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Foot and Ankle Care Pathway Overview

MSK guidance and COVID-19

Please see the NHS England guidance on the management of patients with musculoskeletal and rheumatic conditions on corticosteroids during the coronavirus pandemic here.

This guidance is to help primary or community care practitioners recognise serious pathology which requires urgent or emergency referral to secondary care when patients present with new or worsening musculoskeletal symptoms. Serious pathology as a cause of musculoskeletal conditions is considered rare but needs to be managed either as an emergency or as urgent onward referral as directed by local pathwaysere is the accordion content

Please see the NHS England guidance on 'Urgent and emergency musculoskeletal conditions requiring onward referral' here.

From April 2018, Gloucester Care Services Musculoskeletal Advanced Practitioner Service (MSK APS) will be triaging all referrals for foot and ankle Orthopaedic review. This will be the only pathway for patients registered with a Gloucestershire GP to see an Advanced Practitioner or an Orthopaedic consultant.

Triage and the offer of choice will use the electronic referral system (eRS), streamlining the process of referral, triage and the offer of choice, reducing workload in Primary and Secondary Care.

From July 2018, all other body parts will be triaged in the same way.

Please strongly consider Supported Self-Management.

Please click on the relevant flowchart box to be taken directly to textual information. 

Presentation

Patient presents to Primary Care with:

  • pain in the foot/ankle
  • visible deformity
  • reduced movement
  • difficulty using/walking on the foot or joint.
Red Flags
Key Clinical Observations of concern
  • Hot / red / swollen joint with raised body temperature .
  • Rapidly worsening deformity .
  • Inability to weight bear.
  • Neuro-vascular compromise.
 If the patient is still under consultant care post-operatively any issues relating to post-operative recovery should be referred back to the consultant.
 If suspected tumour - refer via 2ww
Refer to the Trauma Triage Service or A& E for suspected fracture or acute ankle injury such as tendon rupture.
For patients with diabetes please refer to the Diabetic Foot pathway
Differential Diagnosis

Please do not refer to the MSK Foot and Ankle Triage Service for the following:

Exclude

Action to take

Suspected fracture or acute traumatic injury

Refer to A&E or the Trauma Triage Service

Suspected new diagnosis of inflammatory arthritis

Refer to Rheumatology

Patient with significant likelihood or peripheral vascular disease or occlusion 

Refer to Vascular Surgery

Patient with suspected DVT

Follow DVT pathway

Supported Self-Management

Many patients with foot and ankle problems can, with advice and guidance, manage their problems without additional support.

Advice on how to do this can be found in the individual bitesize guidance pages.

See the Core Podiatry and Physiotherapy Services section below for patient self-referral information.

When to do Investigations

Imaging

  • X-ray indicated if there is bony involvement suspected – could be a fracture and this would follow a different pathway

  • X-ray not indicated routinely. Consider Ultrasound if no improvement after 3 months of conservative treatment

  • AP/Mortise and lateral standing foot X-ray prior to onward referral if first line actions fail or if patient reports sharp catching or locking

  • AP/Mortise and lateral standing foot X-ray only if injury suspected.

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