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:

  • Consider diagnosis (discuss within peer review):
    • Hallux Rigidus.
    • Hallux Valgus.
    • Hammer Toes.
    • Morton’s Neuroma.
    • Metatarsalgia.
    • Exclude spinal (proximal problem).


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


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

  • Consider guidelines in previous section.
  • Assessment / Diagnosis and detailed advice.
  • Foot orthotic/Bunion splint/Padding/Footwear service.
  • Treat corns and callosities.
  • Exercise/Mobilisation/Taping.
  • Nail surgery; most procedures can be undertaken within core Podiatric services (if co-morbidities are present or DVT prophylaxis is appropriate onward referral may be required).

If no improvement after approximately 3 months of comprehensive management refer to the Interface Team.

Interface Team
  • Review previous assessment, diagnosis and management.
  • Footwear modification/Shoe stiffeners/shoe rocker soles and aircast walkers can be given/ Gait analysis.
  • If no improvement consider steroid injection. Maximum of 2.
  • If none of the above consider referral to surgeon.

If patient does not wish to explore surgical option consider referral to Pain Consultant for advice regarding analgesia.


  • The definitive imaging for Morton’s Neuroma is Ultrasound (U/S); steroid injection can be given under imaging.
  • For other Forefoot conditions consider undertaking a standing AP and Lateral foot
  • X-rays before onward referral to surgery.
  • Consider US / MRI  if unclear diagnosis e.g. if stress fracture is suspected.
Surgical Criteria

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

  • No improvement despite 6 months of conservative management


  • The patient has shown commitment to weight reduction through active participation in a weight management programme if the patient's BMI is >30


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


  • Footwear modifications have been considered and undertaken (if appropriate)


  • Steroid injection has been considered and undertaken (if appropriate)


  • Health Care Professional has discussed surgery with the patient who has confirmed they want explore surgery


  • General Health including fitness for anaesthesia has been considered and believed adequate to proceed to potential surgical intervention and it is believed that the patient is likely to derive quality of life benefits from surgery


No referrals relating to concerns about the cosmetic appearance of feet will be accepted.


Individual Funding Requests

Bunions are listed on Gloucestershire CCG's Effective Clinical Commissioning Policy.  Please the attached link for details of access criteria and funding arrangements.