RAG rating: n/a
Document type: Clinical pathways
Place: Hertfordshire and West Essex ICB
Output type: Clinical Pathways
Pathway: Foot Pain Ankle Pain Urgent Diabetic Foot / Charcot pathway Foot Health | Diabetic Patients
Information leaflet: MSK Triage Letter | Patient MSK Physiotherapy Letter | Patient

Foot & Ankle Pain and Disorders excluding Bunions

PLEASE NOTE FOR MOST MSK PATHWAYS –

DO NOT ORDER MSK MRIs FROM PRIMARY CARE.
UNLESS THE PATIENT HAS A RED FLAG MOST MSK PATHWAYS REQUIRE A PERIOD OF CONSERVATIVE MANAGEMENT AND REFERRAL ONLY ON NON-RESOLUTION ONTO TO PHYSIO OR MSK TRIAGE SERVICES (SEE DETAIL FOR EACH PATHWAY ATTACHED).
PLEASE NOTE MSK TRIAGE SERVICES CAN ORDER MRIs AND OTHER DIAGNOSTICS

ONLY REFER DIRECT TO SECONDARY CARE IF RED FLAGS OR PRIOR APPROVAL HAS BEEN OBTAINED

Foot symptoms:

Consider referral to podiatry or secondary care for patients with conditions such as:

Diabetes mellitus
Inflammatory joint disease
Connective tissue disease

Consider x-ray (Ottawa Rules)

The Ottawa foot rules indicate whether a foot X-ray series is required. It states that it is indicated if there is any pain in the midfoot zone and any one of the following:

Bone tenderness at the base of the fifth metatarsal (for foot injuries), OR
Bone tenderness at the navicular bone (for foot injuries), OR
An inability to weight bear both immediately and in the emergency department for four steps

Hindfoot symptoms:

Joint osteoarthritis: investigate with plain X-ray. Treat with ROM exercises, supportive footwear and analgesia
Soft tissue mass: rule out red flags (see pathway), if benign: reassure and observe
Tendon/ ligament injury: no investigations necessary. Treat with ROM exercises, supportive footwear, analgesia, weight loss if appropriate and, if plantar fasciitis, undertake approved exercises

Midfoot symptoms:

Flexible foot (possibly correctable flat foots): investigate with plain x ray. If painless, observe & reassure, advise on footwear and padding, if abnormality on report manage as appropriate
Rigid midfoot deformity (not correctable, OA): investigate with plain x ray. Range of movement (ROM) exercises, supportive footwear, if tendinopathy advise on lifestyle/weight loss, if plantar fasciitis undertake approved exercises, if abnormality on report manage as appropriate

Forefoot and toe symptoms:

Lesser toes deformities/ metarsalgia: advise on footwear, padding and strapping of digit
Morton’s neuroma/ soft tissue mass: investigate Morton’s neuroma with US scan, if benign/ painless – observe & reassure. Consider referral for aspiration if appropriate, advise on footwear and padding

In all of above, if no improvement after 6 weeks, refer to MSK triage

Ankle pain:

Exclude red flags:

The following require urgent referral to the Emergency Department:

Polytrauma
High-energy injury
Open injury
Evidence of nerve or circulatory injury or compartment syndrome
Septic arthritis
Suspected Achilles rupture

For suspected ankle fracture- consider the Ottawa rule for x-rays

An ankle X-ray is only required if there is any pain in the malleolar zone and any one of the following:

Bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus;
Bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus; or
An inability to bear weight both immediately and in the Emergency Department for four steps.

Traumatic soft tissue injury: for traumatic injuries without red flags manage initial symptoms with analgesia and conservative measures. Consider physiotherapy referral after 6 weeks if not resolved

Osteoarthritis: Advise on; modification of activities, analgesia, orthotics/ footwear, walking aids. Consider corticosteroid injection. Consider referral to physiotherapy if no improvement after 4 weeks.

Tendinopathies: Given advice on conservative management. Refer to physiotherapy if not improving after 6 weeks self-management

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