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Info For GP’s

Ask Mr Sturdee a Question

If you have a general question about any foot and ankle problem please feel free to email me below. He will endeavor to answer your question but cannot comment on specific cases without seeing the patient. General advice however can be given.

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Request a Talk/Seminar from WYFAC

If any GP or physiotherapy practices want a seminar / informal teaching on common foot and ankle conditions and how to deal with them in primary care Mr Sturdee is more than happy to come to practices to do this.

A brief summary of such a talk that has been given in primary care can be found in the ‘How to manage foot and ankle disorders in primary care’ section below.

Foot Anatomy

The foot is a complex part of the body. It is not just at the end of our legs to stop them fraying! (Quote Nick Geary, Wirral Foot and ankle unit) If is healthy and pain free it allows us to stand Walk, run and jump. There are 26 bones in the foot, 33 joints and more than 100 muscles tendons and ligaments. Approximately one quarter of all the bones in the human body are in the human foot.

The structures of the foot change with age. The padding tissues become thinner and muscles loose their strength. Tendons and ligaments loose their elasticity and joints wear out and become degenerative. Injuries to the foot can cause serious problems and poorly fitting shoes can worsen many problems.

Problems with the foot can be treated in a number of ways from insoles, shoe modifications and sometimes surgery. If non-operative treatments are prescribed you will often be referred to the appliance department in the hospital to see an Orthotist who is an expert in assessing the suitability for treatments such as insoles and will often make them and then fit them.

If surgery is undertaken it is important to understand what the risks and benefits of surgery are and these will be explained to you during your consultation and during signing of a consent form.

Everyone has a different shaped foot but there are five main types of foot. The different shapes predispose to different conditions and pathology.
1, Grecian (Morton’s) foot. The second and third metatarsals are relatively long in relation to the first and fifth. This can lead to increased pressure and pain under the longer metatarsals, which is called metatarsalgia. Approximately 22% of the population have this shape of foot.

2, Egyptian foot. Long first ray relative to the central metatarsals. This can predispose the first metatarsal phalangeal joint to become arthritic (Hallux rigidis). Approximately 69% of the population have this shape of foot.

3, Simian foot. Metatarsus primus varus, which means that the 1st metatarsal is deviated towards the opposite foot. This causes less weight to be taken through the 1st ray, as the joint at the base of the 1st metatarsal tends to be hypermobile. As a result more weight and force is transferred to the other metatarsals and this can result in pain. (Transfer metatarsalgia).

4, Peasant foot. The metatarsals are all of similar length resulting in a broad square foot. The foot is very stable making it an ideal platform for dancing. Approximately 9% of the population have this shape of foot.

5, Models foot. This foot is long and slender with an exaggerated cascade from the 1st to the 5th metatarsal.
(Ref Viladot A. Patologia del Antepie. Barcelona: Ediciones Toray, 1957.

How to refer a Patient to a Clinic

Mr Sturdee is happy to discuss any patient problems prior to referral. Either contact him via his secretary or use the contact us section of the website and he will arrange to answer you question by email or alternatively arrange a mutually convenient time to discuss the matter over the phone.

If any GP practices want a seminar / informal teaching on common foot and ankle conditions and how to deal with them in primary care Mr Sturdee is more than happy to come to practices to do this. A brief summary such a talk can be found on the website. (See attached file, what to do with foot and ankle disorders in primary care)
What x rays should be requested for foot and ankle conditions ?

If X rays are requested prior to us seeing the patient in clinic it would be helpful if they could be weight bearing x rays as they are much more informative than non weight bearing x rays. Requesting the correct x rays will avoid the need for repeating the x rays.

Referral criteria for Hallux Valgus

Hallux valgus or bunion (from latin word bunio = Turnip) is lateral deviation of the great toe at the 1st metatarsal phalangeal joint (MTPJ) with prominence and pain over the medial eminence of the 1st MTPJ. As the deformity progresses the great toe can cause deformities of the lesser toes as well. The function of the foot becomes impaired and this can cause secondary problems in the knees, hips and spine.

Primary treatment:
Advice on low heeled, wide forefoot shoes with soft leather uppers.
Referral to chiropodist.
Referral to orthotics (eg comfort shoes).

Refer when:
There is severe deformity (overriding toes).
There is severe pain from the metatarsophalangeal joint or bunion.
Conservative methods have failed.
“Indications for repair of hallux valgus include painful joint ROM, deformity of the joint complex, pain or difficulty with footwear, inhibition of activity or lifestyle, and associated foot disorders that can be caused by this condition.
Contraindications to surgery include the following:
• Lack of pain or deformity (Surgery not done for cosmesis)
• Advanced age
• Lack of compliance

Surgical therapy: Surgical treatment can be offered when conservative therapy is impractical or fails to relieve the patient’s symptoms. The goals of surgical treatment are to relieve symptoms, restore function, and correct the deformity. The clinician must consider the patient’s history and physical and radiographic findings before selecting a procedure.”

The only information we could find on the effectiveness of surgery to prevent further deterioration of the foot relates to patients with symptomatic hallux valgus, which may still be of interest to you.

A Cochrane systematic review of interventions for [symptomatic] hallux vulgus employed the inclusion criteria of patients presenting for treatment of hallux valgus found:
“No good evidence was found that conservative treatments, involving splinting or orthoses, prevent the progression of hallux valgus deformity.

One good study comparing surgical correction of hallux valgus with conservative treatment or no treatment found in favour of the surgical treatment. In the trials reported, there was no evidence that any one type of surgical procedure was superior to another across a range of outcomes. New methods of fixation being introduced into surgical practice do not appear detrimental to traditional methods, although benefits to the patient in terms of early return to activities need to be demonstrated.”

In the author’s conclusion, they remark:
“Final outcomes were most frequently measured at one year, with a few trials maintaining follow-up for 3 years. Such time-scales are minimal given that the patients will be on their feet for at least another 20-30 years after treatment. Future research should include patient-focused outcomes, standardised assessment criteria and longer surveillance periods, more usefully in the region of 5-10 years.”

References
1. Orthopaedic referral guidelines. March 2005. (http://www.gp-training.net/rheum/orthoref.htm#bunions).
2. Frank C and Robinson D. Hallux valgus. E-Medicine. March 2005. (http://www.emedicine.com/orthoped/topic126.htm).
3. Ferrari J, Higgins JPT, Prior TD. Interventions for treating hallux valgus (abductovalgus) and bunions. The Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD000964.pub2. DOI: 10.1002/14651858.CD000964.pub2. (http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD000964/pdf_fs.html)

Post Operative Protocols in Surgery

General treatment protocols for post operative mobilisation and rehabilitation.

For all patients first two weeks following surgery the foot should be elevated as much as possible. I tell all patients the following phrase “Tea, toast and toilet toilet.” This means they can get up to make a cup of tea, a slice of toast and go to the toilet and the rest of the time they must have the leg elevated to minimise the soft tissue swelling and to get the wounds healed with the minimum of complications. The amount of weight bearing allowed when they get up will depend on the surgery they have had done. Once the wounds have healed and the sutures are out I relax these rules but always suggest that when they get the chance they should sit rather than stand and if they sit to elevate the leg.

Forefoot Surgery

Most will be ambulatory in a flat soled post op shoe. Some of the more common procedures are outlined in more detail below.

Scarf osteotomy
Day case or One night stay in hospital elevating leg then home weight bearing in a heel wedge post op shoe.
Seen at 2 weeks for removal of sutures and change from heel wedge post op shoe to flat soled post op shoe for a further 4 weeks, taking them to 6 weeks post op.

At 2 weeks can start passive range of movement of the first MTP joint.
At 6 weeks can go into a normal flat shoe that will accommodate swelling such as a trainer shoe. Usually discharged at 6 weeks if all OK.

1st Metatarsal phalangeal joint arthrodesis
One night stay in hospital elevating the leg. From theatre will have a wool and crepe dressing and within this will be a plaster slab to stiffen the dressing around the great toe. Mobile in flat soled post op shoe and can weight bear.
Seen at 2 weeks for removal of sutures and then just require dressing as required and continue to mobilise in flat soled post op shoe.
At 6 weeks X ray is done and if this is satisfactory can be left free to mobilise in a normal shoe.
See at 3 months with a final x-ray and if this confirms solid union discharged.

Lesser toe arthrodesis (PIP or DIP or Both PIP and DIP)
Usually done as a day case and post operatively can mobilise in a flat-soled post op shoe.

Seen at 2 weeks for removal of sutures. If wounds have healed at that stage and if have wires sticking out of the end of the toes they can shower at this stage but must not immerse the foot in a bath. Wires can be protected with some tape or a small dressing once the foot is dried.
Seen at 6 weeks and at this stage the wires are removed and the flat-soled post op shoe can be discarded. If all OK can be discharged.

Midfoot and Hindfoot surgery

Examples include, Triple arthrodesis, subtalar arthrodesis, talar navicular arthrodesis, tarsal metatarsal arthrodesis, lapidus procedure.

Most will be in a below knee non weight bearing plaster, often for up to six weeks and then have 6 weeks of immobilisation partially weight bearing. I.e. 3 months total immobilisation post op.
Seen at 2 weeks for removal of plaster, removal of sutures and re application of a below knee non-weight bearing plaster.
At 6 weeks if the x rays are OK then my preference is usually for them to change from a plaster to a below knee removable walker boot with air cells, (e.g Nex Step walker boot or Aircast XP walker boot). At this stage unless specified patient can partially weight bear with crutches.
At 3 months seen with plaster off and x ray. If x ray OK can be left free and start mobilisation. May require physiotherapy to regain strength and confidence in walking.
See approx 5 months post op and if OK discharged.

Post operative protocols in Ankle surgery

Ankle arthrodesis will be treated like the midfoot and hindfoot cases above.

Ankle arthroscopies don’t usually have any specific immobilisation and can start physiotherapy as required depending on the pathology.
Seen at 2 weeks for removal of sutures.
Ankle ligament repair / reconstruction will be a below knee plaster for six weeks then will start physio and have a ankle brace for a further six weeks (e.g. A60 aircast sport ankle brace). First 2 weeks will need to be non-weight bearing.
Seen at 2 weeks for removal of plaster and removal of sutures. Then reapplication of a below knee plaster and can partially weight bear.
Seen at 6 weeks for removal of plaster and application of an ankle brace theta needs to be worn for a further 6 weeks. Start physiotherapy at this stage to work on strength and proprioception.

How to Manage Foot and Ankle

What to do with foot and ankle disorders in primary care
Foot anatomy and function
Foot shapes
Egyptian 69% Predisposes to hallux rigidus
Grecian (Mortons) 22% Predisposes to metatarsalgia
Simian Metatarsus primus varus
Peasants foot 9% V good dancing as stable
Models foot variation of Egyptian foot Long and slender, exagerated cascade 1st to 5th

Causes of foot pathology
With age structures change
The padding tissues become thinner
Muscles loose stength
Tendons and ligaments loose elasticity
Joints wear out becoming degenerate
Injuries
Sporting activities put a lot of strain on the F & A structures
Peripheral neuropathy has a profound affect on the foot
Diabetes is commonest see affecting autonomic nerves, loss of sweating, proprioception etc
Other haematological, endocrine, metabolic diseases
CNS and spinal diseases
Hereditary neuropathies such as HSMN CMT

Surgery
Surgery not without risks
3 mths to be fair, 6 mths to be good and 1 yr to be right
Patients need to have realistic expectations

Hallux Valgus
Bunion derived from Latin word BUNIO = TURNIP
2 ways of treating them,
Either modify footwear (Extra depth shoes with wide toe box or can try bunion supports / pads)
Or modify foot shape by an operation (Osteotomy, over 100 described in medical books)

Hallux Rigidus
Conservative treatments include
Stiff insoles
Modular shoes with rocker sole
Activity modification
Analgesics
If these fail can refer for surgery either cheilectomy or fusion, 1st MTP joint replacements fail.

Plantar fasciitis
Early diagnosis and treatment is key
If get within 6 weeks most can be cured with simple non op Rx
If get nocturnal pain need to question the diagnosis. Could be calcaneal stress fracture or tarsal tunnel syndrome
General advice
Avoid walking bare foot

Supportive insoles
Cushioned heel inserts
Night splint or stassborg sock
Physiotherapy
Topical NSAID
Inject ? Under US guidance
If after 12 – 18 mths of decent conservative treatment can consider other treatments such as lithotripsy (Shockwave) or surgical release.
Surgery 60 – 70% success.

Achilles tendinopathy
Insertional tendinopathy and non insertional tendinopathy.
Retrocalcaneal bursitis / Haglund deformity (“Pump bumps”)
Similar Rx to P fasciitis but DO NOT Inject
Supportive insoles
Cushioned heel inserts
Physiotherapy
Topical NSAID
If after 12 – 18 mths of decent conservative treatment can consider other treatments such as radio frequency coblation, lithotripsy (shockwave), surgical decompression or for severe cases TA reconstruction.
Surgery 60 – 70% success.

Tibialis Tendon dysfunction
Tib post is vital for normal foot and gait function.
Start off with pain around posterior border of medial malleolus with no deformity. Cant do a single stance heel rise. Best Rx with rest (Plaster) and NSAID at this stage.
Once have deformity will need supportive insole as long as deformity is correctable.
Severe cases may need bespoke shoes and callipers.
If investigate US easiest Ix otherwise a MRI scan can diagnose.
Once deformity is fixed only surgical option is hindfoot fusion. (Triple)

Ankle arthritis
Usually post traumatic arthritis but also so in osteoarthritis and Rheumatoid.
Standard arthritic Rx with analgesia etc
If deformity an insole might help
If instability an ankle brace can be used
If not responding to conservative measures surgical options are arthroscopic debridement, ankle fusion (Open or arthroscopic) or total ankle replacement.
Mr S W Sturdee FRCS, FRCS (Tr&Orth)
Consultant Orthopaedic and Trauma Surgeon
Calderdale and Huddersfield NHS Trust
NHS Secretary 01484 347264