Leeds Health Pathways

Foot / Ankle pain - Adult Leeds

1. Background Information / Scope of Pathway

Quick info:

These pathways were developed to guide clinicians when managing adults with common musculoskeletal problems. The pathways are not provider specific and so the guidance and forms apply to all providers.

2. Information Resources for Patients and Carers

Quick info:

Patient information

Please see attached patient information leaflet on sprained ankle. Please see attached patient information leaflet on plantar fasciitis.

Please see attached patient information leaflet on achilles tendinopathy.

Please see attached patient information leaflet on Morton's Neuroma.

Please see attached patient information leaflet on hallux rigidus.

Please see attached patient information leaflet on hallux valgus.
Please see attached patient information leaflet on ganglions.
MSK TAS Patient Information Leaflet

3. Development and Updates to this Pathway

Quick info:

Development

The pathway redesign was a clinicaly lead city wide process. It was conducted through the Musculoskeletal Steering Group which had representation from the 3 CCGs, Patients, NHS Leeds, Leeds Teaching Hospitals Trust and the Leeds Musculoskeletal Services.

The individual pathways were authored by the appropriate clinical staff involved in delivering the pathway, but chiefly comprised of GPs, Consultants and Therapists.

The pathways went live on the 2/7/2012

Updates

Referrals Forms Updated October 2012. Major Review and Update June 2013

This involved reformating of the pathway and referral forms.

4. Referral Forms

Quick info:

Referral Forms:

Mail Merged
The forms below are provided as a repository. They can be downloaded to your computer and be imported to your clinical system. This is so all practices have access to the most up to date forms.

EMIS - merged
MSK7 Foot Ankle V3
MSK 8 Specialist Foot Management V3
MSK14 Problem Not on Pathway Form V3

SystmOne - merged
MSK7 Foot Ankle V3
MSK 8 Specialist Foot Management V3
MSK14 Problem Not on Pathway Form V3

6. Red Flags

Quick info:

GP information

Remember the red flags and manage accordingly:

fever
malaise
night sweats/night pain
weight loss
IV drug use
excess alcohol
steroid use
cancer history
immunocompromised

Note also:

Management of swellings is discussed in the 'Ganglion suspected' pathway, and if any doubt exists an ultrasound scan should be obtained.

See also 'Toe pain or Deformity' pathway and management of potential vascular problems - Pedal pulse check is mandatory.

8. Midfoot or Ankle Pain

Quick info:

Patient Information

Tibialis posterior Patient Information Leaflet

(Specific for this condition not for all presentations use if confident of diagnosis)

GP information

Dorsal bony enlargement/deformity (osteophytes)
Affected joints may appear swollen
Pain on passive inversion or eversion of the midfoot
Demonstrating a capsular pattern and loss of range of motion into inversion
Pain on medio-lateral squeeze of mid-foot
Bony changes on weight bearing X-ray highlight reduced joint spaces, sclerosis, cysts, and presence of osteophytes; however, clinical findings should suffice

Differential diagnoses:

Stress Fracture
Trauma
Coalitions
Tendonitis
Tendon Dysfunction
Tendon Rupture
Ligament Strains
Nerve Entrapment/Compression
Tarsal Tunnel Syndrome
Deep Peroneal Nerve
Superficial Peroneal Nerve
Medial Plantar Nerve
First Branch of Lateral Plantar Nerve
Plantar Fasciitis/Fibromatosis
Rheumatoid Arthritis/ Other systemic inflammatory disorders
Ankylosing Spondylitis
Reactive Arthritis
Gout
Osteoarthritis
Osteoporosis
Synovitis
Ischaemic Pain
Neuropathic Pain
Bursitis
Accessory Bones
Lipoma
Fibroma
Osteochondroma
Osteosarcoma
Bone Cysts
Periostitis
Foreign Bodies
Psychological
Obesity
Iatrogenic

9. Forefoot Pain

Quick info:

GP information

The forefoot consists of anything distal to and including the metatarsals see attached image

Metatarsals are prone to fracture. This usually occurs as a result of trauma; however, underlying bone pathology can be of a non- traumatic origin, eg pathological. If the foot is painful and swollen over the metatarsal region, a fracture must be ruled out.

Pain under the ball of the foot, which is relieved with removing shoes, may be due to an intermetatarsal neuroma, often referred to as "Morton's Neuroma". These can present in other ways such as pins and needles or a painful numbness in the ball of the foot. There may be numbness in adjacent toes or a feeling like walking on a stone. The commonest interspace is the 3rd & 4th, but a neuroma can exist in any interspace.

Other forefoot pains can be the result of:

inflammatory arthropathy
diabetic neuropathy
intermetatarsal bursitis (similar symptoms to Morton's Neuroma)
joint osteoarthritis (OA)
MTPJ dislocation (or pre-dislocation syndrome)
fat pad atrophy
tendinitis
osteochondromas (Freiberg's infraction)
ganglions
tumours
poor-fitting, worn, or poor-quality footwear

11. Sprained Ankle

Quick info:

Patient information

Please see attached patient information leaflet on sprained ankle.

GP information

Ankle sprains:

occur frequently
often present to emergency departments but also to GPs
ankle inversion injuries are most common (70-85%), damaging the lateral-ligament complex
eversion injuries damage the medial-ligament complex

The anterior talofibular ligament (ATFL) of the lateral-ligament complex is most susceptible to injury. Clinical examination will often reveal tenderness and swelling over the anterolateral aspect of the ankle corresponding to the ATFL location.

Emergency departments use the Ottawa rules to determine which ankle injuries require X-rays, and familiarisation with these is advisable, though it should be noted that ankle injuries presenting to primary care are unlikely to warrant X-ray. Ability to weight-bear suggests a sprain rather than fracture.

Ottawa rules recommend X-rays when:

point tenderness is present at the:
- posterior edge/tip of the lateral/medial malleolus
- base of fifth metatarsal
- tarsal navicular
- proximal fibular; or
the patient cannot weight-bear

Ankle sprains are classified Grades 1, 2 and 3. Grade 1 injuries are least severe, with no joint instability whilst Grade 3 injuries have significant joint instability.

Management of ankle sprains in primary care involves the following principles (further detail is provided in the accompanying patient.co.uk patient information leaflet, which should be provided to patients):

ADVISE:
- Protection (eg semi-rigid support), Rest, Ice, Compression, Elevation (PRICE)
- Gentle mobilisation is encouraged
AVOID:
- Heat, Exercise, Alcohol, Massage (HARM) in the 72-hours post-injury
ANALGESIA:
- As required.

Most sprains settle within 3-4 weeks. Tier 1 physiotherapy referral is indicated for persistent/recurrent sprains with access to MSK- MDT if required.

12. Ganglion Suspected

Quick info:

GP information

A typical ganglion may arise from the top of the foot or around the ankle. These cystic swellings arise from a tendon sheath or joint capsule. They should move freely under the skin, and trans-illuminate when a pen-torch is pressed against it.

If there is any clinical doubt, such as irregularity of the lesion, or a solid, immobile feel, it is appropriate to refer for an ultrasound scan to clarify the diagnosis.

13. Diagnosis Uncertain

Quick info:

GP information

A patient may have foot or ankle pain requiring referral yet does not fit into the above categories and/or diagnosis is uncertain. A variety of referral options exist, so factors to consider include (but not limited to):

are there features of inflammation, multi-joint involvement or raised inflammatory markers? If so, consider rheumatology referral
for undifferentiated problems, with none of the above features, consider MSK-MDT referral

14. Problem Not on Pathway

Quick info:

There are 2 broad groups of patients who fall into this category:

Those who have a clear problem but there is no Leeds pathway and so you are ensure of where to refer the patient.

Those with a clear problem and course of action but you are unable to make the referral because of referral restrictions caused by some pathways still not allowing GPs to directly refer to the appropriate surgeon. Pathways where these restrictions still occur are the Shoulder / Elbow, Spine, Knee and Foot / Ankle.

16. Self-management

Quick info:

GP information

A period of self management for 3-4 weeks is appropriate following the principles outlined in the "Sprained Ankle" node. Please provide and discuss with patients the information leaflet attached in previous node.

17. Refer Tier 1 Podiatry Referral Form (MSK7)

Quick info: Referral Forms: MSK7 Foot Ankle V3

Choose and Book

You can find this clinic on Choose and Book under:

Speciality: Podiatry

Clinic type: Biomechanical

Provider information

The only provider of Tier 1 Podiatry in the city is the Leeds Community Health Service. This service is directly bookable via Choose and Book. Please complete the appropriate form and send via Choose and Book.

If symptoms persist, referral to Tier 1 Podiatry is appropriate, who will refer onward to MSK-MDT if symptoms persist or there is diagnostic doubt.

Tier 1 Podiatry can provide the following services:

Non-weight and weight-bearing clinical tests
Foot posture assessment
Gait assessment

Where indicated:

Orthotics
Exercises
Silicone splints
Taping
Padding
Footwear appraisal
Advice on managing their individual presentation
Onward referral to MSK-MDT if required

18. Refer to MSK-TAS (Telephone Assessment Service) Form (MSK14)

Quick info:

MSK TAS Patient Information Leaflet

Referral Forms:

MSK14 Problem Not on Pathway Form V3

Choose & Book

You can find this clinic on Choose & Book under:

Speciality: Orthopaedics

Clinic Type: Foot & Ankle

The MSK Telephone Assessment Service (MSK-TAS) is offered as a way of ensuring patients get into the right clinic when it is not clear from the pathways what the right course of action is.

This is distinct from the Diagnosis Unclear Pathway which is there to offer quick access to diagnostic assessment when patients present with symptoms that don't immediately fall into a diagnostic group.

Patients who are appropriate for the MSK-TAS fall into two categories:

Those who have a clear problem but there is no Leeds pathway and so you are ensure of where to refer the patient.

When you book the patient into the MSK-TAS via Choose & Book you are booking them a telephone appointment.

Once the referral form has been completed and sent via Choose & Book a senior Physiotherapist will review the referral form within 48 hours. They will then decide the appropriate course of action and the patient will be contacted by phone at the allotted time in order to make the necessary arrangements for onward referral.

19. Refer Tier 1 Physiotherapy Referral Form (MSK7)

Quick info:

Referral Forms:

MSK7 Foot Ankle V3

Choose and Book

You can find this clinic on Choose and Book under:

Speciality: Physiotherapy

Clinic Type: Musculoskeletal

Provider information

The only provider of Tier 1 physiotherapy in the city is the Leeds Musculoskeletal Service. This service is directly bookable via Choose and Book. Please complete the appropriate form and send via Choose and Book.

If symptoms persist, referral to Tier 1 physiotherapy is appropriate, who will refer onward to MSK-MDT if symptoms persist or there is diagnostic doubt.

20. Refer Tier 1 Podiatry Referral Form (MSK7)

Quick info:

Referral Forms: MSK7 Foot Ankle V3

Choose and Book

You can find this clinic on Choose and Book under:

Speciality:Podiatry

Clinic type:Biomechanical

Provider information

If symptoms persist, referral to Tier 1 Podiatry is appropriate, who will refer onward to MSK-MDT if symptoms persist or there is diagnostic doubt.

Tier 1 can provide the following services:

Non-weight and weight-bearing clinical tests
Foot posture assessment
Gait assessment

Where indicated:

Orthotics
Exercises
Manual Therapy
Taping
Padding
Footwear appraisal
Advice on managing their individual presentation
Onward referral to MSK-MDT if required

Key Dates

Published: 09-0ct-2015, by Leeds
Valid until: 17-Jun-2016