While many acute injuries and some foot and ankle conditions evidently require a specialist referral, others are less clear-cut. Consultant orthopaedic surgeons Mr Martin Klinke, Mr Matthew Solan and Mr Anthony Perera provide a concise guide to when to refer, what to look for and commonly missed problems.
The ‘ankle sprain’ that won’t heal
Ankle sprains account for about 10 per cent of A&E attendances and while the majority will heal with rest (and sometimes physiotherapy), a significant number will not. Up to 40 per cent of patients will be symptomatic six months after their injury.
Refer
The sprained ankle which does not heal steadily within two months of the injury taking place.
Bear in mind
- Standard x-rays will not show damage to the articular surface of the talus, lateral ligament insufficiency, tendon injury or synovial impingement.
- Even if the patient can walk, this does not exclude the possibility of a fracture. The Jones fracture of the 5th metatarsal occurs on the top of the foot, often with an ankle sprain, but is often missed.
- If there is swelling in the foot, rather than ankle, with bruising on sole of foot, promptly refer. This strongly indicates a Lisfranc ligament injury or fracture, which is a significant injury.
Arthritis
Referral to a specialist for surgery is often only considered at an advanced stage. But earlier referral is very beneficial because much can be done before major surgery.
Refer
As soon as the patient is in pain and/or experiences reduced function.
Bear in mind
- Orthotics prescribed by a podiatrist can alleviate symptoms considerably.
- Arthroscopy is a very good treatment option for clearing scar tissue and removing arthritic spurs, but many patients are referred too late for this to be considered.
- Early referral for patients with rheumatoid arthritis is essential; feet in this patient group are often undertreated.
- New generation ankle replacements now provide a reliable alternative to fusion for many patients.
Heel pain
About one in 10 people experience heel pain at some stage. About 80 per cent of this group will get better either with relative rest and conservative treatment (calf stretching exercises guided by a physiotherapist). However, one in five will not improve.
Refer
No improvement after six months, including conservative treatment.
Bear in mind
- Heel pain is commonly caused by plantar fasciitis, but can also be due to insertional achilles tendinopathy and a stress fracture of the calcaneal (heel bone).
- Steroid injection is not recommended due to risk of Achilles tendon rupture.
- Shockwave therapy is now well established as being an effective treatment for heel pain.
- A smaller proportion will require calf release surgery due to the muscular structure of their lower limbs.
Bunions
Around a third of adults will develop a bunion, with women more likely to be affected than men.
Refer
If there is pain, an increasing deformity of the big toe or if the bunion is causing further forefoot deformity, for example, hammer toe.
Bear in mind
- Bunions can be corrected very successfully with surgery and new techniques significantly reduce tissue trauma, swelling and post-operative pain.
- A bunion which causes no pain should not be operated on for cosmetic reasons.
Flat foot
Another very common foot condition and while some people manage perfectly well with very little arch, others will experience significant problems.
Refer
If there is pain (not necessarily a lot), if there is stiffness or hypermobility, if the patient wears out shoes very quickly and if feet seem weak, if there is swelling on the inside of the ankle and if the deformity is increasing.
Bear in mind
- Pain behind the posteromedial aspect of the ankle is a strong indication of a tibialis posterior tendon dysfunction and this will get progressively worse.
- Treatment options and outcomes are far better if undertaken at an early stage.
- Calcaneal osteotomy (heel shift surgery) to address very poor alignment can now also be undertaken as a minimally invasive procedure.
