ODG -TWC

ODG Treatment

Integrated Treatment/Disability Duration Guidelines

Ankle & Foot (Acute & Chronic)

Back to ODG - TWC Index

 

(updated 12/19/13)

 

CONTENTS

 

 

(1) Treatment Planning.………………………………………………………………………..2

 

(2) Codes for Automated Approval……………………………………………………………8

 

(3) Procedure Summary…..…………………………………………………………….…..10

 

 

 

Reference Summaries…………………………………………………..………….…..….….69

(Including findings, evaluations, and ratings; click on PMID# for complete abstracts)

 

           

 

Explanation of Medical Literature Ratings (see Contents for more detail):

 

Ranking by Type of Evidence:

1. Systematic Review/Meta-Analysis

2. Controlled Trial – Randomized (RCT) or Controlled

3. Cohort Study - Prospective or Retrospective

4. Case Control Series

5. Unstructured Review

            OTHER:

6. Nationally Recognized Treatment Guideline (from guidelines.gov)

7. State Treatment Guideline

8. Other Treatment Guideline

9. Textbook

10. Conference Proceedings/Presentation Slides

 

Ranking by Quality within Type of Evidence:

a. High Quality

b. Medium Quality

c. Low Quality

 

 

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ODG Integrated Treatment/Disability Duration Guidelines

Occupational Disorders of the Ankle and Foot

 

Note: The Treatment Planning section is not designed to be a rule, and therefore should not be used as a basis for Utilization Review. The Treatment Planning section outlines the most common pathways to recovery, but there is no single approach that is right for every patient and these protocols do not mention every treatment that may be recommended. See the Procedure Summaries for complete lists of the various options that may be available, along with links to the medical evidence. The Procedure Summaries are the most important section of ODG Treatment, and that section, not the Treatment Planning section, should be used as a basis for Utilization Review.

 

Initial Evaluation and Presumptive Diagnosis of Ankle Injuries

The injury should be classified into a presumptive diagnosis which will dictate the path of care. After a complete definitive evaluation is finished, the injury may, in some cases, need to be reclassified. Subsequent to a thorough evaluation, the diagnosis may change (e.g., if the physician classifies a patient with a sprain and the x-rays subsequently show a fracture).

 

Initial Evaluation

1.      Ascertain the type of trauma (inversion/eversion or dorsiflexion/plantar flexion).

2.      Determine whether the problem is acute, subacute, chronic, or of insidious onset.

3.      Determine the severity and specific anatomic location of the pain.

4.      Assess the ability of the patient to bear weight, from no to full weight-bearing ability.

5.      Search for any evidence of an open or penetrating wound.

6.      Search for any evidence of deformity (anterior/posterior or lateral/medial).

7.      Test the range-of-motion of the joint.

8.      Document any present medication.

9.      Document any history of systemic disease, or previous ankle injury or disability.

 

Presumptive Diagnosis

·        Sprain, Sprain-fracture, or Contusion [ICD-9 Codes: 845.0X, 924.21]

·        Laceration [ICD-9 Codes: 891.X]

·        Achilles Tendonitis [ICD-9 Codes: 726.71, 727.67, 727.81, 845.09]

·        Other diagnoses (See Procedure Summary for multiple treatment recommendations)

§         Plantar fasciitis [ICD-9 Code: 728.71]

§         Calcaneal spur [ICD-9 Code: 726.73]

§         Hallux valgus [ICD-9 Code: 735.0]

§         Tarsal tunnel syndrome [ICD-9 Code: 355.5]

§         Traumatic Arthritis, Acute Episode [ICD-9 Code: 716.17]

§         Systemic Disease (e.g., gout, RA, psoriasis)

 

Fracture or Dislocation [ICD-9 Codes: 823.2X, 823.3X, 824.X, 837.X, 928.21]

 

A. Definitive Evaluation

Record a history of the cause of the injury.

Search for any evidence of an open wound in the vicinity of the fracture.

Perform a clinical examination for deformity, tenderness, or ecchymosis or associated nerve, neurovascular, or tendon injury.

Evaluate for evidence of joint instability.

Search for any evidence of dislocation or arterial vascular compromise (cold, dusky foot with loss of sensation), pulse and possibly sensation. If found, an immediate reduction should take place (prior to x-rays if necessary).

Perform an evaluation for an associated injury of the foot.

X-ray the ankle (two views). Special views such as mortise should be obtained when necessary. [Refer to the Ottawa Ankle Rules (Stiell, 1994)]

For detailed imaging criteria, see:

·        Indications for imaging -- Plain Films (Radiography: AP, lateral, etc.)

·        Indications for imaging -- MRI (Magnetic resonance imaging)

·        Indications for imaging -- Bone Scan (Radioisotope Bone Scanning)

·        Indications for imaging – Ultrasound

 

B. Initial Therapy

Simple, undisplaced stable fractures with no component of the fracture at the level of the ankle mortise (the gliding joint between the distal ends of the tibia and fibula and the proximal end of the talus) can be treated by the primary care physician.

1.      A trilateral splint should be applied initially for two to three weeks. The patient will need crutches and should avoid weight bearing. Swelling is controlled with constant elevation above the heart.

2.      Ice and elevation for 24-48 hours is appropriate.

3.      Post fracture, two to three weeks (after the swelling has subsided), it is appropriate to apply a fiberglass cast with the foot at 90°. This allows the addition of a shoe for conversion to a walking cast one to three weeks after the cast has been applied. When casting, consider checking for vasomotor and sensory compromise. Weight-bearing is progressed to 50% with crutches until six weeks post injury when full weight-bearing is allowed and crutches are discontinued.

4.      Analgesics for up to two weeks are appropriate, but in treating fractures, NSAIDs may be associated with side effects that are deleterious to treatment outcome, including delayed bone healing. Pain is usually due to swelling, and is best controlled with elevation of the ankle and foot. An initial IM pain injection is often indicated.

5.      The patient should be rechecked seven to ten days after the fracture, seven to ten days after beginning partial weight-bearing, and after progressing to full weight-bearing.

6.      X-rays are repeated during the above visits, and after the cast is removed at six weeks.

7.      Physical therapy (one to five visits) to teach patient range-of-motion and muscle-strengthening exercises may be needed after cast removal.

8.      If using a removable cast, starting at four weeks the patient should be allowed to begin gentle range-of-motion exercises with the cast off.

9.      Prescribe level of activity at work and job modifications at each visit.

Nondisplaced, bimalleolar fractures should be referred to an orthopedic surgeon, as they are potentially unstable.

All other ankle fractures should be referred to an orthopedic surgeon. Compound fractures, when appropriate, should have a tetanus toxoid injection before being referred to an orthopedic surgeon.

 

C. Secondary Evaluation for patients with persistent symptoms or minimal improvement after six weeks of therapy

Review for compliance of the employee and employer to therapy programs and job modifications and restrictions. Also review for insurance company cooperation.

Evaluate for delayed union, malalignment, or signs of associated tendon or nerve injury or signs of reflex sympathetic dystrophy (CRPS I).

Promptly refer to an orthopedic surgeon if one of these conditions is found, otherwise continue therapy.

Refer to specialist needs to be considered before six weeks for conditions like Compartment syndrome.

 

ODG Return-To-Work Pathways

Closed reduction, sedentary/modified work: 1-7 days
Closed reduction, standing work w/o cast: 42 days
Open reduction, internal fixation, sedentary/modified work: 14 days
Open reduction, internal fixation, standing work w/o cast: 84 days
Comorbidity fracture blister, add: 21 days

(See ODG Capabilities & Activity Modifications for Restricted Work under “Work” in Procedure Summary)

 

D. Other Considerations:

·        Posterior fracture dislocation of the ankle is a serious injury and is frequently associated with neurovascular compression and with a cyanotic, cold foot. It is sometimes prudent to immediately reduce the dislocation, even prior to obtaining x-rays. "Pure" dislocations of the ankle are rare.

·        Trimalleolar fractures and Pott's fractures (fractures of the distal fibula with torn deltoid ligament) are more commonly associated with this injury.

·        An open wound in the vicinity of a fracture makes it a compound fracture, even if no clear connection to the fracture site is apparent. All compound fractures should be referred to an orthopedic surgeon immediately for care.

·        Neurovascular injuries are a consideration in any fracture, particularly in the ankle, knee, wrist, and elbow. In the ankle, the common injured structures include the posterior tibial artery (which wraps around the posterior-inferior border of the medial malleolus) and the sural nerve (distal to the lateral malleolus). Therefore, it is important to evaluate the foot distal to the fracture to determine if there is evidence of nerve or vascular damage. The sural nerve is sensory and supplies the lateral foot. Vascular injury is detected by cyanosis and coldness of the foot. Since pulses are often difficult to palpate in a swollen ankle, a Doppler examination should be employed if a pulse is not felt. Vascular competence is further checked by comparing the circulatory return of a blanched nailbed to the contralateral side.

·        Compartment syndrome (CS) is a limb-threatening and life-threatening condition observed when perfusion pressure falls below tissue pressure in a closed anatomic space. The current body of knowledge unequivocally reflects that untreated CS leads to tissue necrosis, permanent functional impairment, and, if severe, renal failure and death. Need referral to ortho/trauma surgeon to check pressures and consider fasciotomy.

·        The standard anteroposterior and lateral ankle x-ray occasionally needs to be enhanced by special views. For example, a mortise view detects small but significant widening of the ankle mortise that requires surgical repair for torn ligaments.

·        Undisplaced ankle fractures, except those having a component of the fracture at the level of the ankle mortise, can be treated by the primary care physician. If the fracture line of the tibia or fibula is adjacent to the level of the mortise, it is prudent to refer the patient to an orthopedic surgeon. Although these fractures may initially appear stable, they are unstable and prone to displace within a few days. Generally, they are treated surgically.

·        A trilateral splint is used for the initial splinting of stable fractures of the ankle until the swelling subsides. The splint is then replaced by one of several types of casts (below the knee nonweight-bearing cast, walking cast, or removable cast boot). The splint is applied in the following manner: With the patient in the prone position, the knee flexed to 90 degree angle, with an assistant or family member supporting the ankle in the neutral position by the great toe, a four-inch Webril or case padding is wrapped from the base of the toes to the tibial tubercle. Next, five layers of 5x30 inch plaster are applied, starting at the back of the upper calf and passing over the heel to the base of the toes, doubling back and are smoothed. Then five layers of a 5x30 inch plaster are applied laterally, beginning high on the calf, passing over the lateral malleolus, under the plantar aspect of the foot and up the medial side as far as possible. This is held in place by an Ace or Coban bandage. A Coban bandage has less give than an Ace bandage and should be applied with just one overlapping layer to avoid excess compression.

·        See Criteria for Fusion (ankle, tarsal, metatarsal) to treat non- or malunion of a fracture, or traumatic arthritis secondary to on-the-job injury to the affected joint.

 

Sprain, Sprain-fracture, or Contusion [ICD-9 Codes: 845.0X, 924.21]

ODG Return-To-Work Pathways

Ankle strapping/soft cast, mild sprain (Grade I)1: 1 day
Ankle strapping/soft cast, severe sprain (Grade II-III) 1, sedentary/modified work (10 days crutches): 4-5 days
Ankle strapping/soft cast, severe sprain, manual/standing work: 21 days
Achilles tendon repair, sedentary/modified work: 10 days
Achilles tendon repair, manual/standing work, w/o cast: 49-63 days

·        A definitive evaluation of a sprain is important, as sprains are the most common injury of the ankle; and inversion sprains make up the majority. Eversion sprains may be more severe due to their association with syndesmosis injuries. One classification of sprains is Grades I, II, and III1 (least serious to most serious), and it is helpful to classify sprains in this manner as a guide to the initial therapy and prognosis. [Ankle sprains can range from stretching (grade 1) to partial rupture (grade 2) to complete rupture of the ligament (grade 3). (Litt, 1992)] Evaluations for a sprained ankle include: check for the area of maximal tenderness; on the lateral side examine the anterior talofibular ligament, the calcaneofibular ligament, and posterial talofibular ligament; check the syndesmosis area; examine the mid-tarsal joint; check for injuries to the posterior tibial and peroneal tendons; examine for possible fracture of the base of the fifth metatarsal, anterior process of the calcaneus, osteochondral lesion of the talus, lateral process of the talus; check for tenderness of the medial and lateral malleoli.

·        A sprain-fracture refers to the small flakes of bone avulsed from the calcaneus or talus in sprains of the ankle. These flakes represent small avulsions of bone attached to the injured calcaneofibular ligament or the talofibular ligament. Sprain-fractures are treated in the same manner as the grade of sprain they represent and can be treated by the primary care physician unless they are clinically a Grade III1.

·        Peroneal tendon injuries are associated with Grades II and III ankle sprains of the inversion type. Peroneal tendons (longus and brevis) traverse distal to the lateral malleolus, and their retaining retinacula are sometimes torn with sprains of the ankle. Examination includes dorsiflexion/eversion of the foot and having the patient resist passive inversion. This forces the injured tendon to ride up over the lateral malleolus. Treatment is a short leg cast with ankle in 30 degree plantar flexion for six weeks.

·        Traction injuries to the peroneal and sural nerves can occur with sprains of the ankle. They are detected by careful palpation of the nerves for tenderness. The sural nerve runs posterior and distal to the lateral malleolus. Injury to these nerves may occasionally lead to reflex sympathetic dystrophy. 12. The Ottawa rules, developed by Stiell, et al., identify those cases of ankle sprain that need x-rays. Fractures commonly associated with ankle sprains include the following:

·        Talus (lateral process) fracture

·        Osteochondral fractures of the dome of the talus (may require MRI or bone scan of the tibial-talar joint for diagnosis)

·        Calcaneus-anterior process fractures

·        Fracture of base or shaft of fifth metatarsal

 

·        Stress x-rays may be indicated in acute sprains, but they are more commonly used in unstable chronic sprains to delineate the degree of ligamentous laxity present. Stress x-rays are usually performed by a radiologist or an orthopedic surgeon.

·        Syndesmosis refers to joints, such as the tibiofibular joint, held by ligaments without articular surfaces. The syndesmosis of the ankle is the tibiofibular ligament between the distal fibula and the tibia. Disruption of the tibiofibular ligament will demonstrate tenderness over that area and can be detected by a positive "squeeze test" and a special x-ray view of the ankle with the tibia held firmly and the foot rotated externally (which may show widening of the ankle mortise). This injury is often a surgical problem and should be referred to an orthopedic surgeon for treatment.

·        The squeeze test is accomplished by grasping the tibia in the palm of one hand and the fibula in the other and squeezing them together in the lower third. Pain in the area just above the ankle mortise on the lateral side is a sign of syndesmosis injuries.

·        The anterior drawer test is for abnormal anterior/posterior motion of the ankle following a sprain. It is performed by firmly applying pressure on the anterior distal tibia and grasping the os calcis posteriorly and pulling anteriorly. Excess motion when compared with the contralateral side is judged a positive test or positive "anterior drawer sign."

·        Inversion instability is tested by holding the distal end of the tibia and fibula firmly. The calcaneus is grasped with the other hand into maximum inversion and eversion. Comparison is made with the contralateral side. See Inversion stress test.

·        Sprains that are not responding to therapy are often an indication to x-ray or repeat x-ray to check for fractures not previously detected, such as osteochondral fractures of the talus.

·        Approximately 10-20% of all sprains will either fail conservative management or will be severe enough to require orthopedic evaluation. A review of 12 studies comparing surgery with functional treatment shows that controlled movement is the treatment of choice for lateral ligament injuries of the ankle. Patients who had failed conservative therapy and delayed surgical repair had as good results from the surgery as patients who had primary surgery. Possible contraindications to nonsurgical management of ankle sprains that require orthopedic referral include the following:

·        Associated displaced osteochrondral fracture

·        Displaced anterior tibial lip fracture

·        Chronic instability

·        Combined medial and lateral ligamentous injuries

 

 

Laceration [ICD-9 Codes: 891.X]

 

ODG Return-To-Work Pathways

Minor: 0 days
Major, clerical/modified work: 3 days
Major, manual work: 8 days
Major, heavy manual work: 14 days

Tendon repair, clerical/modified work: 14 days

Tendon repair, manual work: 91 days

 

Achilles Tendonitis [ICD-9 Codes: 726.71, 726.72, 726.79, 727.06, 727.67, 727.81, 845.09]

 

ODG Return-To-Work Pathways

Without surgery, clerical/modified work: 0 days
Without surgery, manual/standing work: 5-7 days
With surgery, clerical/modified work: 7-10 days
With surgery, manual/standing work: 42-49 days

__________________

1 Definition of Sprain/Strain Severity Grade: In general, a Grade I or mild sprain/strain is caused by overstretching or slight tearing of the ligament/muscle/tendon with no instability, and a person with a mild sprain usually experiences minimal pain, swelling, and little or no loss of functional ability. Although the injured muscle is tender and painful, it has normal strength. A Grade II sprain/strain is caused by incomplete tearing of the ligament/muscle/tendon and is characterized by bruising, moderate pain, and swelling, and a Grade III sprain/strain means complete tear or rupture of a ligament/muscle/tendon. A sprain is a stretch and/or tear of a ligament (a band of fibrous tissue that connects two or more bones at a joint). A strain is an injury to either a muscle or a tendon (fibrous cords of tissue that connect muscle to bone). (Hannafin-NIH, 2004)

 

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Codes for Automated Approval

Note: Ideally each claim should be managed based on the details of the case using the Procedure Summary.  The codes below are provided for payors without the resources to manage each case, who want to auto-pay the more routine claims based only on the diagnosis and procedure codes. These recommendations may be used to approve a treatment, but lack of inclusion on this list may not be used to deny a treatment. Only the Procedure Summary has a complete list of all approved treatments, including any detailed criteria for use. This is also a partial list of diagnoses covered by ODG. For a complete list of diagnoses covered, use the appropriate ICD9 diagnosis code in the RTW guidelines to access the ODG UR Advisor.

Diagnoses

ICD9 Code

Name

824.x

Fracture of ankle

837.x

Dislocation of ankle

Procedures allowed:

 

CPT® Code

 

Name

Maximum

Occurrences

99202

Office/outpatient visit new

1

99203

Office/outpatient visit new

99283

Emergency dept visit

1

99212

Office/outpatient visit est.

5

99213

Office/outpatient visit est.

99204

Office consult, mod complexity

1

99243

Office consult, mod complexity, specialist

1

99244

Office consult, mod complexity, specialist

73600

X-ray exam, ankle, 2 views

2

73610

X-ray exam, ankle, 3 views

73721

MRI, lower extremity joint

1

97001

Physical therapy evaluation

1

97110

Physical therapy procedure

8

97002

Physical therapy re-evaluation

1

97530

Therapeutic activities/exercises

6

29515

Leg splint

1

29405

Leg cast

1

29425

Walking cast

1

27760

Closed treatment of medial malleolus fracture

1

27786

Closed treatment of distal fibular fracture

27818

Closed reduction of trimalleolar fracture

27810

Closed reduction of bimalleolar fracture

27822

Open treatment of trimalleolar fracture

27814

Open treatment of bimalleolar fracture

01480

Anesthesia

1

20680

Removal of support implant

1

 

Diagnosis

ICD9 Code

Name

845.x

Sprain

Procedures allowed:

 CPT Code

Name

Maximum

99202

Office/outpatient visit new

1

99203

Office/outpatient visit new

99283

Emergency dept visit

1

99212

Office/outpatient visit est.

5

99213

Office/outpatient visit est.

99204

Office consult, mod complexity

1

99243

Office consult, mod complexity, specialist

1

73600

X-ray exam, ankle, 2 views

1

73610

X-ray exam, ankle, 3 views

97001

Physical therapy evaluation

1

97110

Physical therapy procedure

8

97002

Physical therapy re-evaluation

1

97530

Therapeutic activities/exercises

6

29515

Leg splint

1

29405

Leg cast

1

29425

Walking cast

1

 

CPT © 2008 American Medical Association. All Rights Reserved.
No fee schedules, basic units, relative values or related listings are included in CPT. AMA does not directly or indirectly practice medicine or dispense medical services. AMA assumes no liability for data contained or not contained herein.

CPT is a registered trademark of the American Medical Association

 

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Procedure Summary – Ankle & Foot

Procedure/topic

Summary of medical evidence

Click to jump ahead: A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | R | S | T | U | V | W

Accommodative modalities

Not recommended for plantar fasciitis. Evidence indicates mechanical treatment with stretching, prefabricated shoe inserts, taping and orthoses to be more effective than accommodative modalities in the treatment of plantar fasciitis. (Pfeffer, 1999) (Lynch, 1998) (Aldridge, 2004)

Achilles tendon ruptures (treatment)

Recommended as indicated below. Open operative treatment of acute Achilles tendon ruptures significantly reduces the risk of rerupture compared to non-operative treatment, but produces a significantly higher risk of other complications, including wound infection. The latter may be reduced by performing surgery percutaneously. Post-operative splintage in a functional brace appears to reduce hospital stay, time off work and sports, and may lower the overall complication rate. (Khan-Cochrane, 2004) Six months of nonsurgical therapy is appropriate for middle-aged patients or athletes with chronic Achilles tenosynovitis. Those that fail this treatment will improve with a limited debridement of diseased tissue without excessive soft tissue dissection of the tendon. Those patients who respond to nonoperative therapy tend to be younger than those who have degenerative tendon changes requiring surgery. (Johnston, 1997) Open operative treatment of acute Achilles tendon ruptures significantly reduces the risk of rerupture compared with nonoperative treatment, but operative treatment is associated with a significantly higher risk of other complications. Operative risks may be reduced by performing surgery percutaneously. Postoperative splinting with use of a functional brace reduces the overall complication rate. (Khan, 2005) Comparisons of surgically and nonsurgically treated Achilles tendon ruptures have demonstrated that those treated with surgery allow earlier motion and tend to show superior results. However, early motion enhances tendon healing with or without surgery and may be the important factor in optimizing outcomes in patients with Achilles tendon rupture. This RCT supports early motion (progressing to full weightbearing at 8 weeks from treatment) as an acceptable form of rehabilitation in both surgically and nonsurgically treated patients with comparable functional results and a low rerupture rate. (Twaddle, 2007) Acute Achilles tendons ruptures may be managed either operatively or non-operatively. However, generally 6 weeks following a rupture a direct repair opposing the tendon ends becomes increasingly difficult. Over time, scar tissue forms, the muscles atrophy with disuse, and the tendon ends weaken. Chronic and neglected Achilles tendon ruptures are debilitating: their optimal management is surgical. (Carmont, 2007) In this study, patients with acute Achilles tendon rupture who underwent mobilization and rehabilitation within 72 hours of their injury reported outcomes similar to those in patients treated with surgery. The surgical patients had better function in one test, the heel-rise test, but otherwise outcomes were the same. (Helander, 2010) This systematic review covered evidence for interventions specific to insertional Achilles tendinopathy (damage where the tendon attaches to the heel bone), and concluded that the sub-group of patients with insertional Achilles tendinopathy is even more difficult to manage. Conservative methods should be used before operative interventions, favoring eccentric loading, while evaluation of operative interventions has been mostly retrospective and remains inconclusive. (Kearney, 2010) Open surgical repair of an Achilles tendon rupture significantly reduces the risk of a re-rupture, according to a new meta-analysis, but non-operative management should be strongly considered in patients who will put less demand on the tendon. The re-rupture rate was 3.6% in patients treated surgically and 8.8% in patients managed nonoperatively, but 2.36% of surgery patients developed deep infections, which didn't arise at all in the nonsurgical group. Risk factors for deep infections include age above 60, diabetes, corticosteroids, and smoking. Patients with these risk factors are also likely to place less demand on the tendon, and non-operative management should be strongly considered for them. (Wilkins, 2012) Whether surgical or nonsurgical treatment is best for Achilles tendon rupture depends on whether patients undergo early range-of-motion functional rehabilitation, according to a meta-analysis. Without this rehabilitation, surgery reduces the risk for rerupture by 8.8% over nonsurgical treatment. The authors concluded that nonsurgical treatment is a reasonable treatment choice at centers that use functional rehabilitation with early range of motion since surgical repair did not decrease the rerupture rate and was associated with a higher rate of other complications, but given that not all complications are major, some patients and surgeons may consider the increased rate of other complications following surgical treatment to be an acceptable trade-off for the reduced rerupture rate if functional ROM rehab is not available. (Soroceanu, 2012) See also Surgery for achilles tendon ruptures.

Activity restrictions

See Work.

Actovegin

Not recommended. The results of an experimental preparation of a calf-derived deproteinized haemodialysate, Actovegin, were promising for the treatment of Achilles tendinitis, but the severity of patient symptoms was questionable in the single small trial testing this comparison. (McLauchlan-Cochrane, 2002) In a recent study better recovery time from injury was demonstrated with autologous conditioned serum (ACS) compared with Actovegin. (Wright-Carpenter, 2004) Actovegin is not approved for sale, importation, or use in the United States. This potentially performance-enhancing drug for athletes is under investigation by U.S. authorities. It is an extract of calf blood produced by Nycomed Austria GmbH. In research studies, Actovegin has been shown to exert insulin-like activity, such as stimulating the transport of glucose in the body, as well as glucose oxidation. (FDA, 2011)

Acupuncture

No quality studies for the ankle. See the Pain Chapter.

Adult aquired flatfoot (pes planus)

Recommend conservative treatment for at least the first 6-8 weeks before consideration of surgery. Originally known as posterior tibial tendon dysfunction or insufficiency, adult-acquired flatfoot deformity encompasses a wide range of deformities. Establishing a diagnosis as early as possible is one of the most important factors in treatment, and prompt early, aggressive nonsurgical management is important. A patient in whom such treatment fails should strongly consider surgical correction to avoid worsening of the deformity. Medical or nonoperative therapy for posterior tibial tendon dysfunction involves rest, immobilization, nonsteroidal anti-inflammatory medication, physical therapy, orthotics, and bracing. There are 4 stages of posterior tibial tendon dysfunction used to dictate treatment: (1) Stage 1 is characterized by peritendinitis and tendon degeneration, but the tendon length remains normal, and this stage presents clinically as pain and swelling along the posterior tibial tendon sheath; (2) In Stage 2, the posterior tibial tendon elongates, and a supple flat foot deformity develops, but, although deformed on weight bearing, the hindfoot and midfoot deformities are passively correctable to neutral; (3) Stage 3 occurs over time as the hindfoot becomes rigid in a valgus position, and the patient develops a rigid flatfoot deformity; & (4) Stage 4 develops as the deltoid ligament becomes incompetent and the talus tilts into valgus within the ankle mortise. The following is a summary of conservative treatments for acquired flatfoot by stage: (1) Stage 1 - NSAIDs and short-leg walking cast or walker boot for 6-8 weeks, full-length semirigid custom molded orthosis, physical therapy; (2) Stage 2 - UCBL orthosis (well fitted anti pronation foot orthotic) or short articulated ankle orthosis; (3) Stage 3 - Molded AFO, double-upright brace, or patellar tendon–bearing brace; & (4) Stage 4 - Molded AFO, double-upright brace, or patellar tendon–bearing brace. The following is a summary of surgical treatments for acquired flatfoot by stage: (1) Stage 1 - Tenosynovectomy, tendon debridement, and tendon repair of partial tears; (2) Stage 2 - Add Achilles tendon lengthening or gastrocnemius recession in cases of equinus contracture; (3) Stage 3 - Subtalar fusion, Triple arthrodesis; (4) Stage 4 - Tibiotalocalcaneal fusion, Pantalar fusion. See also Fusion (arthrodesis). During stage 1, pain, rather than deformity, predominates. Cast immobilization is indicated for acute tenosynovitis of the posterior tibial tendon or for patients whose main presenting feature is chronic pain along the tendon sheath. A well-molded short leg walking cast or removable cast boot should be used for 6-8 weeks. Weight bearing is permitted if the patient is able to ambulate without pain. If improvement is noted, the patient then may be placed in custom full-length semirigid orthotics, and the patient may then be referred to physical therapy for stretching of the Achilles tendon and strengthening of the posterior tibial tendon. In stage 2 dysfunction, a painful flexible deformity develops, and more control of hindfoot motion is required. In these cases, a rigid University of California at Berkley (UCBL) orthosis or short articulated ankle-foot orthosis (AFO) is indicated. (Deland, 2008) (Lee, 2005) (Kelly, 2001) See also Surgery for posterior tibial tendon ruptures.

Aircast

See Semi-rigid ankle support.

Allograft for ankle reconstruction

Recommended as indicated below. Percutaneous lateral ligament reconstruction with allograft may be a useful method as a salvage procedure for the treatment of severe and complicated types of chronic lateral ankle instability. (Youn, 2012) See also Lateral ligament ankle reconstruction (surgery).

Criteria for allograft for ankle reconstruction --

At least one of the following criteria:

- Previously failed reconstruction of the ligament

- Severe ankle instability (more than 15 degrees of talar tilt, more than 10 mm of anterior drawer)

- General laxity of ligaments

- Body mass index (BMI) higher than 25

Ankle foot orthosis (AFO)

Recommended as an option for foot drop. An ankle foot orthosis (AFO) also is used during surgical or neurologic recovery. The specific purpose of an AFO is to provide toe dorsiflexion during the swing phase, medial and/or lateral stability at the ankle during stance, and, if necessary, push-off stimulation during the late stance phase. An AFO is helpful only if the foot can achieve plantigrade position when standing. Any equinus contracture prohibits its successful use. The most commonly used AFO in foot drop is constructed of polypropylene and inserts into a shoe. If it is trimmed to fit anterior to the malleoli, it provides rigid immobilization. This is used when ankle instability or spasticity is problematic, such as in patients with upper motor neuron diseases or stroke. If the AFO fits posterior to the malleoli (posterior leaf spring type), plantar flexion at heel strike is allowed, and push-off returns the foot to neutral for the swing phase. This provides dorsiflexion assistance in instances of flaccid or mild spastic equinovarus deformity. A shoe-clasp orthosis that attaches directly to the heel counter of the shoe also may be used. (Geboers, 2002)

Ankle prostheses (total ankle replacement)

See Arthroplasty (total ankle replacement).

Anterior drawer test

Recommended as the most sensitive test for ankle sprain. Indications for the ankle anterior drawer test: lateral ankle sprain evaluation. Advantages in evaluation of ankle stability: most sensitive test and least painful test. Technique: (1) patient positions foot in slight plantar flexion, (2) brace anterior shin with left hand, (3) pull heel anteriorly with right hand, (4) positive test findings are laxity and poor endpoint on forward translation. Interpretation of positive test: Grade II-III1 ankle sprain (Litt, 1992), anterior talofibular ligament rupture, possible calcaneofibular ligament rupture (tested with Inversion stress test). (Bulucu, 1991) (Tohyama, 2003) Special tests such as the anterior drawer and inversion talar tilt tests have more diagnostic accuracy five days after injury than two days after injury. (Kaminski, 2013)

Anti-inflammatory medications (NSAIDs)

Recommended. In treating acute ankle sprains, non-steroidal anti-inflammatory drugs (NSAIDS) provide increased pain relief and a more rapid return to activity compared with a placebo group. (Slatyer, 1997) However, in treating fractures NSAIDs are associated with side effects that are deleterious to treatment outcome, including delay in bone healing. (Biederman, 2005) For detailed information see the PAIN Chapter of ODG Treatment.

Arizona Brace

See Bracing (immobilization). Not recommended in the absence of a clearly unstable joint. There are no quality published studies specific to the Arizona Brace.

Arthrodesis (fusion)

See Fusion.

Arthrography

See MR arthrogram.

Arthroplasty (total ankle replacement)

Not recommended for total ankle using cemented devices approved via the FDA 510(k) process. [The FDA 510(k) process does not require data demonstrating improved outcomes.] Under study for first metatarsophalangeal joint implant arthroplasty. Recommended as an option in selected patients for non-constrained uncemented devices with FDA PMA approval. See Scandinavian total ankle replacement system (STAR). Total ankle replacement has been investigated since the 1970s with initially promising results, but the procedure was essentially abandoned in the 1980s due to a high long-term failure rate, both in terms of pain control and improved function. Currently, four ankle prostheses are commercially available or under investigation in the U.S. The main alternative to total ankle replacement is arthrodesis. While both procedures are designed to reduce pain, the total ankle replacement is additionally intended to improve function. At the present time there are inadequate data on available total ankle replacements to permit conclusions regarding their safety and effectiveness. (BlueCross BlueShield, 2004) (SooHoo, 2004) (Stengel, 2005) (Valderrabano, 2007) (Vickerstaff, 2007) Nearly 86% of patients who undergo implant arthroplasty for end-stage degenerative disease of the first metatarsophalangeal joint (MPJ) are satisfied with the outcome, findings from a meta-analysis suggest. The satisfaction rate was even higher when lower quality studies were excluded from the analysis. A number of studies have evaluated these implants over the years, however, they have generally focused on a particular device brand or model, and this is the first meta-analysis that focuses on first MPJ replacement. In terms of implant materials, the findings suggest that metallic hemi, silicone total, metallic total, and ceramic total yield higher patient satisfaction than does silicone hemi. (Cook, 2009) See also Focal joint resurfacing.

For average hospital LOS if criteria are met, see Hospital length of stay (LOS).

Arthroscopy

Recommended. An arthroscope is a tool like a camera that allows the physician to see the inside of a joint, and the surgeon is sometimes able to perform surgery through an arthroscope, which makes recovery faster and easier. Having started as a mainly diagnostic tool, ankle arthroscopy has become a reliable procedure for the treatment of various ankle problems. (Stufkens, 2009) Ankle arthroscopy provides the surgeon with a minimally invasive treatment option for a wide variety of indications, such as impingement, osteochondral defects, loose bodies, ossicles, synovitis, adhesions, and instability. Posterior ankle pathology can be treated using endoscopic hindfoot portals. It compares favorably to open surgery with regard to less morbidity and a quicker recovery. (de Leeuw, 2009) There exists fair evidence-based literature to support a recommendation for the use of ankle arthroscopy for the treatment of ankle impingement and osteochondral lesions and for ankle arthrodesis. Ankle arthroscopy for ankle instability, septic arthritis, arthrofibrosis, and removal of loose bodies is supported with only poor-quality evidence. Except for arthrodesis, treatment of ankle arthritis, excluding isolated bony impingement, is not effective and therefore this indication is not recommended. Finally, there is insufficient evidence-based literature to support or refute the benefit of arthroscopy for the treatment of synovitis and fractures. (Glazebrook, 2009) See also Diagnostic arthroscopy, or the Surgery listings for detailed information on specific treatments that may be done arthroscopically.

Arthrosurface HemiCAP

Recommended as an option. See Focal joint resurfacing.

Autologous blood-derived injections

Not recommended except in a research setting, as high quality evidence is either lacking or inconsistent. See Autologous conditioned serum; Autologous whole blood; Platelet-rich plasma (PRP). Autologous blood-derived injections include platelet-rich plasma, autologous conditioned serum, and autologous whole blood. Platelet rich plasma (PRP) is a bioactive component of whole blood, with a higher concentration of platelets compared with baseline blood, and containing many growth factors, including platelet-derived growth factor, transforming growth factor, insulin-like growth factor, and vascular endothelial growth factor. The theory is that a concentrated preparation of PRP, with its inherent growth factors, may promote faster healing of injuries, when an area of injury is injected with PRP derived from the patient’s own blood (autologous). PRP injection(s) may be administered in an outpatient setting. Autologous conditioned serum (ACS) is produced by incubating a patient’s venous blood in the presence of medical grade glass beads inducing the white blood cells in the blood sample to produce interleukin-1 receptor antagonist, the biological antagonist of interleukin-1 (IL-Ra), a key agent in osteoarthritis or intervertebral disc degeneration/prolapse pathology. The proposed theory behind the therapy is that IL-1Ra acts as an anti-inflammatory, relieves pain and protects joint cartilage. The injections may be administered in an outpatient setting and generally consists of a series of six injections given once or twice weekly. Autologous whole blood injection is a re-injection, at an injury site, of a few millimeters of blood taken from the patient. These autologous blood-derived injections are considered therapies and therefore are not regulated by the FDA. These techniques have been studied clinically in humans to a very limited degree so far, and the evidence is insufficient to recommend them for routine clinical use. (Creaney, 2008)

Autologous conditioned serum (ACS)

Not recommended. Better recovery time from injury was demonstrated with autologous conditioned serum (ACS) compared with Actovegin. (Wright-Carpenter, 2004) These techniques have been studied clinically in humans to a very limited degree so far, and the evidence is insufficient to recommend this modality for routine clinical use. (Creaney, 2008) Autologous conditioned serum (ACS) is produced by incubating a patient’s blood, inducing the white blood cells in the blood sample to produce interleukin-1 receptor antagonist, a key agent in osteoarthritis pathology. The proposed theory behind the therapy is that IL-1Ra acts as an anti-inflammatory, relieves pain and protects joint cartilage. The injections may be administered in an outpatient setting and generally consists of a series of six injections given once or twice weekly. See also Autologous blood-derived injections.

Autologous whole blood

Not recommended. The data available for for autologous whole blood injections are limited and are currently insufficient to recommend this modality for routine clinical use. (Kampa, 2010) Autologous whole blood injection is a re-injection, at an injury site, of a few millimeters of blood taken from the patient. See also Autologous blood-derived injections

Barefoot running (versus shoes)

Recommended as an option for experienced runners. Barefoot running changes the amount of work done at the knee and ankle joints and this may have therapeutic and performance implications for runners. The dynamics of running overground while barefoot are different to that of running in a minimalist shoe that has cushioning and an elevated heel. Running barefoot induces mechanical changes to habitually shod highly trained runners gait and it is inherently different to shod running. The increase in work done at the ankle must be considered when transitioning to running barefoot as too rapid a transition may overload the triceps surae complex. Conversely, the reduction in joint moments and work done at the knee while running barefoot may provide potential benefits for the management of knee pain and injury. Most modern running shoes typically feature heavily cushioned and elevated heels, thick midsoles, arch supports and motion control features. While manufacturers have developed minimalist running shoes, which have a lower profile, greater sole flexibility, reduced heel-forefoot offset and lack motion control and the heavy cushioning features of conventional running shoes, there is little evidence to support the notion that the mechanics of running in a minimalist shoe is different to a conventional running shoe and/or similar to barefoot running. (Bonacci, 2013) See also Barefoot walking in the Knee Chapter.

Bed rest

Not recommended beyond 24 hours. RICE (rest, ice, compression, elevation) is appropriate for first 24 hours following sprain/fracture. Later, partial weight bearing as tolerated is recommended. (Kerkhoffs-Cochrane, 2002) (Shrier, 1995) (Colorado, 2001)

Biofeedback

Not recommended. There is little information available from trials to support the use of many therapeutic procedures for treating disorders of the ankle and foot, and there is no information to support the use of biofeedback for ankle injuries. In general, it would not be advisable to use these modalities beyond 2-3 weeks if signs of objective progress towards functional restoration are not demonstrated. (Crawford-Cochrane, 2002) (Colorado, 2001)

Bone growth stimulators

See Bone growth stimulators, electrical; & Bone growth stimulators, ultrasound.

Bone growth stimulators, electrical

Recommended as an option for non-union of long bone fractures. (Petrisor, 2005) See the Knee Chapter for specific indications.

Bone growth stimulators, ultrasound

Recommended as an option for non-union of long bone fractures or fresh fractures with significant risk factors. Also, limited studies show that patients who received post-operative low intensity ultrasound following ankle fusion showed a statistically significant faster healing rate on plain radiographs at 9 weeks and CT scan at 12 weeks. A 100% fusion rate was noted. (Coughlin, 2008) (Ishikawa, 2002) (Jones, 2006) (Khan, 2008) (Siska, 2008) Limited evidence has been shown for the use of ultrasound fracture healing in Charcot neuroarthropathy. (Strauss, 1998) See the Knee Chapter for specific indications.

Bone scan (imaging)

Recommended as indicated below. Bone scanning is generally accepted, well established and widely used. Bone scanning is more sensitive but less specific than MRI. (Colorado, 2001) (ACR-foot, 2002)

Indications for imaging -- Bone Scan (Radioisotope Bone Scanning):

Bone scans may be utilized to rule out:

o         Tumor (suspected neoplastic conditions of the lower extremity)

o         Stress fractures in chronic cases (occult fractures, especially stress fractures, may not be visible on initial x-ray; a follow-up radiograph and/or bone scan may be required to make the diagnosis)

o         Infection (99MTechnecium diphosphonate uptake reflects osteoblastic activity and may be useful in metastatic/primary bone tumors, stress fractures, osteomyelitis, and inflammatory lesions, but cannot distinguish between these entities.)

o         Complex regional pain syndrome/CRPS-I/ Reflex sympathetic dystrophy (discontinued nomenclature), if plain films are not diagnostic

Botox®

See Botulinum toxin.

Botulinum toxin

Under study for plantar fasciitis. There is limited evidence at this point. A small RCT concluded that botulinum toxin A injection for plantar fasciitis yields significant improvements in pain relief and overall foot function at both 3 and 8 weeks after treatment. (Babcock, 2005) This review concluded that the weight of evidence is in favor of BTX type A as a treatment in plantar fasciitis. (Jeynes, 2008) In this small RCT in patients with chronic plantar fasciitis, the positive effect detected six months after treatment with botulinum toxin type A was maintained at 12 months and there was a further improvement in pain and foot function. (Díaz-Llopis, 2013) In this RCT a combination of BTX-A and plantar fascia stretching exercises yielded better results for the treatment of plantar fasciitis than intralesional steroids. (Elizondo-Rodriguez, 2013)

Bracing (immobilization)

Not recommended in the absence of a clearly unstable joint. Functional treatment appears to be the favorable strategy for treating acute ankle sprains when compared with immobilization. Partial weight bearing as tolerated is recommended. However, for patients with a clearly unstable joint, immobilization may be necessary for 4 to 6 weeks, with active and/or passive therapy to achieve optimal function. (Kerkhoffs-Cochrane, 2002) (Shrier, 1995) (Colorado, 2001) (Aetna, 2004) After Achilles tendon repair, patients splinted with a functional brace rather than a cast post-operatively tended to have a shorter in-patient stay, less time off work and a quicker return to sporting activities. There was also a lower complication rate (excluding rerupture) in the functional brace group. (Khan-Cochrane, 2004) In a randomized, controlled trial of a removable brace versus casting in younger patients with low-risk ankle fractures, treatment with a removable ankle brace was superior to treatment with a cast. (Boutis, 2007) According to this systematic review of treatment for ankle sprains, for mild-to-moderate ankle sprains, functional treatment options (which can consist of elastic bandaging, soft casting, taping or orthoses with associated coordination training) were found to be statistically better than immobilization for multiple outcome measures. (Seah, 2011) It is recommended to use a brace or a tape to prevent a relapse after ankle sprain, but also to phase out the use of brace or tape in time. The use of tape or a brace reduces the risk of recurrent inversion injuries, but is unclear whether a brace is more effective than a tape. The preference for the choice of a brace or a tape depends on the individual situation, but due to considerations about practical usability and evaluation of costs, a brace is initially preferable to tape. (Kerkhoffs, 2012)

Cam walker

See Cast (immobilization). A cam walker is a brand name for what is basically a removable cast.

Cast (immobilization)

Not recommended in the absence of a clearly unstable joint or a severe ankle sprain. Functional treatment appears to be the favorable strategy for treating acute ankle sprains when compared with immobilization. Partial weight bearing as tolerated is recommended. However, for patients with a clearly unstable joint, immobilization may be necessary for 4 to 6 weeks, with active and/or passive therapy to achieve optimal function. (Kerkhoffs-Cochrane, 2002) (Shrier, 1995) (Colorado, 2001) In young patients with low-risk ankle fractures, treatment with a removable ankle brace leads to greater activity level and faster return to baseline activity level vs treatment with a cast, and the removable ankle brace is also more cost-effective and preferred by more patients than treatment with a cast. (Boutis, 2007) A 10-day period of immobilization in a below-knee cast or Aircast results in a more rapid recovery from severe ankle sprain compared with the current clinical practice of mobilization after a severe ankle sprain according to an RCT in The Lancet. The researchers conclude that below-knee cast is a better choice for clinicians treating severe ankle sprains than a tubular compression bandage because it aids recovery, lessens symptoms, and helps patients return to normal function. The results of the study call into question the current standard of aggressive functional treatment of patients recovering from acute ankle sprains. (Lamb, 2009) According to this systematic review of treatment for ankle sprains, for severe ankle sprains, a short period of immobilization in a below-knee cast or pneumatic brace results in a quicker recovery than tubular compression bandage alone. (Seah, 2011) For patients with temporary artificial functional limb length discrepancy (LLD) sequelae from use of a CAM immobilization device, a temporary lift (eg, a device designed to attach to the contralateral shoe to compensate for the boot-induced functional LLD) can produce a more normal gait by eliminating the functional LLD and avoiding the symptoms commonly associated with a LLD. It is not necessary to put a CAM walker on an uninjured leg to correct the LLD when the injured leg is in such a device. (Song, 2009) See also Immobilization; & Limb length temporary adjustment device.

Causality (determination)

Recommended as indicated below. Determination of causation typically involves mechanism of injury, temporal relationship, and dose effect. Plantar fasciitis does not appear to be caused by occupations requiring walking or standing or prolonged use of ladders; instead, body mass index (BMI) and age are the primary variables that are significantly associated with this disability, but it is possible that work activities could aggravate symptoms and therefore accommodations should be made if necessary. (Riddle, 2004) Similar findings apply to other cumulative trauma disorders of the foot and ankle. (Guyton, 2000) Obesity and pronated foot posture are associated with Chronic plantar heel pain (CPHP) and may be risk factors for the development of the condition. Decreased ankle dorsiflexion, calf endurance and occupational lower limb stress do not seem to play a role in CPHP. There is no association for calf endurance or time spent sitting, standing, walking on uneven ground, squatting, climbing or lifting. (Irving, 2007) See also Work; & ODG Capabilities & Activity Modifications for Restricted Work.

ODG Causality Likelihood. Based on the raw data, Causality Likelihood indicates the benchmark percentage of total lost workdays, both occupational and non-occupational, that are occupational in nature. It can be used statistically to estimate what percentage of costs for this condition is represented by workers' comp. This indicator should not be used in an industrial injury setting to imply a likelihood of causation. See Preface for more information.

355.5 Tarsal tunnel syndrome, Causality Likelihood: Zero

716 Other and unspecified arthropathies, Causality Likelihood: Zero

726.7 Enthesopathy of ankle and tarsus, Causality Likelihood: 6%

727.8 Other disorders of synovium, tendon, and bursa, Causality Likelihood: Under 5%

728.7 Other fibromatoses, Causality Likelihood: Under 5%

735 Acquired deformities of toe, Causality Likelihood: Under 5%

823 Fracture of tibia and fibula, Causality Likelihood: Under 5%

824 Fracture of ankle, Causality Likelihood: Under 5%

837 Dislocation of ankle, Causality Likelihood: Under 5%

845 Sprains and strains of ankle and foot, Causality Likelihood: 70%

891 Open wound of knee, leg [except thigh], and ankle, Causality Likelihood: Under 5%

924 Contusion of lower limb and of other and unspecified sites, Causality Likelihood: 33%

928 Crushing injury of lower limb, Causality Likelihood: Under 5%

Charcot arthropathy surgery

See Surgery for charcot arthropathy.

Chiropractic

See Manipulation.

Closed reduction for toe

For treatment of a dislocated MTP joint, see Turf toe treatment (hyper dorsiflexion first meta tarso phalangeal joint).

Coblation therapy

Under study. Coblation devices direct radiofrequency energy, rupturing target tissue cells and disintegrating molecules with minimal heat production. Coblation technology can be delivered by a variety of wands, hand pieces and stylette tips used at different anatomic sites. Coblation-based wands such as the Topaz Microdebrider (ArthroCare Corporation, Sunnyvale, CA) are used for debridement, decompression, and removal of soft tissue during minimally invasive arthoscopic procedures involving tendons in the ankle and foot. Currently, there are no randomized controlled trials in the medical literature demonstrating the efficacy of Coblation technology and related devices for treatment of joint or musculoskeletal soft tissue conditions. Further prospective, randomized studies with large sample sizes reporting long-term outcomes are needed to demonstrate the safety and efficacy of this approach compared to established methods of management of musculoskeletal conditions. Topaz coblation or Topaz radiofrequency is often used by podiatrists as a treatment for recalcitrant tendon problems of the foot such as the achilles or peroneal tendinosis or for plantar fasciitis. (Sherk, 2002) Coblation using a radiofrequency (RF) probe is a minimally invasive procedure for treating chronic tendinopathy. It has been described for conditions including tennis elbow and rotator cuff tendinitis. There have been no quality studies to show the effectiveness of this procedure for plantar fasciitis. In a small case series, early results were encouraging in using Topaz RF coblation microtenotomy for the treatment of recalcitrant plantar fasciitis. (Sean, 2010) RF therapy for chronic achilles tendinitis produced satisfactory results in this case series. (Liu, 2008) See also Radiofrequency epicondylitis treatment (Topaz procedure) in the Elbow Chapter.

Cold packs

Recommended. Regular local application of cold packs is appropriate following acute injury for 24 to 48 hours and with continued swelling. RICE (rest, ice, compression, elevation) is appropriate for first 24 hours for sprain/fracture. (Colorado, 2001) Ice works better than heat to speed recovery. (Thompson, 2003) There is evidence that ice plus exercise is most effective after ankle sprain and postsurgery. (Bleakley, 2004) See also Ice packs.

Compression

See Rest (RICE).

Computed tomography (CT)

Recommended. CT provides excellent visualization of bone and is used to further evaluate bony masses and suspected fractures not clearly identified on radiographic window evaluation. (Colorado, 2001) (ACR-ankle, 2002) (ACR-foot, 2002) See also ACR Appropriateness Criteria™.

Continuous-flow cryotherapy

Not recommended. In the postoperative setting, continuous-flow cryotherapy units have been proven to decrease pain, inflammation, swelling, and narcotic usage; however, the effect on more frequently treated acute injuries in the ankle and foot has not been fully evaluated. Continuous-flow cryotherapy units provide regulated temperatures through use of power to circulate ice water in the cooling packs. Most studies are for the knee; evidence is marginal that treatment with ice and compression is as effective as cryotherapy after an ankle sprain. (Hubbard, 2004) (Wilke, 2003) (Stockle, 1995)

Corticosteroids (topical)

Under study. Not widely used or recommended, but limited evidence exists for the effectiveness of local corticosteroid therapy in reducing plantar heel pain. Topical corticosteroid administered by iontophoresis may be more effective than injected corticosteroid. (Crawford, 2002) (Crawford-Cohrane, 2003)

Cryotherapy

See Cold packs; Continuous-flow cryotherapy; & Ice packs.

Deep vein thrombosis (DVT)

See Venous thrombosis.

Diabetes comorbidity

Under study. It is widely believed that diabetes mellitus affects fracture healing but present data suggests that diabetes mellitus in general does not affect the healing foot and ankle fractures - provided there is effective delivery of standard treatment in time. (Boddenberg, 2004) Diabetic complications may affect the outcome and early recognition and appropriate treatment of fractures in diabetic patients appears to be important in the prevention of Charcot joint changes. (Holmes, 1994) Tight glucose control may improve the fracture milieu and ameliorate the potential complications. Appropriate stable fixation with adequate length of immobilization is crucial for successful fracture resolution. (Bibbo, 2001) Some studies have shown that percutaneous delivery of platelet rich plasma (PRP) delivery at the fracture site normalized the early (cellular proliferation and chondrogenesis) parameters while improving the late (mechanical strength) parameters of diabetic fracture healing. These results suggest a role for PRP in mediating diabetic fracture healing and potentially other high risk fractures. (Gandhi, 2006) (Gandhi, 2005) Regarding sprains and strains, patients with diabetes may have decreased range of motion and increased stiffness. (Rao, 2006)

Diagnostic arthroscopy

Recommended as indicated below. Having started as a mainly diagnostic tool, there has been a gradual shift towards other, less invasive modalities to diagnose ankle pathology, leaving the arthroscope to be a mainly therapeutic tool. However, there are still some indications in which the diagnostic aspect of arthroscopy can be of value. These include articular assessment after ankle fracture and after ankle sprain. Absolute contraindications for ankle arthroscopy are infection and severe degenerative joint disease. Relative contraindications are joint space narrowing or moderate to severe arthrosis, vascular disease and oedema. In the past diagnostic arthroscopy was performed in cases of unexplained pain, swelling, stiffness, haemarthrosis, locking and ankle instability. The role of diagnostic ankle arthroscopy is currently limited due to the increased accuracy of radiological procedures and due to the fact that diagnostic ankle arthroscopy has been demonstrated to be associated with relatively poor outcome. (Stufkens, 2009) Second-look arthroscopy is not necessary to evaluate repaired talar cartilage compared to MRI. (Lee2, 2010) MRI has very high specificity and positive predictive value in diagnosing tears of the anterior talofibular ligament, calcaneofibular ligament and osteochondral lesions. However sensitivity was low with MRI. In a symptomatic patient with ligamentous and chondral pathology in the ankle, negative results on MRI must be viewed with caution and an arthroscopy may still be required for a definitive diagnosis and treatment. (Joshy, 2010)

Diathermy

Not recommended. There is little information available from trials to support the use of diathermy for treating disorders of the ankle and foot. (Crawford, 2002) (Van der Windt-Cochrane, 2001) (Peres, 2002) Ultrasound, laser, short-wave therapy and electrotherapy have no added value in lateral ankle injuries and are not recommended. (Kerkhoffs, 2012) May be an option for heat; see Heat therapy.

Dorsiflexion night splints

Recommended. In individuals with chronic plantar heel pain, there is limited evidence for the effectiveness of dorsiflexion night splints in reducing pain. . (Crawford, 2002) (Van der Windt-Cochrane, 2001) (Powell, 1998)

Drug therapy

See Medications.

Education (patient)

Recommended. Injured workers should receive instruction regarding the nature of their condition, risk factors, preventive measures and goals of therapy. They should be instructed in eliminating or modifying aggravating activities during treatment, and informed of norms on disability duration (see ODG). (Denniston-ODG) (Colorado, 2001)

Elastic bandage (immobilization)

Under study. For ankle sprains, the use of an elastic bandage has fewer complications than taping but appears to be associated with a slower return to work, and more reported instability than a semi-rigid ankle support. Lace-up ankle support appears effective in reducing swelling in the short-term compared with semi-rigid ankle support, elastic bandage and tape. (Kerkhoffs-Cochrane, 2002) According to this systematic review of treatment for ankle sprains, for mild-to-moderate ankle sprains, functional treatment options (which can consist of elastic bandaging, soft casting, taping or orthoses with associated coordination training) were found to be statistically better than immobilization for multiple outcome measures. (Seah, 2011)

Electrical stimulators (E-stim)

Not recommended. Ultrasound, laser, short-wave therapy and electrotherapy have no added value in lateral ankle injuries and are not recommended. (Kerkhoffs, 2012) See the Pain Chapter. See also Functional electrical stimulation (FES), Recommended for foot drop.

Electron generating device

Not recommended. There is no evidence to support the use of an electron-generating device in treating plantar heel pain. (Crawford, 2002)

Elevation

See Rest (RICE).

Exercise

Recommended. Exercise program goals should include strength, flexibility, endurance, coordination, and education. Patients can be advised to do early passive range-of-motion exercises at home by a physical therapist. (Colorado, 2001) Treatments that are used to reduce heel pain seem to bring only marginal gains over no treatment and control therapies such as stretching exercises. (Crawford-Cohrane, 2003) An unsupervised home based proprioceptive training programme given in addition to usual care is effective in reducing the incidence of recurrent ankle sprains in athletes. There was a twofold reduction in risk of recurrence, with the same effect for time loss because of recurrences, and ankle sprains leading to costs were 3.6 times higher in control athletes than in intervention athletes. Athletes in the intervention group received a balance board (Avanco AB, Sweden), exercise sheets, and an instructional DVD showing all exercises of the program. Proprioception is the sense of the relative position of neighboring parts of the body. The proprioceptive sense can be sharpened through many disciplines, including the Alexander Technique, standing on a wobble board or balance board, standing on one leg as used in such disciplines as Yoga, and the slow focused movements of Tai Chi. (Hupperets, 2009) After ankle fracture surgical fixation, commencing exercise in a removable brace or splint significantly improved activity limitation but also led to a higher rate of adverse events. Because of the potential increased risk, the patient's ability to comply with this treatment regimen is essential. (Lin, 2009) Inflammation of the Achilles tendon often resolves with exercise therapy alone, a new study concludes. A full recovery might take time, as tendons are often slow to heal, but sticking with exercise could help avoid more invasive treatments. Exercise therapy is known to be effective for Achilles tendinopathy, particularly so-called eccentric exercises where the calf muscles contract while being lengthened. (An example would be rising onto the balls of the feet, then slowly lowering the heels back to the ground.) A common recommendation is for people with Achilles tendinopathy to try exercise therapy for three months, and if they have not recovered at that point, to consider other options, but three months may be too short a time for a full recovery because a tendon can take a year to heal. In longer duration exercise therapy, people can learn exercises to perform on their own at home, and if needed, see their physical therapist for follow-ups. Patients' "fear of movement" was related to their long-term recovery of functional ability; those with a greater level of anxiety about exercising causing pain or raising the risk of an Achilles tendon rupture tended to show less recovery of their muscular endurance. (Silbernagel, 2010) Exercise therapy should be used in the treatment of lateral ankle injury, including at home. Exercise therapy also seems to prevent a recurrence over the long term. Rehabilitation after lateral ankle injury should include a variety of exercises in which propriocepsis, strength, coordination and function of the extremity are maintained. (Kerkhoffs, 2012)

Exostosis excision (for hallux valgus)

See Surgery for hallux valgus.

Extracorporeal shock wave therapy (ESWT)

Not recommended using high energy ESWT. Recommended using low energy ESWT as an option for chronic plantar fasciitis, where the latest studies show better outcomes without the need for anesthesia.

Plantar fasciitis: Trials in this area have yielded conflicting results. A high quality study concluded that, “Extracorporeal shock wave therapy is ineffective in the treatment of chronic plantar fasciitis”. (Haake-BMJ, 2003) (Blue Cross Blue Shield, 2003) A meta-analysis of data from six randomised-controlled trials that included a total of 897 patients was statistically significant in favor of low energy ESWT for the treatment of plantar heel pain but the effect size was very small. A sensitivity analysis including only high quality trials did not detect a statistically significant effect. (Thomson, 2005) ESWT should be done without local anesthesia (LA) in patients suffering from chronic heel pain. LA applied prior to treatment reduced the efficiency of ESWT. (Rompe, 2005) Success rates after low-energy ESWT with local anesthesia are significantly lower than after identical low-energy ESWT without local anesthesia. Higher energy levels could not balance the disadvantage of this effect. (Labek, 2005) Corticosteroid injection is more efficacious and multiple times more cost-effective than high energy ESWT in the treatment of plantar fasciopathy. (Porter, 2005) While another study also reported that ultrasound-guided ESWT is ineffective (in line with placebo) in the treatment of plantar fasciitis (Buchbinder-JAMA, 2002), others have reported conflicting evidence for the effectiveness of low energy extracorporeal shock wave therapy in reducing night pain, resting pain and pressure pain in the short term for heel pain/plantar fasciitis. (Crawford, 2002) (Crawford-Cohrane, 2003) (Hammer, 2002) Prior to these, ESWT was reported to be a safe and effective nonsurgical method for treating chronic, recalcitrant heel pain syndrome. (Ogden, 2001) (Ogden, 2002) (Rompe, 2002) (Rompe, 1996) (Weil, 2002) Other recent studies are mixed. (Theodore, 2004) (Lee, 2003) (Hammer, 2003) (Speed, 2003) The results of various measures both within and across the above studies did not provide consistent and compelling evidence that ESWT improved health outcomes related to plantar fasciitis. The improvements seen could have been a result of the natural course of the disease. (BlueCross BlueShield, 2004) From a recent clinical trial: The overall results were 69.1% excellent, 13.6% good, 6.2% fair, and 11.1% poor for the shockwave group; and 0% excellent, 55% good, 36% fair, and 9% poor for the control group. The recurrence rate was 11% for the shockwave group versus 55% for the control group. (Wang, 2006)

Recent research: A recent RCT with in 245 patients with chronic plantar fasciitis concluded that low energy ESWT without anesthesia was significantly superior to placebo, with a reduction of the visual analog scale composite score of 72.1% compared with 44.7%, and an overall success rate of 61.0% compared with 42.2% in the placebo group at 12 weeks, and superiority was even more pronounced at 12 months. (Gerdesmeyer, 2008) Using a single session of low-energy, ultrasound- and patient feedback-guided low-energy ESWT proved to be an effective treatment option for the majority of patients with chronic plantar fasciitis that failed to respond to conservative treatment. Predictive parameters for successful outcome are male gender and an easily detectable pain center at the heel. (Höfling, 2008) A recent technology assessment by the California Technology Assessment Forum (CTAF) recommended that the use of ESWT for the treatment of plantar fasciitis does not meet technology assessment criteria for safety, effectiveness, and improvement in health outcomes. (Tice, 2009) Radial shock wave (RSW) therapy is considered an appropriate alternative because of its lower price and probably better effectiveness. After employing network meta-analysis, the probability of being the best therapy was the highest in RSW therapy, followed by low-, medium-, or high-intensity FSW therapy. The meta-regression indicated that the success rate of FSW therapy was not related to its intensity, whereas elevated energy efflux densities tended to relieve pain more. (Chang, 2012)

Achilles tendinopathy: A randomized, double-blind, placebo-controlled trial of either active ESWT or sham ESWT over 4 weeks found that both groups improved during the treatment and follow-up period, and concluded that there is no convincing evidence for recommendation of ESWT. (Rasmussen, 2008)

Neuropathic foot ulcers in diabetes: This study assessed the safety and efficacy of shock waves for the treatment of diabetic ulcers and showed that the healing rate was significantly increased in ESWT-treated patients when compared with patients treated with standard care. This was accompanied by a significant reduction in the median time required to heal the ulcer with no increase in the rate of adverse reactions. (Moretti, 2009)

Note: See the Elbow and Shoulder chapters for other uses of ESWT.

Criteria for the use of Extracorporeal Shock Wave Therapy (ESWT):

(1) Patients whose heel pain from plantar fasciitis has remained despite six months of standard treatment.

(2) At least three conservative treatments have been performed prior to use of ESWT. These would include: (a) Rest; (b) Ice; (c) NSAIDs; (d) Orthotics; (e) Physical Therapy; (e) Injections (Cortisone).

(3) Contraindicated in: Pregnant women; Patients younger than 18 years of age; Patients with blood clotting diseases, infections, tumors, cervical compression, arthritis of the spine or arm, or nerve damage; Patients with cardiac pacemakers; Patients who had physical or occupational therapy within the past 4 weeks; Patients who received a local steroid injection within the past 6 weeks; Patients with bilateral pain; Patients who had previous surgery for the condition.

(4) Maximum of 3 therapy sessions over 3 weeks. Low energy ESWT without local anesthesia recommended.

Flatfoot

See Adult aquired flatfoot.

Focal joint resurfacing

Recommended as an option for patients with severe disabling symptoms from hallux valgus or hallux rigidus due to degenerative joint disease of the first MTP joint, as a motion-preserving surgical alternative for providing pain relief and functional improvement. Not recommended for joints other than the first MTP joint. Arthrosurface offers HemiCAP resurfacing products to treat toe pain in the 1st MTP Joint, commonly used to treat hallux ridigidus. See also the Knee Chapter, where it is Not recommended. Advanced stages of first metatarsophalangeal (MTP) arthritis have traditionally been treated with various arthroplasties or arthrodesis. Studies suggest the outcomes of arthrodesis are superior to those of metallic joint replacement; however, complications and suboptimal outcomes in active patients still remain with arthrodesis of the first MTP joint. In this study, preservation of joint motion, alleviation of pain, and functional improvement data were very encouraging. Because minimal joint resection was performed, conversion to arthrodesis or other salvage procedures would be relatively simple if further intervention became necessary. (Kline, 2013) In this study metatarsal head metal resurfacing hemiarthroplasty provided high patient satisfaction level and good functional outcome in the short-term, in the surgical treatment of advanced stage hallux rigidus refractory to conservative treatment options. (Erdil, 2012) The early results of the HemiCAP implant on the metatarsal head are promising. (Aslan, 2012)

Criteria for Focal joint resurfacing:

Partial or total replacement of the first metatarsophalangeal (MTP) joint is medically necessary as an alternative to arthrodesis when the following criteria have been met:

- Persistent severe disabling symptoms from hallux valgus or hallux rigidus due to degenerative joint disease of the first MTP joint

- Grade II and early Grade III MTP changes

- Failure of conservative medical management

- Not recommend MTP joint replacement for any other toe joint (e.g., interphalangeal joints) or tarsal metatarsal (TMT) joint

Foot drop treatment

See Ankle foot orthosis (AFO); Functional electrical stimulation (FES); Surgery for peroneal nerve dysfunction.

Functional electrical stimulation (FES)

Recommended for foot drop to help patients with spinal cord injury (SCI) to ambulate as indicated below. Functional electrical stimulation (FES) reduces foot drop and improves walking speed. (Springer, 2012) (Marsden, 2012) Therapy combining FES and a conventional rehab program is superior to a conventional rehab program alone, in terms of reducing spasticity, improving dorsiflexor strength and lower extremity motor recovery. (Sabut, 2011) Peroneal FES seems to be superior to an AFO with regard to obstacle avoidance ability in community-dwelling people with stroke. The observed gains in obstacle avoidance ability appear to be clinically most relevant in the people with relatively low leg muscle strength. (van Swigchem, 2012) See also Foot drop treatment.

Criteria for use of functional electrical stimulation (FES):

- Diagnosis of spinal cord injury with intact lower motor units (L1 and below); &

- Can bear weight on upper and lower extremities to maintain an upright posture independently; &

- Shows muscle contraction to neuromuscular electrical stimulation and sensory perception of electrical stimulation sufficient for muscle contraction; &

- Patient is highly motivated and has the cognitive ability to use such devices for walking; &

- Can transfer independently and stand for at least 3 minutes; &

- Has hand and finger function to manipulate the controls; &

- At least 6 months post recovery of spinal cord injury and restorative surgery; &

- No hip or knee degenerative disease and has no history of long bone fracture secondary to osteoporosis; &

- Completion of a training program, 32 PT sessions with the device over a 3 months period; &

- Using devices, such as Parastep I, that are FDA approved for this treatment, but not devices approved as exercise equipment, such as the FES Power Trainer, ERGYS, REGYS, NeuroEDUCATOR, STimMaster Galaxy, RT300 motorized FES ergometer, and SpectraSTIM.

Functional treatment

Recommended. Early mobilization, functional treatment and partial weight bearing as tolerated appear to be a favorable treatment strategy for acute ankle sprains when compared with immobilization. (Kerkhoffs-Cochrane, 2002) (Shrier, 1995) Functional treatment comprises a broad spectrum of treatment strategies and as of yet no optimal strategy has been identified. The use of an elastic bandage has fewer complications than taping but appears to be associated with a slower return to work, and more reported instability than a semi-rigid ankle support. Lace-up ankle support appears effective in reducing swelling in the short-term compared with semi-rigid ankle support, elastic bandage and tape. (Kerkhoffs, 2002) While a short period of plaster immobilization or similar rigid support can be helpful in the acute phase of the treatment of lateral ankle injury in facilitating a rapid decrease of pain and swelling, functional treatment for 4 to 6 weeks is preferable to immobilization after that short period. (Kerkhoffs, 2012)

Fusion (arthrodesis)

Recommended as indicated below. In painful hindfoot osteoarthritis the arthroscopic technique provides reliable fusion and high patient satisfaction with the advantages of a minimally invasive procedure. (Glanzmann, 2007) In stage III and IV adult acquired flatfoot due to posterior tibial tendon dysfunction, correcting and stabilizing arthrodeses are advised. (Kelly, 2001) Also see Surgery for calcaneal fractures; Surgery for posterior tibial tendon ruptures.

ODG Indications for Surgeryä -- Ankle Fusion:

Criteria for fusion (ankle, tarsal, metatarsal) to treat non- or malunion of a fracture, or traumatic arthritis secondary to on-the-job injury to the affected joint:

1. Conservative Care: Immobilization, which may include: Casting, bracing, shoe modification, or other orthotics. OR Anti-inflammatory medications. PLUS:

2. Subjective Clinical Findings: Pain including that which is aggravated by activity and weight-bearing. AND Relieved by Xylocaine injection. PLUS:

3. Objective Clinical Findings: Malalignment. AND Decreased range of motion. PLUS:

4. Imaging Clinical Findings: Positive x-ray confirming presence of: Loss of articular cartilage (arthritis). OR Bone deformity (hypertrophic spurring, sclerosis). OR Non- or malunion of a fracture. Supportive imaging could include: Bone scan (for arthritis only) to confirm localization. OR Magnetic Resonance Imaging (MRI). OR Tomography.

Procedures Not supported: Intertarsal or subtalar fusion, except for stage 3 or 4 adult acquired flatfoot.

(Washington, 2002) (Kennedy, 2003) (Rockett, 2001) (Raikin, 2003)

For average hospital LOS if criteria are met, see Hospital length of stay (LOS).

Ganglion cyst removal

Recommended if the ganglion cyst is painful, the ganglion cyst is pushing directly on a nerve and can cause nerve damage, or the ganglion cyst is large enough that it makes it difficult to wear shoes. In the case of ganglion cysts originating from the tendon sheath, careful attention should be paid to locate satellite masses to avoid recurrence. (Ahn, 2010)

Growth factor injections

See Autologous blood-derived injections.

Gustilo open fracture classification

Recommended classification system for open fractures of the tibia and other long bones. The ICD-10 diagnostic coding system requires the Gustilo classification. The Gustilo system classifies open fractures into three main categories: Type I, Type II, and Type III, with Type III injures being further divided into Type IIIA, Type IIIB, and Type IIIC subcategories. The categories are defined by three characteristics, including: (1) Mechanism of injury; (2) Degree of bone injury or involvement; & (3) Extent of soft tissue damage. Skin size of laceration is an attempt to quantify the soft tissue injury. A higher grade suggests a higher degree of energy involved in the injury. Grade IIIC fracture implies vascular injury as well. (Gustilo, 1984)

Gustilo Classification

I. Low energy, wound less than 1 cm

II. Wound greater than 1 cm with moderate soft tissue damage

III. High energy wound greater than 1 cm with extensive soft tissue damage

IIIA. Adequate soft tissue cover

IIIB. Inadequate soft tissue cover

IIIC. Associated with arterial injury

Gym memberships

Not recommended as a medical prescription unless a home exercise program has not been effective and there is a need for equipment. Plus, treatment needs to be monitored and administered by medical professionals. While an individual exercise program is of course recommended, more elaborate personal care where outcomes are not monitored by a health professional, such as gym memberships or advanced home exercise equipment, may not be covered under this guideline, although temporary transitional exercise programs may be appropriate for patients who need more supervision. For more information on recommended treatments, see Physical therapy (PT) & Exercise. See also the Low Back Chapter.

Hammer toe treatment

See Surgery for hammer toe syndrome.

Hardware implant removal (fracture fixation)

Not recommend the routine removal of hardware implanted for fracture fixation, except in the case of broken hardware or persistent pain, after ruling out other causes of pain such as infection and nonunion. Not recommended solely to protect against allergy, carcinogenesis, or metal detection. Although hardware removal is commonly done, it should not be considered a routine procedure. The decision to remove hardware has significant economic implications, including the costs of the procedure as well as possible work time lost for postoperative recovery, and implant removal may be challenging and lead to complications, such as neurovascular injury, refracture, or recurrence of deformity. Current literature does not support the routine removal of implants to protect against allergy, carcinogenesis, or metal detection. (Busam, 2006) Despite advances in metallurgy, fatigue failure of hardware is common when a fracture fails to heal. Revision procedures can be difficult, usually requiring removal of intact or broken hardware. (Hak, 2008) Following fracture healing, improvement in pain relief and function can be expected after removal of hardware in patients with persistent pain in the region of implanted hardware, after ruling out other causes of pain such as infection and nonunion. (Minkowitz, 2007) The routine removal of orthopaedic fixation devices after fracture healing remains an issue of debate, but implant removal in symptomatic patients is rated to be moderately effective. Many surgeons refuse a routine implant removal policy, and do not believe in clinically significant adverse effects of retained metal implants. Given the frequency of the procedure in orthopaedic departments worldwide, there is an urgent need for a large randomized trial to determine the efficacy and effectiveness of implant removal with regard to patient-centred outcomes. (Hanson, 2008)

Heat therapy (ice/heat)

Under study. Ice works better than heat to speed recovery of acute ankle sprains. (Thompson, 2003) Range-of-motion improvement may be greater after heat and stretching than after stretching alone. (Peres, 2002)

Heel pads

Recommended as an option for plantar fasciitis, but not for Achilles tendonitis.

Plantar fasciitis: This RCT concluded that a silicone insole should be considered a first-line treatment option in patients with plantar fasciitis. (Yucel, 2013) This RCT found stretching and heel pads the most effective treatments for plantar fasciitis, with silicone inserts showing the largest percentage improvement. As part of the initial treatment of proximal plantar fasciitis, when used in conjunction with a stretching program, a prefabricated shoe insert is more likely to produce improvement in symptoms than a custom polypropylene orthotic device or stretching alone. The percentages improved in each group were: (1) silicone insert, 95%; (2) rubber insert, 88%; (3) felt insert, 81%; (4) Achilles tendon and plantar fascia stretching only, 72%; and (5) custom orthosis, 68%. (Pfeffer, 1999)

Achilles tendonitis: There is little information available from trials to support the use of heel pads in the treatment of acute or chronic Achilles tendinitis. (McLauchlan-Cochrane, 2002)

Heparin

Not recommended. There is little information available from trials to support the use of low dose heparin in the treatment of acute or chronic Achilles tendinitis. (McLauchlan-Cochrane, 2003)

Hospital length of stay (LOS)

Recommend the median length of stay (LOS) based on type of surgery, or best practice target LOS for cases with no complications. For prospective management of cases, median is a better choice that mean (or average) because it represents the mid-point, at which half of the cases are less, and half are more. For retrospective benchmarking of a series of cases, mean may be a better choice because of the effect of outliers on the average length of stay. Length of stay is the number of nights the patient remained in the hospital for that stay, and a patient admitted and discharged on the same day would have a length of stay of zero. The total number of days is typically measured in multiples of a 24-hour day that a patient occupies a hospital bed, so a 23-hour admission would have a length of stay of zero. (HCUP, 2011)

ODG hospital length of stay (LOS) guidelines:

Toe Amputation (icd 84.11 - Amputation of toe)

Actual data -- median 7 days; mean 8.4 days (± 0.1); discharges 40,710; charges (mean) $45,468

Best practice target (no complications) – 7 days

Foot Amputation (icd 84.12 - Amputation through foot)

Actual data -- median 9 days; mean 12.3 days (±0.3); discharges 13,797; charges (mean) $73,160

Best practice target (no complications) -- 9 days

Ankle Fusion (icd 81.11 - Ankle fusion)

Actual data -- median 2 days; mean 2.8 days (±0.1); discharges 6,892; charges (mean) $37,465

Best practice target (no complications) – 2 days

Triple Arthrodesis (icd 81.12 - Triple arthrodesis of foot and ankle)

Actual data -- median 2 days; mean 2.6 days (±0.1); discharges 4,271; charges (mean) $37,130

Best practice target (no complications) -- 2 days

Total Ankle (icd 81.56 - Total ankle replacement)

Actual data -- median 2 days; mean 2.5 days (±0.1); discharges 1,549; charges (mean) $50,653

Best practice target (no complications) -- 2 days

Destruction Ankle Lesion (icd 80.87 - Other local excision or destruction of lesion of ankle)

Actual data -- median 4 days; mean 5.9 days (±0.4); discharges 1,490; charges (mean) $45,681

Best practice target (no complications) -- 4 days

Ankle Arthrotomy (icd 80.17 - Other arthrotomy-ankle)

Actual data -- median 5 days; mean 7.7 days (±0.5); discharges 1,375; charges (mean) $50,381

Best practice target (no complications) – 5 days

Subtalar Fusion (icd 81.13 - Subtalar fusion)

Actual data -- median 2 days; mean 2.7 days (±0.3); discharges 1,294; charges (mean) $31,840

Best practice target (no complications) -- 2 days

Ankle Repair (icd 81.49 - Other repair of ankle)

Actual data -- median 2 days; mean 2.5 days (±0.3); discharges 1,018; charges (mean) $31,344

Best practice target (no complications) -- 2 days

Hyalgan®

See Hyaluronic acid injections.

Hyaluronic acid injections

Not recommended, based on recent research in the ankle, plus several recent quality studies in the knee showing that the magnitude of improvement appears modest at best. Was formerly under study as an option for ankle osteoarthritis. Hyaluronic acids are naturally occurring substances in the body's connective tissues that cushion and lubricate the joints. Intra-articular injection of hyaluronic acid may decrease symptoms of osteoarthritis of the knee, and possibly the ankle. This double blind, randomized, controlled study examined the safety and efficacy of intraarticular sodium hyaluronate (Hyalgan) in the treatment of pain associated with ankle osteoarthritis (OA), and concluded that this may be a safe and effective option for pain associated with ankle OA, although larger studies are needed. (Cohen, 2008) This clinical trial suggested that viscosupplementation combined with arthroscopy may be more beneficial than arthroscopy alone. (Carpenter, 2008) The goal of this study was to determine whether hyaluronic acid (HA) or exercise therapy can improve functional parameters in patients with osteoarthritis (OA) of the ankle, and both HA injections and exercise therapy provided similar functional improvement. However, larger trials with longer follow-up are necessary for more definite conclusions. (Karatosun, 2008) According to this systematic review of treatment for ankle sprains, therapeutic hyaluronic acid injections in the ankle may have a role in expediting return to sport after ankle sprain, but evidence is limited. (Seah, 2011) See the Knee Chapter for more information.

Recent research: While intra-articular injections of hyaluronic acid are potentially useful to treat ankle osteoarthritis, their effectiveness has not been proven. This RCT comparing hyaluronic acid with placebo for ankle osteoarthritis concluded that hyaluronic acid is not superior to saline solution injection. (DeGroot, 2012)

Hyaluronic acid or Hylan for the Ankle is Not Recommended by ODG.

Patient selection criteria for ankle hyaluronic acid injections if provider & payor agree to perform anyway:

A series of three to five intra-articular injections of Hyaluronic acid (or just three injections of Hylan) in the target ankle with an interval of one week between injections.

Indicated for patients who:

· Experience significantly symptomatic osteoarthritis but have not responded adequately to standard nonpharmacologic and pharmacologic treatments or are intolerant of these therapies (e.g., gastrointestinal problems related to anti-inflammatory medications).

· Are not candidates for total ankle replacement or who have failed previous ankle surgery for their arthritis, such as arthroscopic debridement.

· Repeat series of injections: If relief for 6-9 months and symptoms recur, may be reasonable to do another series. Recommend no more than 3 series of injections over a 5-year period, because effectiveness may decline, this is not a cure for arthritis, but only provides comfort and functional improvement.

Hylan

See Hyaluronic acid injections.

Hyperbaric oxygen therapy (HBOT)

Recommended as an option for diabetic skin ulcers. The routine use of hyperbaric oxygen therapy (HBOT) is not justified for any type of wound. In people with foot ulcers due to diabetes, HBOT significantly reduced the risk of major amputation and may improve the chance of healing at 1 year. The application of HBOT to these patients may be justified where HBOT facilities are available, however economic evaluations should be undertaken. Hyperbaric oxygen therapy may improve oxygen supply to wounds and therefore improve their healing. Pooled data showed a reduction in the risk (RR) of major amputation of 0.31 when adjunctive HBOT was used, compared to the alternative therapy. This analysis predicts that we would need to treat 4 individuals (NNT) with HBOT in order to prevent 1 amputation in the short term. HBOT may also be used in post-traumatic crush injury following open fracture, in compromised skin grafts, or in the re-implantation of traumatically amputated limb segment. In every case, the measurement of transcutaneous oxygen pressure is recommended as an index for the definition of the indication and of the evolution of treatment. (Kranke-Cochrane, 2004) (Berendt, 2006) Also see the Diabetes Chapter.

Ice packs

Recommended. Regular local (home use) application of cold packs is appropriate following acute injury for 24 to 48 hours and with continued swelling. RICE (rest, ice, compression, elevation) is appropriate for first 24 hours for sprain/fracture. (Colorado, 2001) Ice works better than heat to speed recovery. (Thompson, 2003) The use of ice and compression, in combination with rest and elevation, is an important aspect of treatment in the acute phase of lateral ankle injury. (Kerkhoffs, 2012) See also Cold packs; Rest (RICE).

Imaging

Recommended. Imaging studies are generally accepted, well established and widely used diagnostic procedures. (Colorado, 2001) See also Computed Tomography (CT); Lineal Tomography; Magnetic Resonance Imaging (MRI); Ottawa Ankle Rules; Bone scans (imaging); Radiography; Ultrasound; & MR arthrogram. (ACR, 2002) See also ACR Appropriateness Criteria™.

Immobilization

Not recommended as a primary treatment. Early mobilization, functional treatment and partial weight bearing as tolerated appear to be a favorable treatment strategy for acute ankle sprains when compared with immobilization. However, for patients with a clearly unstable joint: immobilization may be necessary for 4 to 6 weeks, with active and/or passive therapy to achieve optimal function. (Kerkhoffs-Cochrane, 2002) (Shrier, 1995) (Colorado, 2001) Immobilization and rest appear to be overused as treatment. Early mobilization benefits include earlier return to work; decreased pain, swelling, and stiffness; and a greater preserved range of joint motion, with no increased complications. (Nash, 2004) Functional treatment for severe ruptures of the lateral ankle ligaments leads to better results than cast immobilization for six weeks. (Pijnenburg, 2000) After surgical reconstruction for chronic lateral ankle instability, early functional rehabilitation was shown to be superior to six weeks immobilization regarding time to return to work and sports. (de Vries-Cochrane, 2006) Comparisons of surgically and nonsurgically treated Achilles tendon ruptures have demonstrated that those treated with surgery allow earlier motion and tend to show superior results. However, early motion enhances tendon healing with or without surgery and may be the important factor in optimizing outcomes in patients with Achilles tendon rupture. This RCT supports early motion (progressing to full weightbearing at 8 weeks from treatment) as an acceptable form of rehabilitation in both surgically and nonsurgically treated patients with comparable functional results and a low rerupture rate. (Twaddle, 2007) After ankle fracture surgical fixation, commencing exercise in a removable brace or splint significantly improved activity limitation but also led to a higher rate of adverse events. Because of the potential increased risk, the patient's ability to comply with this treatment regimen is essential. (Lin, 2009) According to this systematic review of treatment for ankle sprains, for mild-to-moderate ankle sprains, functional treatment options (which can consist of elastic bandaging, soft casting, taping or orthoses with associated coordination training) were found to be statistically better than immobilization for multiple outcome measures. (Seah, 2011) According to a Cochrane review, after surgical reconstruction, early functional rehabilitation appears to be superior to immobilization in restoring early function. (de Vries, 2011) While a short period of plaster immobilization or similar rigid support can be helpful in the acute phase of the treatment of lateral ankle injury in facilitating a rapid decrease of pain and swelling, functional treatment for 4 to 6 weeks is preferable to immobilization after that short period. (Kerkhoffs, 2012) New guidelines for treating and preventing ankle sprains in athletes call for functional rehabilitation rather than immobilization for grade I and II sprains, and prophylactic ankle supports for athletes with a history of previous ankle sprains. Grade III sprains should be immobilized for at least 10 days with a rigid stirrup brace or below-knee cast and then controlled therapeutic exercise instituted. (Kaminski, 2013)

Implant removal

See Hardware implant removal (fracture fixation).

Ingrown toenail surgery

Not recommended. Ingrowing toenails are a common condition which, when recurrent and painful, are often treated surgically. The evidence suggests that simple nail avulsion combined with the use of phenol, compared to surgical excisional techniques without the use of phenol, is more effective at preventing symptomatic recurrence of ingrowing toenails. The addition of phenol when simple nail avulsion is performed dramatically decreases symptomatic recurrence, but at the cost of increased post-operative infection. (Rounding-Cochrane, 2005) (Shaath, 2005)

Injections

Under study. Limited quality evidence. See specific indications below.

Heel pain: There is no evidence for the effectiveness of injected corticosteroid therapy for reducing plantar heel pain. (Crawford, 2000) Steroid injections are a popular method of treating the condition but only seem to be useful in the short term and only to a small degree. (Crawford, 2003) Corticosteroid injection is more efficacious and multiple times more cost-effective than ESWT in the treatment of plantar fasciopathy. (Porter, 2005) This RCT concluded that a single ultrasound guided dexamethasone injection provides greater pain relief than placebo at four weeks and reduces abnormal swelling of the plantar fascia for up to three months, but significant pain relief did not continue beyond four weeks. (McMillan, 2012)

Achilles tendonitis: There is little information available from trials to support the use of peritendonous steroid injection in the treatment of acute or chronic Achilles tendinitis. (McLauchlan, 2000)

Morton’s Neuroma: There are no RCTs to support corticosteroid injections in the treatment of Morton’s Neuroma. (Thomson, 2004) Alcohol injection of Morton's neuroma has a high success rate and is well tolerated. The results are at least comparable to surgery, but alcohol injection is associated with less morbidity and surgical management may be reserved for nonresponders. (Hughes, 2007)

Achilles tendon: Achilles tendon corticosteroid injections have been implicated in achilles tendon ruptures. (Coombes, 2010)

Intra-articular corticosteroids: Most evidence for the efficacy of intra-articular corticosteroids is confined to the knee, with few studies considering the joints of the foot and ankle. No independent clinical factors were identified that could predict a better postinjection response. (Ward, 2008) While evidence is limited, therapeutic injections are generally used procedures in the treatment of patients with ankle or foot pain or pathology. Ideally, a therapeutic injection will: reduce inflammation; relieve secondary muscle spasm; relieve pain; and support therapy directed at functional recovery. If overused, injections may be of significantly less value. (Colorado, 2001)

See also Hyaluronic acid injections; Autologous blood-derived injections; & Platelet-rich plasma (PRP).

Insoles (plantar fasciitis)

See Heel pads.

Insoles with magnetic foil

Not recommended. There is no evidence to support the use of insoles with magnetic foil in treating plantar heel pain. (Crawford, 2002) (Crawford-Cohrane, 2003) Despite anecdotal reports, rigorous scientific evidence of the effectiveness of magnetic insoles for the pain of plantar fasciitis is lacking. Static bipolar magnets embedded in cushioned shoe insoles do not provide additional benefit for subjective plantar heel pain reduction when compared with nonmagnetic insoles. (Winemiller-JAMA, 2003)

Inversion stress test

Recommended for possible calcaneofibular ligament rupture. Indication for the inversion stress test (also called talar tilt test): lateral ankle sprain. Technique: (1) brace heel with left hand, (2) invert foot with right hand, (3) compare to opposite side. Signs of ankle joint instability: joint laxity and lack of endpoint on translation. Interpretation of positive test: Grade III1 ankle sprain (Litt, 1992), calcaneofibular ligament rupture, anterior talofibular ligament also ruptured (tested with Anterior drawer test). (Bahr, 1997) Special tests such as the anterior drawer and inversion talar tilt tests have more diagnostic accuracy five days after injury than two days after injury. (Kaminski, 2013)

Iontophoresis

Not recommended. There is limited evidence for the effectiveness of topical corticosteroid administered by iontophoresis in reducing plantar heel pain. (Crawford, 2002) (Crawford-Cohrane, 2003)

Jones fracture (surgery)

Not recommend surgery except for Torg type III (nonunion fractures or significantly displaced). A Jones fracture is a fracture of the fifth metatarsal of the foot, at the base of the small toe. If a Jones fracture is not significantly displaced, it can be treated with a cast, splint or walking boot for four to eight weeks. Nonoperative treatment remains a viable alternative to surgery in all acute and delayed cases, providing there is no established nonunion and the patient is aware of the implications (in the athletic individual there may be an advantage for surgery in terms of time to return to sporting activity). (Dean, 2012) Bandaging is superior to below knee cast immobilization for patient-reported functional and pain scores, with no difference in fracture union or re-fracture, and a shorter duration for return to work. (Smith, 2011) Of all foot fractures the fifth metatarsal fracture is the most common. The indication for surgical treatment of Jones' fractures depends on activity level and Torg classification: type I fractures are treated non-operatively. Type II fractures can be treated non-operatively or operatively, depending on patient activity level. Type III fractures have more complications and should be treated operatively. (Zwitser, 2010)

K3 Promoter

See Tensegrity prosthetic foot (K3 Promoter).

Kinesio tape (KT)

Not recommended. The efficacy of kinesio tape in preventing ankle sprains is unlikely as it had no effect on muscle activation of the fibularis longus, and kinesio tape had no significant effect on mean or maximum muscle activity compared to no tape. (Briem, 2011)

Lace-up ankle support

Recommended. For ankle sprains, the use of an elastic bandage has fewer complications than taping but appears to be associated with a slower return to work, and more reported instability than a semi-rigid ankle support. Lace-up ankle support appears effective in reducing swelling in the short-term compared with semi-rigid ankle support, elastic bandage and tape. (Kerkhoffs, 2002) (Aetna, 2004) According to this systematic review of treatment for ankle sprains, lace-up supports are a more effective functional treatment than elastic bandaging and result in less persistent swelling in the short term when compared with semi-rigid ankle supports, elastic bandaging and tape. (Seah, 2011) The use of lace-up ankle braces is beneficial in significantly reducing the rate of ankle injuries. Athletes who wore Mcdavid Ultralight lace-up ankle braces had a 3.6% acute ankle injury rate, versus 10.8 % in the control group with no supports. Researchers hypothisized that the improvement was from a combination of a limited amount of support plus neuromuscular feedback to help the muscles react better to failure. There were nearly twice as many other lower extremity injuries in the braced, compared with the control group, but most of these injuries consisted of mild muscle strains and/or tendonitis. (McGuine, 2011)

Laser therapy (LLLT)

Not recommended. Low-intensity laser therapy appears to be wholly ineffective in the treatment of plantar fasciitis (Basford, 1998) (Crawford, 2002) (Crawford-Cohrane, 2003) There is little information available from trials to support the use of topical laser therapy in the treatment of acute or chronic Achilles tendinitis. (McLauchlan, 2000) (Bjordal, 2006) Low Level Laser Therapy (LLLT) was introduced as an alternative non-invasive treatment for Osteoarthritis (OA) about 20 years ago, but its effectiveness is still controversial. LLLT is a light source that generates extremely pure light, of a single wavelength. The effect is not thermal, but rather related to photochemical reactions in the cells. For OA, the results are conflicting in different studies and may depend on the method of application and other features of the LLLT application. Despite some positive findings, data is lacking on how LLLT effectiveness is affected by four important factors: wavelength, treatment duration of LLLT, dosage and site of application over nerves instead of joints. There is clearly a need to investigate the effects of these factors on LLLT effectiveness for OA in randomized controlled clinical trials. (Brosseau_Cochrane_2004) Ultrasound, laser, short-wave therapy and electrotherapy have no added value in lateral ankle injuries and are not recommended. (Kerkhoffs, 2012)

Lateral ligament ankle reconstruction (surgery)

Recommended as indicated below. This RCT concluded that, in terms of recovery of the preinjury activity level, the long-term results of surgical treatment of acute lateral ligament rupture of the ankle correspond with those of functional treatment. Although surgery appeared to decrease the prevalence of reinjury of the lateral ligaments, there may be an increased risk for the subsequent development of osteoarthritis. Surgical treatment comprised suture repair of the injured ligament(s) within the first week after injury, and a below-the-knee plaster cast was worn for six weeks with full weightbearing. Functional treatment consisted of the use of an Aircast ankle brace for three weeks. (Pihlajamäki, 2010) According to a Cochrane review, there is insufficient evidence to support any one surgical intervention over another surgical intervention for chronic ankle instability, but it is likely that there are limitations to the use of dynamic tenodesis. (de Vries, 2011) Functional treatment is preferred over surgical therapy for lateral ankle injury, but surgical treatment can be considered on an individual basis. (Kerkhoffs, 2012) See also Surgery for ankle sprains; & Allograft for ankle reconstruction.

ODG Indications for Surgeryä -- Lateral ligament ankle reconstruction:

Criteria for lateral ligament ankle reconstruction for chronic instability or acute sprain/strain inversion injury:

1. Conservative Care: Physical Therapy (Immobilization with support cast or ankle brace & Rehab program). For either of the above, time frame will be variable with severity of trauma. PLUS

2. Subjective Clinical Findings: For chronic: Instability of the ankle. Supportive findings: Complaint of swelling. For acute: Description of an inversion. AND/OR Hyperextension injury, ecchymosis, swelling. PLUS

3. Objective Clinical Findings: For chronic: Positive anterior drawer. For acute: Grade-3 injury (lateral injury). [Ankle sprains can range from stretching (Grade I) to partial rupture (Grade II) to complete rupture of the ligament (Grade III).1 (Litt, 1992)] AND/OR Osteochondral fragment. AND/OR Medial incompetence. AND Positive anterior drawer. PLUS

4. Imaging Clinical Findings: Positive stress x-rays (performed by a physician) identifying motion at ankle or subtalar joint. At least 15 degree lateral opening at the ankle joint. OR Demonstrable subtalar movement. AND Negative to minimal arthritic joint changes on x-ray.

Procedures Not supported: Use of prosthetic ligaments, plastic implants, calcaneous osteotomies.

(Washington, 2002) (Schmidt, 2004) (Hintermann, 2003)

For average hospital LOS if criteria are met, see Hospital length of stay (LOS).

Limb length temporary adjustment device

Recommend a heel/sole lift as an option for temporary limb length discrepancy sequelae caused by use of a CAM walker or other immobilization device, when it is necessary to balance the limb lengths from use of an orthotic device that will add more than 2 cm length to one lower extremity for a long duration. Bilateral foot orthotics/orthoses are not recommended to treat unilateral ankle-foot problems. For patients with temporary artificial functional limb length discrepancy (LLD) sequelae from use of a CAM immobilization device, a temporary off-the-shelf lift (eg, a device designed to attach to the contralateral shoe to compensate for the boot-induced functional LLD) can produce a more normal gait by eliminating the functional LLD and avoiding the symptoms commonly associated with a LLD. It is not necessary to put a CAM walker on an uninjured leg to correct the LLD when the injured leg is in such a device. (Song, 2009) See also Cast (immobilization).

Lineal tomography

Under study. Lineal tomography is infrequently used, yet may be helpful in the evaluation of joint surfaces and bone healing. (Colorado, 2001)

Lisfranc injury (surgery)

Recommend surgery if there is a fracture in the joints of the midfoot or abnormal positioning of the joints. The Lisfranc fracture is an injury of the foot in which one or all of the metatarsal bones are displaced from the tarsus. Direct injuries are usually caused by a heavy object crushing the midfoot, such as when the foot is run over by a car or after a fall. Indirect Lisfranc injuries are caused by a sudden rotational force on a plantar flexed forefoot, such as from windsurfing or snowboarding bindings. If there are no fractures in the joint and the dislocation is less than 2 mm, and the ligaments are not completely torn, nonsurgical treatment may be considered, including wearing a non-weightbearing cast for 6 weeks. For most Lisfranc injuries, open reduction with internal fixation (ORIF) and temporary screw or Kirschner wire (K-wire) fixation is recommended. Surgery is recommended for all injuries with a fracture in the joints of the midfoot or with abnormal positioning (subluxation) of the joints. Successful closed reduction of displaced Lisfranc dislocations is quite rare. If the injury is severe and has damage that cannot be repaired with screws or plates or when the ligaments are severely ruptured, or when there is severe post-traumatic arthritis of the joint, fusion (athrodesis) may be recommended. (Stavlas, 2010) (Watson, 2010) (Chaney, 2010) (Panagakos, 2012)

Low-intensity laser therapy (LLLT)

See Laser therapy.

Lymphedema pumps

Recommended home-use for the treatment of lymphedema after a four-week trial of conservative medical management that includes exercise, elevation and compression garments. See the Forearm, Wrist, & Hand Chapter for more information and references. See also Vasopneumatic devices.

Magnets

Not recommended. There is no evidence to support the use of insoles with magnetic foil in treating plantar heel pain. (Crawford, 2002) (Crawford-Cohrane, 2003) Despite anecdotal reports, rigorous scientific evidence of the effectiveness of magnetic insoles for the pain of plantar fasciitis is lacking. Static bipolar magnets embedded in cushioned shoe insoles do not provide additional benefit for subjective plantar heel pain reduction when compared with nonmagnetic insoles. (Winemiller-JAMA, 2003) See also the Pain Chapter.

Magnetic resonance imaging (MRI)

Recommended as indicated below. MRI provides a more definitive visualization of soft tissue structures, including ligaments, tendons, joint capsule, menisci and joint cartilage structures, than x-ray or Computerized Axial Tomography in the evaluation of traumatic or degenerative injuries. (Colorado, 2001) (ACR-ankle, 2002) (ACR-foot, 2002) The majority of patients with heel pain can be successfully treated conservatively, but in cases requiring surgery (eg, plantar fascia rupture in competitive athletes, deeply infiltrating plantar fibromatosis, masses causing tarsal tunnel syndrome), MR imaging is especially useful in planning surgical treatment by showing the exact location and extent of the lesion. (Narvaez, 2000) MRI is being used with increasing frequency and seems to have become more popular as a screening tool rather than as an adjunct to narrow specific diagnoses or plan operative interventions. This study suggests that many of the pre-referral foot or ankle MRI scans obtained before evaluation by a foot and ankle specialist are not necessary. (Tocci, 2007) Second-look arthroscopy is not necessary to evaluate repaired talar cartilage compared to MRI. (Lee2, 2010) MRI has very high specificity and positive predictive value in diagnosing tears of the anterior talofibular ligament, calcaneofibular ligament and osteochondral lesions. However sensitivity was low with MRI. In a symptomatic patient with ligamentous and chondral pathology in the ankle, negative results on MRI must be viewed with caution and an arthroscopy may still be required for a definitive diagnosis and treatment. (Joshy, 2010) Magnetic resonance imaging (MRI) reliably detects acute tears of the anterior talofibular ligament and calcaneofibular ligament. After acute trauma, MRI is highly sensitive, specific and accurate for determining the level of injury to the ankle syndesmotic ligaments. (Kaminski, 2013) See also ACR Appropriateness Criteria™.

Indications for imaging -- MRI (magnetic resonance imaging):

o         Chronic ankle pain, suspected osteochondral injury, plain films normal

o         Chronic ankle pain, suspected tendinopathy, plain films normal

o         Chronic ankle pain, pain of uncertain etiology, plain films normal

o         Chronic foot pain, pain and tenderness over navicular tuberosity unresponsive to conservative therapy, plain radiographs showed accessory navicular

o         Chronic foot pain, athlete with pain and tenderness over tarsal navicular, plain radiographs are unremarkable

o         Chronic foot pain, burning pain and paresthesias along the plantar surface of the foot and toes, suspected of having tarsal tunnel syndrome

o         Chronic foot pain, pain in the 3-4 web space with radiation to the toes, Morton's neuroma is clinically suspected

o         Chronic foot pain, young athlete presenting with localized pain at the plantar aspect of the heel, plantar fasciitis is suspected clinically

o         Repeat MRI is not routinely recommended, and should be reserved for a significant change in symptoms and/or findings suggestive of significant pathology. (Mays, 2008)

Manipulation

Not recommended. There is limited evidence from trials to support the use of manipulation for treating disorders of the ankle and foot, although it is commonly done and there is anecdotal evidence of its success. In general, it would not be advisable to use this beyond 2-3 weeks if signs of objective progress towards functional restoration are not clearly demonstrated. (Crawford, 2002) (Van der Windt, 2001) (Fryer, 2002) (Pellow, 2001) (Eisenhart, 2003) (Lawrence, 2001) Manual mobilization of the ankle has limited added value and is not recommended. (Kerkhoffs, 2012)

ODG Chiropractic Guidelines -

(If a decision is made to use this treatment despite the lack of evidence)

Ankle Sprain:

Allow for fading of treatment frequency (from up to 3 visits per week to 1 or less), plus active self-directed home therapy
9 visits over 8 weeks

Massage

Not recommended. There is little information available from trials to support the use of many physical medicine interventions for treating disorders of the ankle and foot. In general, it would not be advisable to use these modalities beyond 2-3 weeks if signs of objective progress towards functional restoration are not demonstrated. See also Manipulation. (Crawford, 2002) (Van der Windt, 2001) Manual mobilization of the ankle has limited added value and is not recommended. (Kerkhoffs, 2012)

Mechanical treatment (taping/orthoses)

Recommended. Evidence indicates mechanical treatment with taping and orthoses to be more effective than either anti-inflammatory or accommodative modalities in the treatment of plantar fasciitis. (Lynch, 1998)

Medications

For detailed information see the Pain Chapter of ODG Treatment. In this Ankle Chapter, these listings may also be relevant: Actovegin; Anti-inflammatory medications (NSAIDs); Autologous conditioned serum (ACS); Botox®; Botulinum toxin; Corticosteroids (topical); Heparin; Hyalgan®; Hyaluronic acid injections; Hylan; Injections; Narcotics; Nonprescription medications; & Steroids (injection); Synvisc® (hylan); Viscosupplementation; Wound dressings.

Microprocessor-controlled foot prostheses

Recommended as an option for amputees whose knee musculature strength does not constitute a handicap, and who are motivated to go through the necessary training. See also Prostheses (artificial limb). Conventional prosthetic feet cannot adapt to specific conditions such as walking on stairs or ramps. The Proprio-Foot (Ossur) microprocessor-controlled foot prostheses may reduce these compensation mechanisms by automatically increasing dorsiflexion during stair ambulation thanks to an adaptive microprocessor-controlled ankle. This study concluded that, despite its additional weight compared to a conventional prosthetic ankle, the Proprio-Foot should be beneficial to active transtibial amputees whose knee musculature strength does not constitute a handicap. (Alimusaj, 2009)

Modified duty

See Work.

Morton's neuroma treatment

Recommend surgey as an option. See Surgery for Morton's neuroma. Morton's neuroma is a common, paroxysmal neuralgia affecting the web spaces of the toes, typically the third. The pain is often so debilitating that patients become anxious about walking or even putting their foot to the ground. Insoles, corticosteroid injections, excision of the nerve, transposition of the nerve and neurolysis of the nerve are commonly used treatments, but except for the surgical procedures, there is little evidence to support these. There is no evidence to support the use of supinatory insoles or corticosteroid injections. As far as surgical technique, there is limited indication that transposition of the transected plantar digital nerve may yield better results than standard resection of the nerve in the long term. There are limited indications to suggest that dorsal incisions for resection of the plantar digital nerve may result in less symptomatic post-operative scars when compared to plantar excision of the nerve. (Thomson, 2004)

Motorized scooters

See Power mobility devices (PMDs).

MR arthrogram

Recommended if radiographs normal, but suspected osteochondral injury or ankle instability. For evaluating ankle disability, using plain MRI alone is not adequate for correctly detecting lateral collateral ligamentous injury of the ankle joint. MR arthrography improves the sensitivity and the accuracy for anterior talofibular and calcaneofibular ligament injuries. It also helps in assessing coexisting pathologic lesions of ankle joints, especially impingement syndromes and osteochondral lesions, and provides more information for therapeutic decisionmaking. (Chou, 2006) MR arthrography is more accurate (100%) in diagnosing chronic anterior talofibular and calcaneofibular ligament tears than MRI (59% to 63%) and stress radiography (65%). MR arthrography has also been found to be an accurate method for assessing both anterolateral and anteromedial impingement with the advantage of joint capsule distention by intra-articular contrast injection. (Jacobson, 2009) Arthrography and tenography are less accurate than MRI and CT, especially when performed 48 hours after lateral ligamentous injury. (Kaminski, 2013)

Narcotics

Not recommended. Narcotics should be primarily reserved for the treatment of severe lower extremity pain for 3 to 7 days (maximum duration: 2 weeks). (Colorado, 2001) For chronc pain see the Pain Chapter.

Negative pressure wound therapy (NPWT)

Recommended in the treatment of diabetes-associated chronic leg wounds and diabetic ulcers of the feet. Under study for other wounds. See Vacuum-assisted closure wound-healing.

Neuromuscular electrical stimulation (NMES)

See Functional electrical stimulation (FES), Recommended for foot drop to help patients with spinal cord injury (SCI) to ambulate. See also the Pain Chapter, Not recommended for pain. Neuromuscular electrical stimulation (NMES) devices may be either muscle stimulators to treat muscle atrophy, or devices to enhance functional activity in neurologically impaired individuals using electrical impulses to activate paralyzed or weak muscles in precise sequence to provide SCI patients with the ability to walk, and these devices are commonly known as functional electrical stimulators (FES).

Neuromuscular reeducation

Recommended as an optional PT treatment. See Physical therapy (PT).

Night splints

Recommended. In individuals with plantar heel pain, there is evidence for the effectiveness of dorsiflexion and tension night splints in reducing pain. (Crawford, 2002) (Crawford-Cohrane, 2003) (Batt, 1996) (Powell, 1998)

Nonprescription medications

Recommended. Nonprescription medications (acetaminophen, NSAIDS) will provide sufficient pain relief for most acute and subacute disorders of the ankle and foot. (McLauchlan, 2000) For detailed information see the PAIN Chapter of ODG Treatment.

Office visits

Recommended as determined to be medically necessary. Evaluation and management (E&M) outpatient visits to the offices of medical doctor(s) play a critical role in the proper diagnosis and return to function of an injured worker, and they should be encouraged. The need for a clinical office visit with a health care provider is individualized based upon a review of the patient concerns, signs and symptoms, clinical stability, and reasonable physician judgment. The determination is also based on what medications the patient is taking, since some medicines such as opiates, or medicines such as certain antibiotics, require close monitoring. As patient conditions are extremely varied, a set number of office visits per condition cannot be reasonably established. The determination of necessity for an office visit requires individualized case review and assessment, being ever mindful that the best patient outcomes are achieved with eventual patient independence from the health care system through self care as soon as clinically feasible. The ODG Codes for Automated Approval (CAA), designed to automate claims management decision-making, indicates the number of E&M office visits (codes 99201-99285) reflecting the typical number of E&M encounters for a diagnosis, but this is not intended to limit or cap the number of E&M encounters that are medically necessary for a particular patient. Office visits that exceed the number of office visits listed in the CAA may serve as a “flag” to payors for possible evaluation, however, payors should not automatically deny payment for these if preauthorization has not been obtained. Note: The high quality medical studies required for treatment guidelines such as ODG provides guidance about specific treatments and diagnostic procedures, but not about the recommended number of E&M office visits. Studies have and are being conducted as to the value of “virtual visits” compared with inpatient visits, however the value of patient/doctor interventions has not been questioned. (Dixon, 2008) (Wallace, 2004) Further, ODG does provide guidance for therapeutic office visits not included among the E&M codes, for example Chiropractic manipulation and Physical/Occupational therapy.

Open reduction internal fixation (ORIF)

Recommended as an option for fractures when radiographic evidence indicates a displaced fracture or comminuted fracture, or an open fracture with bone protrusion. Open reduction internal fixation (ORIF) is a method of surgically repairing a fractured bone, in which surgery is used to reduce or set the fracture fragments and then hardware (such as a rod, plate and/or nails) is then implanted to hold the reduction in place. (Lange, 2007)

Opioids

Not generally recommended for acute pain, except for severe cases, not to exceed two weeks. See the Pain Chapter for more information and studies, and for use in chronic pain. When used only for a time-limited course, opioid analgesics are an option in the management of patients with acute pain. The decision to use opioids should be guided by consideration of their potential complications relative to other options. Patients should be warned about potential physical dependence and the danger associated with the use of opioids while operating heavy equipment or driving. For more information, and Criteria for Use of Opioids, see the Pain Chapter.

Orthotic devices

Recommended for plantar fasciitis and for foot pain in rheumatoid arthritis. See also Prostheses (artificial limb). Both prefabricated and custom orthotic devices are recommended for plantar heel pain (plantar fasciitis, plantar fasciosis, heel spur syndrome). (Thomas, 2010) Orthoses should be cautiously prescribed in treating plantar heel pain for those patients who stand for long periods; stretching exercises and heel pads are associated with better outcomes than custom made orthoses in people who stand for more than eight hours per day. (Crawford, 2003) As part of the initial treatment of proximal plantar fasciitis, when used in conjunction with a stretching program, a prefabricated shoe insert is more likely to produce improvement in symptoms than a custom polypropylene orthotic device or stretching alone. The percentages improved in each group were: (1) silicone insert, 95%; (2) rubber insert, 88%; (3) felt insert, 81%; (4) Achilles tendon and plantar fascia stretching only, 72%; and (5) custom orthosis, 68%. (Pfeffer, 1999) Evidence indicates mechanical treatment with taping and orthoses to be more effective than either anti-inflammatory or accommodative modalities in the treatment of plantar fasciitis. (Lynch, 1998) (Gross, 2002) For ankle sprains, the use of an elastic bandage has fewer complications than taping but appears to be associated with a slower return to work, and more reported instability than a semi-rigid ankle support. Lace-up ankle support appears effective in reducing swelling in the short-term compared with semi-rigid ankle support, elastic bandage and tape. (Kerkhoffs, 2002) For hallux valgus the evidence suggests that orthoses and night splints do not appear to be any more beneficial in improving outcomes than no treatment. (Ferrari-Cochrane, 2004) Semirigid foot orthotics appear to be more effective than supportive shoes worn alone or worn with soft orthoses for metatarsalgia. (Chalmers, 2000) The use of shock absorbing inserts in footwear probably reduces the incidence of stress fractures. There is insufficient evidence to determine the best design of such inserts but comfort and tolerability should be considered. Rehabilitation after tibial stress fracture may be aided by the use of pneumatic bracing but more evidence is required to confirm this. (Rome-Cochrane, 2005) Foot orthoses produce small short-term benefits in function and may also produce small reductions in pain for people with plantar fasciitis, but they do not have long-term beneficial effects compared with a sham device. The customized and prefabricated orthoses used in this trial have similar effectiveness in the treatment of plantar fasciitis. (Landorf, 2006) Eleven trials involving 1332 participants were included in this meta-analysis: five trials evaluated custom-made foot orthoses for plantar fasciitis (691 participants); three for foot pain in rheumatoid arthritis (231 participants); and one for hallux valgus (209 participants). Custom-made foot orthoses were effective for rearfoot pain in rheumatoid arthritis (NNT:4) and painful hallux valgus (NNT:6); however, surgery was even more effective for hallux valgus. It is unclear if custom-made foot orthoses were effective for plantar fasciitis or metatarsophalangeal joint pain in rheumatoid arthritis. (Hawke, 2008) Rocker profile shoes are commonly prescribed based on theoretical considerations with minimal scientific study and validation. Rocker profiles are used to afford pressure relief for the plantar surface of the foot, to limit the need for sagittal plane motion in the joints of the foot and to alter gait kinetics and kinematics in proximal joints. In this review, efficacy has not been demonstrated. The effectiveness of rocker-soled shoes in restricting sagittal plane motion in individual joints of the foot is unclear. Rocker profiles have minimal effect on the kinetics and kinematics of the more proximal joints of the lower limb, but more significant effects are seen at the ankle. (Hutchins, 2009) According to this systematic review of treatment for ankle sprains, pneumatic braces provide beneficial ankle support and may prevent subsequent sprains during high-risk sporting activity. (Seah, 2011) Outcomes from using a custom orthosis are highly variable and dependent on the skill of the fabricator and the material used. A trial of a prefabricated orthosis is recommended in the acute phase, but due to diverse anatomical differences many patients will require a custom orthosis for long-term pain control. A pre-fab orthosis may be made of softer material more appropriate in the acute phase, but it may break down with use whereas a custom semi-rigid orthosis may work better over the long term. See also Ankle foot orthosis (AFO).

OssaTron®

See Extracorporeal shock wave therapy (ESWT).

Osteochondral autologous transfer system (OATS)

Not recommended in the ankle. While osteochondral autografting has been principally performed on the knee, the OATS technique may have promise in the ankle. Although the OATS procedure is generally reserved for salvage of failed debridement and drilling in the ankle, it may have applications in primary surgical management, but long-term outcome of the OATS procedure is not yet available. (Easley, 2003) Further sufficiently powered, randomized clinical trials with uniform methodology and validated outcome measures should be initiated to compare the outcome of osteochondral transplantation (OATS). (Zengerink, 2010) See the Knee Chapter, where Osteochondral autograft transplant system (OATS) is recommended.

Osteotomy

Recommended for hallux valgus. Surgical osteotomy appears to be an effective treatment for painful hallux valgus. (Torkki-JAMA, 2001) See also Surgery for hallux valgus.

Ottawa ankle rules (OAR)

Recommended. Studies show that the clinical criteria known as the Ottawa Ankle Rules (OAR), used for determining the need for radiographs of the ankle when a fracture is suspected, have a sensitivity approaching 100%, a specificity of 25-50%, and an overall reduction in radiographs of the ankle of 15-28%. The OAR is an adequate screening tool for ankle fractures. (Verma, 1997) (Pijnenburg, 2002) (Stiell, 1994) (Dalinka, 2000) (ACR, 2002) The use of the Ottawa Ankle Rules is strongly recommended to exclude fractures after ankle sprains. In lateral ankle injury the existence of a fracture is the main red flag. The ability to walk again within 48 h after trauma is an auspicious sign and indicates a good prognosis. Most patients who visit the emergency room are examined using radiographs to rule out fractures despite the fact that the prevalence of ankle fractures is less than 15%. (Kerkhoffs, 2012) The Ottawa Ankle Rules (OARs) are valid for determining need for x-rays. (Kaminski, 2013) See also ACR Appropriateness Criteria™.

The Ottawa Ankle Rules are as follows:

o        A foot radiographic series is indicated if pain is present in the midfoot area and any of the following are also found: 1) tenderness at the base of the fifth metarsal; 2) tenderness at the navicular bone; 3) inability to bear weight both immediately and in the emergency department.

o        An ankle radiographic series is indicated if pain is present in the malleolar area and any of the following are also found: 1) tenderness at the posterior edge or tip of the lateral malleolus; 2) tenderness at the posterior edge or tip of the medial malleolus; 3) inability to bear weight both immediately and in the emergency department.

Parastep I system

See Functional electrical stimulation (FES), Recommended for foot drop.

Patient education

Recommended. Injured workers should receive instruction regarding the nature of their condition, risk factors, preventive measures & goals of therapy. They should be instructed in eliminating or modifying aggravating activities during treatment, and informed of norms on disability duration (see ODG). (Colorado, 2001) (Denniston-ODG)

PE (pulmonary embolism)

See Venous thrombosis.

Peroneal nerve decompression

See Surgery for peroneal nerve dysfunction.

Peroneal nerve functional electrical stimulation (pFES)

See Functional electrical stimulation (FES), Recommended for foot drop.

Peroneal tendinitis/ tendon rupture (treatment)

Recommend conservative treatment for tendinitis, and surgery as an option for a ruptured tendon. Patients with peroneal tendonitis, but no significant peroneal tendon tear, can usually be treated successfully non-operatively. In patients with a large peroneal tendon tear or a bony prominence that is serving as a physical irritant to the tendon, surgery may be beneficial. Peroneal tendonitis is an irritation to the tendons that run past the back outside part of the ankle, and it is a common cause of lateral ankle pain. Commonly it is an overuse condition that responds to conservative treatment, but if it is left untreated it can progress to a complete tendon rupture. Predisposing factors for peroneal tendonitis and rupture include varus alignment of the hindfoot and peroneal subluxation and dislocation. Participation in certain sports, including downhill skiing, skating, ballet, running and soccer creates higher risk for peroneal tendon tears. If caught early, peroneal tendonitis or instability may be treated conservatively with NSAIDs, immobilization and avoidance of exacerbating activities. Once secondary changes in the tendon occur, however, surgical treatment often becomes necessary. Surgery is indicated in the acute phase for peroneus brevis tendon rupture, acute dislocation, anomalous peroneal brevis muscle hypertrophy, and in peroneus longus tears that are associated with diminished function. (Cerrato, 2009)

Pharmaceuticals

See Medications.

Phonophoresis

Not recommended. There is little information available from trials to support the use of many physical medicine modalities for treating disorders of the ankle and foot. In general, it would not be advisable to use these modalities beyond 2-3 weeks if signs of objective progress towards functional restoration are not demonstrated. (Crawford, 2002) (Crawford-Cohrane, 2003) (Van der Windt, 2001)

Physical therapy (PT)

Recommended. Exercise program goals should include strength, flexibility, endurance, coordination, and education. Patients can be advised to do early passive range-of-motion exercises at home by a physical therapist. See also specific physical therapy modalities by name. (Colorado, 2001) (Aldridge, 2004) This RCT supports early motion (progressing to full weightbearing at 8 weeks from treatment) as an acceptable form of rehabilitation in both surgically and nonsurgically treated patients with Achilles tendon ruptures. (Twaddle, 2007) After ankle fracture surgical fixation, commencing exercise in a removable brace or splint significantly improved activity limitation but also led to a higher rate of adverse events. Because of the potential increased risk, the patient's ability to comply with this treatment regimen is essential. (Lin, 2009) According to a Cochrane review, neuromuscular training is effective in treating chronic ankle instability. (de Vries, 2011)

Active Treatment versus Passive Modalities: In general, the use of active treatment modalities instead of passive treatments is associated with substantially better clinical outcomes. The most commonly used active treatment modality is Therapeutic exercises (97110), but other active therapies may be recommended as well, including Neuromuscular reeducation (97112), Manual therapy (97140), and Therapeutic activities/exercises (97530). See the Back Chapter for references.

ODG Physical Therapy Guidelines –

Allow for fading of treatment frequency (from up to 3 visits per week to 1 or less), plus active self-directed home PT. Also see other general guidelines that apply to all conditions under Physical Therapy in the ODG Preface.

Ankle/foot Sprain (ICD9 845):
Medical treatment: 9 visits over 8 weeks
Post-surgical treatment: 34 visits over 16 weeks

Enthesopathy of ankle and tarsus (ICD9 726.7):

Medical treatment: 9 visits over 8 weeks

Post-surgical treatment: 9 visits over 8 weeks

Achilles bursitis or tendonitis (ICD9 726.71):

Medical treatment: 9 visits over 5 weeks

Achilles tendon rupture (727.67):

Post-surgical treatment: 48 visits over 16 weeks

Hallux valgus (ICD9 735.0):

Medical treatment: 9 visits over 8 weeks

Post-surgical treatment: 9 visits over 8 weeks

Hallux varus (ICD9 735.1):

Medical treatment: 9 visits over 8 weeks

Post-surgical treatment: 9 visits over 8 weeks

Hallux rigidus (ICD9 735.2):

Medical treatment: 9 visits over 8 weeks

Post-surgical treatment: 9 visits over 8 weeks

Other hammer toe (ICD9 735.4):

Medical treatment: 9 visits over 8 weeks

Post-surgical treatment: 9 visits over 8 weeks

Plantar Fasciitis (ICD9 728.71):

6 visits over 4 weeks

Fracture of tibia and fibula (ICD9 823)

Medical treatment: 30 visits over 12 weeks

Post-surgical treatment (ORIF): 30 visits over 12 weeks

Fracture of ankle (ICD9 824):

Medical treatment: 12 visits over 12 weeks

Post-surgical treatment: 21 visits over 16 weeks

Fracture of ankle, Bimalleolar (ICD9 824.4):

Medical treatment: 12 visits over 12 weeks

Post-surgical treatment (ORIF): 21 visits over 16 weeks

Post-surgical treatment (arthrodesis): 21 visits over 16 weeks

Fracture of ankle, Trimalleolar (ICD9 824.6):

Medical treatment: 12 visits over 12 weeks

Post-surgical treatment: 21 visits over 16 weeks

Metatarsal stress fracture (ICD9 825):

Medical treatment: 12 visits over 12 weeks
Post-surgical treatment: 21 visits over 16 weeks

Calcaneus fracture (ICD9 825.0):

Medical treatment: 12 visits over 12 weeks
Post-surgical treatment: 21 visits over 16 weeks

Fracture of one or more phalanges of foot (ICD9 826):

Medical treatment: 12 visits over 12 weeks

Post-surgical treatment: 12 visits over 12 weeks

Closed dislocation of ankle (ICD9 837):

9 visits over 8 weeks

Amputation of toe (ICD9 895):

Post-replantation surgery: 20 visits over 12 weeks

Crushing injury of ankle/foot (ICD9 928.2):

Medical treatment: 12 visits over 12 weeks

Amputation of foot (ICD9 896):

Post-replantation surgery: 48 visits over 26 weeks

Crushing injury of ankle/foot (ICD9 928.2):

Medical treatment: 12 visits over 12 weeks

Arthritis (Arthropathy, unspecified) (ICD9 716.9)

Medical treatment: 9 visits over 8 weeks

Post-injection treatment: 1-2 visits over 1 week

Post-surgical treatment, arthroplasty/fusion, ankle: 24 visits over 10 weeks

Contusion of lower limb (ICD9 924)

6 visits over 3 weeks

Crushing injury of lower limb (ICD9 928)

Medical treatment: 12 visits over 12 weeks

Tarsal tunnel syndrome (ICD9 355.5)

Medical treatment: 10 visits over 5 weeks

Plantar fascia stretch

Recommended. Some studies have found that stretching the plantar fascia was 75 percent successful in relieving pain and enabling patients to return to full activity within 3-6 months, and after doing the exercise, about 75 percent of patients needed no further treatment. To do the stretch, patients sit with one leg crossed over the other and stretch the arch of the foot by taking one hand and pulling the toes back toward the shin for a count of 10. The stretch needs to be repeated 10 times, and patients need to do at least three stretching sessions a day. (DiGiovanni, 2003) (Digiovanni, 2006)

Plantar fasciitis

See Accommodative modalities; Botulinum toxin; Causality (determination); Corticosteroids (topical); Dorsiflexion night splints; Electron generating device; Extracorporeal shock wave therapy (ESWT); Heel pads; Injections; Insoles with magnetic foil; Iontophoresis; Laser therapy (LLLT); Magnets; Magnetic resonance imaging (MRI); Mechanical treatment (taping/orthoses); Night splints; Orthotic devices; Physical therapy (PT); Plantar fascia stretch; Radiography; Stretching (flexibility); Surgery for plantar fasciitis; Taping; Tension night splints (TNS); Ultrasound, diagnostic; Ultrasound, therapeutic; & Work.

Platelet-rich plasma (PRP)

Not recommended, with recent higher quality evidence showing this treatment to be no better than placebo. The first high quality study (an RCT in JAMA) concluded that injections of platelet-rich plasma (PRP) for chronic Achilles tendon disorder, or tendinopathy (also known as tendinitis), does not appear to reduce pain or increase activity more than placebo. Making a prediction based on previous studies, the authors hypothesized that the VISA-A (Victorian Institute of Sports Assessment-Achilles) score of the PRP group would be higher than that of the placebo group, but their findings proved otherwise. Results after 24 weeks showed that for the PRP group, the mean VISA-A score improved by 21.7 points, and the placebo group's score increased by 20.5 points, with no significant distinction between the 2 groups during any measurement period. Plus, no differences were seen in secondary outcome measures, including subjective patient satisfaction and the number of patients returning to activity. Both treatment groups showed clinical progression in this study and also in other studies on PRP, maybe due to the fact that exercises were performed in each group, and exercises have been shown to be effective, but conservative treatment is disappointing and 25% to 45% of patients eventually require surgery. (de Vos, 2010) PRP looks promising, but it is not yet ready for prime time. PRP has become popular among professional athletes because it promises to enhance performance, but there is no science behind it yet. In a prospective cohort study 30 patients with chronic refractory Achilles tendonosis were treated with PRP, and the authors concluded that PRP should be reserved for the worst of the worst patients with refractory Achilles tendonosis. (AAOS, 2010) This systematic review concluded that PRP injections for Achilles tendinopathy does not improve health outcomes. Overuse injuries of the Achilles tendon are common, particularly among runners, and many injuries can be managed conservatively, but recovery is often slow and prolonged. The limited blood supply to the tendon may contribute to slow or stalled healing, and the growth factors in PRP are hypothesized to jump-start the healing process. One case report highlighted the rapid recovery of a competitive athlete, and one case series of 14 patients reported dramatic improvements. However, the one high quality, double-blinded, sham-controlled randomized trial found no benefit to PRP injections compared with sham injections. The trial was relatively small, so it may have been underpowered to detect small improvements from PRP injection. There are also alternative approaches to processing and activating PRP. It may be that the approach used in this trial was not effective, but other approaches will be effective. However, based on the current evidence, PRP injection does not appear to be an effective approach to the treatment of Achilles tendinopathy. (Tice, 2010) This small low quality case series suggested that treating chronic plantar fasciitis with PRP injections is safe and has the potential to reduce pain. (Martinelli, 2012) For more discussion and references, see the Elbow Chapter. Platelet rich plasma (PRP) is a bioactive component of whole blood, with a higher concentration of platelets compared with baseline blood, and containing many growth factors, including platelet-derived growth factor, transforming growth factor, insulin-like growth factor, and vascular endothelial growth factor. The theory is that a concentrated preparation of PRP, with its inherent growth factors, may promote faster healing of injuries, when an area of injury is injected with PRP derived from the patient’s own blood (autologous). PRP injection(s) may be administered in an outpatient setting. See also Autologous blood-derived injections.

Posterior tibial tendon dysfunction (PTTD)

See Adult aquired flatfoot.

Power mobility devices (PMDs)

Not recommended if the functional mobility deficit can be sufficiently resolved by the prescription of a cane or walker, or the patient has sufficient upper extremity function to propel a manual wheelchair, or there is a caregiver who is available, willing, and able to provide assistance with a manual wheelchair. Early exercise, mobilization and independence should be encouraged at all steps of the injury recovery process, and if there is any mobility with canes or other assistive devices, a motorized scooter is not essential to care. See the Knee Chapter.

Prolotherapy (sclerotherapy)

Not recommended. Laboratory studies may lend some biological plausibility to claims of connective tissue growth, but high quality published clinical studies are lacking. The dependence of the therapeutic effect on the inflammatory response is poorly defined, raising concerns about the use of conventional anti-inflammatory drugs when proliferant injections are given. The evidence in support of prolotherapy is insufficient and therefore, its use is not recommended. (Colorado, 2001)

Proprio-Foot (Ossur)

Recommended as an option for amputees whose knee musculature strength does not constitute a handicap, and who are motivated to go through the necessary training. See Microprocessor-controlled foot prostheses.

Prostheses (artificial limb)

Recommended as indicated below. See the Knee Chapter. A prosthesis is a fabricated substitute for a missing body part. Lower limb prostheses may include a number of components, such as prosthetic feet, ankles, knees, endoskeletal knee-shin systems, socket insertions and suspensions, lower limb-hip prostheses, limb-ankle prostheses, etc. See also Microprocessor-controlled foot prostheses; Proprio-Foot (Ossur); & Tensegrity prosthetic foot.

Criteria for the use of prostheses:

A lower limb prosthesis may be considered medically necessary when:

1. The patient will reach or maintain a defined functional state within a reasonable period of time;

2. The patient is motivated to ambulate; and

3. The prosthesis is furnished incident to a physician's services or on a physician's order.

Pulmonary embolus

See Venous thrombosis.

Radiofrequency treatment

See Coblation therapy.

Radiography

Recommended as indicated below. If a fracture is considered, patients should have radiographs if the Ottawa ankle criteria are met. Radiographic evaluation may also be appropriate if there is rapid onset of swelling and bruising, if the patient is older than 55 years, or in the case of obvious dislocation. Plain films are routinely obtained to exclude arthritis, infection, fracture, or neoplasm. (Verma, 1997) (Pijnenburg, 2002) (Colorado, 2001) See also Ottawa Ankle Rules. (Stiell, 1994) (Dalinka, 2000) (ACR-ankle, 2002) (ACR-foot, 2002) See also ACR Appropriateness Criteria™.

Indications for imaging -- Plain Films (AP, lateral, etc.):

o         Suspected ankle injury in patient meeting Ottawa Rules:

1)       Inability to bear weight immediately after the injury,

2)       Point tenderness over the medial malleolus, or the posterior edge or inferior tip of the lateral malleolus or talus or calcaneus,

3)       Inability to ambulate for four steps in the emergency room

o         Chronic ankle pain, suspected osteochondral injury, initial study

o         Chronic ankle pain, suspected tendinopathy, initial study

o         Chronic ankle pain, suspected ankle instability, initial study

o         Chronic ankle pain, pain of uncertain etiology, initial study

o         Chronic foot pain, suspected to have Reiter's disease and complains of heel pain and swollen toes

o         Chronic foot pain, burning pain and paresthesias along the plantar surface of the foot and toes, suspected of having tarsal tunnel syndrome

o         Chronic foot pain, pain and tenderness over head of second metatarsal, rule out Freiberg's disease

o         Chronic foot pain, pain in the 3-4 web space with radiation to the toes, Morton's neuroma is clinically suspected

o         Chronic foot pain, young athlete presenting with localized pain at the plantar aspect of the heel, plantar fasciitis is suspected clinically

Removal of orthopedic fixation devices (after fracture healing)

See Hardware implant removal (fracture fixation).

Rest (RICE)

Recommended as indicated below. RICE (rest, ice, compression, elevation) is appropriate for first 24 hours for sprain/fracture. (Colorado, 2001) Rest and immobilization appear to be overused as treatment. Early mobilization benefits include earlier return to work; decreased pain, swelling, and stiffness; and a greater preserved range of joint motion, with no increased complications. (Nash, 2004) The use of ice and compression, in combination with rest and elevation, is an important aspect of treatment in the acute phase of lateral ankle injury. (Kerkhoffs, 2012)

Return to work

Recommended. Patients should be encouraged to return to modified or full duty as soon as the condition permits (see ODG for expected disability duration). (Denniston-ODG) (Colorado, 2001) After a lateral ankle injury, workers who use a semirigid ankle brace seem to resume work faster than workers who use an elastic bandage. A resumption of work strategy and a return to work schedule, which takes into account the task requirements and the degree of injury, can optimize reintegration towards work. For a distortion inversion injury, 2 weeks of light duty is recommended, with mostly sitting work, lifting up to 10 kg, and limiting standing and walking on uneven surfaces. Then full return to former work is recommended at 3-4 weeks depending on the task requirements. For partial or total rupture of ligaments, 3-6 weeks of light duty is recommended, and full return to former work is recommended at 6-8 weeks depending on the task requirements and the results of physical therapy. (Kerkhoffs, 2012) See also the ODG Capabilities & Activity Modifications for Restricted Work.

RICE

See Rest (RICE).

Richie Brace

See Bracing (immobilization). Not recommended in the absence of a clearly unstable joint. There are no quality published studies specific to the Richie Brace.

Rolling knee walker

Recommended for patients who cannot use crutches, standard walkers or other standard ambulatory assist devices (e.g., a patient with an injured foot who only has use of one arm). See Walking aids (canes, crutches, braces, orthoses, & walkers).

SanuWave

See Extracorporeal shock wave therapy (ESWT).

Scandinavian total ankle replacement system (STAR®)

Recommended as an option in selected patients. The Scandinavian total ankle replacement system (STAR®) is a non-constrained uncemented device, which provides 4 axes of rotation. See also Arthroplasty (total ankle replacement), which indicates that total ankle replacement using cemented devices is not recommended at this time. The FDA approved the Scandinavian Total Ankle Replacement System (STAR) made by Small Bone Innovations in Morrisville, Pennsylvania, via a PMA (a PMA requires more extensive data as opposed to the 510k process used for historical ankle replacement devices), to offer patients more mobility to move the foot up and down than fusion surgery and other FDA-approved fixed-ankle replacement systems. To adhere to FDA approval requirements, the company will conduct further studies during the next 8 years to test the safety and effectiveness of the device. (FDA, 2009) A large prospective controlled trial concluded that, by 24 months, ankles treated with the STAR ankle replacement had better function and equivalent pain relief as ankles treated with fusion. In addition, the STAR device requires significantly less bone resection than other ankle replacement devices, due to both the design and the uncemented fixation, which may allow successful conversion to ankle fusion if necessary. (Saltzman, 2009) The American Orthopaedic Foot & Ankle Society position statement on total ankle replacement surgery recommends this device for adult patients with primary, post-traumatic, and rheumatoid arthritis who have moderate or severe pain, loss of mobility, and loss of function of the involved ankle. Before considering total ankle replacement, patients should have completed several months of conservative treatment, should have satisfactory vascular perfusion in the involved extremity, and must have adequate soft-tissue coverage about the ankle that affords a safe surgical approach to total ankle replacement. In such patients, high-level evidence indicates that total ankle replacement safely relieves pain and may provide superior functional results when compared to ankle fusion. (AOFAS, 2009) Further reinforcing the value of PMA versus 510k approvals, a report in the Archives of Internal Medicine found that between 2003 and 2007 more high-risk devices were approved via the 510(k) rather than the Premarket approval (PMA) process. According to the authors, the 510(k) process is a short-cut backdoor approach. (Zuckerman, 2011) This systematic review concluded that the STAR prosthesis achieved good intermediate to long-term outcomes. While the five and ten year survival rates were acceptable, the failure rate was still somewhat high (11%), primarily due to aseptic loosening and malalignment. Increased surgeon experience and better patient selection could improve outcomes and decrease failure rate. (Zhao, 2011) Further support was provided in another review. (Seth, 2011)

Criteria for the use of the Scandinavian total ankle replacement system (STAR):

(1) Adult patients with end-stage ankle osteoarthritis, post-traumatic arthritis and rheumatoid arthritis, who have moderate or severe pain, loss of mobility, and loss of function of the involved ankle.

(2) Completion of at least six months of conservative treatment, including medications, physical therapy, and exercise.

(3) Satisfactory vascular perfusion in the involved extremity, and must have adequate soft-tissue coverage about the ankle.

(4) Workers who have a light duty job to return to. (DOL medium and heavy laborers should be steered toward arthrodesis.)

Sclerotherapy (prolotherapy)

Not recommended. Laboratory studies may lend some biological plausibility to claims of connective tissue growth, but high quality published clinical studies are lacking. The dependence of the therapeutic effect on the inflammatory response is poorly defined, raising concerns about the use of conventional anti-inflammatory drugs when proliferant injections are given. The evidence in support of sclerotherapy is insufficient and therefore, its use is not recommended. (Colorado, 2001)

Semi-rigid ankle support

Recommended as indicated below. For ankle sprains, the use of an elastic bandage has fewer complications than taping but appears to be associated with a slower return to work, and more reported instability than a semi-rigid ankle support. Lace-up ankle support appears effective in reducing swelling in the short-term compared with semi-rigid ankle support, elastic bandage and tape. (Kerkhoffs, 2002) (Aetna, 2004) A 10-day period of immobilization in a below-knee cast or Aircast results in a more rapid recovery from severe ankle sprain compared with the current clinical practice of mobilization after a severe ankle sprain according to an RCT in The Lancet. The researchers conclude that below-knee cast is a better choice for clinicians treating severe ankle sprains than a tubular compression bandage because it aids recovery, lessens symptoms, and helps patients return to normal function. The results of the study call into question the current standard of aggressive functional treatment of patients recovering from acute ankle sprains. (Lamb, 2009) The UK CAST trial group did an RCT comparing the clinical effectiveness and cost-effectiveness of tubular bandage, below knee cast, Aircast ankle brace or Bledsoe boot, all applied 2-3 days after presentation to allow swelling to resolve. The below knee cast offered a small but statistically significant benefit at 4 weeks. Neither the Aircast brace nor the Bledsoe boot was statistically or clinically better. At 12 weeks the below knee cast was significantly better than tubular bandage, and the Aircast brace was better only in terms of ankle-related QoL and mental health. The Bledsoe boot conferred no significant advantage over tubular bandage. By 9 months there were no significant differences. Based on mean direct health-care costs per participant, the Bledsoe boot was the most expensive and tubular bandage the least. Inclusion of indirect costs (sick leave) raised overall costs substantially and removed any significant differences between the therapies. Cost-utility analysis demonstrated that the Aircast brace and below knee cast were more cost-effective than the Bledsoe boot. (Cooke, 2009) According to this systematic review of treatment for ankle sprains, semi-rigid orthoses and pneumatic braces provide beneficial ankle support and may prevent subsequent sprains during high-risk sporting activity. (Seah, 2011)

Shock wave therapy, extracorporeal (ESWT)

See Extracorporeal Shock Wave Therapy (ESWT).

Shoes

See Barefoot running (versus shoes); Heel pads; & Insoles with magnetic foil in the Ankle Chapter. See also Barefoot walking; Footwear, knee arthritis; Insoles; & Shoes in the Knee Chapter.

STAR® device

See Scandinavian total ankle replacement system (STAR®).

Stem cell autologous transplantation

Under study. See the Knee Chapter for more information and references. Stem cell therapy has been used for osteoarthritis, rheumatoid arthritis, spinal injury, degenerative joint disease, autoimmune diseases, systemic lupus erythematosus, cerebral palsy, critical limb ischemia, diabetes type 2, heart failure, multiple sclerosis, and other conditions. Adult stem cells are harvested from many areas of the body, including the bone marrow, fat and peripheral blood, and they are purified and reintroduced back in the patient. According to the theory, stem cells isolated from a patient (i.e. from the bone marrow or fat) have the ability to become different cell types (i.e. nerve cells, liver cells, heart cells and cartilage cells), and they are capable of "homing in" on and repairing damaged tissue. In this review of diabetic Charcot patients who underwent foot and ankle reconstructive surgery with and without mesenchymal stem cells (MSC) grafting, the radiographic healing time parameter was most striking between groups, 6.4 versus 9.2 weeks. In both groups, there were non-unions, mal-unions, and/or delayed unions noted. Surgical application of MSC appears to be safe, and has the potential to be effective as an autograft substitute, but remains inconclusive. (Lee, 2010)

Steroids (injection)

Under study. There is little information available from trials to support the use of peritendonous steroid injection in the treatment of acute or chronic Achilles tendinitis. (McLauchlan, 2002) Most evidence for the efficacy of intra-articular corticosteroids is confined to the knee, with few studies considering the joints of the foot and ankle. No independent clinical factors were identified that could predict a better postinjection response. (Ward, 2008) See also Injections.

Stretching (flexibility)

Recommended. Low stress aerobic activities and stretching exercises can be initiated at home and supported by a physical therapist. (Colorado, 2001) A program of non-weight-bearing stretching exercises specific to the plantar fascia is superior to the standard program of weight-bearing Achilles tendon-stretching exercises for the treatment of symptoms of proximal plantar fasciitis. (DiGiovanni, 2003) (Digiovanni, 2006) See also Plantar fascia stretch. Generally, stretching increases flexibility, but when done before physical activity, there is little evidence that it decreases the risk of injury, and it may actually be detrimental to athletic performance. On the other hand, regular stretching, done after or apart from exercise, is associated with better athletic performance. Time spent stretching before physical activity would be better spent warming up in other ways, in terms of injury prevention. (Herbert-BMJ, 2002) (Thacker, 2004) (Shrier, 2004) See also Flexibility.

Subtalar arthroscopy

Recommended. Surgical indications for arthroscopy of the ankle and subtalar joints include chronic pain, swelling, buckling, and/or locking that fails conservative treatment. In patients with chronic lateral ankle pain following an inversion injury, the subtalar joints are completely normal and the pathology is usually limited only to the ankle joint. In patients with the following diagnoses at arthroscopy -- synovitis, degenerative joint disease, subtalar dysfunction, chondromalacia, nonunion of os trigonum, arthrofibrosis, loose bodies, and osteochondral lesions of the talus -- the results of subtalar arthroscopy are good-to-excellent in treatment decision-making. (Williams, 1998)

Supartz (Artzal, Durolane)

See Hyaluronic acid injections.

Supports

See Elastic bandage (immobilization), Lace-up ankle support, Orthotic devices, Semi-rigid ankle support, Taping.

Surgery

See Surgery for achilles tendon ruptures; Surgery for ankle sprains; Surgery for calcaneal fractures; Surgery for hallux valgus; Surgery for hammer toe syndrome; Surgery for peroneal nerve dysfunction; Surgery for plantar fasciitis; Surgery for posterior tibial tendon ruptures; & Surgery for tarsal tunnel syndrome. See also Achilles tendon ruptures; Arthroscopy; Arthroplasty (total ankle replacement); Diagnostic arthroscopy; Fusion; Lateral ligament ankle reconstruction; Ingrown toenail surgery; Surgery for charcot arthropathy; Osteotomy; Hardware implant removal (fracture fixation); Open reduction internal fixation (ORIF); Peroneal tendinitis/ tendon rupture (treatment); Subtalar arthroscopy; Surgery for Morton's neuroma; Turf toe treatment (hyperdorsiflexion first metatarsophalangeal joint); Allograft for ankle reconstruction; Jones fracture (surgery); Lisfranc injury (surgery); Ganglion cyst removal; Focal joint resurfacing.

Surgery for achilles tendon ruptures

Recommended as indicated below. Open operative treatment of acute Achilles tendon ruptures compared with non-operative treatment is associated with a lower risk of rerupture, but a higher risk of other complications including infection, adhesions and disturbed skin sensibility. Percutaneous repair compared with open operative repair was associated with a shorter operation duration, and lower risk of infection. (Khan-Cochrane, 2004) Six months of nonsurgical therapy is appropriate for middle-aged patients or athletes with chronic Achilles tenosynovitis. Those that fail this treatment will improve with a limited debridement of diseased tissue without excessive soft tissue dissection of the tendon. Those patients who respond to nonoperative therapy tend to be younger than those who have degenerative tendon changes requiring surgery. (Johnston, 1997) Whether surgical or nonsurgical treatment is best for Achilles tendon rupture depends on whether patients undergo early range-of-motion functional rehabilitation, according to a meta-analysis. Without this rehabilitation, surgery reduces the risk for rerupture by 8.8% over nonsurgical treatment. Surgical options include open, minimally invasive, and percutaneous repair of the tendon, and nonsurgical treatments include casts or special boots with the foot being placed in plantar flexion, which forces movement toward to the sole. The researchers found considerable variation among study results on the basis of whether patients were given functional rehabilitation or were subjected to prolonged immobilization after initial treatment. Patients who underwent surgery returned to work 19.16 days earlier than nonsurgical patients. The authors concluded that nonsurgical treatment is a reasonable treatment choice at centers that use functional rehabilitation with early range of motion since surgical repair did not decrease the rerupture rate and was associated with a higher rate of other complications, but given that not all complications are major, some patients and surgeons may consider the increased rate of other complications following surgical treatment to be an acceptable trade-off for the reduced rerupture rate if functional ROM rehab is not available. (Soroceanu, 2012) See also Achilles tendon ruptures.

Surgery for ankle sprains

Recommended as indicated below for Grade III1 sprains. Operative treatment for severe ruptures of the lateral ankle ligaments leads to better results than functional treatment, and functional treatment leads to better results than cast immobilization for six weeks. (Pijnenburg, 2000) There was some evidence for a lower incidence of long-term ankle swelling in surgically treated patients. However, as well as tending to take longer to resume normal activities, including work, there was some limited evidence from a few trials for a higher incidence of ankle stiffness, impaired ankle mobility and complications in the surgical treatment group. (Kerhoffs, 2002) In view of the low quality methodology of almost all the studies, this review does not provide sufficient evidence to support any specific surgical intervention for chronic ankle instability. After surgical reconstruction for chronic lateral ankle instability, early functional rehabilitation was shown to be superior to six weeks immobilization regarding time to return to work and sports. (de Vries-Cochrane, 2006) This RCT concluded that, in terms of recovery of the preinjury activity level, the long-term results of surgical treatment of acute lateral ligament rupture of the ankle correspond with those of functional treatment. Although surgery appeared to decrease the prevalence of reinjury of the lateral ligaments, there may be an increased risk for the subsequent development of osteoarthritis. (Pihlajamäki, 2010) According to this systematic review of treatment for ankle sprains, there is a role for surgical intervention in severe acute and chronic ankle injuries, but the evidence is limited. (Seah, 2011) In comparing immobilization, functional treatment and surgical treatment, the evidence does not endorse the choice of surgical over conservative treatment (or vice versa) following acute ankle sprain. With respect to secondary outcomes, the results suggest a possible positive effect of surgery on objectively measured instability (radiographical assessment of talar tilt or anterior drawer test), but complications were generally higher in the surgical group. (Kamper, 2012) Functional treatment is preferred over surgical therapy for lateral ankle injury, but surgical treatment can be considered on an individual basis. (Kerkhoffs, 2012) See also Lateral ligament ankle reconstruction.

ODG Indications for Surgeryä -- Lateral ligament ankle reconstruction:

Criteria for lateral ligament ankle reconstruction for chronic instability or acute sprain/strain inversion injury:

1. Conservative Care: Physical Therapy (Immobilization with support cast or ankle brace & Rehab program). For either of the above, time frame will be variable with severity of trauma. PLUS

2. Subjective Clinical Findings: For chronic: Instability of the ankle. Supportive findings: Complaint of swelling. For acute: Description of an inversion. AND/OR Hyperextension injury, ecchymosis, swelling. PLUS

3. Objective Clinical Findings: For chronic: Positive anterior drawer. For acute: Grade-3 injury (lateral injury). [Ankle sprains can range from stretching (Grade I) to partial rupture (Grade II) to complete rupture of the ligament (Grade III).1 (Litt, 1992)] AND/OR Osteochondral fragment. AND/OR Medial incompetence. AND Positive anterior drawer. PLUS

4. Imaging Clinical Findings: Positive stress x-rays identifying motion at ankle or subtalar joint. At least 15 degree lateral opening at the ankle joint. OR Demonstrable subtalar movement. AND Negative to minimal arthritic joint changes on x-ray.

Procedures Not supported: Use of prosthetic ligaments, plastic implants, calcaneous osteotomies.

(Washington, 2002) (Schmidt, 2004) (Hintermann, 2003)

For average hospital LOS if criteria are met, see Hospital length of stay (LOS).

Surgery for calcaneal fractures

Recommended. There is a trend for patients with surgically treated calcaneal fractures to be more likely to return to the same type of work as compared with nonoperatively treated individuals. There also was a trend for nonoperatively treated patients to have a higher risk of experiencing severe foot pain than did operatively treated patients. (Randle, 2000) In general, patients whose injury was not associated with a Worker's Compensation claim demonstrated significantly better subjective outcomes, and surgical intervention did not significantly affect subjective patient outcome. However, those who were treated nonoperatively were significantly more likely to require late subtalar arthrodesis. (Dooley, 2004)

Surgery for charcot arthropathy

Not recommended. Recommend bracing and orthotics. Charcot arthropathy is a destructive process, most commonly affecting joints of the foot and ankle in diabetics with peripheral neuropathy. Affected individuals present with swelling, warmth, and erythema, often without history of trauma. Bony fragmentation, fracture, and dislocation progress to foot deformity, bony prominence, and instability. This often causes ulceration and deep infection that may necessitate amputation. Treatment should be focused on providing a stable and plantigrade foot for functional ambulation with accommodative footwear and orthoses. Foot-specific patient education and continued periodic monitoring may reduce the morbidity and associated expense of treating the complications of this disorder and may improve the quality of life in this complex patient population. (Sanders, 2004) (Pinzur, 2004) (Trepman, 2005) Limited evidence has been shown for the use of ultrasound fracture healing in Charcot neuroarthropathy. (Strauss, 1998) See Bone growth stimulators, ultrasound.

Surgery for hallux valgus

Recommended. Surgical osteotomy appears to be an effective treatment for painful hallux valgus. Surgery (chevron osteotomy) was shown to be beneficial compared to orthoses or no treatment, but when compared to other osteotomies, no technique was shown to be superior to any other. (Ferrari-Cochrane, 2004) (Torkki-JAMA, 2001) See also Osteotomy.

Surgery for hammer toe syndrome

Recommended as indicated below. Nonsurgical treatment is often the initial treatment choice for the symptomatic digital deformity. Various padding techniques exist, serving to cushion or offload pressure points that may involve both the affected toe(s) as well as its respective metatarsal head plantarly. Orthotic devices or shoe insole modifications using a metatarsal pad may offer relief of excessive metatarsal head pressures. Debridement of associated hyperkeratotic lesions usually is effective in helping to reduce symptoms. If local inflammation or bursitis exists, a corticosteroid injection into the affected area may be beneficial. Taping to reduce and splint flexible deformities may be performed, especially in the setting of an early crossover second toe deformity. Finally, footwear changes such as a wider and/or deeper toe box may be used to accommodate the deformity and decrease shoe pressure over osseous prominences.

Criteria for hammer toe syndrome surgery:

I. Diagnosis

   A. History: This may include any of the following:

      1. An evaluation of the chief complaint (including the nature, location, duration, onset, course, anything that improves or exacerbates, and any previous treatment)

      2. The past medical history (including allergies/medications, medical history, surgical history, family history, and social history)

   B. Physical examination: The following may be important parts of the appropriate examination:

      1. Peripheral vascular

      2. Neurological

      3. Orthopedic (involvement may be ascertained by examining the foot in either the weight bearing or non-weight bearing positions): a. Palpation; b. Range of motion; c. Biomechanical/ gait analysis

      4. Dermatologic (presence of lesions or hyperkeratoses)

II. Diagnostic Procedures

    A. Radiological examination: X-rays must be taken. They may be used to evaluate the type of deformity as well as other factors. X-rays may be weight bearing, partial weight bearing, or non-weight bearing.

    B. Laboratory tests: Not required in the nonsurgical patient, unless underlying factors exist (i.e., infection or inflammatory disease)

    C. Additional tests (nerve conduction studies, electromyography (EMG), noninvasive vascular testing). These studies may be utilized in isolated situations when deemed necessary.

III. Nonsurgical Treatment (at least 2 of 6): 1. Padding; 2. Orthotic devices or shoe insole modifications; 3. Debridement of associated hyperkeratotic lesions; 4. Corticosteroid injection; 5. Taping; 6. Footwear changes (wider and/or deeper toe box).

IV. Surgical Treatment. The primary reasons for surgical treatment are:

      A. Failure of nonsurgical treatment

      B. Impracticality of nonsurgical treatment

      C. The patient desires correction of a presenting deformity that is painful and/or causes a degree of loss of function.

      D. The patient is informed of the procedure(s) to be performed, the treatment alternatives, and the reasonable risks involved and elects to have surgical intervention.

(Thomas, 2009) (AAFAS, 2003)

Surgery for Morton's neuroma

Recommended. Morton's neuroma is a common cause of metatarsalgia caused by intermetarsal digital nerve thickening. Postoperatively, 82% report excellent or good results. With conservative treatment, high-heeled and narrow shoes should be avoided, and the use of a metatarsal pad orthotic device can help keep pressure off the nerve, but the success rate for nonsurgical management is only about 20-30%. Surgical care for Morton neuroma involves a few different options for either decompressing or resecting the nerve, depending on the experience of the surgeon. (Pace, 2010) As far as surgical technique, there is limited indication that transposition of the transected plantar digital nerve may yield better results than standard resection of the nerve in the long term. There are limited indications to suggest that dorsal incisions for resection of the plantar digital nerve may result in less symptomatic post-operative scars when compared to plantar excision of the nerve. (Thomson, 2004)

Surgery for peroneal nerve dysfunction

Recommended as indicated below. Common peroneal nerve dysfunction is damage to the peroneal nerve leading to loss of movement or sensation in the foot and leg, including foot drop. The first line of treatment is avoiding activity that makes the pain worse, especially prolonged squatting. Steroid injections near the peroneal nerve at the fibular head help some patients, but recurrences are common. If the patient has a foot drop, then an ankle splint may be prescribed. In general, when symptoms persist for longer than three months despite these conservative measures, surgery is an option. Decompression of the peroneal nerve at the fibular head is performed in day surgery with the skin numbed with lidocaine and the patient sedated. Using a 3-inch incision, the procedure takes about 30-40 minutes. During surgery the skin is incised, and then the peroneal nerve is identified under the skin and followed to where it is compressed by fascia and muscle near the fibular head. All compression points are released and it is made certain the fibula itself is not compressing the nerve. (King, 2008)

Surgery for plantar fasciitis

Not recommended execept as indicated below. No randomized trials evaluating surgery for plantar heel pain against a control group have been identified; therefore no conclusions can be drawn. (Crawford, 2002) Generally, surgical intervention may be considered in severe cases when other treatment fails. In general, heel pain resolves with conservative treatment. In recalcitrant cases, however, entrapment of the first branch lateral plantar nerve should be suspected. Surgical release of this nerve can be expected to provide excellent relief of pain and facilitate return to normal activity. (Baxter, 1992) Nonsurgical management of plantar fasciitis is successful in approximately 90% of patients. Surgical treatment is considered in only a small subset of patients with persistent, severe symptoms refractory to nonsurgical intervention for at least 6 to 12 months. (Neufeld, 2008) Plantar fasciotomy, in particular total plantar fasciotomy, may lead to loss of stability of the medial longitudinal arch and abnormalities in gait, in particular an excessively pronated foot. (Tweed, 2010)

Surgery for posterior tibial tendon ruptures

Recommended as indicated below. In the early stages, posterior tibial tendon dysfunction may be treated with rest, nonsteroidal anti-inflammatory drugs such as aspirin or ibuprofen, and immobilization of the foot for 6 to 8 weeks with a rigid below-knee cast or boot to prevent overuse. After the cast is removed, shoe inserts such as a heel wedge or arch support may be helpful. If the condition is advanced, a custom-made ankle-foot orthosis or support may be necessary. If conservative treatments don't work, surgery is necessary. The function of the posterior tibial (PT) tendon is to stabilize the hindfoot against valgus and eversion forces. It functions as the primary invertor of the foot and assists the Achilles tendon in plantar flexion. Acute injuries of the PT tendon are rare and mostly affect the active middle-aged patient or they are the result of complex injuries to the ankle joint complex. Dysfunction of the PT tendon following degeneration and rupture, in contrast, has shown an increasing incidence in recent years, and advancing age, comorbidities, and obesity may play a role. Dysfunction of the PT tendon results in progressive destabilization of the hind- and midfoot. Clinically, the ongoing deformation of the foot can be classified into four stages: in stage I, the deformity is distinct and fully correctable; in stage II, the deformity is obvious, but still correctable; in stage III, the deformity has become stiff; and in stage IV, the ankle joint is also involved in the deformity. Treatment modalities depend on stage: while conservative measures may work in early stages, surgical treatment is mandatory for the later stages. Reconstructive surgery is advised in stage II, whereas in stage III and IV correcting and stabilizing arthrodeses are advised. See also Fusion (arthrodesis). A promising treatment option for stage IV may be adding an ankle prosthesis to a triple arthrodesis, as long as the remaining competence of the deltoid ligament is sufficient. (Hintermann, 2010) Adult flatfoot deformity can arise from multiple causes, the most common of which remains posterior tibial tendon rupture with subsequent elongation of secondary supportive structures. Regardless of the cause, the fundamental goals of surgical management include correcting peritalar subluxation, restoring hindfoot-midfoot-forefoot relationships and muscle balance, attaining a plantigrade foot, and preserving motion when possible. (Lin, 2011) See also Adult aquired flatfoot (pes planus).

Surgery for tarsal tunnel syndrome

Recommended after conservative treatment for at least one month. Patients with clinical findings and positive electrodiagnostic studies of tarsal tunnel syndrome warrant surgery when significant symptoms do not respond to conservative management. When conservative therapy fails to alleviate the patient's symptoms, surgical intervention may be warranted since space-occupying masses require removal. Tarsal tunnel syndrome is caused by compression of the tibial nerve or its associated branches as it passes underneath the flexor retinaculum at the ankle level or distally. (Gondring, 2003) (Sammarco, 2003)

Synvisc® (hylan)

Synvisc is a brand of hylan supplied by Genzyme Corporation. See Hylan.

Tai Chi

Recommended as an exercise-therapy option. Tai Chi, interchangeably known as Tai Chi Chuan, is an ancient Chinese health-promoting martial art form that has been recognized in China as an effective arthritis therapy for centuries. The results suggest Tai Chi has statistically significant benefits on lower extremity range of motion, in particular ankle range of motion. In addition, Tai Chi does not exacerbate symptoms of rheumatoid arthritis. Since outcomes from this therapy are very dependent on the highly motivated patient, we recommend approval only when requested by such a patient, but not adoption for use by any patient. (Han-Cochrane, 2004) (Wang, 2004) (Jones, 2005) Tai Chi is also effective in decreasing the risk of falling, and it improves functional balance and physical performance in physically inactive elderly persons. (Li, 2005) Tai Chi may also have an association with higher bone mineral density and neuromuscular function in postmenopausal women. (Qin, 2005) A large RCT of a sixteen-week program of community-based tai chi classes of 1 hour a week found that falls were less frequent in the tai chi group than in the control group, and there were statistically significant differences in balance favoring the tai chi group. The functional performance benefits of tai chi were maintained long after after classes finished, unlike other exercise programs. Tai chi may be easier to incorporate into daily life than other forms of exercise, so people continue to practice principles of tai chi after ceasing to attend formal classes. For example, some participants indicated informally that they practiced the tai chi walk (being conscious of foot placement and balance) while going about their daily activities. (Voukelatos, 2007) This systematic review showed that t'ai chi, combining deep breathing and relaxation with slow and gentle movements, may exert exercise-based general benefits for fall prevention and improvement of balance in older people as well as some meditative effects for improving psychological health, but t'ai chi does not effectively treat inflammatory diseases such as RA, cancer and cardiorespiratory disorders. (Lee, 2011) See Physical therapy for recommended number of visits if exercise training is prescribed.

Talar tilt test

See Inversion stress test.

Taping

Recommended. Evidence indicates mechanical treatment with taping and orthoses to be more effective than either anti-inflammatory or accommodative modalities in the treatment of plantar fasciitis. (Lynch, 1998) (Gross, 2002) (Aetna, 2004) For ankle sprains, the use of an elastic bandage has fewer complications than taping but appears to be associated with a slower return to work. Lace-up ankle support appears effective in reducing swelling in the short-term compared with semi-rigid ankle support, elastic bandage and tape. (Kerkhoffs, 2002) According to this systematic review of treatment for ankle sprains, for mild-to-moderate ankle sprains, functional treatment options (which can consist of elastic bandaging, soft casting, taping or orthoses with associated coordination training) were found to be statistically better than immobilization for multiple outcome measures. (Seah, 2011) It is recommended to use a brace or a tape to prevent a relapse after ankle sprain, but also to phase out the use of brace or tape in time. The use of tape or a brace reduces the risk of recurrent inversion injuries, but is unclear whether a brace is more effective than a tape. The preference for the choice of a brace or a tape depends on the individual situation, but due to considerations about practical usability and evaluation of costs, a brace is initially preferable to tape. (Kerkhoffs, 2012) See also Kinesio tape (KT).

Tensegrity prosthetic foot (K3 Promoter)

The Tensegrity K3 Promoter prosthetic foot performs the functions of microprocessor-controlled feet mechanically rather than electronically. See also Prostheses (artificial limb); & Microprocessor-controlled foot prostheses.

Tension night splints (TNS)

Recommended. When used in combination with a visco-elastic heel pad, stretching program and nonsteroidal anti-inflammatory drugs, the TNS is an effective treatment of plantar fasciitis. (Batt, 1996)

Tests

See Anterior drawer test; Imaging (with separate links); Inversion stress test; Ottawa ankle rules (OAR); Talar tilt test; Thompson test.

Therapeutic exercise

Recommended. Exercise program goals should include strength, flexibility, endurance, coordination, and education. Patients can be taugh to do early passive range-of-motion exercises at home by a physical therapist. (Colorado, 2001) See Physical therapy for recommended number of visits if exercise training is prescribed.

Thompson test

Recommended on all patients with suspected injury of the Achilles tendon. An abnormal Thompson test is defined as no movement in a dorsiflexed foot with squeezing of the calf of a prone patient. The patient should lie prone on the examination table, flexing the knee on the injured side, and the calf should be gently squeezed by the physician, who watches for plantar flexion in the patient's foot. If the foot moves, the tendon is presumed to be at least partially intact. No movement is indicative of rupture, and the test results are considered abnormal. If the Thompson test is equivocal, a sphygmomanometer should be placed on the patient's calf and inflated to 100 mm Hg and the affected foot should be dorsiflexed. The pressure will rise to approximately 140 mm Hg if the tendon is intact. In a patient with an Achilles rupture, only a flicker of movement on the pressure gauge is discernible with dorsiflexion. Indications: heel pain suggestive of achilles tendon rupture. Technique: (1) patient lies prone with knee flexed at 90 degrees, (2) examiner squeezes calf, (3) observe for plantar flexion of foot. Interpretation: Normal response - plantar flexion as reflex response (falsely normal if accessory muscles squeezed); Achilles tendon rupture - plantar flexion absent. Confirmatory test (if Thompson Test equivocal): (1) patients foot allowed to rest, (2) sphygmomanometer applied to affected calf, (3) inflate sphygmomanometer to 100 mmHg, (4) dorsiflex foot and observe pressure gauge [Normal response - pressure rises and stays at 140 mmHg; Achilles tendon rupture: only flicker of movement] (Mazzone, 2002)

Tibialis posterior tendon ruptures

See Adult aquired flatfoot (pes planus).

Topaz radiofrequency treatment

See Coblation therapy.

Total ankle replacement (arthroplasty)

See Arthroplasty (total ankle replacement).

Transcutaneous electrical neurostimulation (TENS)

Not recommended. There is little information available from trials to support the use of many interventions for treating disorders of the ankle and foot. In general, it would not be advisable to use these modalities beyond 2-3 weeks if signs of objective progress towards functional restoration are not demonstrated. (Crawford, 2002) (Van der Windt, 2001)

Turf toe treatment (hyper dorsiflexion first meta tarso phalangeal joint)

Recommend conservative treatment and surgery after failure of 1-3 months of conservative treatment. Nonoperative treatment may often suffice for incomplete injuries; however, surgery may be warranted for a complete plantar plate disruption or injury to one or both sesamoids. Conservative management in the acute stages, regardless of grade, consists of rest, ice, compression, and elevation (RICE). Taping is not recommended in the acute stages because of swelling and the risk of vascular compromise. Nonsteroidal anti-inflammatory drugs (NSAIDs) may help minimize pain and inflammation. In some cases, a short leg cast with a toe spica in slight plantarflexion or a walker boot may be used for the first week to help decrease pain. Gradual range of motion begins in 3-5 days following injury. After the acute stages, conservative management is based on the grade of injury, as follows: Grade I injuries are treated by taping the great toe to the lesser toes to prevent movement of the hallux metatarsophalangeal (MTP) joint. The overall goal is to restrict forefoot motion. Grade 2 injuries are treated in the same way as grade 1 injuries are, but use of a fracture walker and/or crutches is preferred. Grade 3 injuries usually require long-term immobilization in a boot or cast rather than surgical intervention. When conservative treatment fails, as evidenced by persistent pain and difficulty with pushing off and with cutting or pivoting motions, surgical therapy may be indicated. The use of artificial turf in the U.S. has created a dramatic increase in first metatarsophalangeal joint dorsiflexion injuries. (Coughlin, 2010)

Ultrasound, diagnostic

Recommended. With proper expertise ultrasound may replace MRI. (ACR-foot, 2002) Compared with MRI, diagnostic ultrasound is useful but less accurate and sensitive. (Kaminski, 2013)

Indications for imaging – Ultrasound:

o         Chronic foot pain, burning pain and paresthesias along the plantar surface of the foot and toes, suspected of having tarsal tunnel syndrome

o         Chronic foot pain, pain in the 3-4 web space with radiation to the toes, Morton's neuroma is clinically suspected

o         Chronic foot pain, young athlete presenting with localized pain at the plantar aspect of the heel, plantar fasciitis is suspected clinically

Ultrasound, therapeutic

Not recommended. Therapeutic ultrasound is no more effective than placebo in the treatment of plantar heel pain. (Crawford, 1996) There is little information available from trials to support the use of many physical medicine modalities for treating disorders of the ankle and foot. In general, it would not be advisable to use these modalities beyond 2-3 weeks if signs of objective progress towards functional restoration are not demonstrated. (Crawford, 2002) (Van der Windt, 2001) The results of this Cochrane review do not support the use of ultrasound in the treatment of acute ankle sprains. The potential treatment effects of ultrasound appear to be generally small and limited clinical importance, especially in the context of the usually short-term recovery period for these injuries. However, the available evidence is insufficient to rule out the possibility that there is an optimal dosage schedule for ultrasound therapy that may be of benefit. (van den Bekerom, 2011) Ultrasound, laser, short-wave therapy and electrotherapy have no added value in lateral ankle injuries and are not recommended. (Kerkhoffs, 2012) May be an option for heat; see Heat therapy.

Ultrasound fracture healing (bone-growth stimulators)

See Bone growth stimulators, ultrasound.

Vacuum-assisted closure wound-healing

Recommended in the treatment of diabetes-associated chronic leg wounds and diabetic ulcers of the feet. Under study for other wounds. Chronic skin wounds (including pressure ulcers, diabetic ulcers, and vascular ulcers) are a major source of morbidity, lead to considerable disability, and are associated with increased mortality. Vacuum-assisted closure therapy is a technology designed to improve wound healing. A thorough systematic review found consistent evidence of the benefit of negative pressure wound therapy (NPWT) in the treatment of diabetic ulcers of the feet. Results for bedsores was conflicting and research on mixed wounds was of poor quality, but promising. The review did not find evidence of increased significant complications. The review concluded that there is now sufficient evidence to show that NPWT is safe, and will accelerate healing, to justify its use in the treatment of diabetes-associated chronic leg wounds. There is also evidence, though of poor quality, to suggest that healing of other wounds may also be accelerated. (Xie, 2010) See also the Knee Chapter, where it is recommended, and the Shoulder Chapter, where it is Under study.

Vasopneumatic devices (wound healing)

Recommended as an option to reduce edema after acute injury. Vasopneumatic devices apply pressure by special equipment to reduce swelling. They may be considered necessary to reduce edema after acute injury. See the Forearm, Wrist, & Hand Chapter for more information and references. See also Lymphedema pumps.

Venous thrombosis

Recommend identifying subjects who are at a high risk of developing venous thrombosis and providing prophylactic measures such as consideration for anticoagulation therapy. Minor injuries in the leg are associated with greater risk of venous thrombosis. A venous thrombosis is a blood clot that forms within a vein. Deep venous thromboses (DVTs) form in the deep veins of the legs, and if a piece of a blood clot formed in a vein breaks off it can be transported to the right side of the heart, and from there into the lungs, and is called an embolism, and this process called a venothromboembolism (VTE). See the Knee Chapter for more information and references. A retrospective study of > 7,000 podiatry patients identified a low overall risk of VTE in podiatric surgery, suggesting that routine prophylaxis is not warranted. Prophylaxis for preventing deep vein thrombosis (DVT) and pulmonary embolism (PE) has been receiving increasing attention in recent years. The Agency for Healthcare Research and Quality, for example, ranks prevention of venous thromboembolism (VTE) as one of the top preventive initiatives that can improve patient safety in health-care settings. The overall incidence of postprocedure VTE in podiatric surgery was 0.30%. Three risk factors were significantly and independently associated with VTE in podiatric surgery: prior VTE (incidence, 4.6%; relative risk, 23.0), use of hormone replacement therapy or oral contraceptives (incidence, 0.55%; relative risk, 4.2), and obesity (incidence, 0.48%; relative risk, 3.0). For patients undergoing a podiatric procedure with a history of VTE, the risk for a procedure-related VTE increases significantly and periprocedure prophylaxis is recommended. (Felcher, 2009)

Viscosupplementa-tion

See Hyaluronic acid injections.

VTE (venous thromboembolism)

See Venous thrombosis.

Walking aids (canes, crutches, braces, orthoses, & walkers)

Recommended for patients with conditions causing impaired ambulation, when there is a potential for ambulation with these devices. See the Knee Chapter.

Wheelchair

Recommend manual wheelchair if the patient requires and will use a wheelchair to move around in their residence, and it is prescribed by a physician. For more information, see the Knee Chapter. For powered wheelchairs, see Power mobility devices (PMDs).

Work

Recommended as indicated below. Plantar fasciitis does not appear to be caused by occupations requiring walking or standing or prolonged use of ladders; instead, body mass index (BMI) and age are the primary variables that are significantly associated with this degenerative disability, but it is possible that work activities could aggravate symptoms and therefore accommodations should be made if necessary. (Riddle, 2004) Similar findings apply to other cumulative trauma disorders of the foot and ankle. (Guyton, 2000) Obesity and pronated foot posture are associated with Chronic plantar heel pain (CPHP) and may be risk factors for the development of the condition. Decreased ankle dorsiflexion, calf endurance and occupational lower limb stress do not seem to play a role in CPHP. There is no association for calf endurance or time spent sitting, standing, walking on uneven ground, squatting, climbing or lifting. (Irving, 2007)

ODG Capabilities & Activity Modifications for Restricted Work:

Sedentary/modified work: Standing limited to 5-10 min/hr; walking only on a smooth surface using crutches with limited pressure on the foot; no walking on an irregular surface; no climbing stairs; no climbing ladders or hill climbing requiring frequent knee flexion; no activities requiring balance; no applying strength against bent knee (squatting, kneeling, crouching, stooping, pedaling, etc.); elevate leg half of time; may need immobilization; limited weight bearing.

Manual/standing work: Standing not more than 50 min/hr; walking on a smooth surface up to 1,200 ft/hr carrying up to 25 lbs; walking on an irregular surface up to 900 ft/hr carrying up to 25 lbs; climbing stairs up to 8 flights/hr carrying up to 40 lbs; climbing ladders up to 50 rungs/hr carrying up to 25 lbs; activities requiring balance up to 45 min/hr (if able to work with two hands without assistance for balance); applying strength against bent knee (pedaling, squatting, kneeling, etc.) up to 60 times/hr; may need brace for uneven ground or ladders.

Work conditioning, work hardening

Recommended as an option, depending on the availability of quality programs. See especially the Low Back Chapter or the Knee Chapter, for more information and references.

Criteria for admission to a Work Hardening (WH) Program:

(1) Prescription: The program has been recommended by a physician or nurse case manager, and a prescription has been provided.

(2) Screening Documentation: Approval of the program should include evidence of a screening evaluation. This multidisciplinary examination should include the following components: (a) History including demographic information, date and description of injury, history of previous injury, diagnosis/diagnoses, work status before the injury, work status after the injury, history of treatment for the injury (including medications), history of previous injury, current employability, future employability, and time off work; (b) Review of systems including other non work-related medical conditions; (c) Documentation of musculoskeletal, cardiovascular, vocational, motivational, behavioral, and cognitive status by a physician, chiropractor, or physical and/or occupational therapist (and/or assistants); (d) Diagnostic interview with a mental health provider; (e) Determination of safety issues and accommodation at the place of work injury. Screening should include adequate testing to determine if the patient has attitudinal and/or behavioral issues that are appropriately addressed in a multidisciplinary work hardening program. The testing should also be intensive enough to provide evidence that there are no psychosocial or significant pain behaviors that should be addressed in other types of programs, or will likely prevent successful participation and return-to-employment after completion of a work hardening program. Development of the patient’s program should reflect this assessment.

(3) Job demands: A work-related musculoskeletal deficit has been identified with the addition of evidence of physical, functional, behavioral, and/or vocational deficits that preclude ability to safely achieve current job demands. These job demands are generally reported in the medium or higher demand level (i.e., not clerical/sedentary work). There should generally be evidence of a valid mismatch between documented, specific essential job tasks and the patient’s ability to perform these required tasks (as limited by the work injury and associated deficits).

(4) Functional capacity evaluations (FCEs): A valid FCE should be performed, administered and interpreted by a licensed medical professional. The results should indicate consistency with maximal effort, and demonstrate capacities below an employer verified physical demands analysis (PDA). Inconsistencies and/or indication that the patient has performed below maximal effort should be addressed prior to treatment in these programs.

(5) Previous PT: There is evidence of treatment with an adequate trial of active physical rehabilitation with improvement followed by plateau, with evidence of no likely benefit from continuation of this previous treatment. Passive physical medicine modalities are not indicated for use in any of these approaches.

(6) Rule out surgery: The patient is not a candidate for whom surgery, injections, or other treatments would clearly be warranted to improve function (including further diagnostic evaluation in anticipation of surgery).

(7) Healing: Physical and medical recovery sufficient to allow for progressive reactivation and participation for a minimum of 4 hours a day for three to five days a week.

(8) Other contraindications: There is no evidence of other medical, behavioral, or other comorbid conditions (including those that are non work-related) that prohibits participation in the program or contradicts successful return-to-work upon program completion.

(9) RTW plan: A specific defined return-to-work goal or job plan has been established, communicated and documented. The ideal situation is that there is a plan agreed to by the employer and employee. The work goal to which the employee should return must have demands that exceed the claimant’s current validated abilities.

(10) Drug problems: There should be documentation that the claimant’s medication regimen will not prohibit them from returning to work (either at their previous job or new employment). If this is the case, other treatment options may be required, for example a program focused on detoxification.

(11) Program documentation: The assessment and resultant treatment should be documented and be available to the employer, insurer, and other providers. There should documentation of the proposed benefit from the program (including functional, vocational, and psychological improvements) and the plans to undertake this improvement. The assessment should indicate that the program providers are familiar with the expectations of the planned job, including skills necessary. Evidence of this may include site visitation, videotapes or functional job descriptions.

(12) Further mental health evaluation: Based on the initial screening, further evaluation by a mental health professional may be recommended. The results of this evaluation may suggest that treatment options other than these approaches may be required, and all screening evaluation information should be documented prior to further treatment planning.

(13) Supervision: Supervision is recommended under a physician, chiropractor, occupational therapist, or physical therapist with the appropriate education, training and experience. This clinician should provide on-site supervision of daily activities, and participate in the initial and final evaluations. They should design the treatment plan and be in charge of changes required. They are also in charge of direction of the staff.

(14) Trial: Treatment is not supported for longer than 1-2 weeks without evidence of patient compliance and demonstrated significant gains as documented by subjective and objective improvement in functional abilities. Outcomes should be presented that reflect the goals proposed upon entry, including those specifically addressing deficits identified in the screening procedure. A summary of the patient’s physical and functional activities performed in the program should be included as an assessment of progress.

(15) Concurrently working: The patient who has been released to work with specific restrictions may participate in the program while concurrently working in a restricted capacity, but the total number of daily hours should not exceed 8 per day while in treatment.

(16) Conferences: There should be evidence of routine staff conferencing regarding progress and plans for discharge. Daily treatment activity and response should be documented.

(17) Voc rehab: Vocational consultation should be available if this is indicated as a significant barrier. This would be required if the patient has no job to return to.

(18) Post-injury cap: The worker must be no more than 2 years past date of injury. Workers that have not returned to work by two-years post injury generally do not improve from intensive work hardening programs. If the worker is greater than one-year post injury a comprehensive multidisciplinary program may be warranted if there is clinical suggestion of psychological barrier to recovery (but these more complex programs may also be justified as early as 8-12 weeks, see Chronic pain programs).

(19) Program timelines: These approaches are highly variable in intensity, frequency and duration. APTA, AOTA and utilization guidelines for individual jurisdictions may be inconsistent. In general, the recommendations for use of such programs will fall within the following ranges: These approaches are necessarily intensive with highly variable treatment days ranging from 4-8 hours with treatment ranging from 3-5 visits per week. The entirety of this treatment should not exceed 20 full-day visits over 4 weeks, or no more than 160 hours (allowing for part-day sessions if required by part-time work, etc., over a longer number of weeks). A reassessment after 1-2 weeks should be made to determine whether completion of the chosen approach is appropriate, or whether treatment of greater intensity is required.

(20) Discharge documentation: At the time of discharge the referral source and other predetermined entities should be notified. This may include the employer and the insurer. There should be evidence documented of the clinical and functional status, recommendations for return to work, and recommendations for follow-up services. Patient attendance and progress should be documented including the reason(s) for termination including successful program completion or failure. This would include noncompliance, declining further services, or limited potential to benefit. There should also be documentation if the patient is unable to participate due to underlying medical conditions including substance dependence.

(21) Repetition: Upon completion of a rehabilitation program (e.g., work conditioning, work hardening, outpatient medical rehabilitation, or chronic pain/functional restoration program) neither re-enrollment in nor repetition of the same or similar rehabilitation program is medically warranted for the same condition or injury.

ODG Work Conditioning (WC) Physical Therapy Guidelines

WC amounts to an additional series of intensive physical therapy (PT) visits required beyond a normal course of PT, primarily for exercise training/supervision (and would be contraindicated if there are already significant psychosocial, drug or attitudinal barriers to recovery not addressed by these programs). See also Physical therapy for general PT guidelines. WC visits will typically be more intensive than regular PT visits, lasting 2 or 3 times as long. And, as with all physical therapy programs, Work Conditioning participation does not preclude concurrently being at work.

Timelines: 10 visits over 4 weeks, equivalent to up to 30 hours.

Wound dressings

Recommend the following combinations: for chronic wounds, (1) debridement stage, hydrogels; (2) granulation stage, foam and low-adherence dressings; and (3) epithelialization stage, hydrocolloid and low-adherence dressings; and for the epithelialization stage of acute wounds, low-adherence dressings. For more information, see the Forearm Wrist & Hand Chapter. Negative pressure wound therapy using a vacuum system is effective for soft tissue injuries around the foot and ankle. Negative pressure wound therapy can be used to cover exposed bone or soft tissue defects without frequent dressing changes, and reduces chronic edema and increases local blood supply, which enhances the formation of healthy granulation tissue. (Lee, 2009) See also Hyperbaric oxygen therapy. And see the Diabetes Chapter, Wound care (diabetic foot ulcers) & Collagenase ointment (wound healing).

 

 

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REFERENCE SUMMARIES

 

Academy of Ambulatory Foot and Ankle Surgery (AAFAS). Hammertoe syndrome. Philadelphia (PA): Academy of Ambulatory Foot and Ankle Surgery; 2003. 8 p. [31 references]

 

Rating: 8b

 

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Aetna Clinical Policy Bulletins, Ankle Orthoses, Ankle-Foot Orthoses (AFOs), and Knee-Ankle-Foot Orthoses (KAFOs), #0565 October 01, 2004

 

Rating: 8c

 

 

 

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Ahn JH, Choy WS, Kim HY. Operative treatment for ganglion cysts of the foot and ankle. J Foot Ankle Surg. 2010 Sep-Oct;49(5):442-5.

 

In the case of ganglion cysts originating from the tendon sheath, careful attention should be paid to locate satellite masses to avoid recurrence.

 

PMID: 20650661

 

Rating: 4b

 

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Aldridge T. Diagnosing heel pain in adults. Am Fam Physician. 2004 Jul 15;70(2):332-8.

The most common cause of heel pain in adults is plantar fasciitis. Heel pad atrophy may present with diffuse plantar heel pain, especially in patients who are older and obese. 

 

PMID: 15291091

 

Rating: 5a

 

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Alimusaj M, Fradet L, Braatz F, Gerner HJ, Wolf SI. Kinematics and kinetics with an adaptive ankle foot system during stair ambulation of transtibial amputees. Gait Posture. 2009 Oct;30(3):356-63. Epub 2009 Jul 17.

 

Conventional prosthetic feet cannot adapt to specific conditions such as walking on stairs or ramps. Amputees are therefore forced to compensate their prosthetic deficits by modifying the kinematics and kinetics of their lower limbs. The Proprio-Foot (Ossur) intends to reduce these compensation mechanisms by automatically increasing dorsiflexion during stair ambulation thanks to an adaptive microprocessor-controlled ankle. The present investigation proposes to analyze the biomechanical effects of the dorsiflexion adaptation in transtibial (TT) amputees during stair ambulation. Sixteen TT amputees and sixteen healthy controls underwent conventional 3D gait analysis. Therefore, despite its additional weight compared to a conventional prosthetic ankle, the Proprio-Foot should be beneficial to active TT amputees whose knee musculature strength does not constitute a handicap.

 

PMID: 19616436

 

Rating: 3b

 

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American College of Foot and Ankle Surgeons, The diagnosis and treatment of heel pain, J Foot Ankle Surg 2001 Sep-Oct;40(5):329-40.

 

The National Guideline Clearinghouse (NGC) Web site, sponsored by the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services in partnership with the American Medical Association and the American Association of Health Plans, has an abstract below:

http://www.guideline.gov/summary/summary.aspx?view_id=1&doc_id=3173

 

Rating: 7b

 

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American College of Radiology (ACR), Expert Panel on Musculoskeletal Imaging. Chronic ankle pain. Reston (VA): American College of Radiology (ACR); 2002. 12 p. (ACR appropriateness criteria). [34 references]

 

Summary

For the assessment of chronic ankle pain, there are multiple imaging options, including stress radiography, radionuclide bone scanning, ultrasound (US), computed tomography (CT), magnetic resonance imaging (MRI), and injection procedures. Injection procedures include arthrography, CT arthrography, magnetic resonance (MR) arthrography, and diagnostic injection with anesthetics. There have been no studies specifically addressing the value of plain films in the assessment of chronic ankle pain. However, plain films are routinely obtained as the first option to exclude arthritis, infection, fracture, or neoplasm.

 

ACR Appropriateness Criteria™ -- Clinical Condition: Chronic Ankle Pain

Appropriateness Criteria Scale: 1 2 3 4 5 6 7 8 9 (1=Least appropriate 9=Most appropriate)

Abbreviations: AP, anteroposterior; US, ultrasound; MRI, magnetic resonance imaging; CT, computed tomography; MR, magnetic resonance

Variant 1: Suspected osteochondral injury, best initial study.

Radiologic Procedure -- Rating

Plain Films:            AP, lateral, and mortise views – 9; AP and lateral views -- 2

Stress Films:            With manual stressing -- 2

Stress using biomechanical device -- 2

Manual stress while under general anesthesia -- 2

Radionuclide Scanning: Radionuclide bone scan -- 2

Cross-Sectional Imaging:            US – 2; MRI – 2; CT -- 2

Injection Procedures:            Conventional arthrography -- 2

CT arthrography -- 2

MR arthrography -- 2

Tenography -- 2

Diagnostic injection of anesthetic -- 2

Variant 2: Suspected osteochondral injury, plain films normal.

Cross-Sectional Imaging:            MRI – 9; US – 2; CT -- 2 (If MRI not available)

Stress Films:            With manual stressing -- 2

Stress using biomechanical device -- 2

Manual stress while under general anesthesia -- 2

Radionuclide Scanning: Radionuclide bone scan -- 2

Injection Procedures:             Conventional arthrography -- 2

CT arthrography -- 2

MR arthrography -- 2

Tenography -- 2

Diagnostic injection of anesthetic -- 2

Variant 3: Suspected tendinopathy, best initial study.

Plain Films:            AP, lateral, and mortise views – 9; AP and lateral views -- 2

Stress Films:            With manual stressing -- 2

Stress using biomechanical device -- 2

Manual stress while under general anesthesia -- 2

Radionuclide Scanning: Radionuclide bone scan -- 2

Cross-Sectional Imaging:            US – 2; MRI – 2; CT -- 2

Injection Procedures:            Conventional arthrography -- 2

CT arthrography -- 2

MR arthrography -- 2

Tenography -- 2

Diagnostic injection of anesthetic -- 2

Variant 4: Suspected tendinopathy, plain films normal.

Cross-Sectional Imaging:            MRI – 9; US -- 6 (Only if experienced examiner available)

CT -- 2

Stress Films:            With manual stressing -- 2

Stress using biomechanical device --2

Manual stress while under general anesthesia -- 2

Radionuclide Scanning: Radionuclide bone scan -- 2

Injection Procedures:            Conventional arthrography -- 2

CT arthrography -- 2

MR arthrography -- 2

Tenography -- 2

Diagnostic injection of anesthetic -- 2

Variant 5: Suspected ankle instability, best initial study.

Plain Films:            AP, lateral, and mortise views – 9; AP and lateral views -- 2

Stress Films:            With manual stressing -- 2

Stress using biomechanical device -- 2

Manual stress while under general anesthesia -- 2

Radionuclide Scanning: Radionuclide bone scan -- 2

Cross-Sectional Imaging:            US – 2; MRI – 2; CT -- 2

Injection Procedures:            Conventional arthrography -- 2

CT arthrography -- 2

MR arthrography -- 2

Tenography -- 2

Variant 6: Suspected ankle instability, plain films normal.

Cross-Sectional Imaging:            MRI – 3; US – 2; CT -- 2

Stress Films:            With manual stressing -- 2

Stress using biomechanical device -- 2

Manual stress while under general anesthesia -- 2

Radionuclide Scanning: Radionuclide bone scan -- 2

Injection Procedures:            Conventional arthrography -- 2

CT arthrography -- 2

MR arthrography -- 2

Tenography -- 2

Diagnostic injection of anesthetic -- 2

Variant 7: Pain of uncertain etiology, best initial study.

Plain Films:            AP, lateral, and mortise views – 9; AP and lateral views -- 2

Stress Films:            With manual stressing -- 2

Stress using biomechanical device -- 2

Manual stress while under general anesthesia -- 2

Radionuclide Scanning: Radionuclide bone scan -- 2

Cross-Sectional Imaging:            US – 2; MRI – 2; CT -- 2

Injection Procedures:            Conventional arthrography -- 2

CT arthrography -- 2

MR arthrography -- 2

Tenography -- 2

Diagnostic injection of anesthetic -- 2

Variant 8: Pain of uncertain etiology, plain films normal.

Cross-Sectional Imaging:            MRI -- 6 (If patient needs an imaging study, it should be MRI)

US – 2; CT -- 2

Injection Procedures:            Diagnostic injection of anesthetic -- 5 (Depending on clinical implication and severity of pain)

Conventional arthrography -- 2

CT arthrography -- 2

MR arthrography -- 2

Tenography -- 2

Stress Films:            With manual stressing -- 2

Stress using biomechanical device -- 2

Manual stress while under general anesthesia -- 2

Radionuclide Scanning: Radionuclide bone scan -- 2

Variant 9: Multiple sites of DJD by plain films, operative candidate.

Injection Procedures:            Diagnostic injection of anesthetic -- 6

Conventional arthrography -- 2

CT arthrography -- 2

MR arthrography -- 2

Tenography -- 2

Stress Films:            With manual stressing -- 2

Stress using biomechanical device -- 2

Manual stress while under general anesthesia -- 2

Radionuclide Scanning: Radionuclide bone scan -- 2

Cross-Sectional Imaging:            US – 2; MRI – 2; CT -- 2

 

Rating: 7b

 

 

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American College of Radiology (ACR), Expert Panel on Musculoskeletal Imaging. Chronic foot pain. Reston (VA): American College of Radiology (ACR); 2002. 7 p. (ACR appropriateness criteria). [51 references]

 

Many conditions can affect the foot and cause chronic foot pain. Some of these conditions and techniques to image them are:

Tarsal Coalition

Tarsal coalition is a congenital abnormality resulting from fibrous, cartilaginous, or osseous union of two or more tarsal bones. Calcaneonavicular and middle-facet talocalcaneal coalitions are the most common. In about half the patients the coalition is bilateral. Calcaneonavicular coalition is easily detected on oblique radiographs of the foot and confirmed by computed tomography (CT). Talocalcaneal (subtalar) coalition is often associated with severe valgus deformity of the hind foot, rigid painful flat foot, and restricted subtalar motion. It is frequently overlooked on standard foot radiographs because of overlapping structures; however, secondary signs on the lateral view could be suggestive of a subtalar coalition. These signs include talar beaking, flattening and broadening of the lateral talar process, positive C-sign, and narrowing of the posterior talocalcaneal joint. A well-penetrated axial view (Harris-Beath view) can demonstrate the posterior and middle subtalar joints. Computed tomography of the subtalar joint is usually diagnostic. Magnetic resonance imaging (MRI) has been shown to be effective in depicting all types of coalition. Inversion-recovery magnetic resonance (MR) images may reveal bone marrow edema along the margins of the abnormal articulation, which is an important clue to the diagnosis.

Reflex Sympathetic Dystrophy (RSD) Syndrome

Reflex sympathetic dystrophy (RSD) also called complex regional pain syndrome type I (CRPS I) is characterized clinically by pain, tenderness, swelling, diminished motor function, and vasomotor instability. Conditions associated with RSD of the foot include fractures and other trauma, central nervous system (CNS) and spinal disorders, and peripheral nerve injury. Reflex sympathetic dystrophy has also been described in children; the patients are predominantly girls. Early diagnosis favorably affects outcome. Diffuse osteopenia of the involved part is seen in 69% of patients with RSD. The osteopenia patterns are not pathognomonic and can be seen as a result of disuse. Three-phase radionuclide scans have been used to diagnose RSD. One study reported characteristic delayed bone scan pattern consisting of diffuse increased tracer throughout the foot, with juxta-articular accentuation of tracer uptake. Overall sensitivity in this study was 100%, specificity 80%, positive predictive value 54%, and negative predictive value 100%. There are no specific findings on MRI in patients with RSD. Using power Doppler sonography, patients with RSD of the lower extremity have increased power Doppler flow compared with asymptomatic control subjects.

Stress Fractures

(See also the National Guideline Clearinghouse [NGC] guideline summary of the American College of Radiology's [ACR] ACR Appropriateness Criteria™ for Stress/Insufficiency Fractures [Excluding Vertebral]). Stress injuries can be categorized into three types: stress reactions, fatigue fractures, and insufficiency fractures. A stress reaction occurs when microfractures are healing and a complete fracture has not yet developed. Activities producing fatigue fractures in the feet include running, marching, and dancing. The second and third metatarsals as well as the calcaneus are the most common sites for stress fractures and stress reactions. Stress fractures have also been described, less frequently, in the tarsal navicular, first metatarsal, and medial sesamoid bones of the great toe. In the early phase, plain radiography may be entirely normal, but with time a fracture line can be identified and only one cortex may be involved; a hint of periosteal reaction with some endosteal new bone may develop. It may take 3-4 weeks for changes to occur in the metaphyseal area of bone and 4-6 weeks for them to occur in the diaphysis. During the healing phase, both periosteal and endosteal new bone are incorporated in the cortex, resulting in a fusiform expansion of the cortex. Occasionally more than one stress fracture is present in the same foot. Most of the navicular fractures are oriented in the sagittal plane and occur in the central third of the bone. Some are partial fractures involving only the dorsal portion of the navicular. Participation in strenuous exercise is not essential for such fractures to develop. Initially plain radiographs can be negative and the panel believes that the next best test is MRI.

Avascular Necrosis of the Metatarsal Head (Freiberg’s Disease)

This disease is characterized by pain, tenderness, swelling and limitation of motion in the affected metatarsophalangeal (MP) joint. The disease is usually detected in adolescents, and adolescent girls predominate about three or four to one. Radiographic changes are characteristic, and they show increased density of the metatarsal head, and flattening, collapse, cystic changes, and widening of the metatarsophalangeal joint. The second metatarsal is most commonly affected, although the third and fourth can also occasionally be involved.

Painful Accessory Bones

Potentially painful normal variants such as accessory navicular and os trigonum have been described. The mechanism of pain in the presence of an accessory navicular has been attributed to traumatic or degenerative changes at the synchondrosis or to soft-tissue inflammation. Symptomatic accessory navicular bones have been studied with radionuclide bone scans and MRI. Symptomatic lesions are reported to show increased radiotracer uptake or marrow edema across the synchondrosis. For a painful os trigonum, selective arthrography of the synchondrosis followed by local anesthetic injection localizes the source of pain.

Neoplasm

Neoplasm is another cause of chronic foot pain, and (diagnostically) these lesions in the foot can be approached like other neoplasms in the musculoskeletal system (see the NGC guideline summaries ACR Appropriateness Criteria™ for Soft Tissue Masses and ACR Appropriateness Criteria™ for Bone Tumors).

Arthritis

All the common forms of arthritis affect the feet and can cause chronic foot pain. Most of the arthritides are best evaluated with plain radiography. Charcot changes are still best detected and followed by plain radiography. Chronic heel pain can be caused by calcaneal stress fractures, tarsal tunnel syndrome, and plantar fasciitis. When the heel pain is bilateral, the seronegative arthritides warrant consideration.

Plantar Fasciitis

Plantar fasciitis is the most common cause of plantar heel pain. It may occur in isolation or as a manifestation of a systemic disease such as the seronegative spondyloarthropathies, rheumatoid arthritis, gout, or systemic lupus erythematosus (SLE). In athletes, plantar fasciitis is a common cause of foot pain and it is attributed to mechanical stresses, presumably due to repetitive trauma causing microtearing of the plantar fascia at its origin as well as fascial and perifascial inflammation. Plantar fasciitis is also common in obese patients and in patients with flat feet. Typically plain radiography is not productive, but bone scintigraphy and magnetic resonance imaging (MRI) have been shown to be helpful in arriving at a diagnosis. One study showed that ultrasonography is effective in differentiating normal plantar fascia from those involved with plantar fasciitis.

Tarsal Tunnel Syndrome

This syndrome is a compressive neuropathy of the posterior tibial nerve or one of its branches. Patients typically complain of poorly localized burning pain and paresthesias along the plantar surface of the foot and toes. Inflammatory processes or mass lesions in the tarsal tunnel are described as the cause for this syndrome in most of patients. Such lesions are best imaged by MRI.

Interdigital (Morton's) Neuroma

This is a nonneoplastic perineural fibrous proliferation involving a plantar digital nerve. Clinical symptoms include pain in the involved web space that often radiates to the toes. These neuromas are seen more often in women and typically involve the three-four or less commonly the two-three intermetatarsal space. They are best detected on MRI using T1-weighted or T1-weighted, fat-suppressed images with gadolinium enhancement and T2-weighted images. The diagnosis of Morton's neuroma at MRI becomes relevant only when transverse diameter of the lesion is 5 mm or more and can be correlated with the clinical findings. High-resolution ultrasound has been used successfully to diagnose Morton's neuromas.

Tendinopathies

Tendinopathies, ranging from tendinosis to complete tear, in and around the foot can result in significant foot pain and disabilities. The most commonly affected tendons are the Achilles tendon, posterior tibial, and peroneal tendons. Tendon dysfunction is best imaged with MRI and ultrasound.

Hallux Valgus

Hallux valgus is a common foot disorder resulting in significant morbidity. Preoperative radiographic evaluation and measurements as well as postoperative follow-up are best evaluated on the weight-bearing posteroanterior (PA) and lateral radiographs of the feet.

 

ACR Appropriateness Criteria™ -- Clinical Condition: Chronic Foot Pain

Appropriateness Criteria Scale: 1 2 3 4 5 6 7 8 9 (1=Least appropriate 9=Most appropriate)

Abbreviations: AP, anteroposterior; CT, computed tomography; MRI, magnetic resonance imaging

Variant 1: 20-year-old male suspected to have Reiter's disease. Now complains of heel pain and swollen toes.

Radiologic Procedure -- Rating

AP, lateral, and oblique - 9; AP and lateral feet - 2; CT - 2; MRI - 2; Bone scan - 2; Ultrasound -- 2

Variant 2: Pain and tenderness over navicular tuberosity unresponsive to conservative therapy. Plain radiographs showed accessory navicular.

MRI - 9; Bone scan - 3; CT - 2; Ultrasound -- 2

Variant 3: Pain and tenderness over head of second metatarsal. Rule out Freiberg's disease.

AP, lateral with or without oblique - 9; CT - 2; MRI - 2; Bone scan - 2; Ultrasound -- 2

Variant 4: Athlete with pain and tenderness over tarsal navicular; plain radiographs are unremarkable.

MRI - 9; CT -- 6 (Especially for follow-up of healing fractures); Bone scan -- 2 (If MRI cannot be performed); Ultrasound -- 2

Variant 5: To rule out reflex sympathetic dystrophy.

AP, lateral and oblique - 9; Bone scan -- 8 (If plain films are not diagnostic); AP and lateral -- 2

CT - 2; MRI - 2; Ultrasound -- 2

Variant 6: Child or adolescent with painful rigid flat foot. Rule out tarsal coalition.

AP, lateral and oblique and Harris-Beath view - 9; CT - 9; AP and lateral (foot) - 2; MRI - 2; Bone scan - 2; Ultrasound -- 2

Variant 7: Middle aged woman with burning pain and paresthesias along the plantar surface of the foot and toes. Clinically, the patient is suspected of having tarsal tunnel syndrome.

AP, lateral, and oblique - 9; MRI - 9; Ultrasound -- 8 (With proper expertise may replace MRI); Bone scan - 2; CT -- 2

Variant 8: Patient is complaining of pain in the 3-4 web space with radiation to the toes. Morton's neuroma is clinically suspected.

AP and lateral - 9; MRI - 9; Ultrasound -- 9 (With proper expertise may replace MRI); CT - 2; Bone scan -- 2

Variant 9: Young athlete presenting with localized pain at the plantar aspect of the heel. Plantar fasciitis is suspected clinically.

AP and lateral - 9; MRI - 9; Ultrasound -- 8 (With proper expertise may replace MRI); Bone scan - 2; CT – 2

 

Rating: 7b

 

 

 

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Basford JR, Malanga GA, Krause DA, Harmsen WS. A randomized controlled evaluation of low-intensity laser therapy: plantar fasciitis. Arch Phys Med Rehabil 1998 Mar;79(3):249-54.
 
Department of Physical Medicine and Rehabilitation, Mayo Clinic and Foundation, Rochester, MN 55905, USA.

Low-intensity IR laser therapy appears safe but, at least within the parameters of this study, is not beneficial in the treatment of plantar fasciitis.

 

PMID: 9523774

 

Rating: 2b

 

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Akseki D, Pinar H, Bozkurt M, Yaldiz K, Arac S. The distal fascicle of the anterior inferior tibio-fibular ligament as a cause of anterolateral ankle impingement: results of arthroscopic resection. Acta Orthop Scand 1999 Oct;70(5):478-82.
 
Celal Bayar University, School of Medicine, Department of Orthopedics and Traumatology, Manisa, Turkey.

We arthroscopically resected the impinged distal fascicle of the anterior inferior tibiofibular ligament (AIT-FL) in 21 patients (mean age 31 (11-68) years, 14 women) with chronic ankle pain after an ankle sprain. At the follow-up after mean 3 (2-4) years, good-to-excellent results were obtained in 17 patients. 19 patients were satisfied with the procedure and 17 patients returned to their previous level of activity.

PMID: 10622481

Rating: 5c

 

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Aslan H, Citak M, Bas EG, Duman E, Aydin E, Ates Y. Early results of HemiCAP(®) resurfacing implant. Acta Orthop Traumatol Turc. 2012;46(1):17-21.

 

PMID: 22545290

 

Rating: 4b

 

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Babcock MS, Foster L, Pasquina P, Jabbari B. Treatment of pain attributed to plantar fasciitis with botulinum toxin a: a short-term, randomized, placebo-controlled, double-blind study. Am J Phys Med Rehabil. 2005 Sep;84(9):649-54.

 

Orthopedic and Rehabilitation Department, Physical Medicine and Rehabilitation Service, Walter Reed Army Medical Center, Washington, DC 20307, USA.

 

DESIGN: This is a randomized, double-blind, placebo-controlled study of 27 patients (43 feet) with plantar fasciitis. CONCLUSIONS: Botulinum toxin A injection for plantar fasciitis yields significant improvements in pain relief and overall foot function at both 3 and 8 wks after treatment.

 

PMID: 16141740

 

Rating: 2c

 

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Bahr R, Pena F, Shine J, Lew WD, Lindquist C, Tyrdal S, Engebretsen L. Mechanics of the anterior drawer and talar tilt tests. A study of lateral ligament injuries of the ankle. Acta Orthop Scand. 1997 Oct;68(5):435-41.

 

Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, USA. roald@brage.idrettshs.no

 

We analyzed the changes in lateral ligament forces during anterior drawer and talar tilt testing and examined ankle joint motion during testing, following an isolated lesion of the anterior talofibular ligament (ATFL) or a combined lesion of the ATFL and calcaneofibular ligament (CFL). Isolated ATFL injury caused only small laxity changes, but a pronounced increase in laxity was observed after a combined CFL and ATFL injury.

 

PMID: 9385242

 

Rating: 5b

 

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Batt ME, Tanji JL, Skattum N. Plantar fasciitis: a prospective randomized clinical trial of the tension night splint. Clin J Sport Med 1996 Jul;6(3):158-62.
 
Department of Family Practice, University of California at Davis School of Medicine, Sacramento, USA.

CONCLUSION: “When used in combination with a visco-elastic heel pad, stretching program and nonsteroidal anti-inflammatory drugs, the TNS is an effective treatment of plantar fasciitis.
 

PMID: 8792046

 

Rating: 2b

 

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Baxter DE, Pfeffer GB. Treatment of chronic heel pain by surgical release of the first branch of the lateral plantar nerve. Clin Orthop. 1992 Jun;(279):229-36.

Baylor College of Medicine, Department of Orthopaedics, Houston, Texas.

Sixty-nine heels (53 patients) with chronic heel pain had a surgical release of the first branch of the lateral plantar nerve. The average duration of heel-pain symptoms was 23 months (range, six months to eight years). No patient had less than six months of conservative treatment before surgery. In general, heel pain resolves with conservative treatment. In recalcitrant cases, however, entrapment of the first branch lateral plantar nerve should be suspected. Surgical release of this nerve can be expected to provide excellent relief of pain and facilitate return to normal activity.

PMID: 1600660

 

Rating: 4b

 

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Benazzo F, Mosconi M, Beccarisi G, Galli U. Use of capacitive coupled electric fields in stress fractures in athletes. Clin Orthop 1995 Jan;(310): 145-9.

Clinica Orthopedica e Trumaologica dell' Universita di Pavia, Italy.

”This preliminary report shows that capacitive coupling can be used safely in the treatment of these stress fractures.”


PMID: 7641431

 

Rating: 2c

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Bennett GL, Graham CE, Mauldin DM. Morton's interdigital neuroma: a comprehensive treatment protocol. Foot Ankle Int 1995 Dec; 16(12): 760-3.
 
Northeast Ohio Universities College of Medicine, Rootstown, USA.

PMID: 8749346

 

Rating: 5b

 

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Berendt AR. Counterpoint: hyperbaric oxygen for diabetic foot wounds is not effective. Clin Infect Dis. 2006 Jul 15;43(2):193-8. Epub 2006 Jun 12.

 

Bone Infection Unit, Nuffield Orthopaedic Centre NHS Trust, Headington, Oxford, OX3 7LD, United Kingdom. tony.berendt@noc.anglox.nhs.uk

 

RESULTS: Although recognized for reimbursement by Medicare and major insurers, the evidence base for hyperbaric oxygen therapy for diabetic foot care remains weak.

 

PMID: 16779746

 

Rating: 5b

 

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Bibbo C, Lin SS, Beam HA, Behrens FF. Complications of ankle fractures in diabetic patients. Orthop Clin North Am. 2001 Jan;32(1):113-33.

 

Department of Orthopaedics, New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark 07103, USA.

 

Ankle fracture in patients with DM mandates a stepwise protocol to minimize the potential complications of delayed fracture healing, wound complications, and development of Charcot arthropathy. The authors advocate tight glucose control in both groups to improve the fracture milieu and to ameliorate the potential complications. Appropriate stable fixation with adequate length of immobilization is crucial for successful fracture resolution.

 

PMID: 11465124

 

Rating: 5c

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Biederman RE. Pharmacology in rehabilitation: nonsteroidal anti-inflammatory agents. J Orthop Sports Phys Ther. 2005 Jun;35(6):356-67.

 

American Board of Podiatric Surgery, San Francisco, CA, USA. rbiederman@apu.edu

 

However, NSAIDs are also associated with frequent and significant side effects that are deleterious to treatment outcome, including delay in soft tissue and bone healing, renal and liver toxicity, hemorrhagic events, gastric irritation and ulceration, and central nervous system effects.

 

PMID: 16001907

 

Rating: 5b

 

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Bjordal JM, Lopes-Martins RA, Iversen VV. A randomised, placebo controlled trial of low level laser therapy for activated Achilles tendinitis with microdialysis measurement of peritendinous prostaglandin E2 concentrations. Br J Sports Med. 2006 Jan;40(1):76-80; discussion 76-80.

 

Physiotherapy Science, University of Bergen, Bergen, Norway. jmbjor@broadpark.no

 

BACKGROUND: Low level laser therapy (LLLT) has gained increasing popularity in the management of tendinopathy and arthritis. Results from in vitro and in vivo studies have suggested that inflammatory modulation is one of several possible biological mechanisms of LLLT action. OBJECTIVE: To investigate in situ if LLLT has an anti-inflammatory effect on activated tendinitis of the human Achilles tendon. SUBJECTS: Seven patients with bilateral Achilles tendinitis (14 tendons) who had aggravated symptoms produced by pain inducing activity immediately before the study. CONCLUSION: LLLT at a dose of 5.4 J per point can reduce inflammation and pain in activated Achilles tendinitis. LLLT may therefore have potential in the management of diseases with an inflammatory component.

 

PMID: 16371497

 

Rating: 11b

 

Note: With a rating of Level 11 this study cannot be used as a basis for an ODG guideline recommendation, since that falls below the cut-off of Level 10. The number of cases in this study, seven, is less than ten, which is the mininum number of cases for a rating Level 4.

 

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Blakeslee TJ. Traumatic injuries of the first ray. Clin Podiatr Med Surg 1996 Jul;13(3):549-73.
 
Department of Orthopedic Surgery, Kaiser Permanente Medical Center, South Sacramento, California, USA.

Injuries involving the first ray are common and can lead to significant pain and disability. The management of these injuries, both conservative and surgical, is discussed in this article. Treatment goals include recreating a uniformly plantigrade weight-bearing surface under all the metatarsal heads, preserving functional anatomy, and preventing traumatic arthritis while maintaining a supple, pliable foot.
 

PMID: 8829041

 

Rating: 5b

 

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Bleakley C, McDonough S, MacAuley D. The use of ice in the treatment of acute soft-tissue injury: a systematic review of randomized controlled trials. Am J Sports Med. 2004 Jan-Feb;32(1):251-61.

 

Rehabilitation Science Research Group, University of Ulster at Jordanstown, Antrim, Ireland.

 

STUDY DESIGN: Systematic review assessing the evidence base for cryotherapy in the treatment of acute soft-tissue injuries. RESULTS: Twenty-two trials met the inclusion criteria. There was a mean PEDro score of 3.4 out of of 10. There was marginal evidence that ice plus exercise is most effective, after ankle sprain and postsurgery. CONCLUSION: Many more high-quality trials are needed to provide evidence-based guidelines in the treatment of acute soft-tissue injuries.

 

PMID: 14754753

 

Rating: 1c

 

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BlueCross BlueShield. Surgery Section - Total Ankle Replacement. Policy No: 115. Effective Date: 09/07/2004

 

Total ankle replacement is considered investigational.

 

Rating: 8b

 

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BlueCross BlueShield. Medicine Section - Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions. Policy No: 90. Effective Date: 05/04/2004

 

Policy/Criteria: ESWT is considered investigational for all indications, including but not limited to plantar fasciitis, lateral epicondylitis, tendinopathies including calcific tendinitis of the shoulder, stress fracture, delayed union, nonunion, and avascular necrosis of the femoral head.

 

Rating: 8b


Boddenberg U. Healing time of foot and ankle fractures in patients with diabetes mellitus: literature review and report on own cases. Zentralbl Chir. 2004 Dec;129(6):453-9.

 

The present data suggest that diabetes mellitus in general does not affect the healing of foot and ankle fractures, provided effective delivery of standard treatment in time. Diabetic complications may affect the outcome.

 

PMID: 15616908

 

Rating: 1b

 

 

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Bonacci J, Saunders PU, Hicks A, Rantalainen T, Vicenzino BG, Spratford W. Running in a minimalist and lightweight shoe is not the same as running barefoot: a biomechanical study. Br J Sports Med. 2013 Apr;47(6):387-92. doi: 10.1136/bjsports-2012-091837.

 

Barefoot running changes the amount of work done at the knee and ankle joints and this may have therapeutic and performance implications for runners.

 

PMID: 23314887

 

Rating: 3c

 

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Bonnin M, Tavernier T, Bouysset M. Split lesions of the peroneus brevis tendon in chronic ankle laxity. Am J Sports Med 1997 Sep-Oct;25(5):699-703.
 
Clinique Charcot, Lyon, France.

Between 1993 and 1995, we operated on 18 patients for split lesions of the peroneal brevis tendon associated with chronic ankle instability. A Chrisman-Snook procedure was performed in 13 cases and a simple tendinous repair in 5 cases.

PMID: 9302480

 

Rating: 5c

 

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Boutis K, Willan AR, Babyn P, Narayanan UG, Alman B, Schuh S. A randomized, controlled trial of a removable brace versus casting in children with low-risk ankle fractures. Pediatrics. 2007 Jun; 119(6): e1256-63.

 

Division of Emergency Medicine, Hospital for Sick Children, 555 University Ave, Toronto, Ontario, Canada M5G 1X8. boutis@pol.net

 

OBJECTIVES: Isolated distal fibular ankle fractures in children are very common and at very low risk for future complications. Nevertheless, standard therapy for these fractures still consists of casting, a practice that carries risks, inconveniences, and use of subspecialty health care resources. CONCLUSIONS: The removable ankle brace is more effective than the cast with respect to recovery of physical function, is associated with a faster return to baseline activities, is superior with respect to patient preferences, and is also cost-effective.

 

PMID: 17545357

 

Rating: 2b

 

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Braun BL. Effects of ankle sprain in a general clinic population 6 to 18 months after medical evaluation. Arch Fam Med 1999 Mar-Apr; 8(2):143-8.

Division of Education and Research, St Mary's-Duluth Clinic Health System, Minn., USA. braunb@hsmnet.com

OBJECTIVE: To assess the 1-year outcome of standard medical care of acute ankle sprains in a general clinic-based population. CONCLUSIONS: Residual lifestyle-limiting symptoms are common 6 to 18 months after an ankle sprain. Ankle sprains may be more problematic than generally thought, or standard medical treatment may be inadequate. Further studies evaluating treatment regimens are needed to identify effective methods to reduce the long-term functional limitations of ankle sprain in general clinic populations.

PMID: 10101985

 

Rating: 5b

 

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Bridgman SA, Dunn KM, McBride DJ, Richards PJ. Interventions for treating calcaneal fractures (Cochrane Review). In: The Cochrane Library, Issue 3, 2002.

A substantive amendment to this systematic review was last made on 29 June 1999. Cochrane reviews are regularly checked and updated if necessary.

 

Reviewers' conclusions: Randomised trials of management of calcaneal fractures are few, small and generally of poor quality.

Even where there is some evidence of benefit of operative compared with non-operative treatment, it remains unclear whether the possible advantages of surgery are worth its risks. Given this it seems best to wait for the results of one large ongoing trial on open reduction and internal fixation against conservative treatment.

One very small trial suggests that impulse compression therapy for intra-articular calcaneal fractures may be beneficial. More large-scale, high quality randomised controlled trials are needed to confirm these results, and to test other interventions in the treatment of calcaneal fractures.

 

PMID: 10796422

 

Rating: 1b

 

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Briem KE, Eythorsdóttir H, Magnúsdóttir RG, Pálmarsson R, Rúnarsdottir T, Sveinsson T. Effects of Kinesio Tape Compared With Non-Elastic Sports Tape and the Untaped Ankle During a Sudden Inversion Perturbation in Male Athletes. J Orthop Sports Phys Ther. 2011 Jan 5.

 

METHODS: Fifty-one male premier-league athletes were tested for functional stability of both ankles. RESULTS: Significantly greater mean muscle activity was found when ankles were taped with non-elastic tape compared to no tape, while kinesio tape had no significant effect on mean or maximum muscle activity compared to the no tape condition. CONCLUSION: Non-elastic sports tape may enhance dynamic muscle support of the ankle. The efficacy of kinesio tape in preventing ankle sprains via the same mechanism is unlikely as it had no effect on muscle activation of the fibularis longus.

 

PMID: 21212501

 

Rating: 2c

 

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Brosseau L, Welch V, Wells G, DeBie R, Gam A, Harman K, Morin M, Shea B, Tugwell P, Low level laser therapy (Classes I, II and III) for treating osteoarthritis, Cochrane Database Syst Rev. 2004;(3):CD002046

School of Rehabilitation Sciences, University of Ottawa, 451 Smyth Road, Ottawa, Ontario, CANADA, K1H 8M5.

BACKGROUND: Osteoarthritis (OA) affects a large proportion of the population. Low Level Laser Therapy (LLLT) is a light source that generates extremely pure light, of a single wavelength. The effect is not thermal, but rather related to photochemical reactions in the cells. LLLT was introduced as an alternative non-invasive treatment for OA about 20 years ago, but its effectiveness is still controversial. OBJECTIVES: To assess the effectiveness of LLLT in the treatment of OA. MAIN RESULTS: Seven trials were included, with 184 patients randomized to laser, 161 patients to placebo laser. Treatment duration ranged from 4 to 12 weeks. Lower dosage of LLLT was found as effective than higher dosage for reducing pain and improving knee range of motion. REVIEWERS' CONCLUSIONS: For OA, the results are conflicting in different studies and may depend on the method of application and other features of the LLLT application. Clinicians and researchers should consistently report the characteristics of the LLLT device and the application techniques used. New trials on LLLT should make use of standardized, validated outcomes. Despite some positive findings, this meta-analysis lacked data on how LLLT effectiveness is affected by four important factors: wavelength, treatment duration of LLLT, dosage and site of application over nerves instead of joints. There is clearly a need to investigate the effects of these factors on LLLT effectiveness for OA in randomized controlled clinical trials.

PMID: 15266461

 

Rating: 1b

 

 

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Buchbinder R, Ptasznik R, Gordon J, Buchanan J, Prabaharan V, Forbes A. Ultrasound-guided extracorporeal shock wave therapy for plantar fasciitis: a randomized controlled trial. JAMA 2002 Sep 18;288(11):1364-72.

Department of Clinical Epidemiology, Cabrini Hospital and Cabrini Medical Centre, Malvern, Victoria, Australia 3144. rachelle.buchbinder@med.monash.edu.au

The RCT included 178 patients, and concluded that there was no evidence to support a beneficial effect on pain, function, and quality of life from ultrasound-guided extracorporeal shock wave therapy.
 

PMID: 12234230

 

Rating: 2a

 

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Bulucu C, Thomas KA, Halvorson TL, Cook SD. Biomechanical evaluation of the anterior drawer test: the contribution of the lateral ankle ligaments. Foot Ankle. 1991 Jun;11(6):389-93.

 

Arabian Gulf University, College of Medicine and Medical Sciences, Manama, Bahrain.

 

The contributions of the lateral ankle ligaments to resisting anterior-posterior displacement of the talus were evaluated in eight unembalmed cadaveric ankles. Under strictly anteroposterior loading and without an axial (weight-bearing) load applied, no single ligament could be isolated as having a dominant stabilizing function. Definition provided of anterior drawer test.

 

PMID: 1894233

 

Rating: 5b

 

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Busam ML, Esther RJ, Obremskey WT. Hardware removal: indications and expectations. J Am Acad Orthop Surg. 2006 Feb;14(2):113-20.

 

Department of Orthopaedics and Rehabilitation, Vanderbilt University, Nashville, TN, USA.

 

Although hardware removal is commonly done, it should not be considered a routine procedure. The decision to remove hardware has significant economic implications, including the costs of the procedure as well as possible work time lost for postoperative recovery. Implant removal may be challenging and lead to complications, such as neurovascular injury, refracture, or recurrence of deformity. When implants are removed for pain relief alone, the results are unpredictable and depend on both the implant type and its anatomic location. Current literature does not support the routine removal of implants to protect against allergy, carcinogenesis, or metal detection.

 

PMID: 16467186

 

Rating: 5b

 

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Carmont MR, Maffulli N. Less invasive Achilles tendon reconstruction. BMC Musculoskelet Disord. 2007 Oct 26;8:100.

 

Department of Trauma and Orthopaedics, University Hospital of North Staffordshire, Keele University School of Medicine, Stoke on Trent, ST7 4QG UK. mcarmont@hotmail.com

 

BACKGROUND: The optimal management of chronic ruptures of the Achilles tendon is surgical reconstruction. Reconstruction of the Achilles tendon using peroneus brevis has been widely reported.

 

PMID: 17963499

 

Rating: 5b

 

Background: Acute Achilles tendons ruptures may be managed either operatively or non-operatively. However, generally 6 weeks following a rupture a direct repair opposing the tendon ends becomes increasingly difficult. Over time, scar tissue forms, the muscles atrophy with disuse, and the tendon ends weaken. Chronic and neglected Achilles tendon ruptures are debilitating: their optimal management is surgical.

 

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Carpenter B, Motley T. The role of viscosupplementation in the ankle using hylan G-F 20.  J Foot Ankle Surg. 2008 Sep-Oct;47(5):377-84.

 

John Peter Smith Hospital, Department of Orthopaedics, Podiatry Section, Fort Worth, TX 76104, USA.

 

These preliminary results suggest that viscosupplementation combined with arthroscopy may be more beneficial than arthroscopy alone, and provide further insight into the role of viscosupplementation in the treatment of ankle osteoarthritis. Level of Clinical Evidence: 4.

 

PMID: 18725116

 

Rating: 2c

 

 

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Cerrato RA, Myerson MS. Peroneal tendon tears, surgical management and its complications. Foot Ankle Clin. 2009 Jun;14(2):299-312.

 

PMID: 19501808

 

Rating: 5b

 

 

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Chalmers AC, Busby C, Goyert J, Porter B, Schulzer M. Metatarsalgia and rheumatoid arthritis--a randomized, single blind, sequential trial comparing 2 types of foot orthoses and supportive shoes. J Rheumatol 2000 Jul;27(7):1643-7.
 
Occupational Therapy Department, Vancouver Hospital and Health Science Centre, British Columbia, Canada.

OBJECTIVE: To compare the effects of semi-rigid and soft orthoses worn in supportive shoes, and supportive shoes worn alone, on metatarsal phalangeal (MTP) joint pain. CONCLUSION: Semi-rigid orthoses worn in supportive shoes were an effective treatment for metatarsalgia. Supportive shoes worn alone or worn with soft orthoses did not provide pain relief for metatarsalgia.

 

PMID: 10914845

 

Rating: 2b

 

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Chandra A, Schafmayer A. Diagnostic value of a clinical test for exclusion of fractures after acute ankle sprains. A prospective study for evaluating the "Ottowa Ankle Rules" in Germany.

Chirurgische Klinik, Stadtisches Klinikum Luneburg, Bogelstrasse 1, 21339 Luneburg.

Following the criteria of the "Ottawa Ankle Rules" (OAR) fractures could be ruled out with a sensitivity of 100% and a specificity of 50% while reducing radiographs by 28. Patients older than 18, who presented with blunt ankle trauma were examined by clinicians, then radiographs were ordered in all and the "OAR" were retrospectively applied. In 397 treated injuries 79 fractures were diagnosed and 5 patients had radiologically suspected fractures. Following to the "OAR" 58 were unnecessarly X-rayed and 5 fractures would not have been discovered, all of which were minor. Sensitivity using the "OAR" was 94% and specificity 17%. We found that 15% less radiographs can be ordered applying the "OAR". The "OAR" have the ability to rule out significant fractures at the ankle and midfoot.

PMID: 11490954

 

Rating: 4c

 

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Chaney DM. The Lisfranc joint. Clin Podiatr Med Surg. 2010 Oct;27(4):547-60.

 

Early studies have shown that primary arthrodesis of the medial 3 rays has performed equally well or better than ORIF for the displaced primarily ligamentous and severe injuries. A paradigm shift may emerge as more studies favor primary arthrodesis.

 

PMID: 20934104

 

Rating: 5b

 

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Chang KV, Chen SY, Chen WS, Tu YK, Chien KL. Comparative effectiveness of focused shock wave therapy of different intensity levels and radial shock wave therapy for treating plantar fasciitis: a systematic review and network meta-analysis. Arch Phys Med Rehabil. 2012 Jul;93(7):1259-68. doi: 10.1016/j.apmr.2012.02.023.

 

Setting the highest and mostly tolerable energy output within medium intensity ranges is the ideal option when applying FSW therapy on plantar fasciitis. RSW therapy is considered an appropriate alternative because of its lower price and probably better effectiveness.

 

PMID: 22421623

 

Rating: 1b

 

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Chou MC, Yeh LR, Chen CK, Pan HB, Chou YJ, Liang HL. Comparison of plain MRI and MR arthrography in the evaluation of lateral ligamentous injury of the ankle joint. J Chin Med Assoc. 2006 Jan;69(1):26-31.

 

For evaluating ankle disability, using plain MRI alone is not adequate for correctly detecting lateral collateral ligamentous injury of the ankle joint. MR arthrography improves the sensitivity and the accuracy for ATaF and CF ligament injuries. It also helps in assessing coexisting pathologic lesions of ankle joints, especially impingement syndromes and osteochondral lesions, and provides more information for therapeutic decision making.

 

PMID: 16447923

 

Rating: 3b

 

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Cohen MM, Altman RD, Hollstrom R, Hollstrom C, Sun C, Gipson B. Safety and efficacy of intra-articular sodium hyaluronate (Hyalgan) in a randomized, double-blind study for osteoarthritis of the ankle. Foot Ankle Int. 2008 Jul;29(7):657-63.

 

Miami Veterans Affairs Medical Center, Surgical Service, 1201 NW 16th St, Miami, FL 33125, USA. michael.cohen@med.va.gov

 

METHODS: Thirty consecutive patients with ankle OA documented by X-ray were randomized to treatment with five weekly injections of either sodium hyaluronate 2 mL (HYL) or phosphate-buffered saline 2 mL (control) in the tibiotalar joint. CONCLUSION: Our study suggests that sodium hyaluronate may be a safe and effective option for pain associated with ankle OA, although larger studies are needed.

 

PMID: 18785414

 

Rating: 2c

 

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Colorado Division of Workers' Compensation, Medical Treatment Guidelines, Rule XVII, Exhibit C, Lower Extremity Injury, 12/01/01.

 

Rating: 7a

 

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Cook E, Cook J, Rosenblum B, Landsman A, Giurini J, Basile P. Meta-analysis of first metatarsophalangeal joint implant arthroplasty.  J Foot Ankle Surg. 2009 Mar-Apr;48(2):180-90. Epub 2009 Jan 9.

 

Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA. ecook@bidmc.harvard.edu

 

Abstract screening produced 112 articles to be read in entirety, of which 47 articles studying 3049 procedures with a mean 61.48 (SD 45.03) month follow-up met all prospective inclusion criteria necessary for analysis. Overall crude patient satisfaction following first MPJ implant arthroplasty was 85.7% (95% confidence interval: 82.5%-88.3%). When adjusting for lower quality studies (retrospective, less than 5 years of follow-up, higher percent of patients lost to follow-up), the overall patient satisfaction increased to 94.5% (89.6%-97.2%) in the highest-quality studies. Additional a priori sources of heterogeneity were evaluated by subgroup analysis and meta-regression. In regards to patient satisfaction, this comprehensive analysis provides supportive evidence to the clinical benefit of first MPJ implant arthroplasties. Level of Clinical Evidence: 1.

 

PMID: 19232970

 

Rating: 1b

 

Nearly 86% of patients who undergo implant arthroplasty for end-stage degenerative disease of the first metatarsophalangeal joint (MPJ) are satisfied with the outcome, findings from a meta-analysis suggest. The satisfaction rate was even higher when lower quality studies were excluded from the analysis. "A number of studies have evaluated these implants over the years, however, they have generally focused on a particular device brand or model," lead author Dr. Emily Cook, from Harvard Medical School, Boston, told Reuters Health. "This is the first meta-analysis that focuses on first MPJ replacement." In terms of implant materials, the findings suggest that metallic hemi, silicone total, metallic total, and ceramic total yield higher patient satisfaction than does silicone hemi. "We hope that future investigators will prospectively evaluate the influence of implant design and materials as well as the impact of patient characteristics on outcome measures," Dr. Cook said. "By comparing devices prospectively, we can develop a better understanding of those characteristics that are related to the best patient outcomes."

 

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Cooke MW, Marsh JL, Clark M, Nakash R, Jarvis RM, Hutton JL, Szczepura A, Wilson S, Lamb SE; CAST trial group. Treatment of severe ankle sprain: a pragmatic randomised controlled trial comparing the clinical effectiveness and cost-effectiveness of three types of mechanical ankle support with tubular bandage. The CAST trial. Health Technol Assess. 2009 Feb;13(13):iii, ix-x, 1-121.

 

INTERVENTIONS: 584 participants were randomised to one of four treatment arms: tubular bandage, below knee cast, Aircast ankle brace or Bledsoe boot, all applied 2-3 days after presentation to allow swelling to resolve. CONCLUSIONS: The below knee cast and the Aircast brace offered cost-effective alternatives to tubular bandage for acute severe ankle sprain, the former having the advantage in terms of overall recovery at 3 months.

 

PMID: 19232157

 

Rating: 2a

 

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Cordova ML, Ingersoll CD, LeBlanc MJ. Influence of ankle support on joint range of motion before and after exercise: a meta-analysis. J Orthop Sports Phys Ther 2000 Apr;30(4):170-7; discussion 178-82.

Athletic Training Department, Indiana State University, Terre Haute 47809, USA. m-cordova@indstate.edu

OBJECTIVE: To evaluate the effects of different types of ankle support on ankle and foot joint range of motion before and after activity using meta-analysis procedures. CONCLUSIONS: The greatest restriction of motion in the frontal plane was offered by the semirigid support condition, whereas taping offered the most support for limiting dorsiflexion range of motion. The results of this study may help clinicians make rational decisions concerning the selection of ankle appliances for preventing acute or chronic reinjury.

 

PMID: 10778794

 

Rating: 1b

 

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Cosentino R, Falsetti P, Manca S, De Stefano R, Frati E, Frediani B, Baldi F, Selvi E, Marcolongo R. Efficacy of extracorporeal shock wave treatment in calcaneal enthesophytosis. Ann Rheum Dis 2001 Nov; 60(11): 1064-7.
 
Institute of Rheumatology, University of Siena, Italy. r.cosentino@katamail.com

OBJECTIVE: To evaluate the efficacy of extracorporeal shock wave treatment (ESWT) in calcaneal enthesophytosis. CONCLUSION: ESWT is safe and improves the symptoms of most patients with a painful heel, it can also structurally modify enthesophytosis, and reduce inflammatory oedema.

 

PMID: 11602481

 

Rating: 2b

 

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Coughlin MJ, Smith BW, Traughber P. The evaluation of the healing rate of subtalar arthrodeses, part 2: the effect of low-intensity ultrasound stimulation. Foot Ankle Int. 2008 Oct;29(10):970-7.

 

Idaho Foot and Ankle Fellowship Program, Foot and Ankle Orthopaedic Surgery, 901 North Curtis Road Suite 503, Suite 503, Boise, ID 83706, USA. FOOTMD@aol.com

 

BACKGROUND: Use of adjuvant low-intensity ultrasound bone stimulation has demonstrated promising results in the treatment of acute fractures and fracture nonunions. The purpose of this 12-month prospective study was to evaluate the healing rate and clinical results of patients undergoing primary subtalar arthrodeses with adjuvant low-intensity ultrasound bone stimulation. RESULTS: The patients who received ultrasound bone stimulation showed a statistically significant faster healing rate on plain radiographs at 9 weeks (p = 0.034) and CT scan at 12 weeks (p = 0.017). A 100% fusion rate was noted. CONCLUSION: We were able to show significantly improved radiographic as well as clinical outcomes compared with a similar cohort of patients who did not receive adjuvant ultrasound stimulation.

 

PMID: 18851812

 

Rating: 3c

 

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Coughlin MJ, Kemp TJ, Hirose CB. Turf toe: soft tissue and osteocartilaginous injury to the first metatarsophalangeal joint. Phys Sportsmed. 2010 Apr;38(1):91-100.

 

The use of artificial turf in the United States has created a dramatic increase in first metatarsophalangeal joint dorsiflexion injuries. Nonoperative treatment may often suffice for incomplete injuries; however, surgery may be warranted for a complete plantar plate disruption or injury to one or both sesamoids.

 

PMID: 20424406

 

Rating: 5b

 

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Creaney L, Hamilton B. Growth factor delivery methods in the management of sports injuries: the state of play. Br J Sports Med. 2008 May;42(5):314-20.

 

In recent years there have been rapid developments in the use of growth factors for accelerated healing of injury. Three commonly utilised techniques are known as platelet-rich plasma, autologous blood injections and autologous conditioned serum. Each of these techniques has been studied clinically in humans to a very limited degree so far, but results are promising in terms of earlier return to play following muscle and particularly tendon injury.

 

PMID: 17984193

 

Rating: 5b

 

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Crawford F, Atkins D, Edwards J. Interventions for treating plantar heel pain (Cochrane Review). In: The Cochrane Library, Issue 3, 2002.

 

Eleven randomised trials involving 465 participants were included. Study quality was generally poor, and pooling of data was not possible. All studies measured a reduction in heel pain as the primary outcome. Seven trials evaluated interventions against placebo/dummy or no treatment. There was limited evidence for the effectiveness of topical corticosteroid, administered by iontophoresis in reducing pain. There was no evidence for the effectiveness of injected corticosteroid. There was limited evidence for the effectiveness of low energy extracorporeal shock wave therapy in reducing night pain, resting pain and pressure pain in the short term (12 weeks). In individuals with chronic pain (longer than six months), there was limited evidence for the effectiveness of dorsiflexion night splints in reducing pain. There was no evidence to support the effectiveness of therapeutic ultrasound, low-intensity laser therapy, exposure to an electron generating device or insoles with magnetic foil. No randomised trials evaluating orthotic devices, surgery, or radiotherapy against a control population were identified. There was limited evidence for the superiority of corticosteroid injections over orthotic devices.

Reviewers' conclusions: Although there is limited evidence for the effectiveness of local corticosteroid therapy, the effectiveness of other frequently employed treatments in altering the clinical course of plantar heel pain has not been established in comparative studies. Well-designed and conducted randomised studies are required.

 

Rating: 1a

 

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Crawford F, Thomson C, Interventions for treating plantar heel pain, Cochrane Database Syst Rev. 2003;(3):CD000416.

RESULTS: Nineteen randomised trials involving 1626 participants were included. Trial quality was generally poor, and pooling of data was not conducted. All trials measured heel pain as the primary outcome. Seven trials evaluated interventions against placebo/dummy or no treatment. There was limited evidence for the effectiveness of topical corticosteroid administered by iontophoresis, i.e using an electric current, in reducing pain. There was some evidence for the effectiveness of injected corticosteroid providing temporary relief of pain. There was conflicting evidence for the effectiveness of low energy extracorporeal shock wave therapy in reducing night pain, resting pain and pressure pain in the short term (6 and 12 weeks) and therefore its effectiveness remains equivocal. In individuals with chronic pain (longer than six months), there was limited evidence for the effectiveness of dorsiflexion night splints in reducing pain. There was no evidence to support the effectiveness of therapeutic ultrasound, low-intensity laser therapy, exposure to an electron generating device or insoles with magnetic foil. No randomised trials evaluating surgery, or radiotherapy against a randomly allocated control population were identified. There was limited evidence for the superiority of corticosteroid injections over orthotic devices. REVIEWER'S CONCLUSIONS: Although there is limited evidence for the effectiveness of local corticosteroid therapy, the effectiveness of other frequently employed treatments in altering the clinical course of plantar heel pain has not been established in randomised controlled trials.At the moment there is limited evidence upon which to base clinical practice. Treatments that are used to reduce heel pain seem to bring only marginal gains over no treatment and control therapies such as stretching exercises. Steroid injections are a popular method of treating the condition but only seem to be useful in the short term and only to a small degree. Orthoses should be cautiously prescribed for those patients who stand for long periods; there is limited evidence that stretching exercises and heel pads are associated with better outcomes than custom made orthoses in people who stand for more than eight hours per day.Well designed and conducted randomised trials are required.

PMID: 12917892

 

Rating: 1a

 

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Crawford F, Snaith M. How effective is therapeutic ultrasound in the treatment of heel pain? Ann Rheum Dis. 1996 Apr;55(4):265-7.

London Foot Hospital & School of Podiatric Medicine, United Kingdom.

OBJECTIVES: To evaluate the therapeutic effect from ultrasound in the treatment of plantar heel pain by physiotherapists and podiatrists, and to quantify the placebo effect of this electrophysical agent. RESULTS: Nineteen patients experienced episodes of heel pain (seven bilateral). Both groups showed a reduction in pain; the improvement was 30% in the treated group and 25% in the placebo group (p = 0.5). CONCLUSIONS: Therapeutic ultrasound at a dosage of 0.5 w/cm2, 3 MHz, pulsed 1:4, for eight minutes is no more effective than placebo in the treatment of plantar heel pain.

 

PMID: 8733444

 

Rating: 2c

 

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Cunnane G, Brophy DP, Gibney RG, FitzGerald O. Diagnosis and treatment of heel pain in chronic inflammatory arthritis using ultrasound. Semin Arthritis Rheum 1996 Jun;25(6):383-9.
 
University Department of Rheumatology, University College Dublin, St. Vincent's Hospital, Ireland.

The authors examined the role of ultrasound (US) in diagnosis and management of heel pain in chronic inflammatory arthritis. Ten of 11 guided injections resulted in full resolution of heel pain. The diverse causes of heel pain are highlighted, and the ability of US to provide information with management implications is confirmed. US-guided corticosteroid injection is beneficial, especially after failure of nonguided injection.

 

PMID: 8792510

 

Rating: 1c, 19 cases

 

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Dalinka MK, Alazraki N, Berquist TH, Daffner RH, DeSmet AA, el-Khoury GY, Goergen TG, Keats TE, Manaster BJ, Newberg A, Pavlov H, Haralson RH, McCabe JB, Sartoris D. Imaging evaluation of suspected ankle fractures. American College of Radiology. ACR Appropriateness Criteria. Radiology 2000 Jun;215(Suppl):239-41. [20 references]

 

Summary

Ankle films should be obtained in patients with the following clinical findings: (1) inability to bear weight immediately after the injury, (2) point tenderness over the medial malleolus, or the posterior edge or inferior tip of the lateral malleolus or talus or calcaneus, (3) inability to ambulate for four steps in the emergency room. It has been convincingly demonstrated that one can approach a sensitivity of 100% in excluding significant ankle fractures using these simple criteria. Limiting ankle radiographs to patients who meet these criteria can eliminate a considerable number of ankle and mid-foot radiographs (estimated range 19%-36%) without missing significant injuries. This would result in a considerable savings in patient cost and waiting time. An evaluation of the traumatized ankle should consist of anteroposterior (AP), lateral, and mortise views of the ankle. Additional views can be added to the minimal series in questionable cases. The fifth metatarsal base distal to the tuberosity should be seen on at least one projection. The use of a pertinent clinical history for the site of point tenderness will decrease the misrate for subtle fractures by approximately 50%.

 

PMID: 11037432

 

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Dean BJ, Kothari A, Uppal H, Kankate R. The jones fracture classification, management, outcome, and complications: a systematic review. Foot Ankle Spec. 2012 Aug;5(4):256-9.

 

Surgical intervention for the acute Jones fracture should be reserved for the athletic individual because there is a clear advantage in terms of time to return to sporting activity. Nonoperative treatment remains a viable alternative to surgery in all acute and delayed cases, providing there is no established nonunion and the patient is aware of the implications.

 

PMID: 22547534

 

Rating: 1c

 

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DeBerardino TM, Arciero RA, Taylor DC. Arthroscopic treatment of soft-tissue impingement of the ankle in athletes. Arthroscopy 1997 Aug; 13(4):492-8.
 
Orthopaedic Surgery Service, United States Miliatry Academy, West Point, New York, USA.

Sixty ankle arthroscopies were performed on patients with chronic soft-tissue impingement of the ankle after an ankle sprain between January 1989 and January 1994. There were 51 excellent, 7 good, 1 fair, and 1 poor results. The diagnosis of chronic soft-tissue impingement of the ankle can be made from an appropriate history, thorough physical examination, and plain radiographs. Ankle arthroscopy with resection of impinging hypertrophic synovium or fibrous bands occurring after an ankle sprain was effective in alleviating pain in athletes.

PMID: 9276057

 

Rating: 5b

 

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DeGroot H 3rd, Uzunishvili S, Weir R, Al-omari A, Gomes B. Intra-articular injection of hyaluronic acid is not superior to saline solution injection for ankle arthritis: a randomized, double-blind, placebo-controlled study. J Bone Joint Surg Am. 2012 Jan 4;94(1):2-8. doi: 10.2106/JBJS.J.01763.

 

PMID: 22218376

 

Rating: 2b

 

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Deland JT. Adult-acquired flatfoot deformity. J Am Acad Orthop Surg. 2008 Jul;16(7):399-406.

 

Foot and Ankle Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA.

 

PMID: 18611997

 

Rating: 5b

 

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de Leeuw PA, van Sterkenburg MN, van Dijk CN. Arthroscopy and endoscopy of the ankle and hindfoot. Sports Med Arthrosc. 2009 Sep;17(3):175-84.

 

Ankle arthroscopy provides the surgeon with a minimally invasive treatment option for a wide variety of indications such as impingement, osteochondral defects, loose bodies, ossicles, synovitis, adhesions, and instability. Posterior ankle pathology can be treated using endoscopic hindfoot portals. It compares favorably to open surgery with regard to less morbidity and a quicker recovery.

 

PMID: 19680114

 

Rating: 5b

 

 

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Denniston, et al., Official Disability Guidelines (ODG), 13th edition, “Return-To-Work Best Practice Guidelines”, December 2008.

 

[Use link above to start up ODG 2008, or see Treatment Protocol for more duration info]

 

METHODOLOGY:

The ODG Best Practice and Summary Guidelines provide normative expectations on length of disability evidence-based on over 3 million cases from the CDC and OSHA. These Best Practice Guidelines identify the factors that determine disability duration for each condition. Definitive values are assigned based on severity, treatment and type of job. Users can match each case to a “pathway” & expected duration. These durations are what can be achieved through management of the disability case, based on analyzing the raw data and a comprehensive review process by the ODG Editorial Advisory Board. From these pathways, it is possible to select values based on surgery versus no surgery (if applicable), and based on modified duty versus no modified duty.

 

CONCLUSIONS:

            These durations take into account modified duty as well as treatment. Rating: 3a

 

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De Simoni C, Wetz HH, Zanetti M, Hodler J, Jacob H, Zollinger H. Clinical examination and magnetic resonance imaging in the assessment of ankle sprains treated with an orthosis. Foot Ankle Int 1996 Mar;17(3):177-82.

Department of Orthopaedic Surgery, Balgrist University of Zurich, Switzerland.

This study concluded. “MR findings after ankle sprain could not predict clinical outcome.

 

PMID: 8919625

 

Rating: 2b

 

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de Vos RJ, Weir A, van Schie HT, Bierma-Zeinstra SM, Verhaar JA, Weinans H, Tol JL. Platelet-rich plasma injection for chronic Achilles tendinopathy: a randomized controlled trial. JAMA. 2010 Jan 13;303(2):144-9.

 

DESIGN: A stratified, block-randomized, double-blind, placebo-controlled trial at a single center (The Hague Medical Center, Leidschendam, The Netherlands) of 54 randomized patients aged 18 to 70 years with chronic tendinopathy 2 to 7 cm above the Achilles tendon insertion. CONCLUSION: Among patients with chronic Achilles tendinopathy who were treated with eccentric exercises, a PRP injection compared with a saline injection did not result in greater improvement in pain and activity.

 

PMID: 20068208

 

Rating: 2b

 

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de Vries JS, Krips R, Sierevelt IN, Blankevoort L. Interventions for treating chronic ankle instability. Cochrane Database Syst Rev. 2006 Oct 18;(4):CD004124.

 

Orthotrauma Research Center Amsterdam (ORCA) Academic Medical Center, Orthopaedic Surgery, Meibergdreef 9, PO Box 22660, Amsterdam, Noord-Holland, Netherlands. j.s.devries@amc.uva.nl

 

BACKGROUND: Chronic lateral ankle instability occurs in 10% to 20% of people after an acute ankle sprain. The initial form of treatment is conservative but if this fails and ligament laxity is present, surgical intervention is considered. OBJECTIVES: To compare different treatments, both conservative and surgical, for chronic lateral ankle instabilityMAIN RESULTS: Seven randomised trials were included and divided into three groups: surgical interventions; rehabilitation programs after surgical interventions; and conservative interventions. Rehabilitation after surgical interventions (two studies): both studies provided evidence that early functional mobilization leads to an earlier return to work and sports than immobilisation. AUTHORS' CONCLUSIONS: In view of the low quality methodology of almost all the studies, this review does not provide sufficient evidence to support any specific surgical or conservative intervention for chronic ankle instability. However, after surgical reconstruction, early functional rehabilitation was shown to be superior to six weeks immobilisation regarding time to return to work and sports.

 

PMID: 17054198

 

Rating: 1b

 

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de Vries JS, Krips R, Sierevelt IN, Blankevoort L, van Dijk CN. Interventions for treating chronic ankle instability. Cochrane Database Syst Rev. 2011 Aug 10;(8):CD004124.

 

Neuromuscular training alone appears effective in the short term but whether this advantage would persist on longer-term follow-up is not known. While there is insufficient evidence to support any one surgical intervention over another surgical intervention for chronic ankle instability, it is likely that there are limitations to the use of dynamic tenodesis. After surgical reconstruction, early functional rehabilitation appears to be superior to six weeks immobilisation in restoring early function.

 

PMID: 21833947

 

Rating: 1b

 

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Díaz-Llopis IV, Gómez-Gallego D, Mondéjar-Gómez FJ, López-García A, Climent-Barberá JM, Rodríguez-Ruiz CM. Botulinum toxin type A in chronic plantar fasciitis: clinical effects one year after injection. Clin Rehabil. 2013 Feb 14.

 

In patients with chronic plantar fasciitis, the positive effect detected six months after treatment with botulinum toxin type A was maintained at 12 months and there was a further improvement in pain and foot function.

 

PMID: 23411793

 

Rating: 2c

 

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Diebold PF, Daum B, Dang-Vu V, Litchinko M. True epineural neurolysis in Morton's neuroma: a 5-year follow up. Orthopedics 1996 May;19(5):397-400.
 
Morton's neuroma is a frequent cause of metatarsalgia. Neuroma resection was the usual recommended surgical treatment. Failure rate of neurectomy can be as high as 14% to 21%, and treatment of recurrences is difficult. The authors have treated Morton's neuroma by neurolysis since 1985. They present their results in a group of 40 patients with 5 years follow up. Thirty-seven of 40 patients had an excellent result after neurolysis and 35 patients had normal toe sensitivity at the date of examination. Thirty-nine patients stated they would undergo the operation again if necessary.

PMID: 8727333

 

Rating: 5b

 

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DiGiovanni BF, Nawoczenski DA, Lintal ME, Moore EA, Murray JC, Wilding GE, Baumhauer JF. Tissue-specific plantar fascia-stretching exercise enhances outcomes in patients with chronic heel pain. A prospective, randomized study. J Bone Joint Surg Am. 2003 Jul;85-A(7):1270-7.

Department of Physical Therapy, Ithaca College, University of Rochester Campus, New York 14623, USA. benedict_digiovanni@urmc.rochester.edu

BACKGROUND: Approximately 10% of patients with plantar fasciitis have development of persistent and often disabling symptoms. A poor response to treatment may be due, in part, to inappropriate and nonspecific stretching techniques. METHODS: One hundred and one patients who had chronic proximal plantar fasciitis for a duration of at least ten months were randomized into one of two treatment groups. The patients received instructions for either a plantar fascia tissue-stretching program (Group A) or an Achilles tendon-stretching program (Group B). RESULTS: Eighty-two patients returned for follow-up evaluation. With the exception of the duration of symptoms (p < 0.01), covariates for baseline measures revealed no significant differences between the groups. The pain subscale scores of the Foot Function Index showed significantly better results for the patients managed with the plantar fascia-stretching program with respect to item 1 (worst pain; p = 0.02) and item 2 (first steps in the morning; p = 0.006). CONCLUSIONS: A program of non-weight-bearing stretching exercises specific to the plantar fascia is superior to the standard program of weight-bearing Achilles tendon-stretching exercises for the treatment of symptoms of proximal plantar fasciitis. 

 

PMID: 12851352

 

Rating: 2b

 

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Digiovanni BF, Nawoczenski DA, Malay DP, Graci PA, Williams TT, Wilding GE, Baumhauer JF. Plantar fascia-specific stretching exercise improves outcomes in patients with chronic plantar fasciitis. A prospective clinical trial with two-year follow-up. J Bone Joint Surg Am. 2006 Aug;88(8):1775-81.

 

Department of Orthopaedics, University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, Box 665, Rochester, NY 14620, USA. benedict_digiovanni@urmc.rochester.edu

 

BACKGROUND: IThe goal of this two-year follow-up study was to evaluate the long-term outcomes of the plantar fascia-stretching protocol in patients with chronic plantar fasciitis. RESULTS: Complete data sets were obtained from sixty-six patients.Descriptive analysis of the data showed that 92% (sixty-one) of the sixty-six patients reported total satisfaction or satisfaction with minor reservations. Fifty-one patients (77%) reported no limitation in recreational activities, and sixty-two (94%) reported a decrease in pain. Only sixteen of the sixty-six patients reported the need to seek treatment by a clinician. CONCLUSIONS: This study supports the use of the tissue-specific plantar fascia-stretching protocol as the key component of treatment for chronic plantar fasciitis. Long-term benefits of the stretch include a marked decrease in pain and functional limitations and a high rate of satisfaction. This approach can provide the health-care practitioner with an effective, inexpensive, and straightforward treatment protocol.

 

PMID: 16882901

 

Rating: 2b

 

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Dooley P, Buckley R, Tough S, McCormack B, Pate G, Leighton R, Petrie D, Galpin B. Bilateral calcaneal fractures: operative versus nonoperative treatment. Foot Ankle Int. 2004 Feb;25(2):47-52.

 

Foothills Hospital, Room 144A, 1403 29 Street N.W., Calgary, Alberta T2N 2T9, Canada. buckclin@ucalgary.ca

 

BACKGROUND: The objective of this study was to analyze demographic characteristics and objective clinical features of patients with bilateral calcaneal fractures as well as subjective outcomes following either operative or conservative management. METHODS: Surgical intervention did not significantly affect subjective patient outcome as measured by either SF-36 or the VAS. This remained true following stratification by Worker's Compensation Board (WCB) status. However, those who were treated nonoperatively were significantly more likely to require late subtalar arthrodesis (p <.05). In general, patients whose injury was not associated with a WCB claim demonstrated significantly better subjective outcomes (p <.01 for SF-36 and VAS). CONCLUSIONS: Other than demonstrating a slightly more depressed Bohler's angle, patients sustaining bilateral calcaneal fractures are very similar to those in whom the injury is confined to one side. The evidence presented here does not definitively support primary operative intervention for bilateral calcaneal fractures.

 

PMID: 14992701

 

Rating: 2b

 

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Easley ME, Scranton PE Jr. Osteochondral autologous transfer system. Foot Ankle Clin. 2003 Jun;8(2):275-90.

 

The OATS technique is one of several cartilage repair procedures that exhibits promising short- to intermediate-term results in the surgical management of OLTs. Although the OATS procedure is generally reserved for salvage of failed debridement and drilling, some investigators are suggesting that it may have applications in primary surgical management of OLTs, particularly those that are associated with subchondral cysts. Long-term outcome of the OATS procedure for OLTs is not yet available.

 

PMID: 12911241

 

Rating: 5b

 

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Eisenhart AW, Gaeta TJ, Yens DP. Osteopathic manipulative treatment in the emergency department for patients with acute ankle injuries. J Am Osteopath Assoc. 2003 Sep;103(9):417-21.

Department of Emergency Medicine, St Barnabas Hospital, Bronx, NY, USA.

STUDY OBJECTIVE: The purpose of this study was to evaluate the efficacy of osteopathic manipulative treatment (OMT) as administered in the emergency department (ED) for the treatment of patients with acute ankle injuries. METHODS: Patients aged 18 years and older with unilateral ankle sprains were randomly assigned either to an OMT study group or a control group. RESULTS: Although at follow-up both study groups demonstrated significant improvement, patients in the OMT study group had a statistically significant improvement in ROM when compared with patients in the control group. CONCLUSIONS: Data clearly demonstrate that a single session of OMT in the ED can have a significant effect in the management of acute ankle injuries.

 
PMID: 14527076

 

Rating: 2c

 

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Elizondo-Rodriguez J, Araujo-Lopez Y, Moreno-Gonzalez JA, Cardenas-Estrada E, Mendoza-Lemus O, Acosta-Olivo C. A comparison of botulinum toxin a and intralesional steroids for the treatment of plantar fasciitis: a randomized, double-blinded study. Foot Ankle Int. 2013 Jan;34(1):8-14. doi: 10.1177/1071100712460215.

 

A combination of BTX-A and plantar fascia stretching exercises yielded better results for the treatment of plantar fasciitis than intralesional steroids.

 

PMID: 23386757

 

Rating: 2c

 

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Erdil M, Bilsel K, Imren Y, Mutlu S, Güler O, Gürkan V, Elmadağ NM, Tuncay I. Metatarsal head resurfacing hemiarthroplasty in the treatment of advanced stage hallux rigidus: outcomes in the short-term. Acta Orthop Traumatol Turc. 2012;46(4):281-5.

 

PMID: 22951760

 

Rating: 4c

 

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Fallat L, Grimm DJ, Saracco JA. Sprained ankle syndrome: prevalence and analysis of 639 acute injuries. J Foot Ankle Surg 1998 Jul-Aug; 37(4):280-5.
 
Podiatric Surgical Residency Program, Oakwood Healthcare System, Dearborn, MI, USA.

PMID: 9710779

 

Rating: 3b

 

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Felcher AH, Mularski RA, Mosen DM, Kimes TM, DeLoughery TG, Laxson SE. Incidence and risk factors for venous thromboembolic disease in podiatric surgery. Chest. 2009 Apr;135(4):917-22. Epub 2008 Nov 18.

 

Kaiser Permanente Center for Health Research, 3800 N Interstate Avenue, Portland, OR 97227, USA. richard.a.mularski@kpchr.org

 

RESULTS: We identified 16,804 surgical procedures in 7,264 patients and detected 22 symptomatic postprocedure VTEs. The overall incidence of postprocedure VTE was 0.30%. Three risk factors were significantly and independently associated with VTE in podiatric surgery: prior VTE (incidence, 4.6%; relative risk, 23.0; p < 0.001), use of hormone replacement therapy or oral contraceptives (incidence, 0.55%; relative risk, 4.2; p = 0.01), and obesity (incidence, 0.48%; relative risk, 3.0; p = 0.02). CONCLUSIONS: We identified a low overall risk of VTE in podiatric surgery, suggesting that routine prophylaxis is not warranted. However, for patients with a history of VTE, periprocedure prophylaxis is suggested based on the level of risk.

 

PMID: 19017868

 

Rating: 3a

 

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Ferrari J, Higgins JPT, Williams RL. Interventions for treating hallux valgus (abductovalgus) and bunions (Cochrane Review). In: The Cochrane Library, Issue 3, 2002.

A substantive amendment to this systematic review was last made on 28 June 1999. Cochrane reviews are regularly checked and updated if necessary.

 

There is insufficient evidence from randomised trials to determine which methods of either conservative, operative or post-operative treatment are the most appropriate for the hallux valgus. It is notable that the numbers of patients remaining dissatisfied at follow-up were consistently high (25 to 33%), even when the hallux valgus angle and pain had improved. Assessment of future research should focus on evaluating basic intervention types in eligible patients with similar degrees of deformity.

 

PMID: 10796404

 

Rating: 1a

 

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Ferrari J, Higgins JP, Prior TD, Interventions for treating hallux valgus (abductovalgus) and bunions, Cochrane Database Syst Rev. 2004;(1):CD000964

Department of Podiatry, University College London, 33 Fitzroy Square, London, UK, W1P 6AY.

OBJECTIVES: To identify and evaluate the evidence from randomised trials of interventions used to correct hallux valgus. MAIN RESULTS: The methodological quality of the 21 included trials was generally poor and trial sizes were small. Three trials involving 332 participants evaluated conservative treatments versus no treatment. There was no evidence of a difference in outcomes between treatment and no treatment. One good quality trial involving 140 participants compared surgery to conservative treatment. Evidence was shown of an improvement in all outcomes in patients receiving chevron osteotomy compared with those receiving orthoses. The use of continuous passive motion appeared to give an improved range of motion and earlier recovery following surgery. REVIEWER'S CONCLUSIONS: Only a few studies had considered conservative treatments. The evidence from these suggested that orthoses and night splints did not appear to be any more beneficial in improving outcomes than no treatment. Surgery (chevron osteotomy) was shown to be beneficial compared to orthoses or no treatment, but when compared to other osteotomies, no technique was shown to be superior to any other. Only one trial had compared an osteotomy to an arthroplasty. There was limited evidence to suggest that the osteotomy gave the better outcomes. It was notable that the numbers of participants in some trials remaining dissatisfied at follow-up were consistently high (25 to 33%), even when the hallux valgus angle and pain had improved. 

 

PMID: 14973960

 

Rating: 1a

 

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Fryer GA, Mudge JM, McLaughlin PA. The effect of talocrural joint manipulation on range of motion at the ankle. J Manipulative Physiol Ther. 2002 Jul-Aug;25(6):384-90.

School of Health Sciences, City Campus, Victoria University, Melbourne, Australia.

OBJECTIVE: To determine whether a single high-velocity, low-amplitude thrust manipulation to the talocrural joint altered ankle range of motion. DESIGN: A randomized, controlled and blinded study. SUBJECTS: Asymptomatic male and female volunteers (N = 41). RESULTS: No significant changes in dorsiflexion range of motion were detected between manipulated ankles and those of control subjects. CONCLUSION: Manipulation of the ankle does not increase dorsiflexion range of motion in asymptomatic subjects.

 

PMID: 12183696

 

Rating: 2c

 

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Gandhi A, Doumas C, O'Connor JP, Parsons JR, Lin SS. The effects of local platelet rich plasma delivery on diabetic fracture healing. Bone. 2006 Apr;38(4):540-6. Epub 2005 Dec 20.

 

New Jersey Institute of Technology, Department of Biomedical Engineering, 323 Martin Luther King Jr. Boulevard, Newark, New Jersey 07102, USA.

 

Several studies have documented that diabetes impairs bone healing clinically and experimentally. The percutaneous delivery of platelet rich plasma (PRP) was used in the diabetic BB Wistar femur fracture model to investigate the use of PRP as a concentrated source of critical early growth factors on bone healing. PRP delivery at the fracture site normalized the early (cellular proliferation and chondrogenesis) parameters while improving the late (mechanical strength) parameters of diabetic fracture healing. These results suggest a role for PRP in mediating diabetic fracture healing and potentially other high risk fractures.

 

PMID: 16368279

 

Rating: 5c

 

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Gandhi A, Beam HA, O'Connor JP, Parsons JR, Lin SS. The effects of local insulin delivery on diabetic fracture healing. Bone. 2005 Oct;37(4):482-90.

 

Department of Orthopaedics, University of Medicine and Dentistry of New Jersey-New Jersey Medical School, 185 South Orange Avenue, MSB-G574, Newark, NJ 07103, USA.

 

Several studies have documented that diabetes impairs bone healing clinically and experimentally. Insulin delivery at the fracture site normalized the early (cellular proliferation and chondrogenesis) and late (mineralized tissue, cartilage content and mechanical strength) parameters of diabetic fracture healing without affecting the systemic parameters of blood glucose. These results suggest a critical role for insulin in directly mediating fracture healing and that decreased systemic insulin levels in the diabetic state lead to reduced localized insulin levels at fracture site with concomitant increases in diabetic fracture healing time.

 

PMID: 16027060

 

Rating: 5c

 

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Geboers JF, Drost MR, Spaans F, Kuipers H, Seelen HA. Immediate and long-term effects of ankle-foot orthosis on muscle activity during walking: a randomized study of patients with unilateral foot drop. Arch Phys Med Rehabil 2002 Feb;83(2):240-5.

Institute for Rehabilitation Research, Hoensbroek & Atrium Medical Centre, Heerlen, The Netherlands. m.geboers@zonnet.nl

This study concluded, “AFO (ankle-foot orthosis) use immediately reduced muscle activity of the ankle dorsiflexors. However, using an AFO for 6 weeks did not lead to a generally lower electromyographic activity level nor did the amount of activity reduction accumulate in comparison with patients who did not use an AFO. It is, therefore, safe to use an AFO, even with recently paretic patients.”
 

PMID: 11833029

 

Rating: 2b

 

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Gerber JP, Williams GN, Scoville CR, Arciero RA, Taylor DC. Persistent disability associated with ankle sprains: a prospective examination of an athletic population. Foot Ankle Int 1998 Oct;19(10):653-60.
 
United States Army Sports Physical Therapy Residency Program, Keller Army Community Hospital, West Point, New York 10996-1197, USA.

The purpose of this study was to examine a young athletic population to update the data regarding epidemiology and disability associated with ankle injuries. Of the 96 sprains, 4 were predominately medial injuries, 76 were lateral, and 16 were syndesmosis sprains. Ninety-five percent had returned to sports activities by 6 weeks; however, 55% of these subjects reported loss of function or presence of intermittent pain, and 23% had a decrement of >20% in the lateral hop test when compared with the uninjured side. At 6 months, all subjects had returned to full activity; however, 40% reported residual symptoms and 2.5% had a decrement of >20% on the lateral hop test. Neither previous injury nor ligament laxity was predictive of chronic symptomatology. Furthermore, chronic dysfunction could not be predicted by the grade of sprain (grade I vs. II). The factor most predictive of residual symptoms was a syndesmosis sprain, regardless of grade. Syndesmosis sprains were most prevalent in collision sports. This study demonstrates that even though our knowledge and understanding of ankle sprains and rehabilitation of these injuries have progressed in the last 20 years, chronic ankle dysfunction continues to be a prevalent problem. The early return to sports occurs after almost every ankle sprain; however, dysfunction persists in 40% of patients for as long as 6 months after injury. Syndesmosis sprains are more common than previously thought, and this confirms that syndesmosis sprains are associated with prolonged disability.

PMID: 9801078

 

Rating: 5a

 

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Gerdesmeyer L, Frey C, Vester J, Maier M, Weil L Jr, Weil L Sr, Russlies M, Stienstra J, Scurran B, Fedder K, Diehl P, Lohrer H, Henne M, Gollwitzer H. Radial extracorporeal shock wave therapy is safe and effective in the treatment of chronic recalcitrant plantar fasciitis: results of a confirmatory randomized placebo-controlled multicenter study. Am J Sports Med. 2008 Nov;36(11):2100-9. Epub 2008 Oct 1.

 

Department of Orthopedic and Traumatology, Technical University Munich, Klinikum Rechts der Isar, Germany. Gerdesmeyer@aol.com

 

METHODS: Three interventions of radial extracorporeal shock wave therapy (0.16 mJ/mm(2); 2000 impulses) compared with placebo were studied in 245 patients with chronic plantar fasciitis. RESULTS: Radial extracorporeal shock wave therapy proved significantly superior to placebo with a reduction of the visual analog scale composite score of 72.1% compared with 44.7% (P = .0220), and an overall success rate of 61.0% compared with 42.2% in the placebo group (P = .0020) at 12 weeks. Superiority was even more pronounced at 12 months, and all secondary outcome measures supported radial extracorporeal shock wave therapy to be significantly superior to placebo (P < .025, 1-sided).

 

PMID: 18832341

 

Rating: 2b

 

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Glanzmann MC, Sanhueza-Hernandez R. Arthroscopic subtalar arthrodesis for symptomatic osteoarthritis of the hindfoot: a prospective study of 41 cases. Foot Ankle Int. 2007 Jan;28(1):2-7.

 

METHODS: Forty-one arthroscopic subtalar fusions were done in 37 consecutive symptomatic patients. CONCLUSIONS: In painful hindfoot osteoarthritis the arthroscopic technique provides reliable fusion and high patient satisfaction with the advantages of a minimally invasive procedure.

 

PMID: 17257530

 

Rating: 4b

 

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Glazebrook MA, Ganapathy V, Bridge MA, Stone JW, Allard JP. Evidence-based indications for ankle arthroscopy. Arthroscopy. 2009 Dec;25(12):1478-90.

 

RESULTS: There exists fair evidence-based literature (grade B) to support a recommendation for the use of ankle arthroscopy for the treatment of ankle impingement and osteochondral lesions and for ankle arthrodesis. Ankle arthroscopy for ankle instability, septic arthritis, arthrofibrosis, and removal of loose bodies is supported with only poor-quality evidence (grade C). Treatment of ankle arthritis, excluding isolated bony impingement, is not effective and therefore this indication is not recommended (grade C against). Finally, there is insufficient evidence-based literature to support or refute the benefit of arthroscopy for the management of synovitis and fractures (grade I).

 

PMID: 19962076

 

Rating: 1b

 

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Gondring WH, Shields B, Wenger S. An outcomes analysis of surgical treatment of tarsal tunnel syndrome. Foot Ankle Int. 2003 Jul;24(7):545-50.

 

Heartland Health Systems, St. Joseph, MO, USA. gondring@ccp.com

 

Sixty patients (68 feet) underwent tarsal tunnel release for the tarsal tunnel syndrome and were re-examined objectively and clinically after they had reached maximum medical benefits and returned to their usual and customary lifestyle and employment. As determined objectively, there was 85% complete symptom relief. As determined subjectively, there was 51% symptom relief. Additionally, there was significant improvement in the quality of work, job productivity, and interpersonal relationships

 

PMID: 12921360

 

Rating: 4b

 

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Gorter K, de Poel S, de Melker R, Kuyvenhoven M. Variation in diagnosis and management of common foot problems by GPs. Fam Pract 2001 Dec;18(6):569-73.

Julius Center for General Practice and Patient Oriented Research, University Medical Center (UMC), PO Box 85060, 3508 AB Utrecht, The Netherlands.

OBJECTIVES: Our aim was to explore the variation of GPs' diagnosis and management of common foot problems and the possible correlation between GPs' characteristics and their competence to diagnose correctly. CONCLUSIONS: More than half of the GPs were competent in diagnosing vignettes of common foot problems. This diagnostic competence showed great variation and was not associated independently with GP characteristics. Educational programmes are recommended. Management showed less variation and often included referral to podiatrists. Further research into the effectiveness of specific treatments for different foot problems is recommended.
 

PMID: 11739338

 

Rating: 5b

 

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Gross MT, Byers JM, Krafft JL, Lackey EJ, Melton KM. The impact of custom semirigid foot orthotics on pain and disability for individuals with plantar fasciitis. J Orthop Sports Phys Ther 2002 Apr;32(4):149-57.

Division of Physical Therapy, Program in Human Movement Science, University of North Carolina at Chapel Hill, 27599-7135, USA. mtgross@med.unc.edu

OBJECTIVE: To determine the impact of custom semirigid foot orthotics on pain and disability for individuals with plantar fasciitis. METHODS AND MEASURES: Eight men and 7 women (mean ages 44.7 +/- 9.0 years) who reported having plantar fasciitis symptoms for an average of 21.3 +/- 23.7 months participated in the study. CONCLUSION: Custom semirigid foot orthotics may significantly reduce pain experienced during walking and may reduce more global measures of pain and disability for patients with chronic plantar fasciitis.

PMID: 11949663

 

Rating: 4c

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Gudeman SD, Eisele SA, Heidt RS Jr, Colosimo AJ, Stroupe AL. Treatment of plantar fasciitis by iontophoresis of 0.4% dexamethasone. A randomized, double-blind, placebo-controlled study. Am J Sports Med 1997 May-Jun;25(3):312-6.
 
Specialty Centers for Orthopaedic & Rehabilitative Excellence, Indianapolis, Indiana, USA.

These results suggest that although traditional modalities alone are ultimately effective, iontophoresis in conjunction with traditional modalities provides immediate reduction in symptoms. Based on these results, iontophoresis of dexamethasone for plantar fasciitis should be considered when more immediate results are needed (i.e., performance athletes and active patients.
 

PMID: 9167809

 

Rating: 2b

 

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Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma. 1984 Aug;24(8):742-6.

 

PMID: 6471139

 

Rating: 5a

 

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Guyton GP, Mann RA, Kreiger LE, Mendel T, Kahan J. Cumulative industrial trauma as an etiology of seven common disorders in the foot and ankle: what is the evidence? Foot Ankle Int. 2000 Dec;21(12):1047-56.

 

UNC School of Medicine, Department of Orthpaedics, Chapel Hill, NC 27599-7055, USA. guyton@med.unc.edu

 

To clarify the current state of knowledge about the The concept of cumulative industrial trauma as an etiology of orthopaedic disease has recently generated considerable attention in both the medical and legal communities. issue as applied to the foot and ankle, we critically reviewed the literature on the etiology of seven foot and ankle disorders commonly involved in compensation litigation in the practice of the senior author: hallux valgus, interdigital neuroma, tarsal tunnel syndrome, lesser toe deformity, heel pain, adult acquired flatfoot, and foot and ankle osteoarthritis. We conclude there is currently no unequivocal literature support upon which to invoke cumulative industrial trauma as a clear etiology of these disorders of the adult foot and ankle.

 

PMID: 11139037

 

Rating: 5b

 

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Haake M, Buch M, Schoellner C, Goebel F, Vogel M, Mueller I, Hausdorf J, Zamzow K, Schade-Brittinger C, Mueller HH, Extracorporeal shock wave therapy for plantar fasciitis: randomised controlled multicentre trial, BMJ. 2003 Jul 12;327(7406):75.

Orthopadische Klinik, Universitat Regensburg, 93077 Bad Abbach, Germany. m.haake@rheumaortho-zentrum.de

OBJECTIVE: To determine the effectiveness of extracorporeal shock wave therapy compared with placebo in the treatment of chronic plantar fasciitis. PARTICIPANTS: 272 patients with chronic plantar fasciitis recalcitrant to conservative therapy for at least six months: 135 patients were allocated extracorporeal shock wave therapy and 137 were allocated placebo. RESULTS: The primary end point could be assessed in 94% (n=256) of patients. The success rate 12 weeks after intervention was 34% (n=43) in the extracorporeal shock wave therapy group and 30% (n=39) in the placebo group (95% confidence interval - 8.0% to 15.1%). No difference was found in the secondary end points. Few side effects were reported. CONCLUSIONS: Extracorporeal shock wave therapy is ineffective in the treatment of chronic plantar fasciitis.

 

PMID: 12855524

 

Rating: 2b

 

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Hak DJ, McElvany M. Removal of broken hardware. J Am Acad Orthop Surg. 2008 Feb;16(2):113-20.

 

Department of Orthopaedic Surgery, Denver Health, University of Colorado, Denver, Colorado 80204, USA.

 

Despite advances in metallurgy, fatigue failure of hardware is common when a fracture fails to heal. Revision procedures can be difficult, usually requiring removal of intact or broken hardware.

 

PMID: 18252842

 

Rating: 5b

 

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Hall RC, Nyland J, Nitz AJ, Pinerola J, Johnson DL. Relationship between ankle invertor H-reflexes and acute swelling induced by inversion ankle sprain. J Orthop Sports Phys Ther 1999 Jun;29(6):339-44.

Wilford Hall Medical Center, San Antonio, Tex., USA.

Grade I or II inversion sprains and the related swelling appear to delay involved ankle flexor digitorum longus latency to a greater extent than peroneus longus latency. Clinicians need to direct greater attention to the ankle invertors when designing and implementing ankle rehabilitation programs, particularly during the swelling management phase of treatment.

PMID: 10370917

 

Rating: 4b

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Hals TM, Sitler MR, Mattacola CG. Effect of a semi-rigid ankle stabilizer on performance in persons with functional ankle instability. J Orthop Sports Phys Ther 2000 Sep;30(9):552-6.

Department of Kinesiology, Temple University, Philadelphia, PA 19122, USA.

OBJECTIVES: To determine the effect of a semi-rigid prophylactic ankle stabilizer (PAS) on performance of subjects with post-acute, unilateral ankle sprains who have mechanically stable ankles, but are functionally impaired. CONCLUSIONS: Use of a semi-rigid PAS significantly increased shuttle-run but not vertical-jump performance. This effect was immediate and did not require PAS acclimation.

 

PMID: 10994865

 

Rating: 2b

 

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Han A, Robinson V, Judd M, Taixiang W, Wells G, Tugwell P, Tai chi for treating rheumatoid arthritis, Cochrane Database Syst Rev. 2004;(3):CD004849

5-83 Pape Avenue, Toronto, Ontario, CANADA, M4M 2V5.

BACKGROUND: Tai Chi, interchangeably known as Tai Chi Chuan, is an ancient Chinese health-promoting martial art form that has been recognized in China as an effective arthritis therapy for centuries. OBJECTIVES: To assess the effectiveness and safety of Tai Chi as a treatment for people with RA. MAIN RESULTS: Four trials including 206 participants, were included in this review. Tai Chi-based exercise programs had no clinically important or statistically significant effect on most outcomes of disease activity, which included activities of daily living, tender and swollen joints and patient global overall rating. For range of motion, Tai Chi participants had statistically significant and clinically important improvements in ankle plantar flexion. No detrimental effects were found. REVIEWERS' CONCLUSIONS: The results suggest Tai Chi does not exacerbate symptoms of rheumatoid arthritis. In addition, Tai Chi has statistically significant benefits on lower extremity range of motion, in particular ankle range of motion, for people with RA. The included studies did not assess the effects on patient-reported pain.

PMID: 15266544

 

Rating: 1c

 

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Hannafin JA, Kitaoka HB, Panagis JS. National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), of the Department of Health and Human Services' National Institutes of Health (NIH), Questions and Answers Sprains and Strains, May 2004.

 

Sprains can range from stretching (grade 1) to partial rupture (grade 2) to complete rupture of the ligament (grade 3)

 

A muscle strain is the stretching or tearing of muscle fibers. Most muscle strains happen for one of two reasons: either the muscle has been stretched beyond its limits or it has been forced to contract too strongly. In mild cases, only a few muscle fibers are stretched or torn, and the muscle remains intact and strong. In severe cases, however, the strained muscle may be torn and unable to function properly. To help simplify diagnosis and treatment, doctors often classify muscle strains into three grades, depending on the severity of muscle fiber damage:

 

In general, a grade I or mild sprain is caused by overstretching or slight tearing of the ligaments with no joint instability. A person with a mild sprain usually experiences minimal pain, swelling, and little or no loss of functional ability. Bruising is absent or slight, and the person is usually able to put weight on the affected joint.

 

A grade II or moderate sprain is caused by further, but still incomplete, tearing of the ligament and is characterized by bruising, moderate pain, and swelling. A person with a moderate sprain usually has more difficulty putting weight on the affected joint and experiences some loss of function. An x ray may be needed to help the health care provider determine if a fracture is causing the pain and swelling. Magnetic resonance imaging is occasionally used to help differentiate between a significant partial injury and a complete tear in a ligament, or can be recommended to rule out other injuries.

 

People who sustain a grade III or severe sprain completely tear or rupture a ligament. Pain, swelling, and bruising are usually severe, and the patient is unable to put weight on the joint. An x ray is usually taken to rule out a broken bone. When diagnosing any sprain, the provider will ask the patient to explain how the injury happened. He or she will examine the affected area and check its stability and its ability to move and bear weight.

 

Rating: 5b

 

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Hanson B, van der Werken C, Stengel D. Surgeons' beliefs and perceptions about removal of orthopaedic implants. BMC Musculoskelet Disord. 2008 May 24;9:73.

 

AO Foundation, Clinical Investigation and Documentation, Dübendorf, Switzerland. beate.hanson@aofoundation.org

 

BACKGROUND: The routine removal of orthopaedic fixation devices after fracture healing remains an issue of debate. METHODS: A 41-item questionnaire was distributed to 730 attendees of the AO Principles and Masters Courses of Operative Fracture Treatment in Davos, Switzerland, to assess their attitudes towards removal of different types of implants, and perceived benefits and risks with this common procedure. RESULTS: Implant removal in symptomatic patients was rated to be moderately effective (mean rating on a 10-point-scale, 5.8, 95% confidence interval 5.7-6.0). CONCLUSION: Many surgeons refuse a routine implant removal policy, and do not believe in clinically significant adverse effects of retained metal implants. Given the frequency of the procedure in orthopaedic departments worldwide, there is an urgent need for a large randomized trial to determine the efficacy and effectiveness of implant removal with regard to patient-centred outcomes.

 

PMID: 18501014

 

Rating: 4a

 

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Hammer DS, Rupp S, Kreutz A, Pape D, Kohn D, Seil R. Extracorporeal shockwave therapy (ESWT) in patients with chronic proximal plantar fasciitis. Foot Ankle Int 2002 Apr;23(4):309-13.

Orthopaedic University Hospital, Homburg/Saar, Germany. dietrich.hammer@med-rz.uni.sb.de

The aim of this study was to compare the effect of extracorporeal shockwave therapy (ESWT) in patients with chronically painful proximal plantar fasciitis with a conventional conservative treatment consisting of nonsteroidal anti-inflammatory drugs, heel cup, orthoses and/or shoe modifications, local steroid injections and electrotherapy. No significant difference of pain and walking time after further non-ESWT treatment (three months) was seen. Six months after ESWT pain decreased by 64% to 88% on the visual analog scale (VAS) and the comfortable walking time had increased significantly in both groups.
 

PMID: 11991475

 

Rating: 2b

 

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Hammer DS, Adam F, Kreutz A, Kohn D, Seil R. Extracorporeal shock wave therapy (ESWT) in patients with chronic proximal plantar fasciitis: a 2-year follow-up. Foot Ankle Int. 2003 Nov; 24(11): 823-8.

Orthopaedic University Hospital, Homburg/Saar, Germany.

The aim of this study was to compare the effect of extracorporeal shock wave therapy (ESWT) in patients with chronically painful proximal plantar fasciitis with a further conventional conservative treatment. Forty-seven patients (49 feet) with a previously unsuccessful nonsurgical treatment of at least 6 months were randomized to two groups. Heel cups had to be worn throughout the study. Two years after ESWT, pain during activities of daily living decreased by 94% in group 1 and by 90% in group 2 on the VAS and the comfortable walking time had increased significantly in both groups.

 PMID: 14655885

 

Rating: 2b

 

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Handoll HHG, Rowe BH, Quinn KM, de Bie R. Interventions for preventing ankle ligament injuries (Cochrane Review). In: The Cochrane Library, Issue 3, 2002.

A substantive amendment to this systematic review was last made on 01 January 2001. Cochrane reviews are regularly checked and updated if necessary.

 

Objectives: To assess the effects of interventions used for the prevention of ankle ligament injuries or sprains in physically active individuals from adolescence to middle age.

Reviewers' conclusions: This review provides good evidence for the beneficial effect of ankle supports in the form of semi-rigid orthoses or air-cast braces to prevent ankle sprains during high-risk sporting activities (e.g. soccer, basketball). Participants with a history of previous sprain can be advised that wearing such supports may reduce the risk of incurring a future sprain. However, any potential prophylactic effect should be balanced against the baseline risk of the activity, the supply and cost of the particular device, and for some, the possible or perceived loss of performance.

Further research is indicated principally to investigate other prophylactic interventions, their cost-effectiveness and general applicability.

 

PMID: 11686947

 

Rating: 1a

 

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Hawke F, Burns J, Radford JA, du Toit V. Custom-made foot orthoses for the treatment of foot pain. Cochrane Database Syst Rev. 2008 Jul 16;(3):CD006801.

 

School of Health Sciences, University of Newcastle, Health Precinct, PO Box 127, Ourimbah, NSW, Australia, 2258. fiona.hawke@newcastle.edu.au

 

RESULTS: Eleven trials involving 1332 participants were included: five trials evaluated custom-made foot orthoses for plantar fasciitis (691 participants); three for foot pain in rheumatoid arthritis (231 participants); and one each for foot pain in pes cavus (154 participants), hallux valgus (209 participants) and juvenile idiopathic arthritis (JIA) (47 participants). Custom-made foot orthoses were effective for painful pes cavus (NNTB:5), rearfoot pain in rheumatoid arthritis (NNTB:4), foot pain in JIA (NNTB:3) and painful hallux valgus (NNTB:6); however, surgery was even more effective for hallux valgus and non-custom foot orthoses appeared just as effective for JIA but the analysis may have lacked sufficient power to detect a difference in effect. It is unclear if custom-made foot orthoses were effective for plantar fasciitis or metatarsophalangeal joint pain in rheumatoid arthritis.

 

PMID: 18646168

 

Rating: 1b

 

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Herbert RD, Gabriel M. Effects of stretching before and after exercising on muscle soreness and risk of injury: systematic review. BMJ. 2002 Aug 31;325(7362):468.

School of Physiotherapy, University of Sydney, PO Box 170, Lidcombe, New South Wales 1825, Australia. R.Herbert@fhs.usyd.edu.au

OBJECTIVE: To determine the effects of stretching before and after exercising on muscle soreness after exercise, risk of injury, and athletic performance. RESULTS: Five studies, all of moderate quality, reported sufficient data on the effects of stretching on muscle soreness to be included in the analysis. CONCLUSIONS: Stretching before or after exercising does not confer protection from muscle soreness. Stretching before exercising does not seem to confer a practically useful reduction in the risk of injury, but the generality of this finding needs testing. Insufficient research has been done with which to determine the effects of stretching on sporting performance.

 

PMID: 12202327

 

Rating: 1c

 

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Helander KN, Farber D. Surgery May Not Be Necessary for Acute Achilles Tendon Rupture. American Association of Orthopaedic Surgeons (AAOS) 2010 Annual Meeting: Abstract 712. Presented March 12, 2010.

 

Patients with acute Achilles tendon rupture who underwent mobilization and rehabilitation within 72 hours of their injury reported outcomes similar to those in patients treated with surgery, according to new research. The surgical patients had better function in one test, the heel-rise test, but otherwise outcomes were the same," said lead researcher Katarina Nilsson Helander, MD, from Kungsbacka Hospital in Sweden. "Our results support the use of early mobilization." There is no consensus regarding the best way to treat acute Achilles tendon rupture, Dr. Helander said. "In Sweden, some clinicians favor surgery and others favor a nonsurgical approach. In the United States, surgery is generally the preferred approach," she told Medscape Orthopaedics. In this study, 97 patients were randomized to receive either surgical treatment (n = 49) or nonsurgical treatment (n = 48). The study's primary end point was rerupture.

 

Rating: 10b

 

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Hertel J, Denegar CR, Buckley WE, Sharkey NA, Stokes WL. Effect of rearfoot orthotics on postural sway after lateral ankle sprain. Arch Phys Med Rehabil 2001 Jul;82(7):1000-3.
 
Department of Kinesiology, Pennsylvania State University, University Park, PA 16802, USA. jnh3@psu.edu

This study concluded, “Rearfoot orthotics, irrespective of design or posting, were ineffective at improving postural sway after lateral ankle sprain.”

 
PMID: 11441393

 

Rating: 5b

 

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Hintermann B, Medial ankle instability., Foot Ankle Clin. 2003 Dec;8(4):723-38.

University of Basel, Clinic of Orthopaedic Surgery, Kantonsspital, CH-4031 Basel, Switzerland. bhintermann@datacomm.ch

Medial instability is suspected on the basis of a patient's ankle feeling like it is "giving way," especially medially, when walking on uneven ground, downhill, or down stairs, pain at the anteromedial aspect of the ankle, and sometimes pain in the lateral ankle, especially during dorsiflexion of the foot. The treatment for symptomatic medial instability of the ankle might include reconstruction of all involved ligaments at the medial, and, if necessary, the lateral ankle. This treatment concept provides high patient satisfaction and reliable clinical results.

 

PMID: 14719838

 

Rating: 5b

 

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Hintermann B, Knupp M. Injuries and dysfunction of the posterior tibial tendon. Orthopade. 2010 Dec;39(12):1148-57.

 

Treatment modalities depend on stage: while conservative measures may work in stage I, surgical treatment is mandatory for the later stages. Reconstructive surgery is advised in stage II, whereas in stage III and IV correcting and stabilizing arthrodeses are advised.

 

PMID: 21088955

 

Rating: 5b

 

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Höfling I, Joukainen A, Venesmaa P, Kröger H. Preliminary experience of a single session of low-energy extracorporeal shock wave treatment for chronic plantar fasciitis. Foot Ankle Int. 2008 Feb;29(2):150-4.

 

Iisalmen Aluesairaala, Riistakatu 21-23, 74101 Iisalmi, Finland. imke.hofling@ys-ysy.fi

 

METHODS: 20 patients (22 heels) with symptomatic plantar fasciitis that did not respond to conservative treatment for at least 6 months were studied. Patients received a single session of low-energy, ultrasound- and patient feedback-guided ESWT. CONCLUSION: Low-energy ESWT proved to be an effective treatment option for the majority of patients with chronic plantar fasciitis that failed to respond to conservative treatment. Predictive parameters for successful outcome are male gender and an easily detectable pain center at the heel.

 

PMID: 18315969

 

Ratig: 4c

 

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Holmes GB Jr, Hill N. Fractures and dislocations of the foot and ankle in diabetics associated with Charcot joint changes. Foot Ankle Int. 1994 Apr;15(4):182-5.

 

Department of Orthopaedic Surgery, Rush-Presbyterian-St. Luke's Medical Center, Chicago, Illinois 60612.

 

This study was undertaken to evaluate the occurrence of Charcot joint changes in diabetic patients after fractures and/or dislocations of the foot and ankle. The early recognition and appropriate treatment of fractures in diabetic patients appears to be important in the prevention of Charcot joint changes.

 

PMID: 7951951

 

Rating: 4c

 

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Hodge MC, Bach TM, Carter GM. Orthotic management of plantar pressure and pain in rheumatoid arthritis. Clin Biomech (Bristol, Avon) 1999 Oct;14(8):567-75.
 
National Centre for Prosthetics and Orthotics, School of Human Biosciences, La Trobe University, Bundoora, Victoria, Australia. m.hodge@latrobe.edu.au

OBJECTIVE: To investigate the effectiveness of foot orthoses in the management of plantar pressure and pain in subjects with rheumatoid arthritis. CONCLUSIONS: Results from this study suggest that average pressure measurement may be a useful indicator in the management of metatarsalgia in RA.

PMID: 10521640

 

Rating: 4b

 

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Hubbard TJ, Denegar CR. Does Cryotherapy Improve Outcomes With Soft Tissue Injury? J Athl Train. 2004 Sep;39(3):278-279.

Pennsylvania State University, University Park, PA.

CLINICAL QUESTION: What is the clinical evidence base for cryotherapy use? MAIN RESULTS: Specific search criteria identified 55 articles for review, of which 22 were eligible randomized, controlled clinical trials. The types of injuries varied widely (eg, acute or surgical). The remaining 17 groups examined patients recovering from operative procedures (anterior cruciate ligament repair, knee arthroscopy, lateral retinacular release, total knee and hip arthroplasties, and carpal tunnel release). Ice submersion with simultaneous exercises was significantly more effective than heat and contrast therapy plus simultaneous exercises at reducing swelling. Ice was reported to be no different from ice and low-frequency or high-frequency electric stimulation in effect on swelling, pain, and range of motion. Ice alone seemed to be more effective than applying no form of cryotherapy after minor knee surgery in terms of pain, but no differences were reported for range of motion and girth. Continuous cryotherapy was associated with a significantly greater decrease in pain and wrist circumference after surgery than intermittent cryotherapy. Evidence was marginal that a single simultaneous treatment with ice and compression is no more effective than no cryotherapy after an ankle sprain. The authors reported ice to be no more effective than rehabilitation only with regard to pain, swelling, and range of motion. Ice and compression seemed to be significantly more effective than ice alone in terms of decreasing pain. Additionally, ice, compression, and a placebo injection reduced pain more than a placebo injection alone. CONCLUSIONS: Based on the available evidence, cryotherapy seems to be effective in decreasing pain. In comparison with other rehabilitation techniques, the efficacy of cryotherapy has been questioned. The exact effect of cryotherapy on more frequently treated acute injuries (eg, muscle strains and contusions) has not been fully elucidated.

PMID: 15496998

 

Rating: 1c

 

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Hughes RJ, Ali K, Jones H, Kendall S, Connell DA. Treatment of Morton's neuroma with alcohol injection under sonographic guidance: follow-up of 101 cases. AJR Am J Roentgenol. 2007 Jun;188(6):1535-9.

 

Department of Radiology, Royal National Orthopaedic Hospital and Kingston Hospital NHS Trust, Brockley Hill, Stanmore, Middlesex HA7 4LP, United Kingdom.

 

OBJECTIVE: Morton's neuroma is a common cause of forefoot pain. For this study, we assessed the efficacy of a series of sonographically guided alcohol injections into the lesion. SUBJECTS AND METHODS: One hundred one consecutive patients with Morton's neuroma were included in this prospective series. An average of 4.1 treatments per person were administered, and follow-up images were obtained at a mean of 21.1 months after the last treatment (range, 13-34 months). RESULTS: Technical success was 100%. Partial or total symptom improvement was reported by 94% of the patients, with 84% becoming totally pain-free. CONCLUSION: We conclude that alcohol injection of Morton's neuroma has a high success rate and is well tolerated. The results are at least comparable to surgery, but alcohol injection is associated with less morbidity and surgical management may be reserved for nonresponders.

 

PMID: 17515373

 

Rating: 4a

 

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Hupperets MD, Verhagen EA, van Mechelen W. Effect of unsupervised home based proprioceptive training on recurrences of ankle sprain: randomised controlled trial. BMJ. 2009 Jul 9;339:b2684. doi: 10.1136/bmj.b2684.

 

Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Centre, Van der Boechorststraat 7, 1081 BT, Amsterdam, Netherlands.

 

PARTICIPANTS: 522 athletes, aged 12-70, who had sustained a lateral ankle sprain up to two months before inclusion. CONCLUSIONS: The use of a proprioceptive training programme after usual care of an ankle sprain is effective for the prevention of self reported recurrences.

 

PMID: 19589822

 

Rating: 2a

 

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Hutchins S, Bowker P, Geary N, Richards J. The biomechanics and clinical efficacy of footwear adapted with rocker profiles--evidence in the literature. Foot (Edinb). 2009 Sep;19(3):165-70. Epub 2009 Feb 28.

 

CONCLUSIONS: Efficacy is demonstrated with regards to relief of forefoot plantar pressures. However, the definitive profile shape has not been demonstrated. The effectiveness of rocker-soled shoes in restricting sagittal plane motion in individual joints of the foot is unclear. Rocker profiles have minimal effect on the kinetics and kinematics of the more proximal joints of the lower limb, but more significant effects are seen at the ankle.

 

PMID: 20307470

 

Rating: 5b

 

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Irving DB, Cook JL, Young MA, Menz HB. Obesity and pronated foot type may increase the risk of chronic plantar heel pain: a matched case-control study. BMC Musculoskelet Disord. 2007 May 17;8:41.

 

Musculoskeletal Research Centre, La Trobe University, Bundoora, Victoria, Australia.

 

METHODS: Eighty participants with CPHP were matched by age (+/- 2 years) and sex to 80 control participants. RESULTS: Univariate analysis demonstrated that the CPHP group had significantly greater BMI, a more pronated foot posture and greater ankle dorsiflexion ROM than the control group. No difference was identified between the groups for calf endurance or time spent sitting, standing, walking on uneven ground, squatting, climbing or lifting. CONCLUSION: Obesity and pronated foot posture are associated with CPHP and may be risk factors for the development of the condition. Decreased ankle dorsiflexion, calf endurance and occupational lower limb stress may not play a role in CPHP.

 

PMID: 17506905

 

Rating: 3b

 

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Ishikawa SN, Murphy GA, Richardson EG. The effect of cigarette smoking on hindfoot fusions. Foot Ankle Int. 2002 Nov;23(11):996-8.

 

Campbell Clinic-University of Tennessee, Department of Orthopaedic Surgery, Memphis, TN, USA.

 

In a group of 160 patients who had hindfoot fusions (isolated subtalar, talonavicular, and calcaneocuboid fusions and double and triple arthrodeses), smokers had a significantly higher rate of nonunion than did nonsmokers (18.6% vs. 7.1%). The relative risk of developing a nonunion was 2.7 times higher for smokers than non-smokers.

 

PMID: 12449402

 

Rating: 3b

 

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Jacobson JA, Daffner RH, Weissman BN, Arnold E, Bancroft L, Bennett DL, Blebea JS, Bruno MA, Fries IB, Luchs JS, Morrison WB, Payne WK, Resnik CS, Roberts CC, Schweitzer ME, Seeger LL, Taljanovic M, Wise JN, Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria® chronic ankle pain. [online publication]. Reston (VA): American College of Radiology (ACR); 2009. 8 p.

 

Rating: 6b

 

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Jeynes LC, Gauci CA. Evidence for the use of botulinum toxin in the chronic pain setting--a review of the literature. Pain Pract. 2008 Jul-Aug;8(4):269-76. Epub 2008 May 23.

 

The Boyle Department of Anesthesia, St. Bartholomew's Hospital, London, UK.

 

There is evidence supporting the use of both BTX type A and type B in the treatment of cervical dystonias. The weight of evidence is in favor of BTX type A as a treatment in: pelvic pain, plantar fasciitis, temporomandibular joint dysfunction associated facial pain, chronic LBP, carpal tunnel syndrome, joint pain, and in complex regional pain syndrome and selected neuropathic pain syndromes. The weight of evidence is also in favor of BTX type A and type B in piriformis syndrome. There is conflicting evidence relating to the use of BTX in the treatment whiplash, myofascial pain, and myogenous jaw pain.

 

PMID: 18503628

 

Rating: 5c

 

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Johnston EC, Howell SJ. Tension neuropathy of the superficial peroneal nerve: associated conditions and results of release. Foot Ankle Int 1999 Sep;20(9):576-82.

Northwest Sports and Orthopedics, Bountiful, Utah, USA.

PMID: 10509685

 

Rating: 5c

 

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Johnston E, Scranton P Jr, Pfeffer GB. Chronic disorders of the Achilles tendon: results of conservative and surgical treatments. Foot Ankle Int. 1997 Sep;18(9):570-4.

University of Washington, Department of Orthopedic Surgery, Seattle, USA.

We reviewed our results of nonoperative and operative treatment of chronic Achilles tenosynovitis to further define outcomes and treatment parameters. Forty-one patients presented with an average of 14 weeks of Achilles tendon symptoms. Those patients who responded to nonoperative therapy tended to be younger (average age, 33 years) than those who had degenerative tendon changes requiring surgery (average age, 48 years). All surgical patients were able to return to unrestricted activity after 31 weeks (range, 27-48 weeks). We believe 4 to 6 months of nonsurgical therapy is appropriate for middle aged patients or athletes with chronic Achilles tenosynovitis. Those that fail this treatment will improve with a limited debridement of diseased tissue without excessive soft tissue dissection of the tendon.

PMID: 9310768

 

Rating: 4b

 

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Jones AY, Dean E, Scudds RJ. Effectiveness of a community-based Tai Chi program and implications for public health initiatives. Arch Phys Med Rehabil. 2005 Apr;86(4):619-25.

 

Department of Rehabilitation Sciences, Hong Kong Polytechnic University, Hong Kong.

 

OBJECTIVES: To establish whether the reported beneficial physiologic effects of Tai Chi when performed under stringent experimental conditions can be generalized to the community. SETTING: A community in Hong Kong. PARTICIPANTS: Phase 1: 51 subjects inexperienced in Tai Chi (novice group) participated in the program. Phase 2: baseline measures of the novice group were compared with those of an experienced group (n=49) who had practiced Tai Chi for at least 6 months. INTERVENTION: A Cheng 119 style program was taught by a Tai Chi master for 1.5 hours, 3 times weekly, for 12 weeks. CONCLUSIONS: A community-based Tai Chi program produces beneficial effects comparable to those reported from experimental laboratory trials of Tai Chi; therefore, it should be considered as a public health strategy.

 

PMID: 15827909

 

Rating: 3b

 

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Jones CP, Coughlin MJ, Shurnas PS. Prospective CT scan evaluation of hindfoot nonunions treated with revision surgery and low-intensity ultrasound stimulation. Foot Ankle Int. 2006 Apr;27(4):229-35.

 

Miller Foot and Ankle Institute, Charlotte, NC, USA.

 

BACKGROUND: The purpose of this study was to evaluate the clinical and radiographic outcomes of revision hindfoot arthrodeses treated with postoperative low-intensity ultrasound. METHODS: Thirteen patients (13 feet) with established hindfoot nonunions were treated with revision arthrodesis and adjunctive postoperative low-intensity ultrasound. CONCLUSIONS: Postoperative low-intensity ultrasound is easy to apply and administer, with no identifiable risks or contraindications. Although this modality may facilitate the fusion process, we cannot definitely conclude the specific relative value of low-intensity ultrasound because this was not a controlled series.

 

PMID: 16624210

 

Rating: 3c

 

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Joshy S, Abdulkadir U, Chaganti S, Sullivan B, Hariharan K. Accuracy of MRI scan in the diagnosis of ligamentous and chondral pathology in the ankle. Foot Ankle Surg. 2010 Jun;16(2):78-80. Epub 2009 Jul 8.

 

CONCLUSIONS: We conclude that MRI scan has very high specificity and positive predictive value in diagnosing tears of ATFL, CFL and osteochondral lesions. However sensitivity was low with MRI. In a symptomatic patient negative results on MRI must be viewed with caution and an arthroscopy may still be required for a definitive diagnosis and treatment.

 

PMID: 20483139

 

Rating: 3b

 

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Kaminski TW, Hertel J, Amendola N, Docherty CL, Dolan MG, Hopkins JT, Nussbaum E, Poppy W, Richie D. National athletic trainers' association position statement: conservative management and prevention of ankle sprains in athletes. J Athl Train. 2013 Jul-Aug;48(4):528-45. doi: 10.4085/1062-6050-48.4.02.

 

PMID: 23855363

 

Rating: 6b

 

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Kampa RJ, Connell DA. Treatment of tendinopathy: is there a role for autologous whole blood and platelet rich plasma injection? Int J Clin Pract. 2010 Dec;64(13):1813-23.

 

Autologous blood injections (ABI) are thought to promote tendon healing, but have been explored clinically in only a few limited studies. Refractory chronic tendinopathy may be responsive to ABIs, but the data available to date are limited by quality and size of study, as well as length of follow up, and are currently insufficient to recommend this modality for routine clinical use.

 

PMID: 21070532

 

Rating: 5b

 

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Kamper SJ, Grootjans SJ. Surgical versus conservative treatment for acute ankle sprains. Br J Sports Med. 2012 Jan;46(1):77-8.

 

SourceMusculoskeletal Division, The George Institute for Global Health, PO Box M201, Missenden Road, NSW 2050, Australia. skamper@georgeinstitute.org.au.

 

PMID: 22167718

 

Rating: 5b

 

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Kane D, Greaney T, Shanahan M, Duffy G, Bresnihan B, Gibney R, FitzGerald O. The role of ultrasonography in the diagnosis and management of idiopathic plantar fasciitis. Rheumatology (Oxford) 2001 Sep;40(9):1002-8.
 
Department of Rheumatology, St Vincent's University Hospital, Dublin 4, Ireland.

OBJECTIVE: To compare ultrasonography with bone scintigraphy in the diagnosis of plantar fasciitis and to compare ultrasound-guided injection with palpation-guided injection in the management of idiopathic plantar fasciitis. CONCLUSION: Ultrasonography and bone scintigraphy are equally effective in the diagnosis of plantar fasciitis. Ultrasound-guided injection is effective in the management of plantar fasciitis but is not more effective than palpation-guided injection. Ultrasonography may be used as an objective measure of response to treatment in plantar fasciitis.
 

PMID: 11561110

 

Rating: 2c

 

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Karatosun V, Unver B, Ozden A, Ozay Z, Gunal I. Intra-articular hyaluronic acid compared to exercise therapy in osteoarthritis of the ankle. A prospective randomized trial with long-term follow-up. Clin Exp Rheumatol. 2008 Mar-Apr;26(2):288-94.

 

Department of Orthopedic Surgery, Dokuz Eylul University Hospital, Balcova, Izmir, Turkey. vasfi.karatosun@deu.edu.tr

 

METHODS: In a prospective clinical trial, 43 ankles (30 patients) with radiographic Kellgren Lawrence grade III OA were randomized to receive three intra-articular HA injections, with one-week interval of or exercise therapy for six weeks. CONCLUSION: This prospective randomized trial confirmed that, both HA injections and exercise therapy provide functional improvement. However, larger trials with longer follow-up are necessary for more definite conclusions.

 

PMID: 18565251

 

Rating: 2c

 

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Kavanagh J. Is there a positional fault at the inferior tibiofibular joint in patients with acute or chronic ankle sprains compared to normals? Man Ther 1999 Feb;4(1):19-24.
 
Physiotherapy Department, Mater Misericordiae Hospital, Dublin, Republic of Ireland.

These results lend support to the hypothesis that a positional fault occurs at the inferior tibiofibular joint in ankle sprain patients. This could have exciting implications for the future direction of the treatment of these injuries.

PMID: 10463017

 

Rating: 4c

 

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Kearney R, Costa ML. Insertional achilles tendinopathy management: a systematic review. Foot Ankle Int. 2010 Aug;31(8):689-94.

 

RESULTS: One hundred eighteen articles were identified through the search strategy. CONCLUSION: There is a consensus that conservative methods should be used before operative interventions. Current evidence for conservative treatment favors eccentric loading and shock wave therapy, although there is limited evidence by which to judge their effectiveness. Evaluation of operative interventions has been mostly retrospective and remains inconclusive.

 

PMID: 20727317

 

Rating: 1b

 

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Kelly IP, Nunley JA. Treatment of stage 4 adult acquired flatfoot. Foot Ankle Clin. 2001 Mar;6(1):167-78.

 

Division of Orthopaedic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA.

 

The surgical options are a tibiotalocalcaneal fusion or a pantalar fusion; however, there are few results reported in the adult acquired flatfoot population.

 

PMID: 11385924

 

Rating: 5b

 

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Kennedy JG, Harty JA, Casey K, Jan W, Quinlan WB, Outcome after single technique ankle arthrodesis in patients with rheumatoid arthritis, Clin Orthop. 2003 Jul;(412):131-8.

Department of Orthopaedics, Hospital for Special Surgery, New York, NY 10021, USA. jgkl@hotmail.com

The established treatment for severe rheumatoid arthritis in the ankle is arthrodesis. One technique of 20 ankle fusions in patients with rheumatoid disease was evaluated. The value of the technique has been confirmed in patients with rheumatoid arthritis by evaluating the outcome using a scoring system that is validated and relevant to this population.

 

PMID: 12838063

 

Rating: 2c

 

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Kerkhoffs GMMJ, Handoll HHG, de Bie R, Rowe BH, Struijs PAA. Surgical versus conservative treatment for acute injuries of the lateral ligament complex of the ankle in adults (Cochrane Review). In: The Cochrane Library, Issue 3, 2002.

 

Main results: There was some evidence for a lower incidence of long-term ankle swelling in surgically treated patients. However, as well as tending to take longer to resume normal activities, including work, there was some limited evidence from a few trials for a higher incidence of ankle stiffness, impaired ankle mobility and complications in the surgical treatment group.

Reviewers' conclusions: There is insufficient evidence available from randomised controlled trials to determine the relative effectiveness of surgical and conservative treatment for acute injuries of the lateral ligament complex of the ankle.

 

PMID: 17443501

 

Rating: 1a

 

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Kerkhoffs GMMJ, Rowe BH, Assendelft WJJ, Kelly K, Struijs PAA, van Dijk CN. Immobilisation and functional treatment for acute lateral ankle ligament injuries in adults (Cochrane Review). In: The Cochrane Library, Issue 3, 2002.

 

 Reviewers' conclusions: Functional treatment appears to be the favourable strategy for treating acute ankle sprains when compared with immobilisation. However, these results should be interpreted with caution, as most of the differences are not significant after exclusion of the low quality trials. Many trials were poorly reported and there was variety amongst the functional treatments evaluated.

 

PMID: 12137710

 

Rating: 1a

 

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Kerkhoffs GMMJ, Struijs PAA, Marti RK, Assendelft WJJ, Blankevoort L, Dijk van CN. Different functional treatment strategies for acute lateral ankle ligament injuries in adults (Cochrane Review). In: The Cochrane Library, Issue 3, 2002.

 

The use of an elastic bandage has fewer complications than taping but appears to be associated with a slower return to work and sport, and more reported instability than a semi-rigid ankle support. Lace-up ankle support appears to be effective in reducing swelling in the short-term compared with semi-rigid ankle support, elastic bandage and tape. However, definitive conclusions are hampered by the variety of treatments used, and the inconsistency of reported follow-up times. The most effective treatment, both clinically and in costs, is unclear from currently available randomised trials.

 

PMID: 12137665

 

Rating: 1a

 

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Kerkhoffs GM, van den Bekerom M, Elders LA, van Beek PA, Hullegie WA, Bloemers GM, de Heus EM, Loogman MC, Rosenbrand KC, Kuipers T, Hoogstraten JW, Dekker R, Ten Duis HJ, van Dijk CN, van Tulder MW, van der Wees PJ, de Bie RA. Diagnosis, treatment and prevention of ankle sprains: an evidence-based clinical guideline. Br J Sports Med. 2012 Sep;46(12):854-60. doi: 10.1136/bjsports-2011-090490.

 

PMID: 22522586

 

Rating: 1b

 

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Khan RK, Fick D, Brammar T, Crawford J, Parker M, Interventions for treating acute Achilles tendon ruptures, Cochrane Database Syst Rev. 2004;3:CD003674

Trauma and Orthopaedics, Perth Orthopaedic Institute, PO Box 1125, Nedlands, Perth, WA, AUSTRALIA, 6011.

BACKGROUND: There is lack of consensus on the best management of the acute Achilles tendon (TA) rupture. Treatment can be broadly classified into operative (open or percutaneous) and non-operative (cast immobilisation or functional bracing). Post-operative splintage can be with a rigid cast (above or below the knee) or a more mobile functional brace. OBJECTIVES: To identify and summarise the evidence from randomised controlled trials of the effectiveness of different interventions in the treatment of acute Achilles tendon ruptures. MAIN RESULTS: Fourteen trials involving 891 patients were included. Several of the studies had poor methodology and inadequate reporting of outcomes.Open operative treatment compared with non-operative treatment (4 trials, 356 patients) was associated with a lower risk of rerupture (relative risk (RR) 0.27, 95% confidence interval (CI) 0.11 to 0.64), but a higher risk of other complications including infection, adhesions and disturbed skin sensibility (RR 10.60, 95%CI 4.82 to 23.28).Percutaneous repair compared with open operative repair (2 studies, 94 patients) was associated with a shorter operation duration, and lower risk of infection (RR 10.52, 95% CI 1.37 to 80.52). These figures should be interpreted with caution because of the small numbers involved. Patients splinted with a functional brace rather than a cast post-operatively (5 studies, 273 patients) tended to have a shorter in-patient stay, less time off work and a quicker return to sporting activities. There was also a lower complication rate (excluding rerupture) in the functional brace group (RR 1.88 95%CI 1.27 to 2.76). REVIEWERS' CONCLUSIONS: Open operative treatment of acute Achilles tendon ruptures significantly reduces the risk of rerupture compared to non-operative treatment, but produces a significantly higher risk of other complications, including wound infection. The latter may be reduced by performing surgery percutaneously. Post-operative splintage in a functional brace appears to reduce hospital stay, time off work and sports, and may lower the overall complication rate.

PMID: 15266495

 

Rating: 1b

 

 

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Khan RJ, Fick D, Keogh A, Crawford J, Brammar T, Parker M. Treatment of acute achilles tendon ruptures. A meta-analysis of randomized, controlled trials. J Bone Joint Surg Am. 2005 Oct;87(10):2202-10.

 

Perth Orthopaedic Institute, Department of Surgery and Pathology, University of Western Australia, Perth, Australia. riazkhan@aol.com

 

BACKGROUND: There is a lack of consensus regarding the best option for the treatment of acute Achilles tendon rupture. Treatment can be broadly classified as operative (open or percutaneous) or nonoperative (casting or functional bracing). Postoperative splinting can be performed with a rigid cast (proximal or distal to the knee) or a more mobile functional brace. The aim of this meta-analysis was to identify and summarize the evidence from randomized, controlled trials on the effectiveness of different interventions for the treatment of acute Achilles tendon ruptures. RESULTS: Twelve trials involving 800 patients were included. There was a variable level of methodological rigor and reporting of outcomes. CONCLUSIONS: Open operative treatment of acute Achilles tendon ruptures significantly reduces the risk of rerupture compared