Red flags for foot & ankle conditions

Prior to referral consider / screen to exclude:

Key Clinical Observations of concern:

  • Hot / red / swollen joint with raised body temperature.
  • Rapidly worsening deformity.
  • Inability to weight bear.
  • Neuro-vascular compromise.
Urgent foot & ankle referral

Acute infection or suspected new traumatic injury should be sent to A&E.

Urgent appointments can be made for patients in consultant led orthopaedic F&A fracture clinic.

  • On going infection
  • Suspected tumour
  • Ankle injury
  • Charcot Arthropathy

Urgent appointments can be made in consultant orthopaedic foot and ankle elective clinics for patients with:

  • Rapidly worsening symptoms.
  • Complex conditions requiring diagnosis.
  • Patients with associated medical conditions e.g. Charcot Marie Tooth Syndrome.

Urgent appointments can be made with podiatrists for:

GP / Primary Clinician
Exclude red flags.
  • Consider diagnosis (discuss within peer review).
  • Steroid injection should be avoided as may cause tendon rupture.


 If no improvement; suggest self referral or refer on to Physiotherapy or Podiatry Service for diagnosis (if not already ascertained) and treatment.


  • X-ray not indicated routinely.
  • Consider Ultrasound if no improvement after 3 months of conservative treatment.
Physiotherapist / Podiatrist
  • Consider guidelines in previous section.
  • Assessment / diagnosis detailed advice.
  • Eccentric Loading exercises/ Achilles tendon stretches for a minimum of 3 months with evidence of patient compliance.
  • Consider Insoles/ heel raise (Podiatry more likely to provide this service especially if more complex types required).

If not responding consider referral to the Interface Team.

Interface Team
  • Review previous assessment, diagnosis and management.
  • If not responding consider immobilisation for 6 weeks in walking cast or brace with rehabilitation afterwards.
  • If none of the above and fits criteria consider referral to surgeon.

Consider the following:

  • Willingness to undergo surgery.
  • General Health.
  • Understand recovery period post surgery.

If patient does not wish to explore surgical option refer back to GP or Pain Consultant for advice regarding analgesia.


  • X ray not indicated routinely.
  • Consider Ultrasound if no improvement after 3 months of conservative treatment.
  • MRI scan can be used as a second line investigation.
Surgical Criteria

No referrals to secondary care unless the following criteria are met:

  • No improvement despite 6 months of comprehensive conservative management


  • Review by Interface suggests patient likely to benefit from further opinion/management/surgery by an orthopaedic consultant

This condition is not generally helped by surgery but interventions that can be used are:

  • Tendon debridement if US scan shows nidus degeneration (recovery period 3-6 months).
  • Haglund’s deformity- open/arthroscopic excision. Full recovery 6-12 months (can be longer if open procedure).
  • Extracorporeal Shockwave Therapy: currently this undertaken at GHT as part of study (treatment can be painful).
  • Ventral dennervation (little evidence).
  • High volume /steroid injection (little evidence).