Updated Foot & Ankle Pathway November 2021
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
Ankle / Hindfoot Pain
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
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.
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
- Ultrasound scan for Morton’s neuroma
- 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.