmuscleforthefirstfewdaysaftertheinjury.Considertheuseof crutchesinsevereinjuries. • Startactivemobilisationafterafewdaysifthepersonhaspain-freeuseofthemuscle inbasicmovementsandtheinjuredmusclecanstretchasmuchasthehealthy contralateral muscle and progress to strengthening and functional exercises• Advise the person to seek further medical advice in 5-7 days or consider referral to physiotherapy if there is: oLackofexpectedimprovement(forexampletheyhavedifficultywalkingorbearingweight). oWorseningofsymptoms(forexampleincreasedpainorswelling). oPresenceofyellowflags

https://cks.nice.org.uk/analgesia-mild-to-moderate-pain

https://cks.nice.org.uk/nsaids-prescribing-issues




• Manage patient expectations–Forexample,itcantake9monthstoreturntofullfunction andsportfollowingananklesprain.Setshorttermandlongtermgoalstofacilitateself- efficacyandmotivationwithrehabilitation.• Advise that the person should: oTakecarewhenexercisingordoingsport.Theyshould: • Warmupbeforeexercising(bydoinganaerobicactivityataneasypacetogently increasetheheartrateandgetthebodyandmusclesreadyformoreintenseactivity). • Cooldownafterexercising(bygraduallydecreasingtheexerciseintensityleveluntil breathingandheartratehavereturnedtonormal,thendoinggentlestretcheswhilstthe musclesarestillwarm). • Useproperequipment. • Wearappropriateshoes,andreplaceshoesastheywearout. • Wearcomfortable,loose-fittingclothesthatallowfreemovement. • Developabalancedfitnessprogramthatincorporatescardiovascularexercise,strength training,rangeofmovementandproprioception–theymayneedphysiotherapytoassist with this • Addactivitiesandnewexercisesinagradedmanner. • Avoidexercisingorplayingsportwhentiredorinpainwhichisnotmanageable. • Scheduleregulardaysofffromexercise. oPracticesafetymeasurestohelppreventfalls,suchaskeepingstairwaysandwalkways freeofclutter,usinganti-slipmatsunderrugs,clearingiceandsnowfromfootpathsinthe winter,andwearingappropriatefootwearinicyconditions(flatfootwearwithrubbersoles ratherthanleather-soledorhigh-heeledshoes). o Take particular care when taking drugs that cause drowsiness (for example opioid analgesics)oriftheyhaveamedicalconditionthatpredisposesthemtofalls(forexample epilepsyorbalancedisorders). oAvoidgettingdrunk. oMaintainahealthyweight.

Referral on for orthopaedic opinion

• Consider the need for referral to an orthopaedic foot and ankle specialist (urgencydependingontheseverityofsymptomsandclinicaljudgement)if: oRecoveryisslowerthanexpected.Ifnoimprovementatallafter3monthsofconservative management,considerreferraltofootandanklespecialist oThereareworseningornewsymptoms. oSymptomsareoutofproportiontothedegreeoftrauma. oNote-Sprainsandstrainsareoftennotamenabletosurgicalintervention• The prognosis of a sprain or strain largely depends on the severity of the injury [Jarvinen,2000][BMJ,2015]. oAmildinjurywillusuallyhealwithinafewweekswithconservativetreatment,withminimal long-termcomplications. oAmoderateinjuryshouldhealwithinafewweeks,butthereisahighriskoffurtherinjuryin thefirst4-6weeks. oAsevereinjurymaytakemonthstohealfully(suchas9monthsforasevereanklesprain), andresultincomplications,suchas: • Forseveresprains–chronicinstability,lossoffunction,pain,andsecondary degenerativechangesintheaffectedjoint. •Forseverestrains–muscleatrophy,musclefibrosis,heterotrophicossification,and compartmentsyndrome.

https://cks.nice.org.uk/sprains-and-strains#!references/323349



CRITERIA FOR REFERRAL TO COMMUNITY PODIATRY SURGEONS(NOTTINGHAMSHIRE HEALTH CARE PODIATRIC SURGEONS)TYPE OFINFORMATION GUIDELINES

Inclusion criteria Indications for assessment or treatment with the Podiatric Surgery team• HalluxAbductoValgus(HAV)or‘bunions’• Hallux Limitus/Rigidus• Hammer/Mallettoeoranyotherdigitaldeformities• Tailors Bunion• Metatarsalgia• Traumaticinjuriesofthefoot• Chronic recalcitrant foot pain• Painfulskinlesions(onlyifcommunitypodiatryfails)• Naildisorders(onlyifcommunitypodiatryfails)• Sesamoid Pain• SubungalExostosis• Intermetatarsal Neuroma or traumatic neuroma• PainfulHaglund’sdeformity• PainfulAccessoryOssicle• Osteochondrosis• Osteoarthritis of foot Joints• Softtissuelumpsandbumps• Tendondisordersofthefoot&lowerleg• Previousfootsurgerywithcomplications• Diabetesrelatedfootdisease

Exclusion criteria Contra-indications for day case surgery• Unstablesystemicdiseases• Peripheralvasculardisease• Lackofpostoperativesupport• UnstablePsychiatricdisorders• Severeacuteanxiety• Recentorunpredictabledrugoralcoholabuse• Anti-coagulanttherapywithINR>3• Considerreferraltosecondarycare*whenGAorIVsedationisrequested• Considerreferraltosecondarycareifinpatientcareisrequired• PodiatricsurgeryteamatNewarkoffersurgeryunderGA



• In general: oIfapersonwithananklesprainhasanuncomplicatedrecovery,walkingisusuallypossible within1-2weeks,withfunctionrestoredafter6-8weeks,andareturntosportingactivities after8-12weeks(dependingontheseverityoftheinjury)[deBieetal,2006].Severe anklesprainscanresultinprolongedtimeawayfromsport(9months). oWithanklesprains,painandintermittentswelling(particularlyonthelateralsideofthe ankle)arethemostcommonresidualproblems[StruijsandKerkhoffs,2010].

Ref- NICE CKS sprains and strains (2016)




DIAGNOSIS: HIND FOOT/TENDONS/TENDINOPATHIES TYPE OFINFORMATION GUIDELINES


Achilles tendinopathyAchillestendinopathyisasofttissuedisorderwhichcausespain,stiffness,andswellingoftheAchillestendon.TheAchillestendonisthelongest(approximately12–15cm)andstrongesttendoninthebody.Itattachesthegastrocnemiusandsoleusmusclesinthelowerlegtotheheelbone(calcaneus)• Mid-portion or mid-substance tendinopathy affects an area of the Achilles tendon approximately2–6cmaboveitsinsertiononthecalcaneus.Thisareaisvulnerabletodamage becauseithasarelativelypoorbloodsupply.Mid-portiontendinopathyisthemostcommonsite ofAchillestendondamage(about75%ofcases).• Insertional tendinopathy affects the insertion of the Achilles tendon on the posterior calcaneum.Thisoccursinabout25%ofcases.• Theterm‘Achillestendinitis’isnolongerusedashistopathologystudieshaveshownthat thepredominantprocessinAchillestendinopathyisdegenerative(‘tendinosis’)ratherthan inflammatory(‘tendonitis’).• Risk factors for Achilles tendinopathy include: oOveruseorstrenuousphysicalactivity,forexamplerunningandjumping. oAgeing-themajorityoftendonsundergodegenerativechangeswithincreasingage. o Biomechanical factors: • Intrinsicfactorsincludeleglengthdiscrepancy,anoverlypronatedfoot,tightor underdevelopedhamstrings,ahigh-arched(pescavus)foot,andlateralinstabilityofthe ankle. • Extrinsicfactorsincludepoorequipment(suchasinappropriatefootwear),changesto trainingregimenorpoortrainingtechniques(suchasasuddenincreaseinintensity), previousinjury,andenvironmentalfactors(suchastrainingonhardsurfacesorhills,andin coldweather).• Other factors thought to contribute to the development of Achilles tendinopathy include: oUseoffluoroquinoloneantibiotics,suchasciprofloxacin. • Achillestendinopathyhasbeenreportedin6%ofpeoplewhohavetakenfluoroquinolone antibiotics. • AcohortstudyinDenmarkfoundthattheincidenceofAchillestendonrupturewithin90 daysoftakingfluoroquinolonesisthreetimeshigherthanthebackgroundpopulation[Sode, 2007]. • Asystematicreviewfoundthat5outof16observationalstudiesstatedthatpeopletaking oralcorticosteroidsandfluroquinoloneswereatgreaterriskoftendoninjurythatthose takingfluroquinolonesalone[Stephenson,2013] • Fluoroquinolonetreatmentshouldbediscontinuedatthefirstsignsofaseriousadverse reaction,includingtendonpainorinflammation(MHRAMarch2019) oMalesex. oRheumatoidarthritisorotherinflammatoryjointdisease(suchaspsoriaticarthritisorreactive arthritis)-usuallyrelatedtoinsertionaltendinopathy. oFamilyhistory-thechanceofdevelopingAchillestendinopathyhasbeenreportedtobefive timeshigherinpeoplewithapositivefamilyhistory. oDyslipidaemia. oType1andType2diabetesmellitus. oObesity. oHypertension.[Sode, 2007; Carcia, 2010; Scott, 2011; Wilson, 2010; DTB, 2012; Asplund, 2013; Childress, 2013]




CAUSES• RepetitivestrainandmicrotraumatotheAchillestendonduringactivitiessuchasrunning (includingsuddenaccelerationordeceleration),andjumpingmakeitsusceptibletoinjuryand degeneration.• Psychosocialfactorssuchaslowself-efficacy,fearavoidanceandcatastrophisationcan contributetotheinitialpainresponseandtheprognosisintermsofwhetherthecondition improves.• Thenormalprocessoftendonrepairafterinjuryinvolves: oAnacuteinflammatoryphasewhichlastsafewdays. oAproliferativephase,lastingapproximately3weeks,wherefibroblastsproducenewcollagen andnewvesselsform. oAcollagenremodellingphasewhichcanlastuptoayear.• ThisnormalhealingresponsefailsinAchillestendinopathyandinstead,cellsandvessels proliferateinadisorganisedwayandcollagenfibresdegenerate.[Wilson, 2010; DTB, 2012; Sussmilch-Leitch, 2012; Asplund, 2013; Childress, 2013]

DIFFERENTIAL DIAGNOSISTruetendonpain(fromruptureortendinopathy)isusuallyconfinedtothetendonitselfOther diagnoses which cause pain in and around the Achilles tendon include: o Achilles tendon rupture - partial or complete rupture oRetrocalcanealbursitis-theretrocalcanealbursaliesbetweenthecalcaneumandthe Achilles tendon oPlantaristendinopathy-theplantarismuscleliesdeeptothegastrocnemiusmuscleandis foundin7–20%ofpeople.Injurytotheplantarismusclecanproducesymptomsthatare similartoAchillestendinopathy oDislocationoftheperonealorotherplantarflexortendons(wouldneedMRandsurgical intervention) o Posteriorankleimpingement-thiscausespainonforcedplantarflexionwhenjumpingorkicking o Ankle osteoarthritis oTendonxanthoma-associatedwithseverehypercholesterolemiaandcanappearasnodules related to the Achilles tendon oHaglund’sdeformity-aposterolateralcalcanealprominence(sometimescalleda‘pump bump’)whichcanbecomeinflamed.Ifsymptomatictypicallyrequireseitherfootwear modificationandorthoticstostabilisethecalcaneous.ReferraltoMSKpodiatryororthotics servicemaybeappropriate oOstrigonumsyndrome—afloatingbonejustbehindtheanklejoint oCalcanealapophysitis—Sever’sdiseaseofadolescents o Calcaneal stress fracture oIrritationorneuromaofthesuralnerveorsacralrootpain oSystemicinflammatorydisease,suchasrheumatoidarthritis—considerthisifthereare bilateralorsystemicsignsOther common foot and ankle tendinopathies to consider are :• Tibialisposterior-Painandswellingposteriortothemedialmalleolus.Painworsewithweight bearingandwithinversionandplantarflexionagainstresistance• Peroneal-Painandswellingposteriortothelateralmalleolus.Painwithactiveeversionand dorsiflexionagainstresistance.Mayhaveahistoryofchroniclateralanklepainandinstability• Flexorhallucislongus-Painandswellingovertheposteromedialaspectoftheankle.Seen indancersorathleteswhouserepetitivepush-offmanoeuvres.Painwithresistiveflexionofthe great toe• Anteriortibial-PainovertheanteriorankleWeakdorsiflexionofthefootCausedbyforced dorsiflexion



Subjective History

ACHILLES TENDON• AskaboutsymptomsthatmightindicateAchillestendonrupture, oSuddenintensepaininthebackoftheleg,andinabilitytowalkorcarryonwiththe precipitatingactivity.• AskabouttypicalsymptomsofAchillestendinopathyincluding:• Paininthebackofthelegorheel:• Painisusuallyintermittent,worseinthemorning,andaggravatedbyactivityorexercise.• Stiffnessinthetendon.• Stiffnessmayoccurinthemorningorafteraperiodofimmobility,andeasewithmovement.• Askhowsymptamsareaffectingfunction:

Askaboutriskfactorssuchasdiabetesmellitus,dyslipidaemia,andfluoroquinoloneuse.


Examine both legs: oExcludeAchillestendonrupture.IfnoevidenceofanAchillestendonruptureisfound: • Lookforswelling,deformity,andanysignsofinflammation. • Palpatealongthelengthofthetendonfortenderness,heat,crepitus,localizedthickening, andnodularity. • Assessfunctionbyaskingthepersontoperformatendon-loadingactivity—inmost people,simplesingle-legheelraisesaresufficient.Moreactivepeoplemayneedtohop onthespottoreproducepain.

Investigations • Achilles tendinopathy is usually a clinical diagnosis and imaging (such as ultrasound or MRI) is not routinely recommended in primary care.ReasonsforX-ray–ifreferringfororthopaedicconsultantopinion• Ifthepatienthasinsertionaltendinopathy-youmaywanttoconsiderX-raytocheckfor Haglund’sdeformity(“Pumpbump”).Lateralweightbearingandcalcanealaxialviewsmaybe helpful.Anx-rayisnotrequiredformid-achillestendinopathy.• ItisusefultodetermineifHaglund’sdeformityisevidentwhensecondarycareorcommunity podiatricsurgeryintervention(surgery,injections)couldbeindicated.Thisisbecausethe prognosiscanbeworsewiththepresenceofaHaglundsdeformityandalsobecauseduring surgicalintervention,thebonyprominencewouldbeshavedaspartoftheprocedure.During surgicalinterventiontheAchillesmayhavetobedetachedanddebrided.Thisaddstothe timetakentorecover-typically12-18months.Thepatientwouldalsobeadvisedthatalump couldstillremainposttreatment.

Alternative investigations• Arrange investigations(suchaslipidprofileorHbA1c)asappropriate,ifanunderlyingsystemiccauseissuspected.


• IfAchillestendonrupturehasbeenexcluded:• ExplainthatthesymptomsofAchillestendinopathyusuallytake12weekstoresolve.• Manageasappropriateanyunderlyingcauses,suchas:• Fluroquinoloneantibiotics—discontinue(discusswithmicrobiologyifunsureregarding alternatives).• Hypercholesterolemia-seetheCKStopicsonHypercholesterolaemia-familialandLipid modification-CVDpreventionforfurtherinformation.• Diabetesmellitus-seetheCKStopicsonDiabetes-type1andDiabetes-type2forfurther information.




• Advise the person that: • Coldpacksoricecanbeappliedtoeasesymptomsafteracuteinjury. • Paracetamolcanbeusedforpainrelief—nonsteroidalanti-inflammatorydrugs(NSAIDs) maybeusefulforanalgesiaintheacutephasebutarenotrecommendedinthelonger term.SeetheCKStopicsonAnalgesia-mildtomoderatepainandNSAIDS-prescribing issuesformoreinformation. • Managethepatient’sloadingstrategiestofacilitateagradedreturntopreviousfunction..• Refer the person to physiotherapy: • Forassessmentandsupervisedgradedloadingexercisesiftheirsymptomsfailtoimprove within7–10days. • Foralltendon-relatedissues–consideranypsychosocialfactorsaswellasphysicalfactors thatmaydelayorinhibitrecoveryandaddressaccordingly.Facilitateself-efficacyand managepatientexpectationseffectivelythroughappropriateadvice,reassuranceandshort- term/long-termgoalsetting.• Adjuncts-Orthoticsforaheelliftcanbeusedtoeasesymptomsandaidrecovery.(arigid 12mmheelliftusedtemporarilymightbeasimple,cost-effectiveandpotentiallybeneficial intervention).


• MostpeoplewithAchilles/Tibialisposterior/peronealtendinopathyimprovewithconservative treatment.Painandfunctionusuallyimproveafter12weeksofconservativetreatment.• Ifthepatientisnotimprovingwithin12weeks,considerreferraltoorthopaedics(footand anklespecialist)inthecommunityclinics(ifongoingmanagementplanisnotclearandneed furtherguidance)orasasecondarycarereferral(ifthemanagementstrategyiscleari.e.the APPfeelsthereisaclearsurgicaltarget).• ForaninsertionaltendinopathyANDankleX-rayhasbeenperformed–thiscouldbebooked asadiscussionpatientatAHWBcommunityclinicforconsiderationofUSGIorderingfrom consultant.• Foramid-portiontendinopathy–USGInotidealduetopossiblerupturerate.Mayconsider highvolumesalineinjectionsbyneedlingorPRP-willneedreviewwithconsultantwhichcan beintheAshfieldcommunityclinicorreferralintosecondarycare

SURGERYSurgeryisveryrarelyperformedforthesepatients.• Prognosis • Onefollow-upstudyofpeoplewithAchillestendinopathyfoundthat8yearsafter injury[Paavolaetal,2000]: • 84%ofpeoplewithAchillestendinopathyhadcompletelyreturnedtotheirnormalactivity leveland94%wereasymptomaticorhadonlymildpainwithstrenuousexercise. • 40%haddevelopedproblemswiththeirotherAchillestendonand29%neededsurgery.• Achillestendinopathybecomesmoreresistanttotreatmentifitisnotrecognizedand managedatanearlystage.

[Paavola et al, 2000; Asplund, 2013]Ref Nice CKS Achilles tendinopathy (2016)


DIAGNOSIS: PLANTAR FASCIITISTYPE OFINFORMATION GUIDELINES


Plantar fasciitis is a condition in which there is persistent pain associated with chronic degenerativeandreparativeprocessesaffectingtheoriginoftheplantarfasciaandsurroundingperi-fascial surfaces• Itaccountsforabout80%ofcasesofheelpain,withalifetimeprevalenceofaround10% andismostcommoninpeople40–60yearsofage• Plantarfasciitisisusuallydiagnosedbyclinicalfindingsalone;ifcharacteristicsignsand symptomsarepresentthediagnosisislikelytobeaccurate

DIFFERENTIAL DIAGNOSISIf characteristic symptoms and signs are not consistent with plantar fasciitis, consider the following:• Achilles tendonitis presents with tenderness on the posterior-superior aspect of the heel and alongtheAchillestendononpalpation,withpainradiatingupthecalfwithextensionof thefootorwhenstandingontiptoes(completerupturecausesseverepainandlossoffoot stability).Itiscausedbyactivitiesassociatedwithoveruseofthecalfmusclessuchas running,andwearinghighheels.• Flexorhallucislongustendinopathymaymimicplantarfasciitis,butcanbedifferentiated fromitbypainwithresistedplantarflexionofthebigtoe.Tendernessisposteriortothe medialmalleolusontheplantarsurfaceofthebigtoe.• Calcanealstressfracture,whichtypicallypresentswithdiffuse,warmswelling,andcanbe diagnosedbysqueezingthecalcaneum,inducingpain.Typicallyitoccursinapersonwho haswalkedalongdistancecarryingaheavypack.Thepaininitiallyoccurswithactivitybut restpainmaydevelop.Itisconfirmedbyradiography,althoughchangesmaybesubtleor evenabsent.• Fatpadatrophywhichcausescentralizedheelpain,andaflattenedatrophiedsurfacemay befeltonpalpation.Suspectifthereisahistoryoftraumasuchaslandingontheheel.This isalsocommoninelderlypeoplewhoareobese,andinathleteswhotrainonhardsurfaces. Walkingbarefootoronhardsurfacesexacerbatesthepain.• Sub-calcanealbursitisismostcommonintheelderly,andathleteswhohavedonealotof running,walkingorjumping.Thepersonpresentswithposteriorheelpainunderthefatpad ofthecalcaneum.Unlikeplantarfasciitisitisnotmadeworsebydorsiflexionofthetoes.• Other causes less likely to be misdiagnosed as plantar fasciitis:NEUROLOGICAL CAUSES:• Tarsaltunnelsyndromepresentswithpoorlylocalizedpain,numbness,andburningon themedialsideofthefoot,ankle,andsometimesthecalfthatisworsenedwithstandingand walking.ReproductionofthesymptomswithTinel’stestsupportsthediagnosis.Thisinvolves tappingwithfingersoratendonhammeroverthetibialnervewhichrunsbelowandposterior tothemedialmalleolus,onadorsiflexed,evertedfoot.Unlikeplantarfasciitis,dorsiflexionof thetoesdoesnotmakethepainworse.• AnL5-S1radiculopathymaycauseplantarheelpain.Itcanberuledoutbyacomprehensive neurologicalexamination.• Nerveentrapment(suchaslateralplantarandmedialnerves)canmimicplantarfasciitis,but tendsnottospecificallyaffectthemedialtuberosity.Inparticular,thefirstbranchofthe lateralplantarnervemaypresentwithtendernessonthemedialsideoftheedgeoftheheel, withpainradiatingtothelateralsideoftheheel.• Peripheralneuropathylacksaspecificfocalareaofpainandsensationsmaystillbefeltat rest.

http://www.eoeortho.com/frcs-preparation-shoulder-elbow-course/




Other musculoskeletal causes including:• Plantarfasciarupture,whichpresentsasasuddenonsetofpainandbruising.Theremaybe apalpablegapandevidenceofcollapseinthemediallongitudinalarch.• Plantarfibromatosiswhichcausespaininthemid-sectionoftheplantarfasciaandpalpable nodules.• Fractureofthecalcaneumcausedbylandingontheheelfromaheight.Thepersonisnot abletoweightbear.• Infection(osteomyelitisorsubtalarpyoarthrosis)whichisrareintheabsenceofanopen wound.Itpresentswithared,hot,swellingandsystemicillness.• Haglunddeformity,whichisaprominenceofthesuperioraspectoftheposteriorcalcaneus. Repeatedpressuresuchasfromill-fittingshoescanleadtoretrocalcanealbursitis.• Retrocalcanealbursitis,whichpresentsaspain,redness,swellingandtendernessto palpationbetweenthecalcaneusandAchillestendon.• Sinustarsisyndromewhichiscausedbyrepeatedhyperpronationofthefootorlateralankle sprains.Thetalocalcanealsulcus(sinustarsi)istheanatomicalspaceboundedbythetalus, calcaneus,talocalcaneonavicularjointandposteriorfacetofthesubtalarjoint.Painisworse whenwalkingonanunevensurface,andafterexercise.• Inflammatoryarthropathies,andgoutcanberuledoutbyappropriateinvestigations.• Neoplasmandvascularinsufficiencyareveryrarecausesofheelpain(butshouldbe consideredinrecalcitrantcases).

Subjective history

• Ask about the nature of the heel pain, and the general health and physical activity of the person• Characteristicsymptomsofplantarfasciitisinclude: • Aninitialinsidiousonsetofpain. • Intensepainduringthefirststepsafterwakingorafteraperiodofinactivity. • Lesseningpainwithmoderatefootactivity,butworseninglaterduringthedayorafterlong periodsofstandingorwalking.• Document any risk factors • Plantarfasciitismostcommonlyaffectspeople40–60yearsofagewhoareoverweightor obese,orwhoareontheirfeetforextendedperiods.


• Examine the foot at rest (when sitting), and when standing and walking. • Tendernessonpalpationoftheplantarheelarea(usually,localizedaroundthemedial calcanealtuberosity)isadefiningsignofplantarfasciitis. • Limitedankledorsiflexionrange(withthekneeinextension)andapositive‘Windlass test’(reproductionofpainbyextensionofthefirstmetatarsophalangealjoint)issuggestive ofplantarfasciitis. • Abnormalwalking/limpingduetopainmaybeobserved.

Investigations • None indicated in initial stages• MRI/CTifsymptomsdonotimproveorfordifferentialdiagnosis



• Self-help advise the person to: oRestthefoot(byavoidingstandingorwalkingforlongperiods)wherepossible. oWearshoeswithgoodarchsupportandcushionedheels(suchaslacedsportsshoes)and avoidwalkingbarefoot. oAdvisepurchasinginsolesandheelpadstoinsertintheshoe,withtheaimofcorrecting footpronation(however‘magnetic’devicesshouldbeavoided). oLoseweightifoverweighttopreventfutureepisodes. oApplyicefor15-20minutes oTakeanalgesiaonan‘asrequired’basistorelievepain. oRecommendself-physiotherapytoincludeAnkleDFstretchesinnon-weightbearingand weightbearingpositions.• Refer people with mild symptoms to a podiatrist or physiotherapist if self-care has not been effective after a few months. oConsiderearlierreferraltoaphysiotherapistandorpodiatristforpeoplewithmoresevere symptomsthatarehavingasignificantimpactontheirabilitytofunctionnormally.• Physiotherapyforloadingandstrengtheningworkandsupportwithgradedreturntonormal activitiestopromotelong-termresolutionofplantarfasciitis.• Orthotics for soft heels / night socks / splints • Insomecircumstancesshort-termreliefofsymptomsbyinjectingtheplantarfasciawitha corticosteroidmaybeconsideredappropriate,afterconsideringthefollowingpoints: oTheinjectionisoftenverypainfulandpost-injectionpainmaylastforseveraldays. oSymptomscommonlyreturnwithinamonthfollowingtheinjection. oRarelyacorticosteroidinjectioncancausefatpadatrophyorplantarfasciarupture.• Iftheinitialtreatmentwasbeneficialbutsymptomsreturn,thetreatmentmayberepeated oncewithaminimumof6weeksbetweeninjections.• Preferenceisforaultrasoundguidedinjectionascanoftenlocateexactlythemost problematicarea.IffailswouldconsiderPRPinjection• ThesepatientscanbebookedinadiscussionslotattheAshfieldconsultantclinicsfor bookingofUSGIifpainsarelocatedtoundertheheel.

Referral on for orthopaedic or podiatric surgeon opinion

• Considerreferraltoanorthopaedicorpodiatricsurgeonifpainpersistsforupto6months withnoimprovementaftertreatmentbyaphysiotherapistorpodiatrist,whichhasincluded strengtheningrehabilitation• Specialisttreatmentsthatmaybeofferedinclude:• UltrasoundguidedsteroidinjectionsorPRPinjections.

PrognosisThelong-termprognosisforplantarfasciitisisgood.Oneprospectivesurveyfoundthatover80%ofpeopleachievedcompleteresolutionoftheirsymptomswithinayear

Ref- https://cks.nice.org.uk/plantar-fasciitis#!topicsummary



DIAGNOSIS: FOREFOOT PAIN- MORTON’S NEUROMA TYPE OFINFORMATION GUIDELINES


Importanttodifferentiatebenignlesionsfromaggressivebenignormalignantlesions.(Cliniciansshouldcheckforredflagsthatcouldindicatesinisterpathologysuchasacanceroustumourandrefertotheappropriatespecialistservices).Morton’sneuromaisanerveentrapmentconditioninwhichthereisabenignneuromaofthecommonplantardigitalnerve(s)whichcancauseseverepain/paraesthesia.Theconditioncanoccurinonefootorbothfeet.Itusuallyaffectsthenervebetweenthethirdandfourthtoes,butsometimesthesecondandthirdtoesareaffected.Morton’sneuromacanoccuratanyage,butmostoftenaffects• Middle-aged(40-60yearolds)• 4-15timesmorecommoninwomen• Maybebecausewomentendtoweartightorhigh-heeledshoesthatcanputpressureon the feet• Typicallyassociatedwithaflexiblefoottype(inwomen)• Increasinglyseeninrunners,possiblybecauseoftheincreasedpressureonthetoesthat occurswhenrunning.

Subjective history

Mortons neuroma:• Typical symptoms ofMorton’sneuromainclude: oPainintheforefoot,mostcommonlyfeltinthethirdinter-metatarsophalangealspace,less commonlyinthesecond,andrarelyinthefirstorfourth. oPainwhilstwalking,exacerbatedbyincreasedactivityorparticularfootwear,andrelieved byremovaloffootwearandmassagingthetoes. oAsharp,stabbing,burning,ortinglingsensation(sometimesdescribedasfeelinglikean electricshock)inthedistributionoftheaffectednerve.• SomepeoplewithMorton’sneuromamaybeasymptomatic,withtheneuromabeing detectedasanincidentalfindingonexaminationofthefootforanotherreason• Mortonsneuromacanoftenbemisdiagnosed-considerdifferentialforexampleMetatarsalgia


• Painiselicitedonapplyingpressuretotheinvolvedinter-metatarsophalangealspace.• Mulder’sclick:• Griptheneuromabetweenyourforefingerandthumb(withyourthumbontheplantaraspect ofthefoot).• Withyourotherhand,simultaneouslysqueezethemetatarsalheads(1–5)togetherinthe transverseplane.• Aclickcanbefeltandheardastheenlargednervesubluxesbetweenthemetatarsalheads astheyarecompressed.• Absenceofthissigndoesnotruleoutneuroma.• LossofsensationtotheaffectedtoesisastrongindicatorofMorton’sneuroma,buta sensorydeficitmaynotbeapparentonexamination.

Reference: NICE CKS Mortons Neuroma

Investigations • Ultrasoundguidedinjection(thereislittlepointdoinganultrasoundonitsownifaninjection willberequiredatthesametime)• AtAHV-MrChilamkurthicanorderanUS-guidedinjectionifthepatientisbookedinasa “discussionpatient”athisAHWBtriageclinic• TheAPPshoulduseadiscussionslotinMrChilamkurthi’scommunityAHWBcentreifthey deemanUS-guidedinjectioncouldbeofbenefit• Referraltopodiatricsurgeonshouldbeconsideredasareferralrouteforthiscondition• IfthereisnoMorton’sneuromashownonUltrasound,theradiologistwillnotinject

https://cks.nice.org.uk/plantar-fasciitis#!topicsummary


DIAGNOSIS: FOREFOOT PAIN- MORTON’S NEUROMA TYPE OFINFORMATION GUIDELINES


• Ifbenign/painless-observeandreassure• Considerpodiatry/podiatricsurgeryreferral• Adviseonfootwearandpadding/orthotics/insoles• Weight loss if appropriate• Ultrasound-guidedinjection(seeabovesectionon“investigations”forMorton’sNeuroma.

ThiscanbeorderedviaMrChilamkurthi’scommunitytriageclinic(useadiscussionslot).


Ifnoimprovementwithconservativemanagementconsiderreferraltospecialistfoot&anklespecialistorpodiatricsurgeon,ifpatientwishestoconsidersurgery.Thepatientshouldbemadeawareofpotentialriskswithsurgery,includingthepotentialforpermanentlossofsensationinthetoes,15%riskofrecurrentorstumpneuromaformationandtheriskofdevelopingCRPS

DIAGNOSIS: (HALLUX VALGUS/RIGIDUS) TYPE OFINFORMATION GUIDELINES


ConsidertheProceduresofLimitedClinicalValueandProceduresNotFundedPolicy–soft tissue correction of hallux valgus to treat Hallux Valgus is a restricted procedure.Prior approval form will need to be completed prior to referral to secondary care or to a podiatric surgery consultant.

Subjective history

• Pthasnoticedhalluxvalgusdeformity• Age:typically45yearsoldandabove• RiskfactorsforOAsuchashypertension,diabetesmellitus,highBMI.


• Halluxvalgus• Restrictionstomovement1stMTP.

Investigations • WeightbearingX-rayAP&Lateral• An MRI is not indicated to diagnose great toe osteoarthritis


• Adviseonfootwearandpadding• Podiatry• Ifmild-ModerateOAtobigtoe–mayconsiderinjectiontojointsassuperficialjoint• InjectioncouldbeadministeredviatheAPP,MSKpodiatry• X-rayorUSguidedinjectionscouldbeofferedinsecondarycareorbypodiatricconsultant


Ifnoimprovementafter6-12weeksofconservativemanagement(dependingonseverityofsymptoms)andthepatientwishestoconsidersurgeryconsidermedicaloptimisationandthenrefertoSpecialistFoot&AnkleConsultantorPodiatricSurgeon.

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DIAGNOSIS: FOREFOOT PAIN- METATARSALGIA TYPE OFINFORMATION GUIDELINES


Metatarsalgia(alsoknownasMetatarsophalagealjointsynovitis)isageneraltermusedtodenoteapainfulfootconditioninthemetatarsalregion.Itisacommoninflammatoryconditionoccurringmostfrequentlyinthesecond,thirdand/orfourthmetatarsophalangealjoints,orisolatedinthefirstmetatarsophalangealjoints.

Subjective history

• Metatarsalgiatypicallyaffectsthebottomofthesecondmetatarsophalangealjoint.However, anyoftheothermetatarsalscanbeaffected.• Symptomsofmetatarsalgiainclude:• Painandtendernessoftheplantarsurfaceoftheheadsofthemetatarsalbonesorofthe metatarsophalangealjoint• Increasedpainduringthemid-stanceandpropulsionphasesofwalkingasbodyweightis shifted forward onto the forefoot• Thepainistypicallydescribedasadeepbruise.Sometimes,itwillfeellikethereisarock undertheballofthefoot.Thesesymptomsareusuallyworsenedwhenwalkingorstanding barefootonahardsurfaceorpoorlycushionedshoe,andbetterwheninwell-cushioned shoes.Attheendofaday,withsubstantialstandingand/orwalking,theareacanthrob.• Thesensationofhavinga‘pebble’or‘lump’underthemetatarsalregionwhenwalking.• Thepatientmaygetsymptomsofmortonsneuroma,whichcanbepartoftheumbrellaterm ofmetatarsalgia(seesectiononmortonsneuromawithinthispathway)


• Painandtendernessoftheplantarsurfaceoftheheadsofthemetatarsalbonesorofthe metatarsophalangealjoint• Developmentofcallusundertheprominentmetatarsalheads• Patientswithneuromawillhavepainwithsqueezetestintheregionofthe3rdand4th metatarsal heads• Bemindfulthatinthediabeticpopulationyoumaynotseecallusformationandthepatient maynotreportpainbutyoumayseeulcerationoftheMTPjoint• Patientmaydemonstratesubtleinflammationatbaseofseconddigit-mustcomparethisto the other foot• Assessmentofpatientinstanding-mayobservethatthelessertoesmaybefloatingand unabletopurchase• MaycoexistwithflexiondeformitiesatPIPjoint(Hammertoes)

Investigations • X-rayWeightbearingandAPlateral


• Adviseonfootwearandpadding• MSKPodiatry/orthotics


• Ifnoimprovementwithconservativemanagementconsiderreferraltospecialistfoot&ankle specialistorpodiatricsurgeon,ifpatientwishestoconsidersurgery.

https://cks.nice.org.uk/knee-pain-assessment#!diagnosissub:1

https://cks.nice.org.uk/knee-pain-assessment#!diagnosissub:1

Documents

MSK SERVICES PATHWAY - FOOT & ANKLE PATHOLOGY · • Swelling of the foot and ankle (caused by synovial fluidthat leaks out of the joint capsule) • Subluxation/deformity of the