REMEDY : BNSSG referral pathways

Foot and Ankle Problems - FAQs

Checked: 02-11-2018 by Rob.Adams Next Review: 02-11-2019

Frequently Asked Questions

Steve Hepple (Foot and Ankle Surgeon at NBT) has provided some information about FAQs .

Ankle Sprain

Q: We have a lot of patients who suffer persistent pain following eversion or inversion ankle injuries, who have normal X-rays. They often do not seem amenable to physiotherapy. Is MRI the best investigation for post-injury pain and at what stage would you like to see these patients if they are not improving?

A: Post ankle sprain persistent symptoms are most commonly due to soft tissue impingement around the ligaments, ostochondral lesion, syndesmotic injury (high ankle sprain) or peroneal tendon problems although other diagnoses are possible and sometimes the sprain can simply be slow to settle. With persistent significant symptoms beyond 3 months it is reasonable to investigate further and MRI is usually the first line investigation (assuming normal X-rays have been previously performed) although dynamic ultrasound may be necessary to pick up impingement or peroneal tendon problems. If there is abnormality on any of these investigations and/or symptoms are failing to settle beyond 3 months referral is recommended.

Toe arthritis

Q: Is there good evidence for MTPJ and toe IPJ/ PIPJ fusion for severe pain in toe arthritis? These cases are now hard for GPs to get through the funding policies and I have many patients who struggle with chronic pain.

A: Hallux Rigidus (1st MTPJ arthritis) is a significant clinical problem with major impact on quality of life and work ability. There is minimal evidence that long term orthotic treatment is beneficial although stiff soled shoes or a rigid insert may alleviate some of the pain. It is very well treated by cheilectomy or fusion which in most cases significantly improves the symptoms with good function thereafter. The condition is often labelled as a ‘bunion’ referring to the lump that forms around the joint but this confuses the condition with hallux valgus, in which there is deformity of the toe but usually no arthritis although a mixed pattern is occasionally possible. The drive to reduce referral for procedures of limited clinical value has led to a decrease in availability surgery for both procedures. In my opinion there is no justification for this restriction in referral patterns as both conditions can affect function and hallux rigidus can certainly be very painful. In respect of lesser toes, frank arthritis is rare but fusion is often performed to correct deformities of the toes such as clawing or hammering. These procedures are justified when rubbing of the toes causes trouble with shower/ulceration etc.

Metatarsalgia and Morton's neuroma

Q: Is there benefit in injecting metatarsalgia and Morton’s neuroma, or is there better evidence for surgery for either of these two conditions?

A: Metatarsalgia is a symptom referring to pain under the ball of the foot. There are numerous potential causes which have to be distinguished either clinically or after investigation. Some of the causes such as Morton’s neurone or inter metatarsal bursitis are amenable to injections. These injections are by no means fool-proof and do have associated risks. Therefore I would recommend that, at least initially, they are performed with ultrasound guidance to ensure that the diagnosis is confirmed and the injections are appropriately sited. Surgery is often performed if conservative measures fail; success rates are at around 80-90% but the patient is left with permanent numbness in the affected webspace so is not usually first line treatment.

Avascular necrosis

Q: Avascular necrosis of ankle bones post-surgery is probably the most severe and persistent problem I have seen in my foot and ankle patients. Is there any good post-op advice you can give patients to give them the best chances of good bone healing?

A: Avascular necrosis of bones in the foot and ankle is a rare condition that can occur spontaneously or after surgery. Non-union or delayed union is more common after surgery. After surgery patients should carefully follow the post-operative instructions given to them. Smoking is known to decrease bone healing and can increase the risk of non-union by up to 16 times. Patients should therefore stop smoking prior to undertaking major hind foot fusion and should be encouraged not to use NSAIDs if possible as they also slow bone healing.