National Foot & Ankle Event
June 2015
Kate James – MSK & Orthopaedic Quality Drive - National Lead
National Support
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MSK & Orthopaedic Quality Drive – Year Two
Dashboard & Indicators
Peer Review
National Foot & Ankle Pathway - Draft
Available Intelligence:
– Activity Data
– Audit Results
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Peer Review
• Chief Exec Letter – Next week
• Visit to each hospital – Supported by Indictor Summary
– Sept to Dec 2015
• Senior Scottish & Senior English Ortho Surgeon, myself
and two ‘peers’
• ‘Pool of Peers’ – Clinicians & Managers from around
Scotland each contributing at 2-3 reviews
• Attendees: Senior Managers, Senior Clinicians,
Workstrand Leads
• Pump-Prime Funding (non-recurring) – Funding
Request via Board Exec Leads - make a difference to
achieving sustainable change in priority focus areas
Peer Review
• Chief Exec Letter
– The focus of the Trauma & Orthopaedic ACCESS programme
is on:
• embedding the gains for patients of the four ‘pathway’ workstrands
in the MSK and Orthopaedic Quality Drive. Progress in AHP MSK
Redesign, Non-operative Fracture Redesign, Elective Enhanced
Recovery and the Hip Fracture Care Pathway can be evidenced via
the clinical quality and efficiency indicators in the 'Rolling Audit'.
• maintaining the significant momentum of change, evidenced by the
strength of multidisciplinary clinical and managerial teams at the
majority of Scottish hospitals and demonstrable gains from the
Quality Drive.
• optimising use of existing trauma and elective capacity – workforce,
beds, and theatres.
• demand and capacity planning and management to understand
which elements of each Board/Hospital’s service are in balance and
which are out of balance.
Musculoskeletal – Foot and Ankle - Management and Referral Pathway – July 2013
Patient
Presentation
Hallux Valgus & Rigidus
(Bunions)
• Swelling or deformity
at 1st MTP joint
• Hallux Rigidus due to
OA – swelling due to
osteophytes. Reduced
range of movement
and pain on activity
• Hallux Valgus due to
lateral deviation of
hallus – Pain over
medial prominence,
exacerbated by tight
shoes. May develop
secondary callous,
corns, ulcers or toe
deformities
Mortons Neuroma /
Metatarsalgia
• Pain under lesser
metatarsal heads or in
webspaces
• Painful paraesthesia or
plantar callosites
• Pain on activity
Midfoot Arthritis /
Tibialis Posterior Rupture
• Pain and stiffness
• Local tenderness
• Loss of medial
longitudinal arch
GP/AHP Assessment
Provide advice on –
• footwear (e.g.
extra width and
low heals)
• rest of feet after
periods of
standing/walking
• exercise for ankles
and stretch of
Achilles Tendon if
appropriate
• weight-loss if
appropriate
• analgesia &
NSAIDS as
appropriate
• Consider Podiatry/
Orthotic referral
• Website for selfhelp –
http://www.nhsinf
orm.co.uk/MSK/lo
werbody
Remember
Diabetic Foot and
refer early to avoid
amputation
(to specialist clinic
where service exists)
Any further guidance from
BOFAS to include?
Primary Care
•
Any indications for diagnostic
tests from Primary care?
How do we make it clear who
should be referred to
Podiatry / orthotics?
•
Podiatry and Orthotics
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•
•
Advice re footwear
Provide specialist
footwear, insoles,
orthotics
Care of secondary
lesions
Intra-articular
steroid injections
•
•
If No
Improvement
after 3 months
provide
information sheet
on surgical
options and
discuss. Do we
have this?
If patient
considering
surgery, refer to
secondary care
Orthopaedic Foot
& Ankle Clinic
Include
information on
conservative
treatment tried
(any to
rheumatology?)
Produced by
Scottish Orthopaedic
Services Development Group
With advice from primary and
secondary care clinicians
Secondary Care
Indications for
surgery
Failure of
conservative
treatment for at
least 3 Months.
Hallux Valgus
and Rigidus
Pain should be
primary
indication for
Surgery.
Recurrent ulcers
and Infection.
Metatarsalgia
Fixed toe
Deformities.
Morton’s
Neuroma
Not responded to
steroid injections.
Refer for
ultrasound
examination
Midfoot Arthritis
Tibialis Posterior
Rupture
Consider surgical
fusion
Page 1 of 3
Any further guidance from BOFAS to include?
Musculoskeletal – Foot and Ankle - Management & Referral Pathway – June• 2013
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Patient
Presentation
Posterior Heel Pain Pump bumps
•
GP/AHP Assessment
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Tenderness and
swelling proximal to
insertion of tendon
to posterior
calcaneum
Plantar Heel Pain Plantar Pad
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Fat pad atrophy with
non-specific pain
under heel
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Plantar Heel Pain Plantar Fasciitis
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•
•
Primary Care
•
Prominent posterior
aspect of calcaneum
Posterior Heel Pain Achilles Tendonosis
•
Simple padding and
footwear advice
Pain is worse on
taking first steps in
the morning
Tenderness at
attachment of
Plantar Fascia to
medical calcaneal
tubercle (illustrated)
Spurs are not
significant
•
•
If No Improvement
after 3 months
provide information
sheet on surgical
options and discuss.
Do we have this?
Advise a 1cm heel
raise
Reduce mileage and
frequency of
exercise
Consider Physio
referral
•
•
Include information
on conservative
treatment tried
Consider
Podiatry/Orthotics
referral for Orthoses
•
(any to
rheumatology?)
Regular calf/ plantar
fascia stretching
Consider
Podiatry/Orthotics
referral for Orthoses,
Steroid injection,
Night splints
As spurs are not
significant X-Rays are
not indicated
Remember Diabetic
Foot and refer early to
avoid amputation (to
specialist clinic where
service exists)
Indications for diagnostic tests from Primary care?
If patient
considering surgery,
refer to secondary
care Orthopaedic
Foot & Ankle Clinic
General advice
•
Advise analgesia and
NSAIDs as
appropriate
•
Advise patient that
weight loss can
reduce heel pain
•
Minimise impact on
feet by wearing
footwear with
padding or shock
absorbing material
•
Website for self-help
http://www.nhsinfor
m.co.uk/MSK/lower
body
Secondary Care
Indications for Surgery
Failure of conservative treatment
for at least 3 Months.
Posterior Heel Pain Pump bumps
• possible surgical excision of bursa
Posterior Heel Pain - Achilles
Tendonosis
• Possible decompression of
Achilles tendon
Plantar Heel Pain - Plantar Pad
•
Surgery rarely indicated
Plantar Heel Pain - Plantar Fasciitis
• 80% resolve within 12-18 months
• Surgery is rarely indicated
Produced by
Scottish Orthopaedic
Services Development Group
With advice from primary and
secondary care clinicians
Page 2 of 3
Musculoskeletal – Foot and Ankle - Management and Referral Pathway – July 2013
Patient
Presentation
GP / AHP Assessment
•
Lateral ankle sprains
Lateral ankle pain,
swelling and giving way
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•
Ankle and hindfoot
disorders
Pain stiffness or
deformity in hindfoot.
Can be caused by
arthiritis, tendon
rupture, neurological
imbalance, diabetic
neuroarthropathy
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Cavus feet?
Flat feet?
Ingrowing toenail?
Secondary Care
Indications for surgery
Acute injury –
protection, rest, ice,
compression,
elevation (PRICE)
X-ray if fracture
suspected
Consider referral for
Physiotherapy
Advise that weight
loss can reduce pain
Standing x-rays of
ankle and foot:
If normal (no
deformity/minimal
arthritis) consider
referral to
Podiatry/Orthotics
If severe OA or
deformity, refer to
Orthopaedics
If Rheumatoid
arthritis refer to
Rheumatology
Remember Diabetic Foot
and refer early to avoid
amputation (to specialist
clinic where service exists)
Primary Care
•
If No Improvement
after 3 months
provide information
sheet on surgical
options and discuss.
Do we have this?
•
If patient
considering surgery,
refer to secondary
care Orthopaedic
Foot & Ankle Clinic
•
Include information
on conservative
treatment tried
Lateral ankle sprains
• No indication for surgery after
acute ligament injuries
• Chronic pain and instability need
further imaging and may require
surgical reconstruction
Ankle and hindfoot disorders
• Consider surgery if…
General advice
•
Analgesia and
NSAIDs as
appropriate
•
High heel shoes can
cause strain on
ankles and Achilles
tendon
•
Advise to wear ankle
supports when
playing sport
•
Website for self-help
http://www.nhsinfor
m.co.uk/MSK/lower
body
Produced by
Scottish Orthopaedic
Services Development Group
With advice from primary and
secondary care clinicians
Page 3 of 3
Activity Data
Audit Slides