Heel or Achilles Pain - Adult Leeds

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1.  Information Resources for Patients and Carers

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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.

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2.  Referral Forms

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Referral Forms:

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MSK7 Foot Ankle V3

MSK 8 Specialist Foot Management V3

MSK14 Problem Not on Pathway Form V3

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

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4.  Heel Pain

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GP information

Heel Pain: Significant History/Findings

Diagnosis can largely be determined from history. Calcaneal insufficiency fracture:

  • Painful during and after activity
  • Pain occurs both with weight-bearing and at rest
  • Nocturnal pain
  • Increase/change in activity – repetitive loading
  • Previous history of stress fractures
  • Osteopenia /osteoporosis
  • Elderly
  • Female
  • Low BMI
  • Diabetes or other endocrine disorder associated with neuropathic fracture
  • Can be reluctance to bear weight on heel /off-load
  • Global or generalised heel pain

Plantar fasciitis:

  • Typically unable to identify an aetiological factor
  • Pain on first standing   eases as day goes on
  • Pain after long periods standing
  • Recent increase in activity
  • Profession   prolonged standing/walking
  • High BMI
  • Common in runners

Calcaneal insufficiency fracture:

  • Pain on calcaneal medial/lateral squeeze
  • May be warmth and swelling
  • Vibration will typically provoke pain – more intense at fracture site (Crescendo sign)
  • Pain on heel strike
  • Signs of broken skin/bruising
  • Reluctance to rock back on heel

Plantar fasciitis:

  • Pain on palpation of the plantar medial tubercle of the calcaneus
  • May be worse on ankle and hallux at end-range passive dorsiflexion (The windlass test)   the plantar fascia can be easily palpated which may elicit pain along its length to the calcaneal insertion
  • Soft tissue ankle equinus – no ankle dorsiflexion past 90º
  • Typically self-limiting

All patients should be asked about:

  • Inflammatory joint disease, including extra-articular features, inflammatory bowel disease, and psoriasis (sero-negative arthropathies can manifest as insertional – enthesopathies)
  • Diabetes and other endocrine disorders
  • neurological disease
  • circulatory problems
  • family history of foot problems, arthritis, or neurological disease
  • trauma to the foot

Differential diagnoses:

  • Neuropathic – tarsal tunnel, disc disease, nerve to quadratus plantae, medial plantar nerve
  • Arthritic – ie psoriatic arthritis, reactive arthritis
  • Tumour
  • Infection
  • Ischaemic pain
  • Referred pain
  • Fat pad pathology injury / bursitis
  • Tendinopathy – ie Achilles, tibialis posterior

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5.  Achilles Pain

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GP information

Achilles Tendinopathy: Significant History

Mid-Portion Tendinopathy:

  • Gradual onset, progressing problem
  • Swelling within the mid portion of the tendon
  • Pain and perceived stiffness on initial weight bearing and diminishes with walking
  • Pain following vigorous exercise
  • Tenderness and thickening 30-50mm from the insertion of the Achilles Tendon (mid portion)
  • More common in runners and other activities with repetitive load
  • Often related to change of footwear style, training or activity program

Insertional Tendinopathy:

  • Insertional tendinopathy for the syndrome arising from the distal 20mm of the tendon
  • Recurrent stress on the tendon where it attaches (the insertion) leads to inflammation, microscopic tearing of the tendon, swelling and pain
  • Related bone spurs arising from the postero-inferior insertion
  • Splits in the tendon, mostly longitudinal
  • Degeneration of the fibro-cartilage that lies on the deep surface of the tendon next to the retro-calcaneal bursa – leading to associated retro-calcaneal bursitis
  • Examine footwear as provocative factor
  • A few patients have evidence of a significant underlying arthropathy or enthesopathy which may require rheumatology investigations and/or consultation.

All patients should be asked about:

  • inflammatory joint disease, including extra-articular features, inflammatory bowel disease and psoriasis
  • sero-negative arthropathies can manifest as insertional – enthesopathies if suspected diagnostic ultrasound or plain film X-ray should confirm the presence erosions when a rheumatology referral should be considered
  • diabetes
  • neurological disease
  • circulatory problems
  • family history of foot problems, arthritis or neurological disease
  • trauma to the foot

Findings suggesting alternative diagnosis:

  • Sudden onset, severe pain
  • Constant and unremitting night pain
  • Trauma
  • Unable to weight bear
  • Systemic signs and symptoms (including infection)
  • Unexplained weight loss
  • Positive Thompson test (see rupture)
  • Limited joint range of motion
  • Tinel’s or Valleix Sign
  • Pain on calcaneal squeeze test

Differential diagnoses:

  • Spondyloarthropathies
  • Partial or total Achilles rupture
  • Retro-calcaneal bursitis
  • Tarsal Tunnel syndrome
  • Tarsal Coalition
  • Posterior impingement syndrome
  • Os Trigonum syndrome
  • Referred pain from neural origin or from the subtalar joint
  • Childhood heel pain, eg Severs disease

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6. Potential Calcaneal Insufficiency Fracture

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GP information

An X-ray should be obtained if the symptoms and signs are suggestive of calcaneal insufficiency fracture (see "Heel pain" node for more information).

If this is abnormal then a referral to Fracture Clinic is appropriate. If this is normal but the patient remains symptomatic, a referral to MSK-MDT is indicated for further assessment and management.

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7.  Plantar Fasciitis (PF)

Quick info:

Patient information

Please see attached patient information leaflet on plantar fasciitis.

GP information

If the patient presents with Plantar fasciitis (see "Heel pain" node for signs and symptoms), an assessment should be made on the severity of the condition.

Factors to consider include:

  • Duration of symptoms
  • Nature of pain   persistent or intermittent? Any benefit from analgesia?
  • Effect on work – does occupation involve prolonged standing?
  • Effect on hobbies, eg keen runner?
  • Has any home management been attempted already?

If the condition is deemed severe, referral to Tier 1 Podiatry is appropriate (please provide the patient with the attached patient information leaflet).

If the condition is not deemed severe, a 6 week trial of self-management is appropriate.

The patient should be provided with the patient information leaflet which discusses self-management, including:

  • Ice
  • Pain relief
  • Footwear modifications
  • Stretching exercises
  • Heel pads / arch supports etc

If a 6 week trial of self-management fails, then a referral to Tier 1 Podiatry is appropriate.

Referral on from Tier 1 Podiatry to MSK-MDT can be considered if necessary for all cases for further assessment and consideration of treatment options.

It may be reasonable to consider steroid injection in-house if expertise exists for recalcitrant cases.

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8.  Mid Portion Achilles Tendinopathy

Quick info:

Patient information

Please see attached patient information leaflet on achilles tendinopathy.

GP information

The signs and symptoms of Mid-portion Achilles Tendinopathy are discussed in the "Achilles pain" node. If diagnosed, a period of self-management is appropriate.

The patient should be provided with the attached patient information leaflet. Self-management includes:

  • Relative rest from exercise, especially high-impact activities eg running
  • Analgesia
  • Ice
  • Foot orthotics, eg heel inserts
  • Eccentric loading exercises   these are the initial mainstay of treatment for Mid-portion Achilles Tendinopathy, and are described on the patient information leaflet

Referral to Tier 1 physiotherapy should be considered after a 4-6 week trial of self-management.

For most people the symptoms of Mid-portion Achilles Tendinopathy clear within 3-6 months with conservative treatment, and failure to do so would lead to a referral from Tier 1 physiotherapy to the MSK-MDT for consideration of alternative interventions.

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9.  Suspected Rupture

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GP information

Acute tendon rupture will be reported as a sensation of a blow on the tendon and a loss of function. The classic test for Achilles tendon rupture is the Thompsons Squeeze Test.

Thompsons Squeeze Test (see image):

  • Patient lies or kneels prone with knee flexed at 90°
  • Examiner squeezes calf
  • Observe for plantar flexion of foot

Interpretation:

  • Normal response: plantar flexion as reflex response
  • Falsely normal if accessory muscles squeezed
  • Achilles tendon rupture: plantar flexion absent

Confirmatory Test (if Thompson Squeeze Test equivocal) (Note: This test can be uncomfortable for the patient):

  • Patients foot allowed to rest
  • Sphygmomanometer applied to affected calf
  • Inflate sphygmomanometer to 100mmHg
  • Dorsiflex foot and observe pressure gauge:
  • Normal response: pressure rises and stays at 140mmHg
  • Achilles tendon rupture: only flicker of movement

If rupture suspected and acute, refer to A&E.

NB: The key to successful outcome whether surgical or palliative via serial casting is a good rehabilitation regimen   a physiotherapy regimen should therefore always be considered after initial acute management.

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10. Insertional Achilles Tendinopathy

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GP information

The signs and symptoms of Insertional Achilles Tendinopathy are discussed in the "Achilles Pain" node. There are two important issues to highlight:

  • This condition does not respond as well as Mid-portion Achilles Tendinopathy to eccentric loading, so immediate referral to Tier 1 Podiatry is appropriate.
  • There is an association with this condition and underlying arthropathy / enthesopathy, which may require rheumatological investigation and/or referral.

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14. 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.

Tier 1 Podiatry can refer onwards to the MSK-MDT if symptoms persist or there is diagnostic doubt.

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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.

Tier 1 Podiatry can refer onwards to the MSK-MDT if symptoms persist or there is diagnostic doubt.

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21. 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.

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24. Refer MSK-MDT 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: Orthopaedics

Clinic Type: Foot and Ankle Pain

Provider information

The only provider of the MSK-MDT clinic in the city is the Leeds Musculoskeletal Service. This is a multiprofessional clinic including senior physiotherapists and musculoskeletal physicians.

This clinic provides diagnosis, investigation, treatment and onward referral if needed.

This service is directly bookable via Choose and Book. Please complete the appropriate form and send via Choose and Book.

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26. 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.

Tier 1 Podiatry can refer onwards to the MSK-MDT if symptoms persist or there is diagnostic doubt.

Key Dates

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

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