Reviewed on : 1 Dec 2022

Reviewed by : Vivek Dhukaram & Gateway Editor & Cheryl Johnson Project Leader UHCW

Expires : 1 Dec 2024

Updated Foot & Ankle Pathway November 2021

Important advice

Do not inject joints/soft tissues more than; once for plantar fasciitis and twice for all others

If injecting in a primary care setting, only inject under image (Xray/USG) guidance

If patient has skin condition or fungal nail infection- please consider referral to dermatology prior to referring to Podiatry

Please refer to secondary care for treatment of corns and callus ONLY secondary to severe deformity requiring surgery

Please refer all in-growing toe nails to Podiatry, only refer to secondary care if requiring general anaesthetic for surgery.

Please include referral summary including all investigation results when referring to secondary care.

If you request for X-rays, please request for weight bearing X-rays for all non-traumatic foot & ankle problems

 

Forefoot Pain

 

Midfoot Pain

Ankle / Hindfoot Pain

References

Functional rehabilitation interventions for chronic ankle instability: a systematic review. Webster KA, Gribble PA. J Sport Rehabil. 2010 Feb;19(1):98-114.

Guillo, S., Bauer, T., Lee. J.W., Takao, M., Kong, S.W., Stone, J.W., Mangone, P.G., Molloy, A.,

Perera, A. and Pearce, C.J. Michels, F., Tourné, Y., Ghorbani, A., and Calder, J. (2013) Consensus in chronic ankle instability: Aetiology, assessment, surgical indications and place for arthroscopy, Orthop Traumatol Surg Res, 99 (8): S411-S419

http://www.blackburnfeet.oruk/hyperbook

http://www.dorset-ots.nhs.uk/Foot&Ankle_Pathway2010.pdf

http://www.northyorkshireandyork.nhs.uk/AdviceInformation/MakingDecisions/docs/Clinical%20Pathways%20and%20Referra l%20Guide%20may%202010.pdf

Martin, R.L., Davenport, T.E., Reischl, S.F., McPoil, T.G., Matheson, J.W., Wukich, D.K., McDonough, C.M., Altman, R.D., Beattie, P., Cornwall, M. and Davis, I., 2014. Heel pain—plantar fasciitis: revision 2014. Journal of Orthopaedic & Sports Physical Therapy, 44(11), pp.A1-A33.

Martin, R.L., Chimenti, R., Cuddeford, T., Houck, J., Matheson, J.W., McDonough, C.M., Paulseth, S., Wukich, D.K. and Carcia, C.R., 2018. Achilles pain, stiffness, and muscle power deficits: Midportion achilles tendinopathy revision 2018: Clinical practice guidelines linked to the international classification of functioning, disability and health from the orthopaedic section of the american physical therapy association. Journal of Orthopaedic & Sports Physical Therapy, 48(5), pp.A1-A38

• NICE GUIDELINES http://cks.nice.org.uk/plantar-fasciitis#.V4dEsUJX2iA.email

Robinson, A.H.N. and Limbers, J.P., 2005. Modern concepts in the treatment of hallux valgus. The Journal of bone and joint surgery. British volume, 87(8), pp.1038-1045.

Surgery vs Orthosis vs Watchful Waiting for Hallux Valgus: A Randomized Controlled Trial. Markus Torkki, Antti

Malmivaara, Seppo Seitsalo, Veijo Hoikka, Pekka Laippala, Pekka Paavolainen.  JAMA. 2001;285(19):2474-2480.

ABBREVIATIONS.

BMI- Body mass index

MTPJ- Metatarsophalangeal Joint

OCD- Osteochondral defect

OTC- Over the counter

PT – Physiotherapy

CMS – Coventry Musculoskeletal Service

CWPT – Coventry and Warwickshire Partnership Trust

NSAIDs – Non Steroidal Anti Inflammatory’s

Morton’s neuroma

• Ultrasound scan for Morton’s neuroma

Plantar Fasciitis

• Although a plain X-ray may show a calcaneal spur this is unlikely to affect the management – therefore unhelpful and request is likely to be refused. Ultrasound and MR can demonstrate plantar fasciitis, but again, are unlikely to help manage the problem.

Osteoarthritis First MTP Joint & Hallux Valgus

GP Gateway has a separate page about commissioning policy for Bunion, click the A-Z tab and go to B for Bunion.

• Uric acid blood test
• Standing X-ray AP and Lateral – hallux rigidus, hallux valgus
• Pre-rheumatology referral -blood tests and standing x-ray of the affected joint.

Tenosynovitis of Foot & Miscellaneous Foot Pain

• Uric acid blood test.
• Consider stress fracture and X-ray if suspicious. Bear in mind that stress fractures can be negative on the initial X-ray, so MR is the investigation of choice if the plain film is normal and pain persists.
• For tenosynovitis or Achilles tendon injury, ultra-sound may be helpful.

Referral to CMS (MSK)

Please see the page on physiotherapy service

Referral to Podiatry

Please see the page on Podiatry

Referral to Secondary Care

Refer to secondary care if any of the following are present:

• Patients currently under the care of a consultant for the same condition
• Patient is amenable to surgical intervention where applicable
• Stress Fracture
• Malignant bone tumour
• Avascular necrosis
• Septic arthritis
• Acute tendon rupture
• Acute infection
• Bunion (requirements under Low Priority Procedure policy: failure of conservative management; severe deformity or severe pain causing severe functional impairment)

Please see right for information on specific foot and ankle conditions.