Toe Pain or Deformity- Adult Leeds

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1.  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.

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2.  Referral Forms

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Referral Forms:

Quick View - PDF

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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5.  Red Flag / Ulceration Check Pedal Pulses

Quick info:

GP information

  • Grade 3 or above ulceration (full thickness tissue loss)
    • NB: as toes have little subcutaneous tissue these can be quite shallow
  • Check pulses - Absent pulses would be an indication for urgent vascular review
  • Infection spreading to surrounding tissue
  • Suspected osteomyelitis – sausage toe/ulcer probes to bone
  • Blue, black, white toe – if a circulation cause, consider referral to vascular
  • Necrosis present – consider referral to vascular

Assess for:

  • Infection
  • Circulation status
  • Diabetes
  • Rheumatoid disease (there is a Rheumatoid Foot Clinic)

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6.  Big Toe Pain and Deformity

Quick info:

GP information

Hallux Rigidus/Limitus Significant Findings. History:

  • Pain and or stiffness in the 1st MTPJ
  • Gradual onset; or
  • Sudden onset if related to trauma of the 1st MTPJ
  • Increased pain with activity
  • Increased pain in heeled shoes or activities with hallux extended, eg kneeling
  • Degenerative joint changes
  • Footwear irritation
  • Lateral metatarsalgia

Physical Examination:

  • Pain on extension of the hallux
  • Reduced range of movement (Hallux Limitus) or no range (Hallux Rigidus)
  • Reduced range of motion (normal MTPJ 65-70°)
  • Pain on palpation of the joint margin
  • Reduced quality in range of motion (crepitus)
  • Hypermobile 1st ray

Observation:

  • Dorsal bump or prominence on 1st MTPJ
  • Spur on the base of the proximal phalanx of hallux
  • Hyperextension of the 1st IPJ
  • Plantar hyperkeratotic lesions plantar, digital and metatarsal area
  • Distinct shoe wear patterns
  • Elevation or plantarflexion of 1st metatarsal
  • Long 1st metatarsal
  • Inverted forefoot
  • Pronated foot type
  • • Mild localised swelling at the 1st MTPJ area

Hallux Valgus Significant Findings:

  • Medial Prominence – "Bunion"
  • Lateral deviation of great toe
  • Abnormal range of movement 1st MTP Joint, 1st Ray
  • Painful Medial Bursitis
  • Neuritic Bunion Pain
  • Widening of Forefoot
  • Family history (usually grandparents)
  • Painful bunion
  • Aggravated by shoes
  • Progressive deformity

Associated Findings of Hallux Valgus:

  • 2nd Digit Hammer toe
  • Plantar Callous
  • Central Metatarsalgia
  • Pronated Foot
  • Ankle Equinus
  • Ingrown Toenail
  • Mobile forefoot

Radiographic Findings of Hallux Valgus:

  • Medial Prominence of 1st Metatarsal Head
  • Joint Space Abnormality
  • Presence of Degenerative Joint Disease
  • Lateral Adaptation of Metatarsal Articular Surface
  • Elevated HA Angle
  • Lateral Displacement of Sesamoids
  • Axial Rotation of Hallux
  • HAI Angle

Big Toe Pain: Findings Suggestive of Alternative Diagnosis:

  • Non-mechanical factors:
    • Pain is not associated with activity (podiatrists can help with mechanical foot pain/pain that occurs with weight-bearing activity)
  • Neurological origin:
    • Joplin's neuroma (pain, tingling, numbness and paraesthesia to the medial and plantar aspects of the 1st MTP joint and hallux); hyperesthesia; transient neuritis, neuropathy, reflex sympathetic dystrophy, referred pain
  • Bony origin:
    • Sesamoiditis, avascular necrosis of the sesamoids, fracture: significant trauma, unable to weight-bear, coalition (rare)
  • Soft tissue origin:
    • Fat pad atrophy/displacement, bursitis, tendonitis, tenosynovitis, tumour, cyst ganglion, plantar plate tear
  • Clinical signs of infection:
    • Joint swelling, redness, heat, pain, tracking, fever, break in the skin
  • Foreign body
  • Rheumatology origin:
    • Joint stiffness in morning for over 1 hour, arthritis of 3 or more joint areas, hand involvement, symmetric arthritis, rheumatoid nodules, positive rheumatoid factor, radiographic changes, X-ray findings; gout
  • Orthopaedic Red Flags:
    • Night pain, systemically unwell, previous history of cancer, unexplained weight loss

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7.  Other Toe Pain and Deformity

Quick info:

GP information

The two main categories are those with and without ulceration.

Those with ulceration must be considered as Red Flags and referred onto the ‘Red Flag’ pathway   which pathway the patient continues onto from here will depend on if they have diabetes or not. Those without ulceration will go onto the ‘Non-Red Flag’ pathway.

The small joints of the foot can be the initial site of rheumatological symptoms. If inflammatory arthritis is suspected, blood test may be indicated (ESR, CRP, Urate, Rheumatoid factor).

Being the extremities, problems with toes may be a sign of peripheral neuropathy, which may be related to undiagnosed diabetes. If suspected, fasting sugar levels should be tested (HbA1c).

Neurological conditions may be suspected if associated with a cavus-type foot, and nerve conduction studies may be of use. Lesser toe digital deformities are associated with joint contractures; there are three main types   see attached image:

  • hammer toe
  • claw toe
  • mallet toe

These may be asymptomatic and just require advice on footwear.

If the toes are painful in themselves, or become painful due to footwear limitations then treatment is indicated. Referral to a Chiropodist to remove associated callus and corns and provide padding can give relief. Insoles with ‘met domes’ can help with MTPJ pain associated with clawing toes.

If flexible, toes can be straightened with strapping or silicone rubber devices and intrinsic muscle exercises can help.

If rigid, silicone devices can help reduce pressure on prominent areas, but surgery to straighten them is usually indicated.

Reference:

Thomas JL, Blitch EL 4th, Chaney DM et al. Diagnosis and treatment of forefoot disorders. Section 1: digital deformities. J Foot Ankle Surg2009; 48(3):418.e1-9.

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10. 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:

  • Foot posture assessment
  • Gait assessment
  • Footwear appraisal
  • Neuro-vascular assessment

Where indicated:

  • Silicone splints
  • Taping
  • Strapping
  • Padding
  • Orthotics
  • Simple insoles
  • Callous debridement

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11. Hallux Rigidus

Quick info:

Patient information

Please see attached patient information leaflet on hallux rigidus.

GP information

Hallux Rigidus/Limitus Management

What advice can be given before referring on to Tier 1 Podiatry?

  • Provide attached patient information leaflet on osteoarthritis of the big toe joint
  • Footwear design ideally should be:
    • wide and deep at the forefoot
    • low heeled
    • thick soled
    • stiff soled (can help)
    • cushioned/shock-absorbing sole
  • Footwear that aggravates that problem should be avoided
  • Rocker-soled walking boots (at the forefoot)
  • Modify activities, eg avoid kneeling, standing in high heels, praying positions that aggravate the pain
  • Pain relief   NSAIDs
  • Review in 6 weeks

X-Ray may be appropriate when there is concern of:

  • Fracture
  • Osteomyelitis
  • Advanced arthropathy

When is it appropriate to refer to Tier 1 Podiatry?

  • Appropriate footwear is being worn
  • Footwear can appropriately accommodate an orthotic
  • Pain is persisting despite following advice
  • Pain is affecting patients' quality of life
  • Pain is affecting patient's daily activities
  • Pain is associated with weight-bearing activities

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12. Hallux Valgus

Quick info:

Patient information

Please see attached patient information leaflet on hallux valgus.

GP information

Treatment for bunions is guided by pain not cosmetic appearance.

It is appropriate to refer to Tier 1 Podiatry for hallux valgus if:

  • Appropriate footwear is being worn; and
  • Pain is occurring in the bunion joint
  • There is significant concern of foot posture
  • Specialist footwear advice is required
  • Patient is not a candidate for surgery, but a second opinion is required

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16. 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:

  • Orthotics
  • Exercises
  • Silicone Splints
  • Padding
  • Specialist Footwear Advice
  • Advice on managing their individual presentation
  • Appraisal of surgical need
  • Onward referral to the MSK-MDT if required

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21. 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:

  • Exercises
  • Orthotics
  • Silicone splints
  • Strapping
  • Padding
  • Manual therapy
  • Specialist footwear advice
  • Advice on managing their individual presentation
  • Onward referral to the MSK-MDT if required

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22. Refer to Specialist Foot Management Team Referral Form (MSK8)

Quick info:
Referral Forms:
MSK 8 Specialist Foot Management V3

Choose and Book
You can find this clinic on Choose and Book under:

Speciality: Podiatry

Clinic Type: At risk foot

Provider information
The Specialist Foot Management Team provides assessment and management of 'Red flag' toe conditions, ie ulceration (please see'Red Flag/ Ulceration' node).

Key Dates

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

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