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History:
Age , occupation and hobbies
Symptoms - pain location, foot and ankle range of motion, weakness, numbness or altered
sensation, giving way, locking, swelling
Onset, mechanism of Injury
Intensity, duration, aggravating and easing factors, night pain, effect on ADLs/work
Past medical history, systemic symptoms (fever, abdominal, cardiovascular symptoms), previous
treatments/surgery, medication, consider fitness for surgery and co-morbidities
Features suggesting an Inflammatory cause:
Symptoms in other joints, sites - previous episodes (consider - Gout),
If other peripheral joints or spine affected (consider sero-negative arthritis)
Spontaneous ankle or foot joint effusion, no history of trauma - refer to rheumatology
Examination
Observation – Expose knee and foot - Posture, lower limb alignment, foot position, deformity,
swelling
Palpation - Local areas of pain, medial and lateral ligaments, ankle joint line, Achilles tendon
Range of Movement - Active and passive; dorsiflexion, plantarflexion, inversion and eversion
Functional tests i.e. heel raise, squat, instability tests
Neurovascular assessment, pulses, sensation
Investigations to consider:
Radiographs - foot and ankle (AP and Lateral weight bearing and mortice view of ankle) - Consider in
those with:
• Significant injury, sensory or motor loss, rheumatological disease
• Painful foot deformity
• Foot and/or ankle joint effusion
• When symptomatic measures have been insufficient for patient’s symptoms
Blood Investigations: CRP, FBC, U&Es, LFTs, Uric Acid, Rheumatoid Factor, Anti-CCP.
Click on individual condition for primary care management and referral advice
Hindfoot Pain
Midfoot Pain
Forefoot Pain
Diabetic Foot
Steroid/LA injection can provide symptomatic improvement if pain main issue - after clear diagnosis
and management plan
Investigations – Consider need for ankle x-ray using the Ottawa Ankle rules .
Treatment – PRICE as soon as possible following the injury; ROM exercises (e.g. alphabet exercises)
started within 24-48 hours, strengthening, supportive footwear.
Consider early referral to physiotherapy for rehabilitation, e.g. strength, mobility and proprioception
exercises.
Surgical management in acute ligament sprains is rarely indicated (Cochrane review).
If initial symptoms not settling within first 6 weeks, consider urgent referral to orthopaedics to exclude
pathology requiring further treatment 0 osteochondral defect, fractures, +/- ‘high ankle’ sprain
(syndesmosis injury).
Plantar Fasciitis –heel pain, typically worse with first few steps in the morning.
Windlass or Jack’s test – passive dorsiflexion of the 1st metatarsalphalangeal joint – quick and
highly specific test for the plantar fascia
X-ray – not indicated; calcaneal spurs generally not significant.
Conservative management is mainstay of treatment – advise weight loss; OTC heel raise; calf
and plantar fascia stretching exercises, 3 times/day for at least 3 minutes; golf ball massage;
appropriate analgesia prescription. Night splints.
Refer to core physio +/- podiatry if no improvement after 3/12.
Consider steroid injection for pain control in patients not responding to adequate and extended
conservative management. Be aware of potential adverse effects – fat atrophy/plantar fascia
rupture
Peroneal tendinopathy
Consider diagnosis in lateral ankle pain, posterior to lateral malleolus and distally to 5th MTT. Pain on
eversion. Possible swelling over lateral foot. Insidious or acute onset after activity.
Investigations – USS could be considered
Refer Podiatry/Physio - Orthotics /Footwear advice – neutral supportive footwear
Management - NSAIDs, analgesia. Decrease sporting activities in short term.
Refer to orthopaedics for operative management if tendon dislocating/subluxing
Achilles tendinopathy
Tenderness/swelling proximal to insertion of tendon to posterior calcaneus
Classically, combination of morning stiffness and pain. Pain eases with activity.
May be related to change of activity (e.g. increase in training volume and/or intensity), footwear
or orthotics
Management - Simple padding and foot wear advice. Avoid low heeled footwear. Avoid boots or
sports shoes which may impinge on the painful area during activity.
Analgesia & NSAIDs as appropriate Off the shelf heel raises/ in shoe orthoses (From
Boots/PhysioMed) may be helpful while awaiting physio/podiatry assessment.
Physiotherapy referral
Stretching and eccentric calf raise programme. See http://www.ouh.nhs.uk/patient-
guide/leaflets/files/11924Ptendinopathy.pdf for an excellent patient information leaflet and
exercise advice
Secondary care referral - Usually not indicated. Surgery occasionally indicated if no response
to adequate physiotherapy (3-6 months).
There are some new injection therapies, e.g. high-volume saline/dextrose injections, +/-
extracorporeal shock wave therapy (ESWT) for Achilles tendinopathy and these may be
indicated for recalcitrant cases
If red flags (solid, atypical features, change in size, significant pain - refer red flag
or same day to secondary care as appropriate.
Treatment - If benign / painless – observe & reassure. Aspiration generally not indicated.
Referral - If no improvement and swelling causing impact on ADLs, e.g. footwear issues.
Referral – If painless or an acute change in their foot shape, refer to core podiatry for
assessment. Prior to referral do a weight-bearing x-ray of ankle with AP, oblique and
lateral views.
Medial foot pain with loss of medial longitudinal arch - Consider TBD
Investigation – Weight bearing AP/Lateral foot and ankle and oblique foot X-Rays
Acute presentation refer to orthopaedics urgently
Chronic presentation refer podiatry for orthotics
If non responsive refer orthopaedics for advanced splinting and investigation
Forefoot
Referral - If no improvement with conservative management. Core podiatry should be the first referral.
Only refer for surgical intervention if prepared to consider surgery and fit for surgery.
Causes of Metatarsalgia
Idiopathic
Tibialis posterior dysfunction
Digital deformity
Inflammatory Joint Disease
Morton’s Neuroma
Frieberg’s
Idiopathic Metatarsalgia
Produces general pain/discomfort under MT heads with no other cause (eg inflammatory,
toe deformity, Frieberg’s, TPD, Morton's Neuroma)
Management – footwear advice, (avoid heels and tight fitting shoes) PIL on choosing
footwear; Analgesia & NSAIDs as appropriate.
Morton’s Neuroma
Due to swelling of the inter-digital nerve causing pain often to radiate into the toes – pins
and needles for example. Most commonly affects 3 rd and 4th toes. ‘There’s a pebble in
my shoe’.
Treatment – If benign / painless – observe & reassure. Advise on footwear and padding
to area.
Claw/Hammer/Mallet toe(s)
Toe deformity may be fixed or flexible/passively correctable at PIP and DIPJ.
Advice - If passively correctable orthotics/metatarsal support may help. Commence slant board
stretches for calf musculature.
• Diabetic patients presenting with foot and ankle pathology need specialist attention –
please refer to local guidelines (https://www.nice.org.uk/guidance/ng19/chapter/1-
recommendations)
• Diabetic patients generally get an annual foot review in primary care
• Foot problems are common in diabetics - 5% develop a foot ulcer in any year
• Foot problems often due to a combination of:
– Peripheral neuropathy causing reduced sensation in the foot
– Peripheral vascular disease causing pain and predisposition to ulceration.
• Encourage good foot hygiene in all diabetic patients
– Daily examination of the feet for problems
– Well-fitting shoes and hoisery
– Good hygiene and nail care
– Ensure diabetics are well-informed about their feet and the dangers associated with
procedures, e.g. corn removal
– If reduced mobility, methods to help with foot assessment/monitoring, e.g. mirrors.
• Advise patients about when to seek medical review
– Any colour change, swelling, breaks in skin or numbness?
• Try to avoid barefoot walking due to risk of unrecognised trauma
• If they develop any skin lesions then seek review either through the GP or podiatrist
• If anyone develops a new foot ulcer – arrange an urgent assessment (ideally within 24
hours) from the multidisciplinary specialist foot care team. Assess ischaemia using
Doppler if available in the surgery.
• Charcot’s joint – neuropathic foot damaged because of trauma secondary to loss of pain
sensation. If suspected, refer immediately to the footcare team for immobilisation and
long-term management.