Foot & Ankle Care Pathway

Review in progress

Disclaimer: The guidance contains helpful primary care information for management of referrals and up to date referral criteria. These guidelines are locality specific to best reflect local services. This guidance does not override or replace the individual responsibility of healthcare and social care professionals involved in the delivery of care to make informed professional judgements appropriate to the circumstances of the individual.

Scope

This guidance refers to:

  • The management of all patients presenting with Foot & Ankle Pain

This guidance does not cover:

  • Under 18s (Wakefield) Under 16s (North Kirklees)

Commissioning Statement:

  • Referrals for Hallux Valgus are subject to an eligibility criteria that must be met before a referral is made - please see Commissioning Statement for further information
  • Referrals for Functional Electrical Stimulation for foot drop are subject to an eligibility criteria that must be met before a referral is made - please see Commissioning Statement for further information
  • For those patients who are not eligible for treatment under these policies consideration will be on an individual basis via the CCGs Prior Approval Process in accordance with NHS North Kirklees and NHS Wakefield CCG Commissioning Policy

Assessment

Signs and Symptoms

Insertional Achilles Tendinopathy

  • Often preceded by a period of unaccustomed loading or activity (may include a sudden increase in a person's usual activity e.g. an extra gym session or a further run than usual
  • Reports pain in the Achilles tendon where it attaches to the calcaneus.
  • Examination will reveal pain and possible swelling in the Achilles tendon where it attaches to the calcaneus.

Mid-portion Achilles Tendinopathy

  • Often preceded by a period of unaccustomed loading or activity (may include a sudden increase in a person's usual activity e.g. an extra gym session or a further run than usual
  • Reports pain in the Achilles tendon away from where it attached to the calcaneus.
  • Examination will reveal pain and possible swelling in the Achilles tendon away from where it attached to the calcane

Plantar Fasciopathy

  • Reports pain in the heel on the plantar aspect of the foot, often worst on the first few steps of the day and after a period of immobility
  • Examination will reveal pain upon palpation at the insertion of the plantar fascia at the medial tubercle of the calcaneus
  • There is often pain upon passive great toe extension and tightness in the calf


Ankle OA

  • Pain reported around the whole ankle but predominantly anteriorly
  • Often have a history of previous ankle trauma/fracture.
  • Complain of pain on weight-bearing and a shortening of tolerable walking distance.
  • Stiffness in the ankle upon waking and after periods of immobility

ATFL Sprain

  • Reports 'going over' on the ankle; mechanism of injury typically combined plantarflexion & inversion.
  • Complain of pain, swelling and bruising over the anterolateral ankle.
  • May report a history of similar episodes.
  • Please utilise Ottawa Ankle Rules to guide x-ray decision

Acquired Flat Foot Deformity

  • Predominantly insidious onset posteromedial ankle and arch pain on weight-bearing.
  • May always have had a reduced arch (30% population do without any issues) or may have lost medial arch overtime. May be associated with Plantar Fasciopathy or 1st MTPJ pain 1st MTP Joint OA
  • Pain localised the great toe, often reported on walking and worse uphill due to the induced extension.
  • May report a history of trauma to the toe or a first degree family member e.g. Mother with similar complaint.
  • More common in females.

History

  • Joint pain exacerbated by increasing activity (OA)
  • Stiffness in the morning (OA or Inflammatory)
  • Swelling (non-specific indicator of pathology)
  • Locking and giving way of ankle (Chronic ankle instability)
  • Referred pain or paresthesia from spine
  • Lacks trauma, persistent, deformity, younger – consider tumour
  • Consider diabetic needs
  • Greater toe- bunion +/- stiffness (OA or hallux valgus)

Examination

  • Site of pain
  • Presence of an effusion
  • Range of movement of affected area ankle or foot, toes
  • Ligament laxity on stress ankle
  • Consider referred pain- spinal?
For additional information on signs and symptoms please click here - Signs and Symptoms

Red flags

Seek immediate or urgent specialist advice/treatment if:

  • Suspicion of Inflammatory joint disease (Rheumatology)
  • Suspected Septic arthritis (urgent admission via A&E)
  • Suspected DVT
  • Suspected tendon rupture Achilles (A&E)
  • Suspected Acute Charcot foot (same day referral- Orthopaedics or Diabetic foot MDT)
  • Sudden joint deformity (Orthopaedics)
  • Diabetic foot care needs (MDT rapid access, as per NICE guidelines)

Immediate referral to an Emergency Department for an X-ray of the ankle following an acute ankle injury is recommended if the person has pain in the malleolar zone AND one of the following (as per NICE guidance):

  • Inability to bear weight (walk four steps) immediately after the injury and when examined.
  • Bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus.
  • Bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus.

Immediate referral to an Emergency Department for an X-ray of the foot is recommended if there is pain in the midfoot zone AND one of the following:

  • Inability to bear weight (walk four steps) immediately after the injury and when examined.
  • Bone tenderness at the base of the fifth metatarsal.
  • Bone tenderness of the navicular bone.

Investigations

Undertake the following to aid diagnosis, inform management or prior to referral:

  • Osteoarthritis is a clinical diagnosis , weight-bearing foot OR ankle x-rays should therefore only be requested if considering referral for surgery or diagnostic uncertainty

Management

Clinical Management

  • Analgesia
  • Footwear advice is key important particularly for bunion care and OA
  • OA -Intra-articular steroids for short term relief, only if not considering surgery in the near future

REFER TO CONNECT COMMUNITY MSK Service if:

  • Persistent pain, instability of ankle after simple sprain (Physiotherapy)
  • Persistent heel pain (Physiotherapy or Podiatry)
  • Pain and limited function from Achilles tendon (Physiotherapy)
  • Persistent painful bunion (Podiatry)
  • OA where pain or disability not acceptable for patient with primary care management.
  • Unexplained pain in the young
  • Unclear on diagnosis, not responding to treatment or moderate-severe pain in absence of red flags.

Referral

Referral Criteria

  • Red Flags
  • Referral to secondary care via 2 week wait rule - Suspected Malignancy
  • North Kirklees (MSK, Trauma and Orthopaedics and Physiotherapy)
    • All MSK referrals (excluding red flags) should be made to Connect Community MSK who will undertake clinical assessment and triage and refer on as appropriate (including to physiotherapy). Choice of provider will be offered following triage
    • Please click here to open the Clinical Decision Making Aid for further guidance on which part of Connect's pathway to refer into i.e. Physioline, Physio or CATs
  • Wakefield – MSK
    • Those not presenting with red flag symptoms or where diagnosis or treatment is unclear should be referred to Connect Community MSK who will undertake clinical assessment and treatment and/or refer on to physiotherapy or secondary care as appropriate. Choice of provider will be offered for onward referrals.
  • Wakefield - Physiotherapy
  • Wakefield – Trauma and Orthopaedics
    • Patients should be offered choice of provider for trauma and orthopaedics

Referral Requirements

  • For Hallux Valgus and Functional Electrical Stimulation (for foot drop) referrals documented evidence is required to demonstrate that the patient meets commissioning statement criteria
  • For those patients who do not meet the eligibility criteria evidence of prior approval authorisation is required

Commissioning Statement:

  • Referrals for Hallux Valgus are subject to an eligibility criteria that must be met before a referral is made - please see Commissioning Statement for further information
  • Referrals for Functional Electrical Stimulation for foot drop are subject to an eligibility criteria that must be met before a referral is made - please see Commissioning Statement for further information
  • For those patients who are not eligible for treatment under these policies consideration will be on an individual basis via the CCGs Prior Approval Process in accordance with NHS North Kirklees and NHS Wakefield CCG Commissioning Policy

Referral Instructions

  • e-Consultation is not currently unavailable for this specialty
  • Referrals should be made via ICG to TRISH (if training has been undertaken) - See user guides (EMIS & S1) for further information.
  • For those Practices who have not received ICG training referrals should be made via eRS
  • Please identify speciality and clinic type

Supporting Information

Shared Decision Making

  • Patients have a right to make decisions about their care and should be fully informed about the options they face. They should be provided with reliable evidence-based information on the likely benefits and harms of interventions or actions, including any uncertainties and risks, eliciting their preferences and supporting implementation. Prior to referral for surgery the patient should understand their options and the benefits and risks and the likelihood of these occurring.

Patient information/Public Health/Self Care

Evidence/additional information

Assurance & Governance

  • This guidance was developed on: 03.2017
  • This guidance was ratified by: The OSCAR Assurance Group
  • Date ratified: 04.2017
  • Publication Date: 05.2017
  • Updated: 06:2018
  • Review Date: 05.2019
  • Ref No: MSK6 - 03.2017
Any feedback or suggestions to improve this guidance should be sent to: oscaradmin@this.nhs.uk
Only the electronic version is maintained, once printed this is no longer a controlled document

 

Home > Care Pathways > Musculoskeletal (MSK)* > Foot & Ankle Care Pathway