Clinical Guidelines

for localised
Musculoskeletal
Foot Pain
A Podiatry Perspective
VERONA DU TOIT | ANDREA BIALOCERKOWSKI
Clinical Guidelines For Localised Musculoskeletal Foot Pain

Verona du Toit
Andrea Bialocerkowski

First published 2013

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© 2013 Verona du Toit and Andrea Bialocerkowski

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permission in writing from the authors and/or publishers.

Library of Congress Cataloging in Publication Data

du Toit, Verona & Bialocerkowski, Andrea

Clinical guidelines for localised musculoskeletal foot pain –

a podiatry perspective

This book includes an overview of the importance of

clinical guidelines for a number of foot conditions, the
systematic review methodology employed to investigate
existing guidelines, and the appraisal processes to develop
a summary of recommendations that are relevant to
podiatry in Australia.

1. Clinical guidelines. 2. Foot and ankle pain.

3. Podiatry. 4. Musculoskeletal conditions.

ISBN: 978-1-74108-249-4 (pbk)

ISBN: 978-1-74108-265-4 (electronic bk)

Printed and bound in Australia by

Page 38 (page38.com.au)
PO Box 381, Matraville, 2036
Australia NSW, Australia
A Podiatry Perspective
CONTENTS

LIST OF ABBREVIATIONS 4

LIST OF TABLES 4

LIST OF FIGURES 4

FOREWORD 5

ACKNOWLEDGEMENTS 6

THE WRITING TEAM 6

Chapter 1

BACKGROUND 8

REFERENCES 11

Chapter 2

METHODOLOGY 14
3
REFERENCES 20

Chapter 3

RESULTS 22

REFERENCES 68

Chapter 4

DISCUSSION 70

REFERENCES 72

Appendix

AGREE II SCORE CALCULATIONS –

AN EXAMPLE BASED ON THE GUIDELINE DEVELOPED
BY THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS 74
Background
Clinical Guidelines For Localised Musculoskeletal Foot Pain

LIST OF ABBREVIATIONS
AAOS American Academy of Orthopaedic Surgeons

ACOEM American College of Occupational and Environmental Medicine

AGREE II Appraisal of Guideline Research and Evaluation II

APodC The Australasian Podiatry Council

iCAHE International Centre for Allied Health Evidence

ICD-10 International Statistical Classiication of Diseases and Related Health Problems 10th Revision

ICSI Institute for Clinical Systems Improvement

KNGF Koninklijk Nederlands Genootschap voor Fysiotherapie

NHMRC National Health and Medical Research Council

NICE National Institute for Health and Care Excellence

WLDI Work Loss Data Institute

LIST OF TABLES
TABLE 2.1 DEFINITION OF SPECIFIC FOOT
AND ANKLE CONDITIONS (ICD-10) 7

TABLE 2.2 GUIDELINE SITES 9

TABLE 2.3 PROFESSIONAL PODIATRIC ASSOCIATION WEBSITES 11

TABLE 2.4 ITEMS CONTAINED IN THE AGREE II 12

TABLE 2.5 ITEMS CONTAINED IN THE ICAHE GUIDELINE CHECKLIST 13

TABLE 2.6 RULES FOR INTERPRETING GUIDELINE QUALITY

BASED ON THE ICAHE GUIDELINE CHECKLIST 14

TABLE 3.1 CLINICAL GUIDELINES WHICH

MET THE SELECTION CRITERIA 18

TABLE 3.2 INCLUDED GUIDELINES AND

CORRESPONDING MUSCULOSKELETAL CONDITIONS 20

TABLE 3.3 QUALITY OF CLINICAL GUIDELINES BASED ON AGREE II 22

TABLE 3.4 QUALITY OF CLINICAL GUIDELINES

BASED ON THE ICAHE GUIDELINE CHECKLIST 22

FIGURE 3.1
STUDY SELECTION PROCESS AND SEARCH YIELD 17
A Podiatry Perspective
 Foreword
FOREWORD
I am delighted to contribute the Forward to this book. The One outcome of writing this book was the identiication
authors are to be congratulated on this initiative, as this of current evidence gaps. These gaps highlight directions
book represents novel, easy-to-read and eicient access for future podiatric research to better inform podiatric
to current best evidence for podiatric management of practice. Ways of addressing current evidence gaps include:
patients with musculoskeletal foot and ankle conditions.
It is speciically targeted to the needs of busy podiatrists 1. More high quality systematic reviews should be
practising in Australia. The book presents carefully conducted to critically appraise and synthesise
summarised clinical practice guidelines drawn from a the available evidence, to provide evidence of the
comprehensive range of international sources. most efective interventions for the most prevalent
conditions treated by podiatrists in Australia.
Evidence-based practice is the integration of best
available research evidence, clinical judgement, and 2. Where there is an absence of high quality systematic
patient choices and values, within the context of reviews and primary research evidence, more
local practice. Thus clinical practice guidelines which high quality primary studies should be conducted
incorporate the best available evidence provide a ‘one- to investigate the efectiveness of the diferent
stop-shop’ of current best evidence for assessment interventions used to manage the most prevalent
and management of a clinical condition. The guidelines conditions treated by Australian podiatrists.
presented in this book have been identiied using
3. Where there is an absence of published research
unbiased, comprehensive, rigorous, transparent searching
evidence, consensus based research, such as Delphi
methods. The included guidelines have then been critically
studies, should be undertaken to identify assessment
appraised, synthesised and reported in an eicient,
techniques and interventions that could be used in the
comprehensive and easy-to-read format. Busy podiatrists
management of patients who seek treatment from
can be conident that this book presents a comprehensive
podiatrists in Australia. This information could not
resource of current best international information on
only inform clinical practice now, but could also inform
assessment and management of musculoskeletal foot
future better quality, targeted primary research.
and ankle conditions.
Podiatrists practising in Australia are indeed fortunate
Each included guideline has been summarised using
to have this resource. Whilst it presents the current best
a standard reporting approach. The book presents
evidence, it also is written in a format which can be readily
the guideline name, publication date, availability,
updated to ensure ongoing currency. Podiatrists should be
end users, content, basis of recommendations (e.g.
consensus, evidence), search period, sources of evidence,
able to eiciently navigate the clinical guidelines reported 5
in this book, and use the information to inform equitable,
strength of recommendation descriptors, summary of
timely, safe, consumer-oriented and efective clinical
recommendations, guideline quality (using scores from two
decisions and treatment plans.
guideline quality appraisal instruments), generalisability,
applicability (to the Australian podiatry setting), and any
other information relevant to the guideline.

To most efectively use the recommendations reported in

this book, podiatrists practicing in Australia should:
Professor Karen Grimmer
1. choose recommendations from highest quality, most
Director, International Centre for Allied Health Evidence
up-to-date included clinical guidelines to inform their
University of South Australia
clinical decision-making; and
10/6/2013
2. use evidence and consensus-based summaries in
these guidelines to provide patients with accurate
information on the evidence base which underpins
treatment options, including beneits versus harm.
Background
Clinical Guidelines For Localised Musculoskeletal Foot Pain

ACKNOWLEDGEMENTS
We acknowledge the support from our families and
the staf at the International Centre for Allied Health
Evidence (particularly Dr Janine Dizon and Professor
Karen Grimmer), the School of Medicine and the School of
Science and Health at the University of Western Sydney,
and the School of Rehabilitation Sciences at Griith
University, who provided us with support.
We also gratefully thank all of the organisations that
provided additional information on the development of
their clinical guidelines, which has been incorporated into
this work. And inally, thanks to Dr Roslyn Weaver (The
Writing Desk) for her editorial services. This work was
funded by a small grant from the Australian Podiatry
Education and Research Fund.

THE WRITING TEAM

ASSOCIATE PROFESSOR ANDREA BIALOCERKOWSKI
PHD, B APP SC (PHYSIO), M APP SC (PHYSIO), GRAD DIP PUBLIC HEALTH, SPECIALIST
CERTIFICATE IN CLINICAL RESEARCH (BIOMEDICAL RESEARCH MANAGEMENT)

School of Rehabilitation Sciences, Griith University

Andrea is the Deputy Head (Learning and Teaching) and lectures in the physiotherapy
programs in the School of Rehabilitation Sciences at Griith University. Andrea has an
adjunct appointment in the School of Science and Health at the University of Western
Sydney, where she was the former Foundation Head of Physiotherapy. Andrea is a
musculoskeletal physiotherapist and researcher, who has a special interest in synthesis of
research evidence for use in the clinical setting. She has published 16 systematic reviews
in peer-reviewed journals over the last eight years.

VERONA DU TOIT,
M APP SC (EXSPSC), ASS DIP POD, B TEACH (ADULT VOCATIONAL EDUCATION)

School of Medicine, University of Western Sydney

Verona is a Research Fellow, in the School of Medicine, conducting research in clinical

education, assessment and workload in health and allied health professions. Verona
was the former Head of the Podiatric Medicine program at the University of Western
Sydney in the School of Science and Health. She is an Australian-registered and practising
podiatrist with a special interest in lower extremity injury prevention, biomechanics,
clinical intervention, evidence-based practice methods, and improving clinical education
in the workplace.
A Podiatry Perspective
 Chapter 1
Chapter 1
7
Background

Background
Clinical Guidelines For Localised Musculoskeletal Foot Pain
Chapter 1
1.1
This chapter introduces the theory associated with
clinical guidelines, explains the diference between clinical
guidelines and care pathways, and describes when and
how clinical guidelines are recommended to be used. The
purpose of assessing the quality of clinical guidelines is
1.2
Clinical guidelines are described as “systematically
developed statements to assist practitioner and patient
decisions about appropriate health care for speciic clinical
circumstances”.1 The statements are recommendations
that are based on the best available evidence2, and may
also include consensus statements by clinicians, in the
absence of research evidence. The National Health and
Medical Research Council (NHMRC) of Australia and other
research bodies internationally recommend that clinical
guidelines should be used by patients and clinicians to
develop appropriate treatment plans.3 They encourage
1.3 WHAT DOES A GUIDELINE LOOK LIKE?
Guidelines often focus on one condition. Alternatively,
a guideline may contain information on a number of
conditions in a speciied anatomical area. The information
contained within a clinical guideline may include the
aetiology of the condition, assessment procedures,
diagnostic tests and their interpretation, prognosis,
preventative measures and patient management using
conservative and surgical techniques.2 Guidelines may also
include information on how to evaluate the efectiveness
of the intervention delivered to the patient.
HOW DOES A CLINICAL
1.4 GUIDELINE DIFFER FROM A CARE PATHWAY?
Often the terms “clinical guideline” and “care pathway”
are used interchangeably because both aim to provide
appropriate and efective health care for a speciic
clinical circumstance and to decrease variations in
clinical practice.11 However, clinical guidelines and care
pathways are distinct entities. Clinical guidelines contain
an evidence-based summary for aspects of clinical
management of patients. Their primary purpose is to
assist health professions to make clinical decisions based
on research evidence to improve the clinical and cost
A Podiatry Perspective
efectiveness of patient management.
OVERVIEW
then discussed and information on the current knowledge
of musculoskeletal clinical guidelines is presented. The
chapter ends with the application of this theory to the
profession of podiatry and the aim of this project.
WHAT ARE GUIDELINES AND
WHY SHOULD THEY BE USED?
the use of evidence-based treatments which have been
identiied as efective4, and thus when acted upon
improve and manage the care process.5 The use of clinical
guidelines potentially reduces practice variation, improves
patient outcomes and reduces the cost of treatment.2,6,7
This, however, may be speciic to the practice setting and
context in which the guideline is utilised.6 Moreover, clinical
guidelines have been used to increase the transparency
of clinical practice and to legitimise a health profession
to external stakeholders, such as potential patients and
insurance companies.8,9
Authors of clinical guidelines often provide readers with
a summary of recommendations or a low diagram
that captures key information, which is underpinned by
research evidence.10 This has been suggested to be useful
for busy clinicians as it assists with making management
decisions. It must be noted that recommendations
made within clinical guidelines tend to be based on
research evidence and on consensus by experts. However,
according to evidence-based practice, other treatment
techniques may be ofered as patient management.
In contrast, care pathways are deined as “locally
agreed, multidisciplinary practice based on guidelines
and evidence where available for a speciic patient or
client group. It forms all or part of the clinical record,
documents the care given and facilitates the evaluation
of outcomes for continuous quality improvement”.12
Thus care pathways aim for seamless care for the entire
management of a condition which involves a number
of health professionals.13 They assist in the coordination
of the work of a clinical team (i.e. they emphasise the
organisational aspects of care), as well as the clinical
delivery of care.

HOW DO I KNOW IF A GUIDELINE
1.5 CONTAINS TRUSTWORTHY INFORMATION?
Clinical guidelines potentially vary in quality, just like
the primary evidence that they contain.14,15 Thus, clinical
guidelines should be evaluated using a standardised critical
appraisal tool to ensure that they are credible and that
clinicians believe their recommendations. Moreover, the
evaluation of guideline quality and implementation of
high quality guidelines into clinical practice decreases the
likelihood that inappropriate recommendations are put
into practice, which may be detrimental to patient care.16
Critical appraisal of guideline quality, therefore, must occur
prior to implementing the guideline in clinical practice.17
A number of critical appraisal tools have been developed
for clinical guidelines,18 and these include the Appraisal
of Guideline Research and Evaluation II (AGREE II), the
Guideline Implementability Appraisal instrument and the
International Centre for Allied Health Evidence (iCAHE)
Guideline Checklist.17 Despite the AGREE II possessing
appropriate psychometric properties, its main limitation is
that it does not contain items that evaluate the strength
of evidence underpinning the recommendations in the
guideline.19,20 The iCAHE Guideline Checklist, however,
contains items that evaluate the evidence base used to
make recommendations.17
WHAT DO WE KNOW ABOUT
1.6 MUSCULOSKELETAL CLINICAL GUIDELINES?
A number of studies have been published on clinical
guidelines for a variety of musculoskeletal conditions,
such as low back pain22 and upper limb musculoskeletal
conditions23, as well as for medical conditions, such as
asthma, cardiovascular disease, diabetes, drugs and
alcohol, obesity, pregnancy and renal disease.24 It has
been suggested that musculoskeletal guidelines vary
1.7 PODIATRY AND CLINICAL GUIDELINES
Podiatry is an allied health profession, which specialises
in the prevention, diagnosis, treatment and rehabilitation
of disorders, medical and surgical conditions of the feet
and the lower limbs.25 In Australia, podiatry is the main
health profession that manages foot and ankle pain and
disability.26 Foot pain afects one in ive people in the
general population.27,28 Risk factors include increasing age
27-29, female gender27,28,30 and obesity.28,31 Foot and ankle
pain are associated with self-reported disability32, inability
to perform activities of daily living30,33 and decreased
health-related quality of life.28,34
Chapter 1
In addition, evidence is usually graded with respect to the
strength of evidence, which arbitrarily categorises each
guideline recommendation based on: 1) the quality of
the underpinning evidence; and 2) if the desired efects
clearly outweigh the undesired efects or if there is a
close or uncertain balance regarding efects.16 There is
great variation in methods used to rate the strength
of evidence. The NHMRC of Australia has provided
recommendations on the levels of evidence and grades for
recommendations for guideline developers.3
Clinical guidelines contain research evidence, which can
be superseded very rapidly. Therefore, clinical guidelines
must be updated regularly to relect changes in science. It
is recommended that updating clinical guidelines should
occur every two to ive years, depending on the volume
of research evidence that is published on the guideline
topic.21 It is paramount to gain an understanding of not
only the quality but also the currency of the evidence
which underpins the recommendations within a guideline.
9
in methodological quality, in particular relating to their
development process and the use of research to underpin
recommendations.23,24 Moreover, within Australia, an
uncoordinated approach currently exists with respect
to identifying national priority areas for developing and
updating clinical guidelines.24
Both conservative management and surgical treatment
have been shown to decrease the pain associated with
many foot disorders.35,36 There are many treatment options
available to address foot and ankle pain, which are ofered
by a myriad of health professions.37 However, the podiatry
profession is well placed to address this established public
health issue, as it is a profession that is building evidence
to support the efectiveness of the treatment techniques
it delivers.38,39 Clinical guidelines serve as an important
element in evidence-based practice as, when used, they
assist podiatrists to make clinical decisions based on
research evidence. This, in turn, may lead to improved clinical
Background
outcomes and cost efectiveness of patient management.18
Clinical Guidelines For Localised Musculoskeletal Foot Pain
1.8
The scope of practice includes paediatrics, diabetes,
sports injuries, structural problems, and treatment of
the elderly, as well as general foot care. The complex
mechanics of feet and a wide range of foot problems
demand professional expertise.25
On 1 July 2010, Australia’s irst national registration
scheme (as well as a new accreditation scheme) came
into being, under the auspices of The Australian Health
Practitioner Regulation Agency. Data on podiatry
practice in Australia are collected annually and published
by the Australian Institute of Health and Welfare. The
supplementary podiatry labour force survey conducted in
2003 provides the most detailed statistics on podiatrists
in the Australian states of New South Wales, Victoria,
Queensland, South Australia and Tasmania.37 In 2003, the
number of registered podiatrists in Australia, excluding
1.9
It is believed that clinical guidelines have been developed
for the management of musculoskeletal conditions which
lead to foot and ankle pain. However, to date, no study
has focused on the identiication, critical appraisal and
synthesis of these clinical guidelines in Australia.
A Podiatry Perspective
PODIATRY IN AUSTRALIA
Western Australia, Australian Capital Territory and the
Northern Territory, totalled 2064.37 Two thirds of these
podiatrists worked in the states of Victoria and New South
Wales, approximately 40% were males, and two thirds
worked in private practice.31
The Australasian Podiatry Council (APodC) has the
overarching responsibility to act as the representative
of the podiatry profession in Australia. Objectives of the
APodC include: (1) representation of the professional needs
of podiatrists to government and industry bodies; (2)
support and implementation of strategies for continued
professional development; (3) encouragement and
assistance in research within podiatry; and (4) preparation
and dissemination of national policies and clinical practice
guidelines to all registered podiatrists in Australia.40
AIM OF THIS WORK
The aim of this work is to systematically identify and
critically appraise existing clinical guidelines that address
musculoskeletal sources of foot and ankle pain. The
recommendations will be extracted from these guidelines
and interpreted with respect to their generalisability to the
Australian podiatry context.

1.10
1. Field MJ and Lohr KN (1990) Clinical practice
guidelines: directions for a new program. Washington
DC: National Academy Press, pp. 38.
2. Grimmer-Somers K (2010) Setting the scene. In
Grimmer-Somers K and Worley A. Practical tips for
using and developing guidelines: an allied health
primer. Manila: UST Publishing House, pp. 5-12.
3. National Health and Medical Research Council
(2009): NHMRC levels of evidence and grades for
recommendations for developers of guidelines.
Canberra, Australia: National Health and Medical
Research Council.
4. Chaudhry B, Wang J, Wu S, Maglione M, Majica W,
Roth E, Morton SC, Shekelle PG (2006) Systematic
review: impact of health information technology on
quality, eiciency and costs of medical care. Annals
of Internal Medicine 144: E12-E22.
5. Grimshaw J, Freemantle N, Wallace S, Russell
I, Hurwitz B, Watt I, Long A, Sheldon T (1995)
Developing and implementing clinical practice
guidelines. Quality in Health Care 4: 55-64.
6. Bahtsevani C, Uden G, Willman A (2004) Outcomes
of evidence-based clinical practice guidelines:
a systematic review. International Journal of
Technology Assessment in Health Care 10(4): 427-433.
7. Woolf S, Frol R, Hutchinson A, Eccles M, Grimshaw
J (1999): Clinical guidelines: potential beneits,
limitations and harms of clinical guidelines. British
Medical Journal 318: 527-530.
8. Eddy D (1990) Clinical decision making from theory
to practice: guidelines for policy statements – the
explicit approach. Journal of the American Medical
Association 263: 2239-2240, 2243.
9. Grimshaw J, Hutchinson A (1995) Clinical practice
guidelines: do they enhance value for money in
health care? British Medical Bulletin 51: 927-940.
10. Grimmer-Somers K (2010) Guidelines: what they
comprise and how to ind them. In Grimmer-
Somers K and Worley A. Practical tips for using and
developing guidelines: an allied health primer. Manila:
UST Publishing House, pp. 13-28.
11. Campbell H, Hotchkiss R, Bradshaw N, Porteous M
(1998) Integrated care pathways. British Medical
Journal 316: 133-137.
12. Kitchiner D, Bundred P (1998) Integrated care
pathways increase use of guidelines. British Medical
Journal 317(7151): 147.
13. de Lac K, Whittle C (2002) An integrated care
pathway appraisal tool: a ‘badge of quality’. Journal
of Integrated Care Pathways 6: 13-17.
Chapter 1
REFERENCES
14. Christiaens T, de Backer D, Burgers J, Baerheim A (2004)
Guidelines, evidence and cultural factors. Scandinavian
Journal of Primary Health Care 22: 141-145.
15. Saturno P, Medina F, Valera F, Montilla J, Escolar P,
Gascon K (2003) Validity and reliability of guidelines
for neck pain treatment in primary health care. A
nationwide empirical analysis in Spain. International
Journal in Quality of Health Care 15:487-493.
16. Guyatt G, Oxman A, Vist G, Kunz R, Falck-Ytter Y,
Alonso-Coello P, Schunemann H (2008) GRADE: an
emerging consensus on rating quality of evidence
and strength of recommendations. British Medical
Journal 336: 924-926.
17. Grimmer-Somers K (2010b) Appraising guideline
quality. In Grimmer-Somers K and Worley A. Practical
tips for using and developing guidelines: an allied
health primer. Manila: UST Publishing House, pp.
43-52.
18. Graham I, Calder L, Herbert P, Carter A, Tetroe J
(2000) A comparison of clinical practice guideline
appraisal instruments. International Journal of
Technology Assessment in Health Care 16: 1024-1038.
19. MacDermid JC, Brooks D, Solway S, Switzer-McIntyre
S, Brosseau L, Graham ID (2005). Reliability and
validity of the AGREE instrument used by physical
therapists in assessment of clinical practice
guidelines. BMC Health Services Research 5: 18
11
doi:10.1186/1472-6963-5-18
20. Vlayen J, Aertgeerts B, Hannis K, Sermeus W,
Ramaekers S (2005) A systematic review of appraisal
tools for clinical practice guidelines: multiple
similarities and one common deicit. International
Journal of Quality in Health Care 17: 235-242.
21. Grimmer-Somers K and Luker J (2010) Upgrading
/ updating a guideline. In Grimmer-Somers K and
Worley A. Practical tips for using and developing
guidelines: an allied health primer. Manila: UST
Publishing House, pp. 53-68.
22. Grimmer KA, Milanese SF, Bialocerkowski AE (2003)
Clinical guidelines for low back pain: physiotherapy
perspective. Physiotherapy Canada 55: 185-194.
23. MacDermid JC (2004) The quality of clinical practice
guidelines in hand therapy. Journal of Hand Therapy
17(2): 200-204.
24. Buchan HA, Currie KC, Lourey EJ, Duggan GR (2010)
Australian clinical practice guidelines – a national
study. Medical Journal of Australia 192(9): 490-494.
25. Australian Podiatry Association (NSW & ACT) (2010),
www.podiatry.asn.au/
Background
26. Jones CL (1995) Who treats feet? Journal of the
American Podiatric Medicine Association 85: 293-294.
Clinical Guidelines For Localised Musculoskeletal Foot Pain
27. Garrow AP, Silman AJ, Macfarlane GJ (2004) The
Cheshire Foot Pain and Disability Survey: a population
survey assessing prevalence and associations. Pain
110: 378-384.
28. Hill CL, Gill T, Menz HB, Taylor AW (2008). Prevalence
and correlates of foot pain in a population-based
study: the North West Adelaide Health Study. Journal
of Foot and Ankle Research 1:2 doi:10.1186/1757-1146-1-2
29. Nancarrow SA (1999) Reported rates of foot problems
in rural south-east Queensland. Australasia Journal
of Podiatric Medicine 33: 45-50.
30. Benvenuti F, Ferrucci L, Guralnik JM, Gangemi S,
Baroni A (1995) Foot pain and disability in older
persons: an epidemiological survey. Journal of the
American Geriatric Society 43: 479-484.
31. Barr ELM, Browning C, Lord SR, Menz HB, Kendig
K (2005) Foot and leg problems are important
determinants of functional status in community
dwelling older people. Disability and Rehabilitation
27: 917-923.
32. Keysor JJ, Dunn JE, Link CL, Badlissis F, Felson DT
(2005) Are foot disorders associated with functional
limitation and disability among community-dwelling
older adults? Journal of Aging Health 17: 734-752.
33. Gorter KJ, Kuyvenhover MM, deMelker RA (2000)
Nontraumatic foot complaints in older people. A
population-based survey of risk factors, mobility
and well-being. Journal of the American Podiatric
Medicine Association 90: 397-402.
A Podiatry Perspective
34. Menz HB, Tiedemann A, Kwan MMS, Plumb K, Lord SR
(2006) Foot pain in community-dwelling older people:
an evaluation of the Manchester Foot Pain and
Disability Index. Rheumatology 45: 863-867.
35. Balint GP, Korda J, Hangody L, Balint PV (2003) Foot
and ankle disorders. Best Practice Research in Clinical
Rheumatology 17: 87-111.
36. Korda J, Balint GP (2004) When to consult the
podiatrist. Best Practice Research in Clinical
Rheumatology 18: 587-611.
37. Australian Institute of Health and Welfare (2009 &
2012), www.aihw.gov.au
38. Brislow I, Dean T (2003) Evidence-based practice – its
origins and future in the podiatry procession. British
Journal of Podiatry 6: 43-47.
39. Keenan A-M, Redmond A (2002) Integrating research
into the clinic – what evidence based practice means
to practicing podiatrists. Journal of the American
Podiatric Medical Association 92: 115-122.
40. Australasian Podiatry Council (2013), www.apodc.
com.au/index.php/education-research/aperf/
 Chapter 1
Chapter 2
13
Methodology

Background
Clinical Guidelines For Localised Musculoskeletal Foot Pain

Chapter 2

2.1 OVERVIEW
This chapter describes the methodology used to systematically identify, critically appraise existing clinical
guidelines and synthesise their recommendations which address musculoskeletal sources of foot and ankle pain.

2.2 SEARCH STRATEGY

A comprehensive and systematic search strategy
was designed by the authors to identify relevant
clinical guidelines which address the management of
musculoskeletal sources of pain localised to the foot
and ankle, and which were relevant to podiatrists. The
keywords ‘ankle’, ‘foot’ and ‘toe’ were used, in addition
to a range of speciic foot conditions such as plantar
fasciitis, metatarsalgia, Morton’s neuroma, hallux limitus,
rigidus and valgus, and heel spur, as well as foot and ankle
fractures (e.g. Pott’s fracture, Jones fracture and stress
fractures), tendinopathies and ligamentous sprains and
toe deformities. These conditions were deined using the
International Statistical Classiication of Diseases and
Related Health Problems 10th Revision (ICD-10) (Table 2.1).1

TABLE 2.1 DEFINITION OF SPECIFIC FOOT AND ANKLE CONDITIONS (ICD-10)

ICD-10 code Deinition Podiatric-relevant

conditions

Morton’s neuroma
Mononeuropathies of
G57 Includes Morton’s neuroma
lower limb
Tarsal tunnel syndrome

Hallux valgus

Includes hallux valgus, hallux Hallux limitus

Acquired deformities of
M20 rigidus, hallux varus and other
ingers and toes
hammer toes Hallux rigidus

Hammer toes

M77 Other enthesopathies Includes plantar fasciitis, Plantar fasciitis

calcaneal heel spur, Heel spur
metatarsalgia, tendinitis Metatarsalgia
Tendinopathies

Includes fracture of the medial

Fracture of lower leg,
S82 and lateral malleoli, bimalleolar Ankle fracture
including ankle
and trimalleolar fractures

Includes injury to the Achilles

Injury of muscle and Achilles tendon rupture
tendon and other posterior,
S86 tendon at the lower leg
anterior and the peroneal
level Achilles tendinopathy/rupture
muscles

Includes contusion to the ankle,

Supericial injury of
S90 toes + nail damage and other
ankle and foot
parts of the foot

Includes open wound to the

Open wound of the foot
S91 ankle, toes + nail damage and
and ankle
A Podiatry Perspective

other parts of the foot

 Chapter 2
Includes open and closed
Fracture to foot, except fractures of the calcaneus, talus,
S92
ankle other tarsal bones, metatarsals
and phalanges

Dislocation, sprain and Includes dislocation of the ankle,

strain of joints and toes and other parts of the foot;
S93 Lateral and medial ankle sprain
ligaments at the ankle rupture of ligaments at the
and foot ankle, foot and toes

Includes injury to the lateral and

Injury to nerves at
S94
ankle and foot level
or medial plantar nerves, deep
peroneal, cutaneous sensory
nerve at the ankle and foot and
other nerves at the level of the
ankle and foot

Includes dorsal and plantar

Injury of blood vessels
arteries, dorsal veins, and other
S95 at the ankle and foot
blood vessels in the foot and
level
ankle area

Includes long lexor and extensor

Injury to muscle and muscles and tendons at the
S96 tendon at the ankle ankle and foot levels, intrinsic Peroneal tendinitis
and foot level muscles, and other muscles in
the foot and ankle area

Includes crushing injuries of the

Crushing injury of the
S97 ankle, toes and other areas of
ankle and foot
the foot

Includes traumatic amputation

Traumatic amputation at the foot at the ankle level,
S98
of the ankle and foot amputation of one or more toes 15
or other parts of the foot

Other and unspeciied Includes multiple injuries and

S99 injuries to ankle unspeciied injuries of the ankle
and foot and foot

2.3 DATABASES
The keywords were applied to the following internet-based guideline sites, as recommended by Grimmer-Somers2:

• Guidelines International Network • Canadian Medical Association (Canada)

• National Guideline Clearinghouse (USA)
• Scottish Intercollegiate Guidelines Network (UK)
• National Health and Medical Research Council
(Australia)
• New Zealand Guidelines Group
(New Zealand)
• National Institute for Health and Care Excellence
(NICE) (UK)
• American Academy of Orthopaedic Surgeons (AAOS)
(USA)
• American Academy of Family Physicians (USA)
• Institute for Clinical Systems Improvement (ICSI) (UK)

Further information regarding these guideline sites is contained in Table 2.2. Google, Google Scholar and websites of
professional podiatry associations (Table 2.3) were also searched to identify other clinical guidelines which may not
have been included or indexed in these guideline databases and sites. Where the clinical guideline was not publicly
available, the authors or sponsoring organisations were contacted and requested to provide the clinical guideline and
any supporting documentation.
Methodology
Clinical Guidelines For Localised Musculoskeletal Foot Pain

TABLE 2.2 GUIDELINE SITES

SITE NAME URL & DETAILS

www.g-i-n.net
Guidelines
International Global network consisting of 48 countries, which supports evidence-based health care
Network and improved health outcomes by reducing inappropriate variation throughout the work.
Membership required to access clinical guidelines.

www.guidelines.gov/browse.guideline_index.aspx
National Guideline
Clearinghouse Supported by the Agency for Healthcare Research and Quality (in the USA). It is a publicly
available resource for evidence-based clinical practice guidelines.

www.sign.ac.uk
Scotish
Intercollegiate Develops evidence-based clinical guidelines for the National Health Service in Scotland for the
Guidelines Network acceleration of the translation of new knowledge to reduce variation in practice and improve
patient outcomes.

www.nhmrc.gov.au/guidelines
National Health
And Medical Australia’s peak body for supporting health and medical research, for developing health advice
Research Council for the Australian community, health professionals and government, and for providing advice
(of Australia) on ethical behaviour in health care and in the conduct of health and medical research. NHMRC
guidelines are developed using a rigorous nine-step evidence-based approach process.

www.nzgg.org.nz/library/cfm

New Zealand The New Zealand Guidelines Group was an independent not-for-proit organisation established
Guidelines Group in 1999 to promote the use of evidence in the delivery of health and disability services. It went
into voluntary liquidation in mid-2012.

www.cma.ca/cam/common/start.do?land=2

Canadian Medical The Canadian Medical Association is the voice of physicians in Canada. It advocates access
Association to high quality healthcare, health promotion and disease and injury prevention policies, and
facilitates changes in health care delivery.

www.nice.org.uk/aboutnice/about_nice.jsp

National Institute Provides independent, authoritative and evidence-based guidance to support healthcare
For Health And professionals and others to make sure that the care they provide is of the best possible quality
Care Excellence and ofers the best value for money to prevent, diagnose and treat disease and ill-health and to
reduce inequalities and variations.

www.aaos.org/
American Academy
of Orthopaedic Founded in 1933, the Academy is the pre-eminent provider of musculoskeletal education to
Surgeons orthopaedic surgeons and others in the world.

www.aafp.org/online/en/home.html

American The American Academy of Family Physicians is one of the largest national medical organisations,
Academy of Family representing 105,900 family physicians, family medicine residents, and medical students
Physicians nationwide. Founded in 1947, its mission has been to preserve and promote the science and art of
family medicine and to ensure high-quality, cost-efective health care for patients of all ages.

htps://www.icsi.org/

Institute For ICSI champions the use of evidence-based medicine. A cornerstone of its work is enlisting
Clinical Systems
A Podiatry Perspective

clinicians from its membership to perform rigorous reviews of current scientiic literature and
Improvement develop evidence-based guidelines and protocols on numerous health conditions that enable
clinicians in 180 countries to practice best medicine.

TABLE 2.3
COUNTRY PROFESSIONAL BODY
Australasian Podiatry Council
Australia
Australasian Academy of Podiatric Sports Medicine
Canadian Podiatric Medical Association
Canada
Canadian Federation of Podiatric Medicine
New New Zealand Society of Podiatrists
Zealand
UK Society of Chiropodists and Podiatrists
American Podiatric Medical Association
USA
American Academy of Podiatric Sports Medicine
2.4
Once guidelines were identiied, they were screened for
eligibility. Clinical guidelines were included in this study
if the guideline was available and reported in English,
addressed the management of musculoskeletal conditions
located in the region of the foot and ankle, and published
within the last 10 years (i.e. from 2002). The most up-to-
date version of the guideline was sourced and included
2.5
The two authors independently assessed the methodological quality of the included clinical guidelines. Any
disagreements were resolved by discussion with an expert in podiatric evidence. Two critical appraisal tools were used:
1. Appraisal of Guideline Research and Evaluation
II (AGREE II)3 is a standardised and internationally
recognised clinical guideline critical appraisal tool. It
was developed to address the variable quality of clinical
guidelines by providing a structured and guided process
to evaluate the methodological rigour and transparency
of guideline development and quality of reporting of
guideline development. The AGREE II consists of 23 items,
which are grouped into six domains: 1) scope and purpose;
2) stakeholder involvement; 3) rigour of development; 4)
clarity of presentation; 5) applicability; and 6) editorial
independence (Table 2.4). Each of these items is rated on
a seven-point scale, ranging from 1 = strongly disagree to
7 = strongly agree. In addition, the two inal items provide
the assessor with the opportunity to make an overall
judgement of the guideline. The assessor rates the overall
quality of the guideline on a seven-point scale ranging
from 1 = lowest possible quality to 7 = highest possible
quality. The assessor can also respond to the question “I
would recommend this guideline for use” by selecting the
most appropriate response option from “yes”, “yes with
modiications” and “no”.
Chapter 2
PROFESSIONAL PODIATRIC ASSOCIATION WEBSITES
WEBSITE
www.apodc.com.au
www.aapsm.org.au
www.podiatrycanada.org
www.podiatryinfocanada.ca/Public
/Home.aspx
www.podiatry.org.nz
www.scpod.org
www.apma.org
www.aapsm.org
SELECTION CRITERIA
in this review. Guidelines were excluded if they addressed
systematic conditions or diseases that afect the foot or
ankle (e.g. arthritis, diabetes) and infections (e.g. tinea,
ingrown toe nails). Secondary searching of the reference
list of included guidelines was undertaken to identify any
other relevant guidelines which met the inclusion criteria.
17
CRITICAL APPRAISAL
The User’s Manual provides detailed instructions on how
to interpret each of the 23 items and how to produce a
total score for the AGREE II. Each of the six domains is
scored separately by summing the score for each item in
the domain and scaling the total as a percentage of the
maximum possible score for that domain.3 (See Appendix.)
2. International Centre for Allied Health Evidence
(iCAHE) Guideline Checklist was used to provide
additional information on the evidence base on which
recommendations were made. The iCAHE Guideline
Checklist consists of 14 criteria grouped into six domains:
1) information; 2) currency; 3) inding the evidence and
determining the evidence base; 4) developers; 5) purpose
and end users; and 6) easy to read (Table 2.5). Grimmer-
Somers (2010b) provides six rules to assist in interpreting
guideline quality (Table 2.6). The iCAHE Guideline
Checklist, therefore, is not scored. Rather, it provides
guidance on interpreting the recommendations made
within the guideline.4
Methodology
Clinical Guidelines For Localised Musculoskeletal Foot Pain

TABLE 2.4 ITEMS CONTAINED IN THE AGREE II3

DOMAIN ITEM

The overall objective(s) of the guideline is (are) speciically described

Scope and The health question(s) covered by the guideline is (are) speciically described
1. purpose
The population (patients, public, etc) to whom the guideline is meant to apply is speciically
described

The guideline development group includes individuals from all relevant professions

Stakeholder
2. involvement
The views and preferences of the target group (patients, public, etc) have been sought

The target users of the guideline are clearly deined

Systematic methods were used to search for evidence

The criteria for selecting the evidence are clearly described

The strengths and limitations of the body of evidence are clearly described

The methods for formulating the recommendations are clearly described

Rigour of
3. development The health beneits, side efects, and risks have been considered in formulating the
recommendations

There is an explicit link between the recommendations and the supporting evidence

The guideline has been externally reviewed by experts prior to its publication

A procedure for updating the guideline is provided

The recommendations are speciic and unambiguous

Clarity of
4. presentation
The diferent options for management of the condition or health issue are clearly presented

Key recommendations are easily identiiable

The guideline describes facilitators and barriers to its application

The guideline provides advice and/or tools on how the recommendations can be put into
practice
5. Applicability
The potential resource implications of applying the recommendations have been considered

The guideline presents monitoring and/or auditing criteria

The views of the funding body have not inluenced the content of the guideline
Editorial
6. independence
Competing interests of guideline development group members have been recorded and addressed

Rate the quality of this guideline

Overall guideline
assessment
I would recommend this guideline for use
A Podiatry Perspective
 Chapter 2
TABLE 2.5 ITEMS CONTAINED IN THE ICAHE GUIDELINE CHECKLIST (GRIMMER-SOMERS4 )

DOMAIN ITEM

Is the guideline readily available in full text?

1. Information Does the guideline provide a complete reference list?

Does the guideline provide a summary of its recommendations?

Is there a date of completion available?

2. Currency Does the guideline provide an anticipated review date?

Does the guideline provide dates for when literature was included?

Does the guideline provide an outline of the strategy they used to ind underlying evidence?

Finding the Does the guideline use a hierarchy to rank the quality of the underlying evidence?
evidence and
3. determining
Does the guideline appraise the quality of the evidence which underpins its recommendations?
the evidence
base
Does the guideline link the hierarchy of evidence and quality
of underlying evidence to each recommendation?

Are the developers of the guideline clearly stated?

4. Developers
Does the qualiications and expertise of the guideline developer(s) link with the purpose of
the guideline and its end users?

Purpose and
5. end users
Are the purpose and the target users of the guideline stated?
19
6. Easy to read Is the guideline readable and easy to navigate?

RULES FOR INTERPRETING GUIDELINE QUALITY BASED

TABLE 2.6 ON THE ICAHE GUIDELINE CHECKLIST (ADAPTED FROM GRIMMER-SOMERS4)

RULE INTERPRETATION

Generally guidelines should not be considered by end users if they are not available in full
1. Information text, do not have a full reference list and do not link evidence to recommendations.

The most up-to-date clinical guideline must be used as evidence in any particular area is rapidly
2. Currency changing. Guidelines must maintain their currency through regular review and updating.

Finding the Each recommendation should be referenced to the strength of evidence which underpins
evidence and it. Speciic search strategies used to locate the evidence must be provided. When
3. determining recommendations are based on expert opinion, details must be provided on the method used
the evidence to generate the recommendation.
base

The guideline developers must be named as well as their ailiation organisations. Any
4. Developers conlict of interest must be listed together with strategies to address the conlict.

The purpose and end users should be clearly stated to allow clinicians to identify the relevance
Purpose and
5. end users
of the guideline in relation to their needs. In general, guidelines which provide multidisciplinary
recommendations should contain developers from each of the end user health professions.
Methodology

6. Easy to read The recommendations must be easy to read, and the guideline easily navigated.
Clinical Guidelines For Localised Musculoskeletal Foot Pain
2.6
Using a custom-developed standardised data extraction
form, the following information was extracted from the
included clinical guidelines: guideline title, development
organisation, publication date, availability, end users,
2.7
First, the number of clinical guidelines sourced was calculated. Second, the number and type of conditions which were
addressed by the sourced clinical guidelines was tabulated. Third, the quality of each clinical guideline was tabulated
and areas of methodological strength and weakness identiied. Finally, a summary pertaining to each guideline sourced
was developed and included:
1. Guideline identiication information, such as guideline
title, publication date, availability.
2. Content, including the end users and
the scope of the guideline.
3. Formulation of recommendations, including the basis
of recommendations (i.e. recommendations based
on research evidence versus based on consensus
opinion), sources of evidence, search period, and
strength of recommendation descriptors.
4. Summary of recommendations, including
recommended conservative, surgical and
pharmacological interventions, and interventions
that are not recommended (if available).
2.8
1. World Health Organization (2010) International
Statistical Classiication of Diseases and Related
Health Problems 10th Revision (ICD-10) Version
for 2010. http://apps.who.int/classiications/icd10/
browse/2010/en
2. Grimmer-Somers (2010a) Guidelines: what they
comprise and how to ind them. In Grimmer-
Somers K and Worley A. Practical tips for using and
developing guidelines: an allied health primer. Manila:
UST Publishing House.
3. Appraisal of Guideline Research and Evaluation II
(AGREE II) (2009) www.agreetrust.org/about-agree/
A Podiatry Perspective
DATA EXTRACTION
content, basis of recommendations, search period,
sources of evidence, strength of recommendation
descriptors, summary of recommendations.
DATA SYNTHESIS
5. Guideline quality, based on the six AGREE II domain
scores, which range from 0 (poor quality) to
100 (highest possible quality), and the six iCAHE
Guideline Checklist domains, by listing the number of
criteria fulilled (denoted by “yes”) for each domain.
6. Generalisability, the degree to which the
population/s studied in the body of evidence
is the same as the target audience for the
guideline, as deined by the NHMRC5.
7. Applicability, the degree to which the evidence base
and therefore the recommendations are directly
applicable to the Australian podiatry context, as
deined by the NHMRC5.
8. Additional information, as deemed appropriate
by the researchers, such as currency of guideline
development and ease of guideline navigation.
REFERENCES
4. Grimmer-Somers K (2010b) Appraising guideline quality.
In Grimmer-Somers K and Worley A. Practical tips for
using and developing guidelines: an allied health primer.
Manila: UST Publishing House, pp. 43-52.
5. National Health and Medical Research Council
(2009) NHMRC levels of evidence and grades for
recommendations for developers of guidelines.
Canberra, Australia: National Health and Medical
Research Council.
 Chapter 3
Results
21

Background Chapter 1
Clinical Guidelines For Localised Musculoskeletal Foot Pain

Chapter 3

3.1
This chapter provides a summary of the results of the
systematic search strategy and quality appraisal.
Recommendations from each clinical guideline per
condition, the quality of evidence and the strength of
OVERVIEW
recommendations have been synthesised to provide
clinicians with management summaries, relevant to the
practice of podiatry in Australia.

3.2
The search strategy yielded 404 potential clinical
guidelines. Once duplicates were removed, 85 clinical
guidelines were compared against the selection criteria
(Figure 3.1). Twenty guidelines appeared to meet the
inclusion criteria. Of these, 12 guidelines were publicly
available on the internet, whereas eight guidelines were
not (Table 3.1). After communicating with the guideline
developers, two of these guidelines were made available
for the purposes of this systematic review and were
subsequently included in this study.
GUIDELINE SECTION
PROCESS & SEARCH YIELD
This work, therefore, comprises data from 14 clinical
guidelines which were developed by the following eight
organisations and published from 2003 - 2011:
1. American Academy of Orthopaedic Surgeons (2009)
2. American College of Foot and Ankle Surgeons
(Thomas et al 2003 x5, Thomas et al 2010)
3. American College of Occupational and Environmental
Medicine (2011)

4. American Physical Therapy Association (Carcia et al

2010, McPoil et al 2008)

5. Koninklijk Nederlands Genootschap voor

Fysiotherapie (KNGF) (2006)

6. Institute for Clinical Systems Improvement (2006)

7. National Institute for Health and

Care Excellence (2009)

8. Work Loss Data Institute (2011)

A Podiatry Perspective
 Chapter 3
FIGURE 3.1 STUDY SELECTION PROCESS AND SEARCH YIELD

Database hits
(n = 404)

Duplicates removed
(n = 319)

Assessed for
eligibility
(n = 85)

Excluded based on
content, language,
date
(n = 65)

Met selection criteria

(content, language,
date)
(n = 20)

23

Guideline publicity Guideline not

available publicity available
(n = 12) (n = 8)

Guideline excluded
due to lack of
availability
(n = 6)

Guideline made
available
(n = 2)

Total number of
guidelines
Results

(n = 14)
Clinical Guidelines For Localised Musculoskeletal Foot Pain

TABLE 3.1 CLINICAL GUIDELINES WHICH MET THE SELECTION CRITERIA

Availability

Guideline developer Condition Text publicly Text Text not

available provided by publicly
guideline available
developer

Academy of Ambulatory Hallux abducto

Foot and Ankle Surgery valgus1 
(2003)

Academy of Ambulatory Hallux limitus and

Foot and Ankle Surgery hallux rigidus2 
(2003)

Academy of Ambulatory Hammer toe

Foot and Ankle Surgery syndrome3 
(2003)

Academy of Ambulatory Heel spur


Foot and Ankle Surgery syndrome4

(2003)

Academy of Ambulatory Intermetatarsal


Foot and Ankle Surgery neuroma5

(2003)

Academy of Ambulatory Metatarsalgia /


Foot and Ankle Surgery intractable plantar
(2003) keratosis / Tailor’s
bunion6

American Academy of Acute Achilles

Orthopaedic Surgeons tendon rupture7 
(2009)

American College of Digital deformities8

Foot and Ankle Surgeons 
(Thomas et al 2009)

American College of Central

Foot and Ankle Surgeons metatarsalgia9 
(Thomas et al 2009)

American College of Morton’s

Foot and Ankle Surgeons intermetatarsal 
(Thomas et al 2009) neuroma10

American College of Tailor’s bunion11

Foot and Ankle Surgeons 
(Thomas et al 2009)

American College of Trauma12

Foot and Ankle Surgeons 
(Thomas et al 2009)

American College of Heel pain13

Foot and Ankle Surgeons 
A Podiatry Perspective

(Thomas et al 2010)
 Chapter 3
Availability

Guideline developer Condition Text publicly Text Text not

available provided by publicly
guideline available
developer

American College of Ankle and foot


Occupational and disorders14
Environmental Medicine
(2011)

American Physical Plantar fasciitis15

Therapy Association 
(McPoil et al 2008)

American Physical Achilles

Therapy Association tendinopathy16 
(Carcia et al 2010)


KNGF (2006) Acute ankle
sprain17

Institute for Clinical Ankle sprain18

Systems Improvement 
(2006)

National Institute Plantar fasciitis19

of Health and Care 
Excellence (2009)

Work Loss Data Institute Ankle and foot

25
(2011) (acute and 
chronic) 20

CONDITIONS ADDRESSED
3.3 IN THE CLINICAL GUIDELINES
The 14 guidelines sourced covered 10 musculoskeletal conditions localised to the foot and ankle (Table 3.2). Guidelines
most frequently addressed the management of Achilles tendinopathy, ankle sprains and plantar fasciitis.

3.4 QUALITY OF CLINICAL GUIDELINES

The quality of the included clinical guidelines was variable, as • American Academy of Orthopaedic Surgeons7
demonstrated in Tables 3.3 and 3.4. AGREE II scores for each
• American College of Occupational and
of the six domains varied considerably. However, based on
Environmental Medicine14
the AGREE II scores, the following guidelines provided high
quality information with respect to their scope and purpose, • Work Loss Data Institute20
stakeholder involvement, rigour of development, clarity of
presentation and editorial independence:

It must be noted that many of the guidelines lacked information on applicability and editorial independence, as well as
speciic details on the method and rigour of their development (e.g. Thomas et al 2009).

As shown in Section 3.5, the majority of guidelines did
not provide information with respect to the evidence
underlying their recommendations. Seventy-eight percent
(n=11) of the guidelines did not provide details regarding
the method used to critically appraise the sourced
evidence and 64 percent (n=9) did not provide details
regarding the search strategy used to locate evidence.
Moreover, the majority of guidelines (n=12) did not provide
the dates for the included evidence.
Results
Clinical Guidelines For Localised Musculoskeletal Foot Pain

TABLE 3.2 INCLUDED GUIDELINES AND CORRESPONDING MUSCULOSKELETAL CONDITIONS

NO. OF
LOCATION CONDITION REFERENCE
GUIDELINES

ANKLE American Academy of Orthopaedic Surgeons

(2009)7
Achilles tendon
rupture7,14,20 3 American College of Occupational and
Environmental Medicine (2011)14

Work Loss Data Institute (2011)20

Carcia et al (2010)16

American College of Occupational and

Achilles Environmental Medicine (2011)14
tendinopathy / 4
tendinitis13,14,16,20 Thomas et al (2010)13

Work Loss Data Institute (2011)20

American College of Occupational and

Environmental Medicine (2011)14

KNGF (2009)17
Ankle sprain14,17,18,20 4
Institute for Clinical Systems Improvement
(2006)18

Work Loss Data Institute (2011)20

American College of Occupational and

Environmental Medicine (2011)14
Tarsal tunnel
syndrome*12,14,20 3 Thomas et al (2009)12

Work Loss Data Institute (2011)20

American College of Occupational and

Environmental Medicine (2011)14
Fracture12,14,20 3 Thomas et al (2009)12

Work Loss Data Institute (2011)20

FOOT American College of Occupational and

Environmental Medicine (2011)14
Plantar fasciitis
McPoil et al (2008)15
Heel / calcaneal 4
spur13-15,20 Thomas et al (2010)13

Work Loss Data Institute (2011)20

Thomas et al (2009)9
Metatarsalgia9,20 2
Work Loss Data Institute (2011)20

Thomas et al (2009)10
Morton’s
neuroma10,20 2
Work Loss Data Institute (2011)20

Thomas et al (2009)11
A Podiatry Perspective

Tailor’s bunion11,20 2
Work Loss data Institute (2011)20

Thomas et al (2009)8
Deformities of the
toes8,20 2
Work Loss Data Institute (2011)20

* Conditions listed in the Work Loss Data Institute Foot and Ankle chapter, but recommendations were not linked to clinical guidelines
TABLE 3.3 QUALITY OF CLINICAL GUIDELINES BASED ON AGREE II*

Carcia et McPoil et Thomas Thomas Thomas Thomas Thomas Thomas

Domains AAOS7* ACOEM14 ICSI18 KNGF17 NICE19 WLDI20
al16 al15 et al8 et al9 et al10 et al11 et al12 et al13

Scope and
83 94 56 67 50 61 67 25 14 11 6 14 36 61
purpose

Stakeholder
75 83 72 75 75 72 50 31 28 28 28 28 47 81
involvement

Rigour of
83 86 66 57 44 57 44 4 3 5 3 3 19 94
development

Clarity of
94 100 89 83 97 89 42 69 64 64 64 53 61 78
presentation

Applicability 48 50 44 88 65 52 25 0 0 0 0 0 13 71

Editorial
100 92 0 100 4 0 0 0 0 0 0 0 100 100
independence

* The Appendix contains an example of the method used to calculate domain scores for the AGREE II for the American Academy of Orthopaedic Surgeons guideline on the diagnosis and treatment of acute Achilles tendon rupture7
27

Results Chapter 3
A Podiatry Perspective Clinical Guidelines For Localised Musculoskeletal Foot Pain

TABLE 3.4
Carcia et McPoil et Thomas Thomas Thomas et Thomas Thomas et Thomas et
AAOS7 ACOEM14 ICSI18 KNGF17 NICE19 WLDI20
al16 al15 et al8 et al9 al10 et al11 al12 al13

AVAILABILITY

Is the guideline available in full text?

Y Y* Y Y Y Y Y N N N N N Y Y*

Does the guideline provide a complete reference list?

FOR ALLIED HEALTH EVIDENCE (ICAHE) GUIDELINE CHECKLIST (SEE TABLE 2.6)
Y Y Y Y Y Y Y Y Y Y Y Y Y Y

QUALITY OF CLINICAL GUIDELINES BASED ON THE INTERNATIONAL CENTRE

Does the guideline provide a summary of its recommendations

Y Y Y Y Y Y Y N N N N N Y Y

DATES

Is there a date of completion available?

Y Y Y Y Y Y Y N N N N N N Y

Does the guideline provide an anticipated review date?

Y Y Y Y N Y N N N N N N N Y

Does the guideline provide dates for when literature was included?

Y N Y N N N N N N N N N N N

UNDERLYING EVIDENCE

Does the guideline provide an outline of the strategy they used to ind underlying evidence?

Y Y Y N N N Y N N N N N N Y
 Carcia et McPoil et Thomas Thomas Thomas et Thomas Thomas et Thomas et
AAOS7 ACOEM14 ICSI18 KNGF17 NICE19 WLDI20
al16 al15 et al8 et al9 al10 et al11 al12 al13

Does the guideline use a hierarchy to rank the quality of the underlying evidence?

Y Y Y Y Y Y N N N N N N N Y

Does the guideline appraise the quality of the evidence which underpins its recommendations?

Y Y N N N N N N N N N N N Y

Does the guideline link the hierarchy of evidence and quality of underlying evidence to each recommendation?

Y Y N Y Y N N N N N N N Y Y

GUIDELINE DEVELOPERS

Are the developers of the guideline clearly stated?

Y Y Y Y Y Y N Y Y Y Y Y Y Y

Does the qualiications and expertise of the guideline developer(s) link with the purpose of the guideline and its end users?

N Y N Y Y N N N N N N N N Y

GUIDELINE PURPOSE AND USERS

Are the purpose and the target users of the guideline stated?

Y Y Y Y Y Y N N Y Y N N N Y

EASE OF USE

Is the guideline readable and easy to navigate?

Y Y Y Y Y Y Y N N N N N N N

* available on request from the American College of Occupational and Environmental Medicine7 and Work Loss Data Institute 20
29

Results Chapter 3
Clinical Guidelines For Localised Musculoskeletal Foot Pain

3.5 SUMMARY OF GUIDELINES

INCLUDES CONTENT, EVIDENCE AND RECOMMENDATIONS, QUALITY,
GENERALISABILITY AND APPLICABILITY TO THE AUSTRALIAN PODIATRY CONTEXT

1. AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS (2009) – THE DIAGNOSIS

AND TREATMENT OF ACUTE ACHILLES TENDON RUPTURE - GUIDELINE AND
EVIDENCE REPORT7

Publication date 2009

Publicly available from the American Academy of Orthopaedic Surgeons, www.aaos.org/

Availability Research/guidelines/atrguideline.asp

Physicians and orthopaedic surgeons. Professional health care practitioners and developers of
End users practice guidelines and recommendations

1. Diagnosis of Achilles tendon 4. Post-operative management, including

rupture, including
• Antithrombotic treatment
• Clinical tests (Thompson test, decreased
• Protected weight-bearing
ankle plantar lexion strength, presence
(limited dorsilexion)
of a palpable gap, increased passive ankle
dorsilexion with gentle manipulation) • Protected devices (orthosis, plaster
splint or cast)
• Radiology, such as magnetic
resonance imaging, ultrasonography • Physiotherapy
and radiography
Content 5. Return to activities of daily living and
2. Non-operative management, including sports/ athletic activity
bracing and immobilisation

3. Operative management, including

• Surgery – type of repair (open, limited

open, percutaneous techniques)

• Inluence of comorbidities

• Use of allograt, autograt, xenograt,

synthetic tissue and biological adjuncts

Basis of Recommendations based on research evidence with the exception of the diagnosis recommendation
recommendations which was based on consensus gained from experts, in the absence of reliable evidence

Search period January 1966 – June 2009

Sources of PubMed, EMBASE, CINAHL, The Cochrane Library, The National Guideline Clearinghouse and
evidence TRIP Database

Strength of Grades of recommendation (including implications for practice)

recommendation
descriptors • Strong: the beneits of the
• Moderate: the beneits exceed the
recommended approach clearly
potential harm (or that the potential
exceed the potential harm (or that the
harm clearly exceeds the beneits in the
potential harm clearly exceeds the
case of a negative recommendation),
beneits in the case of a strong negative
but the strength of the supporting
recommendation), and that the strength
evidence is not as strong. (Practitioners
of the supporting evidence is high.
should generally follow a moderate
(Practitioners should follow a strong
recommendation but remain alert to
recommendation unless a clear and
new information and be sensitive to
completing rationale for an alternative
patient preferences.)
A Podiatry Perspective

approach is present.)

• Limited: the quality of the supporting
evidence that exists is unconvincing,
or that well-conducted studies show
litle clear advantage to one approach
versus another. (Practitioners should be
cautious in deciding whether to follow
a recommendation classiied as limited,
• Consensus: expert opinion supports
and should exercise judgement and be
alert to emerging publications that report
evidence. Patient preference should have
a substantial inluencing role.)
• Inconclusive: there is a lack of compelling
evidence resulting in an unclear
balance between beneits and potential
harm. (Practitioners should feel litle
constraint in deciding whether to follow a
recommendation labelled as inconclusive
Chapter 3
and should exercise judgment and be
alert to future publications that clarify
existing evidence for determining balance
of beneits versus potential harm. Patient
preference should have a substantial
inluencing role.)
the guideline recommendation even
though there is no available empirical
evidence that meets the inclusion
criteria. (Practitioners should be
lexible in deciding whether to follow a
recommendation classiied as consensus,
although they may set boundaries on
alternatives. Patient preferences should
have a substantial inluencing role.)

Summary of recommendations

Diagnosis of Achilles tendon rupture

• Two or more physical examination tests (clinical
Thompson test and Simmonds’ squeeze test), decreased
ankle plantar lexion strength, presence of palpable
gap, or increased passive ankle dorsilexion with
gentle manipulation) should be used to establish the
diagnosis of Achilles tendon rupture (Strength of
recommendation: Consensus)
• There is inconclusive evidence regarding the routine
use of magnetic resonance imaging, ultrasound
(ultrasonography), and radiography (roentgenograms, x-
rays) to conirm the diagnosis of acute Achilles tendon
rupture (Strength of recommendation: Inconclusive)

Non-operative management
• Non-operative treatment may be an option for patients
with acute Achilles tendon rupture (Strength of
recommendation: Limited)
31
• For patients treated non-operatively, there is inconclusive
evidence regarding the use of immediate functional
bracing for patients with acute Achilles tendon rupture
(Strength of recommendation: Inconclusive)

Operative management

• Operative management may be an option for patients
with acute Achilles tendon rupture (Strength of
recommendation: Limited)
• Operative management should be approached more
cautiously in patients with diabetes, neuropathy,
immune-compromised states, age above 65, tobacco
use, sedentary lifestyle, obesity (BMI >30), peripheral
vascular disease or local/ systemic dermatologic
disorders (Strength of recommendation: Consensus)
• For patients managed operatively for an acute Achilles
tendon rupture, there is inconclusive evidence regarding
pre-operative immobilisation or restricted weight-
bearing (Strength of recommendation: Inconclusive)
• Open, limited open and percutaneous techniques may
be options for treating patients with acute Achilles
tendon rupture (Strength of recommendation: Limited)

There is inconclusive evidence regarding the use of allograt, autograt, xenograt, synthetic tissue, or biologic adjuncts in all
acute Achilles tendon ruptures that are treated operatively (Strength of recommendation: Inconclusive)

Post-operative management

• There is inconclusive evidence regarding the use
of antithrombotic treatment for patients with acute
Achilles tendon ruptures (Strength of recommendation:
Inconclusive)
• Patients with acute Achilles tendon rupture who have
been treated operatively should have early (≤2 weeks)
post-operative protected weight-bearing (Strength of
• A protective device that allows mobilisation should
be used by 2-4 weeks post-operatively (Strength of
recommendation: Moderate)
• There is inconclusive evidence regarding post-
operative physiotherapy for patients with acute
Achilles tendon rupture (Strength of recommendation:
Inconclusive)
Results

recommendation: Moderate)
Clinical Guidelines For Localised Musculoskeletal Foot Pain

Return to activities of daily living/ athletic activity

• Following Achilles tendon rupture, there is to sports within 3-6 months ater operative treatment
inconclusive evidence regarding when patients for acute Achilles tendon rupture (Strength of
can return to activities of daily living (Strength of recommendation: Limited)
recommendation: Inconclusive)
• There is inconclusive evidence to recommend a
• In patients who participate in sports, there is limited speciic time at which patients who are managed
evidence to suggest that the option of returning them non-operatively can be returned to athletic activity
(Strength of recommendation: Inconclusive)

Guideline quality AGREE II score (Table 3.3) iCAHE summary (Table 3.4)

• Scope and purpose: 83 • Information (n=3): 3 yes

• Stakeholder involvement: 75 • Currency (n=3): 3 yes

• Rigour of development: 83 • Evidence (n=4): 4 yes

• Clarity of presentation: 94 • Developers (n=2): 1 yes

• Applicability: 48 • Purpose and end users (n=1): 1 yes

• Editorial independence: 100 • Easy to read (n=1): 1 yes

Generalisability It is likely that the samples studied in the body of evidence would be similar to the target
population of the guideline; however, this was not explicitly stated

Applicability The post-operative and non-surgical recommendations are directly applicable to the Australian
podiatry context

Additional • Each recommendation in the guideline is accompanied by an implication for practice

information statement, which operationalises the recommendation in clinical practice terms

• Evidence on this topic may have been published since the development of this guideline

2. AMERICAN COLLEGE OF OCCUPATIONAL AND ENVIRONMENTAL MEDICINE

(2011) – ANKLE AND FOOT DISORDERS14

Publication date 2011

• Summary is publicly available from the National Guideline Clearinghouse htp://guideline.

gov/content.aspx?id=36625
Availability
• Full guideline can be ordered online www.acoem.org/apg-i.aspx

End users Used clinically by a broad cross-section of individuals, including 1) providers in clinical and
preventative practice, including (advanced practice nurses, allied health personnel, health care
providers, occupational therapists, physical therapists, physician assistants, physicians, podiatrists), 2)
healthcare managers including clinical case managers, utilisation reviewers, insurers and insurance
claims mangers, third party administrators, 3) individuals and agencies who inluence the quality of
care through regulatory and judicial decision, including regulators, policy makers, atorneys and judges

Foot and ankle conditions of:
• Achilles tendinopathy
• Achilles tendon rupture
Content
• Plantar heel (plantar fasciitis)
• Tarsal tunnel syndrome
• Ankle sprain
A Podiatry Perspective
• Ankle and foot fractures including
hindfoot fractures (calcaneus, talus), as
well as forefoot and midfoot fractures
(tarsal, metatarsal, phalangeal)
For each condition, the following information
is included: assessment procedures; diagnostic
criteria; initial care; follow-up care; diagnostic
considerations; and guidelines for modiication

of work activities and disability duration.

 Chapter 3
Based on research evidence and consensus that was reached for some recommendations by
Basis of the Evidence-Based Practice Panel (EBPP). The EBPP explicitly considered the health beneits,
recommendations side efects, and risks of the proposed recommendation for the management of each condition/
modality.

Search period 1966 – 2010

Sources of The National Library of Medicine’s MEDLARS database (Medline), EBM Online, The Cochrane
evidence Central Register of Controlled Trials, TRIP Database, CINAHL, EMBASE, PEDro

Strength of Grades of recommendation

recommendation
descriptors A = Strongly Recommended: The intervention is strongly recommended for appropriate
patients. The intervention improves important health and functional outcomes based on high
quality evidence, and the EBPP concludes that beneits substantially outweigh harms and costs.

B = Moderately Recommended: The intervention is recommended for appropriate patients. The

intervention improves important health and functional outcomes based on intermediate quality
evidence that beneits substantially outweigh harms and costs.

C = Recommended: The intervention is recommended for appropriate patients. There is limited

evidence that the intervention may improve important health and functional beneits.

I = Insuicient - Recommended (Consensus based): The intervention is recommended for

appropriate patients and has nominal costs and essentially no potential for harm. The EBPP
feels that the intervention constitutes best medical practice to acquire or provide information
in order to best diagnose and treat a health condition and restore function in an expeditious
manner. The EBPP believes based on the body of evidence, irst principles, or collective
experience that patients are best served by these practices, although the evidence is insuicient
for an evidence-based recommendation.

AND

I = Insuicient – No Recommendation (Consensus based): The evidence is insuicient 33

to recommend for or against routinely providing the intervention. The EBPP makes no
recommendation. Evidence that the intervention is efective is lacking, of poor quality, or
conlicting, and the balance of beneits, harms, and costs cannot be determined.

I = Insuicient – Not Recommended (Consensus based): The evidence is insuicient for an

evidence-based recommendation. The intervention is not recommended for eligible patients
because of high costs or high potential for harm to the patient.

C = Not Recommended: Recommendation against routinely providing the intervention. The

EBPP found at least intermediate evidence that harms and costs exceed beneits based on
limited evidence.

B = Moderately Not Recommended: Moderate recommendation against routinely providing

the intervention to eligible patients. The EBPP found at least intermediate evidence that the
intervention is inefective, or that harms or costs outweigh beneits.

A = Strongly Not Recommended: Strong recommendation against providing the intervention

to eligible patients. The EBPP found high quality evidence that the intervention is inefective, or
that harms or costs outweigh beneits.

Summary of recommendations

ACHILLES TENDINOPATHY

Non-operative management (physical methods and devices)

Recommended No recommendation Not recommended

Eccentric exercises for Night splint for acute, subacute Magnets (Recommendation I)
chronic Achilles tendinopathy or chronic Achilles tendinopathy
Results

(Recommendation B) (Recommendation I)
Clinical Guidelines For Localised Musculoskeletal Foot Pain
Low-level laser therapy for select
patients with chronic Achilles
tendinopathy (Recommendation C)
Extracorporeal shockwave therapy
(ESWT) as an adjunct to an
eccentric exercise for chronic,
recalcitrant Achilles tendinopathy
(Recommendation C)
Education (Recommendation I)
Heat (Recommendation I)
Cryotherapy (Recommendation I)
Stretching and loading exercises,
particularly eccentric exercises,
for acute, subacute, or post-
operative Achilles tendinopathy
(Recommendation I)
Night splints and walking boots
for post-operative Achilles
tendinopathy (Recommendation I)
Pharmacological management (including injectable agents)
Recommended
Non-steroidal anti-inlammatory
drugs (NSAIDs) for acute
Achilles tendinopathy pain
(Recommendation C)
Topical NSAIDs for acute or
subacute Achilles tendinosis
(Recommendation C)
Topical glyceryl trinitrate for pain
in select patients with chronic
Achilles tendinopathy after
other conservative treatment
alternatives have failed
(Recommendation C)
Acetaminophen
(Recommendation I)
Topical NSAIDs for chronic Achilles
tendinosis (Recommendation I)
A Podiatry Perspective
NSAIDs for subacute or chronic
Achilles tendinopathy pain or post-
operative pain or inlammation
(Recommendation I)
Orthotic devices such as heel
lifts, heel pads, or heel braces
(Recommendation I)
Acupuncture (Recommendation I)
Massage and tendon mobilisation
(Recommendation I)
Ultrasound (Recommendation I)
Low-level laser therapy for
acute, subacute, or post-
operative Achilles tendinopathy
(Recommendation I)
No recommendation
Vitamins as therapeutic
intervention or for prevention of
Achilles tendinopathy in doses
recommended by U.S. Food
and Drug Administration (FDA)
(Recommendation I)
Lidocaine patches
(Recommendation I)
Glycosaminoglycan polysulfate local
injection for acute, subacute, or
post-operative Achilles tendinopathy
(Recommendation I)
Actovegin injection for acute,
subacute, or chronic Achilles
tendinopathy (Recommendation I)
Prolotherapy injections for
chronic Achilles tendinopathy
(Recommendation I)
Polidocanol injection for
acute, subacute, or post-
operative Achilles tendinopathy
(Recommendation I)
Dry needling (Recommendation I)
ESWT for acute, subacute, or post-
operative Achilles tendinopathy
(Recommendation I)
Not recommended
Platelet-rich plasma injections.
(Recommendation B)
Aprotinin injection for
chronic Achilles tendinopathy
(Recommendation C)
Heparin subcutaneous injection
for acute or subacute Achilles
tendinopathy (Recommendation C)
Low-dose glucocorticosteroid
injections for acute, subacute, or
post-operative Achilles tendinopathy
(Recommendation I)
Oral or intramuscular steroid
preparations for acute, subacute,
chronic, or post-operative Achilles
tendinopathy (Recommendation I)
Heparin subcutaneous injection
for chronic Achilles tendinopathy
(Recommendation I)

Opioids for short-term use to
treat pain after Achilles tendon
surgery or for patients who have
encountered surgical complications
(Recommendation I)
Low-dose glucocorticosteroid
injections as an alternative therapy
for chronic Achilles tendinopathy
and associated paratendon bursitis
(Recommendation I)
Glycosaminoglycan polysulfate local
injection as an alternative therapy
for chronic Achilles tendinopathy
(Recommendation C)
Polidocanol injection for
chronic Achilles tendinopathy
(Recommendation C)
Iontophoresis with
glucocorticosteroid for acute,
subacute, or chronic Achilles
tendinopathy (Recommendation I)
Surgical management
Recommended
Surgery for select cases of
chronic Achilles tendinopathy
without rupture. There is no
recommendation for any
particular procedure over another
(Recommendation I)
ACHILLES TENDON RUPTURE
Non-operative management (physical methods and devices)
Recommended
Early weight-bearing for post-
operative rehabilitation of Achilles
tendon ruptures for functional
bracing or rigid immobilisation
(Recommendation A)
Functional splinting (bracing) as
primary treatment method for post-
operative care of Achilles tendon
ruptures (Recommendation B)
Chapter 3
High-volume image-guided Aprotinin injection for acute or
injection for chronic Achilles subacute Achilles tendinopathy
tendinopathy Recommendation I) (Recommendation I)
Iontophoresis with NSAIDs Opioids for acute, subacute, or
(Recommendation I) chronic Achilles tendinopathy pain
(Recommendation I)
Phonophoresis Recommendation I) High doses (exceeding U.S. FDA
recommendations) or expensive
compounded preparation
vitamins for prevention of Achilles
tendinopathy (Recommendation I)
Topical NSAIDs for post-
operative Achilles tendinosis
(Recommendation I)
Iontophoresis with
glucocorticosteroid for post-
operative Achilles tendinopathy
(Recommendation I)
Topical glyceryl trinitrate for
acute, subacute, or post-
operative Achilles tendinopathy
(Recommendation I) 35
No recommendation Not recommended
Surgery for acute or subacute
Achilles tendinopathy without
rupture (Recommendation I)
No recommendation Not recommended
Early weight-bearing for non-
operatively managed Achilles
tendon ruptures
(Recommendation I)
Transcutaneous electrical nerve
stimulation as post-operative
treatment for Achilles tendon
rupture (Recommendation I)
Results
Clinical Guidelines For Localised Musculoskeletal Foot Pain

Non-operative management
with functional splinting and
casting for Achilles tendon rupture
(Recommendation C)

Self-application of heat for acute,

subacute, chronic, or post-
operative Achilles tendon rupture
(Recommendation I)

Self-application of cryotherapy
for acute or post-operative
Achilles tendon rupture
(Recommendation I)

A primarily home-based
rehabilitation program (exercise
and education) for Achilles tendon
rupture (Recommendation I)

Pharmacological management (including injectable agents)

Recommended No recommendation Not recommended

Prophylaxis for prevention
of deep venous thrombosis
(Recommendation C)
Prophylaxis, including warfarin, Opioids for treatment of pain from
heparin, low molecular weight subacute or chronic Achilles tendon
heparin, graded compression repair (Recommendation I)
stockings, aspirin, or factor Xa to
prevent deep venous thrombosis
(Recommendation I)

Limited use of opioids for treatment

of acute Achilles tendon rupture as a
treatment option for select patients
with acute or moderate to severe
pain related to Achilles rupture.
Limited use of opioids for a few
days for select patients who have
undergone recent Achilles tendon
repair or encountered surgical
complications (Recommendation I)

Acetaminophen as analgesia for

pain as a result of acute Achilles
tendon rupture (Recommendation I)

Topical NSAIDs for acute or

subacute Achilles tendon rupture
(Recommendation I)

Surgical management

Recommended No recommendation Not recommended

Open repair and percutaneous Augmented repair for Augmented repair for acute
approaches for patients undergoing chronic or neglected ruptures ruptures, unless primary repair is
operative repair. There is no (Recommendation I) not possible (Recommendation C)
recommendation of one approach
over the other (Recommendation C)
A Podiatry Perspective

Surgical repair for ruptured Achilles

tendon (Recommendation C)
 Chapter 3
PLANTAR HEEL (PLANTAR FASCIITIS)

Non-operative management (physical methods and devices)

Recommended No recommendation Not recommended

Heel taping as a short-term Casting for chronic plantar fasciitis Ultrasound (Recommendation C)
treatment for acute or subacute (Recommendation I)
plantar fasciitis or heel pain
(Recommendation C)

Orthotic devices Acupuncture (Recommendation I) ESWT for acute or subacute plantar

(Recommendation C) fasciitis (Recommendation I)

Education for select patients Custom orthoses Radial ESWT for acute or subacute
(Recommendation I) (Recommendation I) plantar fasciitis (Recommendation I)

Heat (Recommendation I) Heel taping for chronic Ultrasound or luoroscopic guidance

plantar fasciitis or heel pain is not recommended over application
(Recommendation I) of energy at point of maximal
tenderness (Recommendation I)

Prefabricated night splints for Low frequency electrical

subacute or chronic plantar heel stimulation (Recommendation I)
pain (Recommendation I)

Stretching exercises of plantar Low-level laser therapy

fascia and Achilles tendon (Recommendation I)
(Recommendation I)

Manipulation (Recommendation I)
37
Massage and tendon mobilisation
(Recommendation I)

Orthotic devices for prevention of

plantar fasciitis or lower extremity
disorders (Recommendation I)

Percutaneous calcaneus
fenestration for chronic plantar
heel pain (Recommendation I)

Radial ESWT for chronic plantar

fasciitis (Recommendation I)

Radiofrequency microtenotomy
for chronic plantar fasciitis
(Recommendation I)

Radiation therapy for

chronic plantar heel pain
(Recommendation I)

Special itted or shock absorbing

shoes for prevention of plantar
fasciitis or lower extremity
disorders (Recommendation I)
Results
Clinical Guidelines For Localised Musculoskeletal Foot Pain
Pharmacological management (including injectable agents)
Recommended
Intracorporeal pneumatic shock
therapy for select chronic plantar
fasciitis (Recommendation B)
Botulinum toxin A injection for
select chronic plantar fasciitis
(Recommendation C)
Glucocorticosteroid injections for
short-term relief of chronic plantar
fasciitis (Recommendation C)
Acetaminophen (Recommendation I)
ESWT for chronic plantar
fasciitis in select patients with
chronic recalcitrant conditions
(Recommendation I)
Cryotherapy (Recommendation I)
Limited use of opioids for a few
post-operative days for select
patients (Recommendation I)
Local anaesthesia in conjunction
with high-energy ESWT
(Recommendation I)
NSAIDs (Recommendation I)
Topical NSAIDs for acute, subacute,
or chronic plantar fascial pain
syndromes (Recommendation I)
Surgical management
Recommended
Surgical release for select chronic
recalcitrant plantar fasciitis. There
is no recommendation for any
particular procedure or method
over another (Recommendation I)
TARSAL TUNNEL SYNDROME (TTS)
Non-operative management (physical methods and devices)
A Podiatry Perspective
Recommended
Self-application of ice/heat
(Recommendation I)
No recommendation
Cryosurgery for chronic plantar
heel pain (Recommendation I)
Hyperosmolar dextrose injections
(Recommendation I)
Iontophoresis with
glucocorticosteroid or acetic acid for
select patients (Recommendation I)
Lidocaine patches
(Recommendation I)
Local anaesthesia used in
conjunction with low- or medium-
energy ESWT (Recommendation I)
Platelet rich plasma injections
(Recommendation I)
Phonophoresis (Recommendation I)
Short-term use of vitamins
for treatment or prevention
(Recommendation I)
Topical NSAIDs for post-operative
plantar fasciitis (Recommendation I)
No recommendation
Augmented repair for
chronic or neglected ruptures
(Recommendation I)
No recommendation
Acupuncture (Recommendation I)
Not recommended
Magnets (Recommendation A)
Wheat grass cream
(Recommendation B)
Autologous blood injection
(Recommendation C)
Ultrasound or scintigraphy imaging
techniques to guide injection
(Recommendation C)
Botulinum toxin A injection for
acute or subacute plantar fasciitis
(Recommendation I)
Cryosurgery for acute or
subacute plantar heel pain
(Recommendation I)
Glucocorticosteroid injections for
acute or subacute plantar fasciitis.
(Recommendation I)
Inliximab (Recommendation I)
Opioids for acute, subacute
or chronic plantar fasciitis
(Recommendation I)
Oral or intramuscular or
prevention (Recommendation
I)glucocorticosteroid
(Recommendation I)
Not recommended
Surgical release for acute or
subacute plantar fasciitis
(Recommendation I)
Not recommended
Magnets (Recommendation I)

Return-to-work programs for
patients with TTS particularly
those with signiicant lost time
(Recommendation I)
Chapter 3
Exercises (Recommendation I) Manipulation or mobilisation
of the distal lower extremity
(Recommendation I)

Orthotics (Recommendation I)

Rest (Recommendation I)

Taping (Recommendation I)

Trial of nocturnal splinting

(Recommendation I)

Ultrasound (Recommendation I)

Work restrictions
(Recommendation I)

Pharmacological management (including injectable agents)

Recommended No recommendation Not recommended

Glucocorticosteroid injections Acetaminophen or NSAIDs Botulinum injections

(Recommendation I) (Recommendation I) (Recommendation I)

Lidocaine patches for select cases Iontophoresis (Recommendation I) Diuretics (Recommendation I)

(Recommendation I)

Limited use (a few days) of Phonophoresis (Recommendation I) Insulin injections

opioids for select patients who (Recommendation I)
have undergone recent tarsal 39
tunnel release and have large
incisions or encountered signiicant
complications that cannot be
managed with other means
(Recommendation I)

Oral glucocorticosteroids for TTS Other vitamins (Recommendation I) Pyridoxine for routine treatment
patients who decline tarsal tunnel of TTS in patients without vitamin
injection (Recommendation I) deiciencies (Recommendation I)

Routine use of opioids

(Recommendation I)

Surgical management

Recommended No recommendation Not recommended

Surgical release of posterior tibial

nerve impingement at tarsal
tunnel upon failure of conservative
treatment and in presence of space
occupying lesion. Surgical release
for cases with non-speciic causes
are otherwise expected to have
mixed results and patients should
be counselled regarding potential
lack of beneit before considering
surgery. There is no recommendation
for any speciic technique as
there is a lack of quality evidence.
Results

(Recommendation I)
Clinical Guidelines For Localised Musculoskeletal Foot Pain
ANKLE SPRAIN
Non-operative management (physical methods and devices)
Recommended
Early mobilisation for acute
ankle sprains without fracture
(Recommendation B)
Ankle support (brace, tape) for
prevention (initial injury) of ankle
injury (Recommendation C)
Balance/proprioception training for
prevention of initial and recurrent
ankle injury (Recommendation C)
Ankle support (brace, tape) for
prevention (recurrent injury) of
ankle injury (Recommendation I)
Appropriate activity-speciic
footwear for prevention of ankle
sprain or recurrent ankle sprain.
There is no recommendation for
the use of one type of shoe over
another for prevention of ankle
sprain or lower extremity disorders
(Recommendation I)
Education for select patients
(Recommendation I)
Elevation for controlling
oedema of acute ankle sprains
(Recommendation I)
Physical or occupational therapy
for select patients with acute,
subacute, or chronic ankle sprain
(Recommendation I)
Physical or occupational therapy
for chronic ankle instability
(Recommendation I)
Rest or non-weight-bearing as an
initial intervention for acute ankle
sprain for patients unable to tolerate
weight (Recommendation I)
Semi-rigid pneumatic or gel ankle
brace supports for acute ankle
sprain, with optional use as needed
A Podiatry Perspective
for mild and moderate sprains
(Recommendation I)
No recommendation
Acupuncture (Recommendation I)
Contrast baths for acute ankle
sprain (Recommendation I)
Compression therapy (i.e. tape,
elastic wrap, tubular elastic,
or pneumatic compression
devices) for acute ankle sprain
(Recommendation I)
Foot orthotics for prevention of
ankle injury (Recommendation I)
Heat for acute ankle sprain
(Recommendation I)
Immobilisation by cast for severe
ankle sprain as splints should be
suicient (Recommendation I)
Magnets (Recommendation I)
Manipulation or mobilisation for
acute or subacute ankle sprain
(Recommendation I)
Non-rigid support therapies (i.e.
tape, elastic wrap, or tubular
elastic) for acute ankle sprain
(Recommendation I)
Stretching or strengthening
exercises for prevention of
initial or recurrent ankle injury
(Recommendation I)
Walking boot for acute ankle sprain
(Recommendation I)
Not recommended
Diathermy for acute ankle sprain
(Recommendation B)
Low-level laser therapy for acute
ankle sprain (Recommendation B)
Ultrasound for acute ankle sprain
(Recommendation B)
Hyperbaric oxygen therapy
for acute ankle sprain
(Recommendation C)
Low frequency electrical
stimulation (Recommendation C)
Diathermy for subacute or chronic
ankle sprain (Recommendation I)
High-voltage pulsed stimulation
(Recommendation I)
Hyperbaric oxygen therapy for
subacute or chronic ankle sprain
(Recommendation I)
Immobilisation by cast for patients
with acute mild to moderate
ankle sprain as splints should be
suicient (Recommendation I)
Low-level laser therapy for
subacute or chronic ankle sprain
(Recommendation I)
Ultrasound for subacute or chronic
ankle sprain (Recommendation I)

Short-term cast immobilisation
with early mobilisation and
physical or occupational
therapy for ankle instability
(Recommendation I)
Cryotherapy for acute ankle sprain
(Recommendation I)
Pharmacological management (including injectable agents)
Recommended
Limited use of opioids for no more
than 1 week for select patients with
severe pain related to acute ankle
sprain (Recommendation A)
NSAIDs for acute ankle sprain
(Recommendation A)
Acetaminophen
(Recommendation B)
Topical NSAIDs for acute ankle
sprain (Recommendation B)
Limited use of opioids for no more
than 1 week may be indicated
for those who have undergone
ankle ligament repair surgery or
those who encountered surgical
complications (Recommendation I)
NSAIDs for subacute, chronic,
or post-operative ankle sprain
(Recommendation I)
Chapter 3
No recommendation Not recommended
Autologous blood injection Oral proteolytic enzyme
(Recommendation I) preparations (Recommendation B)
Benzydamine (Recommendation I) High doses (exceeding U.S. FDA
recommendations) or expensive
compounded preparation vitamins
for prevention of ankle sprain
(Recommendation I)
Glucocorticosteroid injection Oral or intramuscular steroid
(Recommendation I) preparations (Recommendation I)
Hyaluronic acid injection Oral streptokinase/streptodornase
(Recommendation I) preparations (Recommendation I)
Iontophoresis (Recommendation I)
41
Lidocaine patches
(Recommendation I)
Medications (gels) that
stimulate sensation of cold
(Recommendation I)
Movelat (Recommendation I)
Phonophoresis (Recommendation I)
Platelet rich plasma injection
(Recommendation I)
Topical comfrey extract
(Recommendation I)
Topical NSAIDs for subacute,
chronic, or post-operative ankle
sprain (Recommendation I)
Vitamins as therapeutic intervention
or for prevention of ankle sprain in
doses recommended by the U.S. FDA
Results
(Recommendation I)
Clinical Guidelines For Localised Musculoskeletal Foot Pain

Surgical management

Recommended No recommendation Not recommended

Ligament reconstruction for select Surgical repair for routine lateral

cases of chronic ankle instability ligament tear associated with
(Recommendation I) acute or subacute ankle sprain
(Recommendation I)

ANKLE AND FOOT FRACTURES

Non-operative management (physical methods and devices)

Recommended No recommendation Not recommended

Cast immobilisation for
management of ankle fractures
(Recommendation B)
Electrical stimulation for prevention
of muscle atrophy in ankle and
foot fracture management
(Recommendation I)
Interferential therapy for post-
operative swelling following open
reduction internal ixation (ORIF)
for displaced malleolar fracture
(Recommendation B)

Early mobilisation in the Hyperbaric oxygen Interferential therapy for post-

management of post-operative (Recommendation I) operative swelling following ORIF
and stable non-operative ankle for displaced malleolar fracture
fractures (Recommendation B) (Recommendation B)

Early weight-bearing of operatively Hypnosis (Recommendation I) Passive stretching for contractures

ixated ankle fracture post- after immobilisation of ankle
operatively (Recommendation B) fractures (Recommendation B)

Pneumatic compression of foot and Non-operative management Ultrasound (Recommendation B)

ankle to reduce swelling for patients of tibial shaft fractures
with signiicant post-operative (Recommendation I)
oedema (Recommendation C)

Non-operative management for Type of post-operative care Manual therapy as part of an active
non-displaced and reduced stable dressing (Recommendation I) post-ankle fracture rehabilitation
ankle fractures (Recommendation I) program (Recommendation B)

Non-operative management in Use of a speciic operative product.

select circumstances for distal (Recommendation I)
extra-articular tibial fractures
(Recommendation I)

Non-operative management for

tibial plafond fractures in select
patients (Recommendation I)

Non-operative management
for stable syndesmotic injury
(Recommendation I)

Referral of patients with functional

debilities or inability to return to
work for physical or occupational
therapy after cast removal
(Recommendation I)
A Podiatry Perspective
 Chapter 3
Pharmacological management (including injectable agents)

Recommended No recommendation Not recommended

Adequate analgesia (conscious Use of nasal spray calcitonin

sedation, intra-articular block) for prophylaxis of post-fracture
for performing non-operative osteopenia (Recommendation C)
closed reduction of ankle fractures.
(Recommendation C)

Adequate analgesia (haematoma

block, general anaesthesia) for
performing non-operative closed
reduction of ankle fractures
(Recommendation I)

For open fractures, update tetanus

immunisation status as necessary
(Recommendation I)

Limited use of opioids for

acute and post-operative pain
management as adjunctive
therapy to more efective
treatments (Recommendation I)

NSAIDs and acetaminophen for

analgesia of pain associated with
fracture (Recommendation I)

Pre-operative antibiotic prophylaxis

for closed or open ankle fracture
surgery (Recommendation I)
43

Surgical management

Recommended No recommendation Not recommended

Operative ixation for unstable Arthroscopy assisted ORIF Surgical thigh tourniquet for
closed displaced ankle fractures for distal ibular fractures. surgical treatment of closed
(Recommendation C) (Recommendation I) displaced ankle fractures
(Recommendation C)

Operative ixation for deinitive Performing repair of torn

management of displaced tibial deltoid ligament in association
shaft fracture (Recommendation C) with ORIF for ankle fracture
(Recommendation I)

Operative management for tibial

plafond fractures in select patients
(Recommendation I)

Closed reduction and

immobilisation for select non-
comminuted closed displaced ankle
fractures (Recommendation I)

Operative ixation for distal extra-

articular tibial fractures in select
patients (Recommendation I)
Results
Clinical Guidelines For Localised Musculoskeletal Foot Pain

Operative ixation for

displaced distal ibula fracture
(Recommendation I)

Operative ixation for

unstable syndesmotic rupture
(Recommendation I)

HINDFOOT FRACTURES (CALCANEUS, TALUS)

Non-operative management (physical methods and devices)

Recommended No recommendation Not recommended

Pneumatic compression of foot Diathermy for management of

to reduce swelling for patients oedema associated with calcaneus
with signiicant oedema after fractures (Recommendation I)
closed calcaneus fractures
(Recommendation C)

Non-operative cast immobilization Non-operative management

for select calcaneus fractures of non-displaced talar
(Recommendation I) fractures – head, neck, body
(Recommendation I)

Non-operative management
of osteochondral lesions of
the talus for select patients
(Recommendation I)

Pharmacological management (including injectable agents)

Recommended No recommendation Not recommended

Calcium phosphate paste or

bone graft for displaced intra-
articular fracture defects
(Recommendation I)

Surgical management

Recommended No recommendation Not recommended

Operative intervention for

osteochondral lesions of talus
after initial course of conservative
management. Chondroplasty,
microfracture and osteochondral
autograft recommended
(Recommendation I)

Operative management for all

displaced talar fractures – head,
neck, body, lateral process
(Recommendation I)

Operative management for

select calcaneus fractures
(Recommendation I)
A Podiatry Perspective
 Chapter 3
FOREFOOT AND MIDFOOT FRACTURES (TARSAL, METATARSAL, PHALANGEAL)

Non-operative management (physical methods and devices)

Recommended No recommendation Not recommended

Immobilisation for select

patients with distal, middle,
and proximal phalanx fractures
(Recommendation I)

Non-operative management for

low risk lower extremity stress
fracture (Recommendation I)

Non-operative management of
5th metatarsal fractures (including
Jones and avulsion) for select
patients (Recommendation I)

Non-operative management for

non-displaced metatarsal fractures
(Recommendation I)

Non-operative management of
non-displaced tarsal-metatarsal
injury (Lisfranc) for select patients
(Recommendation I)

Pharmacological management (including injectable agents)

Recommended No recommendation Not recommended 45

NSAIDs or acetaminophen to control
pain from phalangeal or metatarsal
fractures (Recommendation I)

Surgical management

Recommended No recommendation Not recommended

Operative management for select

Operative management of lower
patients with distal, middle,
extremity stress fractures in select
and proximal phalanx fractures
patients (Recommendation I)
(Recommendation I)

Operative management for 5th

metatarsal fractures (Jones,
avulsion) for select patients
(Recommendation I)

Operative management for

unstable tarsal-metatarsal injury
(Lisfranc) (Recommendation I)
Results
Clinical Guidelines For Localised Musculoskeletal Foot Pain

AGREE II score (Table 3.3) iCAHE summary (Table 3.4)

• Scope and purpose: 94 • Information (n=3): 3 yes

• Stakeholder involvement: 83 • Currency (n=3): 2 yes

Guideline quality • Rigour of development: 86 • Evidence (n=4): 4 yes

• Clarity of presentation: 100 • Developers (n=2): 2 yes

• Applicability: 50 • Purpose and end users (n=1): 1 yes

• Editorial independence: 92 • Easy to read (n=1): 1 yes

It is likely that the samples studied in the body of evidence would be similar to the target
Generalisability population of the guideline (adults with potentially work-related ankle and foot disorders in
primary care setings); however, this was not explicitly stated

Recommendations particularly pertaining to non-operative management (physical methods/

Applicability devices) are directly applicable to the Australian podiatry context

This guideline is extremely comprehensive with respect to its treatment recommendations.

Additional Comprehensive information is also provided with respect to assessment procedures, diagnostic
information criteria, and guidelines for modiication of work activities and disability duration. This information
is referenced appropriately but not graded using the strength of evidence framework

3. CARCIA ET AL (2010) – ACHILLES PAIN, STIFFNESS AND MUSCLE POWER

DEFICITS: ACHILLES TENDINITIS (ORTHOPAEDIC SECTION OF THE AMERICAN
PHYSICAL THERAPY ASSOCIATION)16

Publication date 2010

Availability Publicly available from www.jospt.org/issues/id.2480/article_detail.asp

Used in the management of patients with Achilles tendinitis by orthopaedic physical therapy
End users clinicians, academic instructors, clinical instructors, students, interns, and residents

Content Impairment/function-based diagnoses

• Prevalence • Diagnosis and classiication

• Pathoanatomical features • Signs and symptoms
• Risk factors • Diferential diagnosis
• Intrinsic risk factors such as
• Conditions listed include ruptures,
dorsilexion range of motion, abnormal
tears, bursitis, nerve and muscle
subtalar range of motion, decreased
involvement
plantar lexion strength, pronation,
tendon structure, and comorbidity
• Extrinsic risk factors including
training errors, environmental factors,
and faulty equipment
• Diagnosis and classiication

Examination

• Outcome measures such as the • Physical impairment measures

• Victorian Institute of Sport • Ankle dorsilexion and subtalar
Assessment (VISA) joint range of motion, plantar lexion
• Foot and Ankle Ability Measure strength and endurance, truncated
A Podiatry Perspective

(FAAM) arch-height ratio, forefoot alignment,

Achilles tendon palpation test, arc
• Activity limitation and participation
sign, and Royal London Hospital test
restriction measures
• Six tests of function, such as jump • Prognosis
tests, strength tests, and a muscular
endurance test
 Chapter 3
Interventions

• Eccentric loading • Iontophoresis

• Laser therapy: • Stretching

• Foot orthoses

• Manual therapy

• Taping

• Heel lits

• Night splints

Basis of Based on research evidence, and included the role of consensus expert opinion and basic
recommendations science research to demonstrate biological and biomechanical plausibility

Search period 1967 – February 2009

Sources of MEDLINE, CINAHL, and The Cochrane Database of Systematic Reviews

evidence

Strength of Grades of recommendation

recommendation
descriptors A = Strong evidence – A preponderance of level I and/ or level II studies support the
recommendation. This must include at least 1 level I study

B = Moderate evidence – A single high -quality randomised controlled trial or a preponderance

of level II studies support the recommendation

C = Weak evidence – A single level II study or a preponderance of level III and IV studies
including statements of consensus by content experts support the recommendation

D = Conlicting evidence – Higher quality studies conducted on this topic disagree with respect 47
to their conclusions. The recommendation is based on these conlicting studies

E = Theoretical/ foundational evidence – A preponderance of evidence from animal or

cadaver studies, from conceptual models/ principles, or from basic sciences/ bench research
support this conclusion

F = Expert opinion – Best practice based on the clinical experience of the guidelines
development team

Summary of recommendations

Impairment/ function-based diagnosis

• Intrinsic and extrinsic risk factors These signs and symptoms are useful clinical indings
for classifying a patient with ankle pain into the ICD
(Recommendation: B, for speciic groups of individuals.
category of Achilles bursitis or tendinitis and the associated
Consider abnormal ankle dorsilexion range of motion,
International Classiication of Functioning impairment-
abnormal subtalar joint range of motion, decreased ankle
based category of Achilles pain [b28015 Pain in lower limb],
plantar lexion strength, increased foot pronation, and
stifness [b7800 Sensation of muscle stifness], and muscle
abnormal tendon structure as intrinsic risk factors associated
power deicits [b7301 Power of muscles of lower limb])
with Achilles tendinopathy. Obesity, hypertension,
hyperlipidaemia, and diabetes are medical conditions • Diferential diagnosis
associated with Achilles tendinopathy. Also consider training
(Recommendation: F, clinicians should consider diagnostic
errors, environmental factors, and faulty equipment as
classiications other than Achilles tendinopathy when the
extrinsic risk factors associated with Achilles tendinopathy)
patient’s reported activity limitations or impairments of
• Diagnosis and classiication body function and structure are not consistent with those
presented in the diagnosis/classiication section of this
(Recommendation: C, self-reported localised pain and
guideline, or when the patient’s symptoms are not resolving
perceived stifness in the Achilles tendon following a period
with interventions aimed at normalisation of the patient’s
of inactivity [i.e. sleep, prolonged siting], lessens with an
impairments of body function)
acute bout of activity and may increase ater the activity.
Results

Symptoms are frequently accompanied with Achilles tendon

tenderness, a positive arc sign, and positive indings on the
Royal London Hospital test.
Clinical Guidelines For Localised Musculoskeletal Foot Pain

Examination

• Outcome measures • Activity limitation and participation restriction

(Recommendation: A, clinicians should incorporate validated
functional outcome measures, e.g. VISA and FAAM. These
should be utilised before and ater interventions intended to
alleviate the impairments of body function and structure,
activity limitations, and participation restrictions associated
with Achilles tendinopathy)
measures (Recommendation: B, when evaluating
functional limitations over an episode of care for
those with Achilles tendinopathy, measures of activity
limitation and participation restriction can include
objective and reproducible assessment of the ability
to walk, descend stairs, perform unilateral heel raises,
single-limb hop, and participate in recreational activity)

Interventions

• Eccentric loading • Foot orthoses

(Recommendation: A, clinicians should consider
implementing an eccentric loading program to
decrease pain and improve function in patients
with midportion Achilles tendinopathy)
• Laser therapy
(Recommendation: B, clinicians should consider the use
of low-level laser therapy to decrease pain and stifness in
patients with Achilles tendinopathy)
• Iontophoresis
(Recommendation: B, clinicians should consider the use of
iontophoresis with dexamethasone to decrease pain and
improve function in patients with Achilles tendinopathy)
• Stretching
(Recommendation: C, can be used to reduce pain and
improve function in patients who exhibit limited
dorsilexion range of motion with Achilles tendinopathy)
(Recommendation: C, can be used to reduce pain and alter
ankle and foot kinematics while running in patients with
Achilles tendinopathy)
• Manual therapy
(Recommendation: F, sot tissue mobilisation can be used to
reduce pain and improve mobility and function in patients
with Achilles tendinopathy)
• Taping
(Recommendation: F, may be used in an atempt
to decrease strain on the Achilles tendon in
patients with Achilles tendinopathy)
• Heel lits
(Recommendation: D, contradictory evidence exists for the
use of heel lits in patients with Achilles tendinopathy)
• Night splints

(Recommendation: C, not beneicial in reducing

pain when compared to eccentric exercise for
patients with Achilles tendinopathy)

AGREE II score (Table 3.3) iCAHE summary (Table 3.4)

• Scope and purpose: 56 • Information (n=3): 3 yes

• Stakeholder involvement: 72 • Currency (n=3): 3 yes

Guideline quality • Rigour of development: 66 • Evidence (n=4): 2 yes

• Clarity of presentation: 89 • Developers (n=2): 1 yes

• Applicability: 44 • Purpose and end users (n=1): 1 yes

• Editorial independence: 0 • Easy to read (n=1): 1 yes

It is likely that the samples studied in the body of evidence would be similar to the target
Generalisability population of the guideline; however, this was not explicitly stated

The recommendations pertaining to the interventions are directly applicable to the Australian
Applicability podiatry context, except for the recommendation on iontophoresis, which is not undertaken by
podiatrists in Australia

The recommendations for the diagnoses, examination types and interventions for this guideline
were extremely comprehensive. The information was referenced appropriately and graded
Additional
A Podiatry Perspective

information against research criteria and strength of evidence. This guideline scored moderately high on the
AGREE II and highly on the iCAHE Guideline Checklist
 Chapter 3
4. INSTITUTE FOR CLINICAL SYSTEMS IMPROVEMENT (ICSI) (2006) –
ANKLE SPRAIN18

Publication date 2006

Guideline can be found in the National Guideline Clearinghouse to members only or resources
Availability available to ICSI members only. A lowchart of the ankle sprain guideline is publicly available
from www.guideline.gov/algorithm/4870/NGC-4870.pdf

A broad cross-section of individuals, including physicians, nurses and other health care
professional and expert audiences such as 1) physicians, nurses and other health care
professional and provider organisations, 2) health plans, health systems, healthcare
End users organisations, hospitals and integrated healthcare delivery systems, 3) medical speciality and
professional societies, 4) researchers, 5) federal, state and local government health care policy
makers and specialists, 6) employee beneit managers

1. Provider visit, including

• Components of a history

• Physical examination

2. Indications for x-ray

Content
3. X-ray abnormalities

4. Treatment and protection during the acute injury phase

5. Rehabilitation for return to prior activity level

6. Resumption of normal activity

Basis of Based on research evidence. It is unclear how these recommendations were developed although
recommendations some references have been provided and have been graded based on study design.

Search period Not stated

49

Resources were selected by the work group and met the following criteria: the site contained
information speciic to the topic of the guideline, the content was supported by evidence-based
Sources of research, included the source/ author and contact information, clearly stated revision dates or
evidence
the date the information was published, and was clear about potential biases, noting conlict of
interest and/ or disclaimers as appropriate

Strength of Grades of recommendation

recommendation
descriptors Classes of research reports: B. Reports that Synthesize or Relect
upon Collections of Primary Reports:
A. Primary Reports of New Data Collection:

Class A: Randomised, controlled trial Class M: Meta-analysis

Class B: Cohort study • Systematic review

Class C: Non-randomised trial with concurrent • Decision analysis

or historical controls
• Cost-efectiveness analysis
• Case-control study

• Study of sensitivity and speciicity of a Class R: Consensus statement

diagnostic test
• Consensus report
• Population-based descriptive study
• Narrative review
Class D: Cross-sectional study
Class X: Medical opinion
• Case series

• Case report
Results
Clinical Guidelines For Localised Musculoskeletal Foot Pain

Summary of recommendations

Provider visit (Class: R)

• The history should include gaining information on the mechanism of injury, location of pain and swelling, ability
to weight bear, history of prior inversion sprains and prior treatment, when the injury occurred, age of the patient,
complicating illness, medication, presence of pain elsewhere in the leg

• Physical examination should include observation for obvious deformity, determination of the location of swelling and
ecchymosis, palpation for local tenderness, squeeze and rotatory tests, evaluation of the peroneal tendons, observation of
the patient walking, neurovascular status. It is optional to perform passive range of motion tests including the anterior
draw test and the talar tilt manoeuvre

Indications for x-ray (Class: C, R)

• An ankle radiographic series (anterioposterior, lateral and mortis views) should be obtained if there is pain in the
malleolar zone and any one of the following: 1) bone tenderness along the crest or midpoint of the lateral malleolus; 2)
bone tenderness along the posterior or midpoint edge or tip of the medial malleolus; and 3) inability to bear reasonable
weight at the time of evaluation

• A foot x-ray series is only required if pain is reported in the forefoot area and any of the following: 1) bone tenderness over the
base of the ith metatarsal; 2) bone tenderness over the navicular; and 3) inability to bear weight at the time of evaluation

• Patients in the following categories are deferred to provider judgement for determining radiographic indications:
pregnant, ankle injury more than 10 days old, intoxication and/ or diminished sensation, isolated injuries of the skin
without underlying sot tissue or bone involvement. Return visit for reassessment

X-ray abnormalities (Class: R)

• An x-ray is considered abnormal if there is evidence of fracture, widening of the mortis or pathology unrelated to the injury

• If displacement or widening at the growth plate is observed, a comparison view of the normal ankle may be indicated

• Findings which are not considered abnormal for the purposes of this guideline include swelling, and avulsion fracture <2-3mm

Treatment and protection during the acute injury phase

• Pain relief, such as simple analgesics (acetaminophen) or analgesic dosages of NSAIDs (Class: A)

• Range of motion exercises (Class: A, M), shoes, pain relief (Class: A, C)

Rehabilitation for return to prior activity level

• Rehabilitation for athletic activity could include hopping, jogging, sprinting, sport-speciic activities, functional bracing as soon
as jogging is begun and continued for 4-8 weeks particularly when engaging in strenuous or competitive activity (Class: R)

• There are advantages and limitations of using an elastic or neoprene sleeve, taping, lexible lace-up or velcro supports,
and semi-rigid supports (stirrup/ air cast type) (Class: C, M, R)

Resumption of normal activity (Class: M)

• Recurrence of ankle injury includes various preventative measures but should be balanced against the risk of activity,
cost of a device and perceived loss of performance

AGREE II score (Table 3.3) iCAHE summary (Table 3.4)

• Scope and purpose: 67 • Information (n=3): 3 yes

• Stakeholder involvement: 75 • Currency (n=3): 2 yes

Guideline quality • Rigour of development: 57 • Evidence (n=4): 2 yes

A Podiatry Perspective

• Clarity of presentation: 83 • Developers (n=2): 2 yes

• Applicability: 88 • Purpose and end users (n=1): 1 yes

• Editorial independence: 100 • Easy to read (n=1): 1 yes

 Chapter 3
There is a paucity of information on the primary studies underpinning the recommendations;
therefore, it is not known whether the indings of these studies are generalisable to the target
Generalisability population (patients 5 years and older presenting with acute lateral pain caused by inversion of
the ankle) of the guideline

Applicability This guideline is directly applicable to the Australian podiatry context

The recommendations may be out of date (as it was published in 2006) and only of moderate
Additional quality with respect to the rigour of development (on the AGREE II) and underlying evidence on
information
the iCAHE Guideline Checklist

5. KNGF (2006) – GUIDELINE FOR PHYSICAL THERAPY IN PATIENTS WITH ACUTE

ANKLE SPRAIN17

Publication date 2006

Guideline is publicly available from www.fysionet-evidencebased.nl/index.php/kngf-

Availability guidelines-in-english

End users Physical therapists treating patients with acute ankle sprains

The guideline contains background 3. Therapy

information on the deinition of acute
• To address the four phases of healing:
ankle sprain, epidemiological data from the
Netherlands, and recommendations on:
1. The screening process, including
presentation, problem identiication,
and pathology requiring medical
atention, information and advice
Phase 1 (inlammatory – 0-3 days post
injury), Phase 2 (proliferation – 4-10 days
post injury), Phase 3 (early remodelling
– 11-21 days post injury) and Phase 4
(late remodelling phase – 3-6 weeks)
including information, advice, exercise,

2. The diagnostic process, including

Content
history taking (including causative
factors, development over time, current
complaints or present status) and
examination (including inspection,
diferential diagnosis, functional
testing, measurement instruments,
analysis, conclusions)
bandaging, tape/bracing, electrophysical 51
agents, footwear
• To address functional instability of
the ankle, including the structure of
physiotherapy, information and advice,
exercise function and activities (gait,
coordination and balance, strength
and endurance, speed, range of motion,
taping, bandaging and bracing) and
managing high loads, e.g. sports)

4. Preventing ankle injuries

Basis of Based on research evidence and expert opinion.

recommendations

Search period Not stated

Sources of Not stated

evidence
Results
Clinical Guidelines For Localised Musculoskeletal Foot Pain

Strength of Grades of recommendation

recommendation
descriptors Review of the evidence Quality levels (intervention and prevention)

1 = One systematic review (A1 quality; see A1 = Systematic reviews included at least
below) or at least two independent studies of some studies of A2 quality, with results
A2 quality consistent across individual studies

2 = At least two independent A2 = Randomised comparative clinical trial

studies of B quality of sound methodological quality (randomised
double-blind controlled trial) of suicient size
3 = One study of A2 or B quality, or several and consistency
studies of C quality
B = Randomised comparative clinical trial
4 = Expert opinion, e.g. that of members of of moderate quality or insuicient size;
the Guideline Commitee other comparative study (non-randomised
comparative cohort study or case-control study)

C = Non-comparative study

D = Expert opinion, e.g. that of members of

the Guideline Commitee

Summary of recommendations

Screening

• Diferential diagnostics for fractures

The Otawa ankle rules are an accurate instrument to exclude fractures within a week ater the ankle sprain is sustained
(Recommendation: 1, Quality of articles: A1)

Diagnostic process

• Passive tests do not generally ofer any added value for the establishment of a physical therapy diagnosis in patients with
ankle sprains (Recommendation: 4, based on Commitee consensus)

• Delayed anterior drawer test can provide supplementary information about the mechanical instability of the ankle
(Recommendation: 3, Quality of articles: A2)

• The use of the delayed anterior drawer test is only indicated for achievement-driven and top-level athletes, to support
the rehabilitation process and the expected return to competition or top-level sporting activities (Recommendation: 4,
Quality of articles: B)

Therapy

• Use of elastic bandages, braces and taping is more efective than immobilisation (Recommendation: 1, Quality of articles: A1)

• There is no conclusive evidence that ultrasound, laser therapy and electrotherapy are efective methods to treat acute
ankle sprains (Recommendation: 1, Quality of articles: A1)

• Short-wave therapy is not an efective method to treat acute ankle sprain (Recommendation: 2, Quality of articles: B)

• Exercises to improve coordination and balance can prevent recurrent ankle sprain among athletes (Recommendation: 2,
Quality of articles: B)

• It is unclear whether bandaging, taping or braces form the most efective treatment in acute ankle sprain
(Recommendation: 2, Commitee consensus)

• The treatment of functional instability, to optimise ankle function, should primarily consist of an exercise program that
is varied and intensive as possible (Recommendation: 3, Quality of articles: C)

• Exercise therapy should be part of the treatment for severe acute ankle sprains (Recommendation: 4, Commitee consensus)
A Podiatry Perspective

• Wobble board exercises alone are insuicient to train all aspects of proprioception. Functional or sport-speciic types
of exercises should be used. Proprioception should be trained across the full range of motion (Recommendation: 4,
Commitee consensus)

• Proprioception training is valuable for athletes who have sustained an acute ankle sprain to prevent recurrence
(Recommendation: 4, Commitee consensus)
 Chapter 3
• An exercise program should be suiciently intensive and include enough repetition to train muscle endurance as well
(Recommendation: 4, Commitee consensus)

• Muscle strength training promotes the recovery of functional instability of the ankle (Recommendation: 3, Quality of
articles: C)

• Icepacks are not an efective method to reduce swelling and pain in acute ankle sprain (Recommendation: 3, Quality of
articles: B)

• Icepacks and compression, combined with rest and elevation, are useful in the acute phase (Recommendation: 4,
Commitee consensus)

• Elastic bandaging is the preferred method of treatment in the acute phase (0-5 days) (Recommendation: 4, Commitee
consensus)

• The choice of taping and using a brace in the rehabilitation process ater the acute phase of an inversion trauma depends
on the patient’s preference. If the patient is an athlete who is being intensively assisted to resume top-level sports
activities, taping can be applied even in the acute phase, provided the tape can be changed every day. An adhesive
bandage is recommended to be used under the tape (Recommendation: 4, Commitee consensus)

• Mobilisation of dorsilexion can be useful for top-level athletes with mild acute ankle injuries (Recommendation: 4,
Commitee consensus)

• The use of passive modalities generally ofers no added value to treatment of functional instability of the ankle
(Recommendation: 4, Commitee consensus)

Preventing ankle injuries

• The use of taping or bracing reduces the risk of ankle sprain in high-risk sports (Recommendation: 1, Quality of articles: A1)

• Manual range of motion exercises initially have a positive impact on dorsilexion of the ankle ater acute or subacute injury
(Recommendation: 2, Quality of articles: A2)

• The therapist should atempt to restore range of motion. If this has insuicient efect, passive techniques can be used as
supplementary treatment (Recommendation: 4, Commitee consensus)

• Routine use of taping or braces during sports or other physically demanding activities can in the long run have a negative
impact on functional stability. Therapists should try to get their patients to gradually reduce the use of external supports.
53
Routine use of taping or braces should only be used by top-level athletes during actual matches (Recommendation: 4,
Commitee consensus)

• Patients should adapt their footwear to the prevailing circumstances, including activities of daily living, work and exercising,
and to the type of the surface. Worn-out footwear should be replaced regularly (Recommendation: 4, Commitee consensus)

AGREE II score (Table 3.3) iCAHE summary (Table 3.4)

• Scope and purpose: 50 • Information (n=3): 3 yes

• Stakeholder involvement: 75 • Currency (n=3): 1 yes

Guideline quality • Rigour of development: 44 • Evidence (n=4): 2 yes

• Clarity of presentation: 97 • Developers (n=2): 2 yes

• Applicability: 65 • Purpose and end users (n=1): 1 yes

• Editorial independence: 4 • Easy to read (n=1): 1 yes

There is a paucity of information on the primary studies underpinning the recommendations;

therefore, it is not known whether the indings of these studies are generalisable to the target
Generalisability population. It must be noted that the detailed methodology and underpinning justiication, and
relevant research evidence could not be accessed, as it is published, and only available, in Dutch

This guideline is directly applicable to the Australian podiatry context; however, it potentially
Applicability contains evidence and recommendations which may be out of date (as it was published in 2006)

Quality scores can be considered as moderate; however, this needs to be interpreted based on
Additional the inability to access the accompanying documents published in Dutch. The recommendations
information
Results

may be out of date (as the guideline was published in 2006)

Clinical Guidelines For Localised Musculoskeletal Foot Pain

6. MCPOIL ET AL (2008) – HEEL PAIN: PLANTAR FASCIITIS (ORTHOPAEDIC

SECTION OF THE AMERICAN PHYSICAL THERAPY ASSOCIATION) 15

Publication date 2008

Availability Guideline publicly available from www.jospt.org/members/getile.asp?id=4158

Used in the management of patients with heel pain or plantar fasciitis by orthopaedic physical
End users therapy clinicians, academic instructors, clinical instructors, students, interns, residents and fellows

Content 1. Impairment/ function-based diagnoses

2. Pathoanatomical features

3. Risk factors

• Clinical course

• Diagnosis and classiication

• Signs and symptoms

• Diferential diagnosis

• Conditions listed include calcaneal stress fracture, bone bruise, fat pad atrophy, tarsal
tunnel syndrome, sot-tissue, primary or metastatic bone tumours, Paget’s disease of
bone, Sever’s disease, and referred pain as a result of an S1 radiculopathy.

• Imaging studies

• Radiographs

4. Examination including outcome measures

• Outcome measures

• Foot Function Index (FFI), Foot Health Status Questionnaire (FHSQ), or FAAM

• Activity limitation measures

• None reported but the Patient-Speciic Functional Scale questionnaire can be used

• Physical impairment measures

• Active and passive ankle dorsilexion, the dorsilexion-eversion test for diagnosis of
tarsal tunnel syndrome, windlass test, and longitudinal arch angle

5. Interventions

• Anti-inlammatory agents • Taping

• Modalities • Orthotic devices
• Manual therapy • Night splints
• Stretching

Basis of Based on research evidence, and included the role of consensus expert opinion and basic science
recommendations research to demonstrate biological and biomechanical plausibility

Search period Prior to May 2007

Sources of evidence Hand-searched published literature (primary and secondary sources) and electronic databases

Strength of Levels of Evidence

recommendation
l = Evidence obtained from high quality randomised controlled trials, prospective studies, or
descriptors
diagnostic studies

ll = Evidence obtained from lesser quality randomised controlled trials, prospective studies, or
A Podiatry Perspective

diagnostic studies (e.g., improper randomisation, no blinding, <80% follow-up)

lll = Case-controlled studies or retrospective studies

lV = Case series

V = Expert opinion
 Chapter 3
Grades of Recommendation

A = Strong evidence – A preponderance of level I and/ or level II studies support the

recommendation. This must include at least 1 level I study

B = Moderate evidence – A single high quality randomised controlled trial or a preponderance

of level II studies support the recommendation

C = Weak evidence – A single level II study or a preponderance of level III and IV studies
including statements of consensus by content experts support the recommendation

D = Conlicting evidence – Higher-quality studies conducted on this topic disagree with respect
to their conclusions. The recommendation is based on these conlicting studies

E = Theoretical/ foundational evidence – A preponderance of evidence from animal or cadaver

studies, from conceptual models/ principles, or from basic sciences/ bench research support this
conclusion

F = Expert opinion – Best practice based on the clinical experience of the guidelines
development team

Summary of recommendations

Impairment/ function-based diagnoses

• Pathoanatomical features The following physical examination measures may be useful

(Recommendation: F, clinicians should assess for
impairments in muscles, tendons, and nerves, as well as the
plantar fascia, when a patient presents with heel pain)
• Risk factors
in classifying a patient with heel pain: system reproduction
with palpatory provocation of the proximal plantar fascia
insertion, active and passive talocrural joint dorsilexion
range of motion, the tarsal tunnel syndrome test, the
windlass test and the longitudinal arch angle)

(Recommendation: B, clinicians should consider limited • Diferential diagnosis

ankle dorsilexion range of motion and a high body mass
index in non-athletic populations as factors predisposing
patients to the development of heel pain/ plantar fasciitis)
• Diagnosis and classiication
(Recommendation: B, functional limitations associated
with pain in the plantar medial heel region, most noticeable
with initial steps ater a period of inactivity but also worse
following prolonged weight-bearing, and oten precipitated
by a recent increase in weight-bearing activity.
(Recommendation: F, clinicians should consider diagnostic
classiications other than heel pain/ plantar fasciitis when 55
the patient’s reported functional limitations or physical
impairments are not consistent with those presented in the
diagnosis/ classiication section of this guideline, or, the
patient’s symptoms are not resolving with interventions
aimed at normalisation of the patient’s physical impairments)

Examination including outcome measures

• Outcome measures • Activity limitation measures

(Recommendation: A, clinicians should use validated self-
report questionnaires, such as the FFI, FHSQ, or the FAAM,
before and ater interventions intended to alleviate the physical
impairments, functional limitations, and activity restrictions
associated with heel pain/ plantar fasciitis. Physical therapists
should consider measuring change over time using the FAAM
as it has been validated in a physical therapy practice seting)
(Recommendation: F, clinicians should utilise easily
reproducible functional limitations and activity restriction
measures associated with the patient’s heel pain/ plantar
fasciitis to assess the changes in the patient’s level of
function over the episode of care)

Interventions

• Orthotic devices • Iontophoresis

(Recommendation: A, prefabricated or custom foot orthoses
can be used to provide short-term [3 months] reduction in
pain and improvement in function. There appear to be no
diferences in the amount of pain reduction or improvement
in function created by custom foot orthoses in comparison
(Recommendation: B, dexamethasone 0.4% or acetic acid 5%
delivered via iontophoresis can be used to provide short-
term [2-4 weeks] pain relief and improved function)
• Taping
Results

to prefabricated orthoses. There is currently no evidence to (Recommendation: C, calcaneal or Low-Dye taping can be
support the use of prefabricated or custom foot orthoses for used to provide short-term [7-10 days] pain relief. Studies
long term [1 year] pain management or function improvement) indicate that taping does cause improvements in function)
Clinical Guidelines For Localised Musculoskeletal Foot Pain

• Stretching • Manual therapy

(Recommendation: B, calf muscle and/ or plantar fascia-
speciic stretching can be used to provide short-term
[2-4 months] pain relief and improvement in calf muscle
lexibility. The dosage for calf stretching can be either 3
times a day or 2 times a day utilising either a sustained [3
minutes] or intermitent [20 seconds] stretching time, as
neither dosage produced a beter efect)
• Night splints
(Recommendation: B, night splints should be considered as an
intervention for patients with symptoms greater than 6 months
in duration. The desired length of time for wearing the night
splint is 1-3 months. The type of night splint used [i.e. posterior,
anterior, sock-type] does not appear to afect the outcome)
(Recommendation: E, there is minimal evidence to support
the use of manual therapy and nerve mobilisation procedures
short-term [1-3 months] for pain and function improvement.
Suggested manual therapy procedures include: talocrural
joint posterior glide, subtalar joint lateral glide, anterior and
posterior glides of the irst tarsometatarsal joint, subtalar
joint distraction manipulation, sot tissue mobilisation
near potential nerve entrapment sites, and passive neural
mobilisation procedures)

AGREE II score (Table 3.3) iCAHE summary (Table 3.4)

• Scope and purpose: 61 • Information (n=3): 3 yes

• Stakeholder involvement: 72 • Currency (n=3): 2 yes

Guideline quality • Rigour of development: 57 • Evidence (n=4): 1 yes

• Clarity of presentation: 89 • Developers (n=2): 1 yes

• Applicability: 52 • Purpose and end users (n=1): 1 yes

• Editorial independence: 0 • Easy to read (n=1): 1 yes

It is likely that the samples studied in the body of evidence would be similar to the target
Generalisability population of the guideline; however, this was not explicitly stated

The recommendations pertaining to the interventions are directly applicable to the Australian
Applicability podiatry context, except for the recommendation on iontophoresis, which is not undertaken by
podiatrists in Australia

The recommendations for the diagnoses, examination types and interventions for this guideline
Additional were comprehensive. The information was referenced but the evidence source was not stated;
information however, the research evidence was graded against research criteria and strength of evidence. This
guideline scored moderately high on the AGREE ll and highly on the iCAHE Guideline Checklist
A Podiatry Perspective
 Chapter 3
7. NATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE (2009) –
INTERVENTIONAL PROCEDURES PROGRAM – INTERVENTIONAL PROCEDURE
OVERVIEW OF EXTRACORPOREAL SHOCKWAVE THERAPY FOR REFRACTORY
PLANTAR FASCIITIS19

Publication date 2009

Availability Guideline publicly available from htp://guidance.nice.org.uk/IPG311

End users Not stated

• Eicacy
Content
• Safety

Basis of Based on a rapid review of the medical literature and specialist opinion
recommendations

Search period Prior to May 2008

Research evidence located from electronic database searches (The Cochrane Database of
Systematic reviews, Database of Abstracts of Reviews of Efects, HTA database, The Cochrane
Sources of Central Database of Controlled trials, Medline, Medline -In- Process, EMBASE, CINAHL, BLIC,
evidence
National Research Register Archive, UK Clinical Research Network Portfolio Database, Current
Controlled Trials metaRegister of Controlled Trials, Clinicaltrials.gov

Strength of
recommendation Not stated
descriptors

Interpretation of the data was diicult due to the diversity of treatment protocols and comparisons
used, varying reported end points, and inconsistencies in terms of the use of local anaesthesia and 57
Summary of energy type. The results of studies (7 randomised controlled trials, 1 cross-sectional survey and
recommendations 1 retrospective review), in terms of eicacy and safety, were conlicting and there was evidence
of substantial placebo response. Therefore, there is inadequate evidence to support the use of
extracorpeal shockwave therapy for the management of refractory plantar fasciitis

AGREE II score (Table 3.3) iCAHE summary (Table 3.4)

• Scope and purpose: 67 • Information (n=3): 3 yes

• Stakeholder involvement: 50 • Currency (n=3): 1 yes

Guideline quality • Rigour of development: 44 • Evidence (n=4): 1 yes

• Clarity of presentation: 42 • Developers (n=2): 0 yes

• Applicability: 25 • Purpose and end users (n=1): 0 yes

• Editorial independence: 0 • Easy to read (n=1): 1 yes

It is highly probable that the samples studied in the body of evidence would be similar to the
Generalisability target population of the guideline

The recommendations pertaining to the intervention are directly applicable to the Australian
Applicability podiatry context; however, podiatrists in Australia refer patients to a specialist/ physician who
will perform the intervention

The guideline developers state that the guideline should not be regarded as a deinitive
Additional assessment of the use of extracorporeal shockwave therapy for refractory plantar fasciitis.
information There was no synthesis of evidence and therefore no summary recommendations. Moreover, a
comprehensive search of the literature was not performed
Results
Clinical Guidelines For Localised Musculoskeletal Foot Pain

8. THOMAS J ET AL (2010) – HEEL PAIN13

Publication date 2010

• Guideline publicly available from www.sciencedirect.com/science/article/pii/

S1067251610000025
Availability • Thomas J, Christensen J, Kravitz S, Mendicino R, Schulerth J, Vanore J, Weil L, Zlotof H,
Bouche R, Baker J (2010) The diagnosis and treatment of heel pain: a clinical practice guideline
– revision 2010. The Journal of Foot and Ankle Surgery 49: S1-S19 doi:10.1053/j.jfas.2010.01.001

End users Not stated

Content

Plantar heel pain (plantar fasciitis, plantar fasciosis, heel spur syndrome)

• Prevalence • Examination
• Aetiology • Treatment options including padding and strapping,
• Signs and symptoms orthotic insoles, oral inlammatory medication, cortisone
injections, stretches, night splints, botulinum toxin,
physical therapy, cast or boot immobilisation, fasciotomy,
extracorporeal shockwave therapy, bipolar radiofrequency

Posterior heel pain (Achilles insertional tendinopathy – enthesopathy / Haglund’s bursitis)

1. Examination

2. Treatment options including

• Non surgical options: heel lits, open backed shoes, cryotherapy, topical analgesics, oral anti-inlammatories, orthoses,
physical therapy, limiting activities, weight loss, immobilisation (cast or CAM walker)

• Surgical options: debridement of the Achilles tendon and surrounding sot tissues, Achilles lengthening or
gastrocnemius resection, extracorporeal shockwave therapy, radiofrequency coblation

Neurologic heel pain (heel pain as a result of an entrapment or irritation of one or more of the nerves that
innervate the region, e.g. tarsal tunnel syndrome and heel neuroma)

• Signs and symptoms • Diferential diagnosis • Treatment

Basis of Consensus of current clinical practice and review of the clinical literature
recommendations

Search period Not stated

Sources of evidence Not stated

Levels of evidence: Grades of recommendation:

I = High quality prospective randomised A = Treatment options are supported by strong

controlled trial evidence (consistent with level I or II studies)

Strength of II = Prospective comparative study B = Treatment options are supported by fair

recommendation III = Retrospective case control study
evidence (consistent with level III or IV studies)
descriptors
C = Treatment options are supported by either
IV = Expert opinion
conlicting or level IV studies

I = Insuicient evidence to make a

recommendation
A Podiatry Perspective
 Chapter 3
Summary of recommendations

Plantar heel pain (plantar fasciitis, plantar fasciosis, heel spur syndrome)

1. Acute management (within 6 weeks 2. Subacute management (up to 6 months

from onset of symptoms) from onset of symptoms)

• Achilles and plantar fascia stretching • Night splint (Recommendation: B)

(Recommendation: B)
• Orthotic insoles (Recommendation: B)
• Padding and strapping (Recommendation: B)
• Oral inlammatory medication (Recommendation: I)
• Prefabricated and custom orthotic insoles
(Recommendation: B)
• Repeat cortisone injections (Recommendation: B)
• Cast or boot immobilisation (Recommendation: C)
• Botulinum toxin (Recommendation: I)
• Physical therapy (Recommendation: I)

3. Chronic management

• Endoscopic plantar fasciotomy, in-step fasciotomy or minimally invasive surgical technique (Recommendation: B)
• Extracorporeal shockwave therapy (Recommendation: B)
• Bipolar radiofrequency (Recommendation: C)

Posterior heel pain (Achilles insertional tendinopathy – enthesopathy)

Surgical management

• Extracorporeal shockwave therapy (Recommendation: B)

• Resection of the posterior superior aspect of the calcaneus, enthesophytes of the Achilles along with pathologic sot
tissue, or more proximal tendon debridement (Recommendation: B)

• Achilles lengthening or gastrocnemius recession (Recommendation: I)

• Radiofrequency coblation (Recommendation: I)

59
Posterior heel pain (Haglund’s bursitis)

Surgical management

• Open resection of the prominent posterior superior aspect of the calcaneus and inlamed bursa (Recommendation: B)

• Calcaneal osteotomy (Recommendation: C)

• Endoscopic calcaneoplasty (Recommendation: I)

Neurologic heel pain

Intervention at both the area of nerve entrapment and the plantar fascia (Recommendation: B)

AGREE II score (Table 3.3) iCAHE summary (Table 3.4)

• Scope and purpose: 36 • Information (n=3): 2 yes

• Stakeholder involvement: 47 • Currency (n=3): 0 yes

Guideline quality • Rigour of development: 19 • Evidence (n=4): 1 yes

• Clarity of presentation: 61 • Developers (n=2): 1 yes

• Applicability: 13 • Purpose and end users (n=1): 0 yes

• Editorial independence: 100 • Easy to read (n=1): 0 yes

The samples studied in the body of evidence may be similar to the target population of the
Generalisability guideline; however, this was not explicitly stated

The recommendations for the management of acute and subacute heel pain are directly
Applicability applicable to the Australian podiatry context
Results

Additional There was a paucity of information provided in the published article regarding the methodology
information used to develop the recommendations
Clinical Guidelines For Localised Musculoskeletal Foot Pain

9. THOMAS J ET AL (2009) – DIGITAL DEFORMITIES8

Publication date 2009

Thomas J, Blitch E, Chaney D, Dinucci K, Eickmeier K, Rubin L, Stapp M, Vanore J (2009)

Availability Diagnosis and treatment of forefoot disorders. Section 1: digital deformities. The Journal of Foot
and Ankle Surgery 48(2): 418.e1-e9 doi:10.1053/j.jfas.2008.12.003

End users Not stated

• Signs and symptoms

• Radiologic indings

Content • Examination

• Diferential diagnosis

• Treatment options including surgical and non-surgical management

Basis of Consensus of current clinical practice and review of the clinical literature
recommendations

Search period Not stated

Sources of evidence Not stated

Strength of
recommendation Not stated that strength of evidence descriptors were used to formulate recommendations
descriptors

• Non-surgical treatment, e.g. padding, orthotic devices or shoe insole modiications,

debridement of hyperkeratotic lesion(s), corticosteroid injections, taping, footwear changes
Summary of
recommendations • Surgical treatment, e.g. tenotomy or tendon lengthening, capsuloligamentous balancing, lexor
tendon transfer, phalangeal head resection, arthrodesis*, metatarsal osteotomy, phalangeal base
resection, exostectomy, amputation (partial or complete), +/- correction of associated pathology

AGREE II score (Table 3.3) iCAHE summary (Table 3.4)

• Scope and purpose: 25 • Information (n=3): 1 yes

• Stakeholder involvement: 31 • Currency (n=3): 0 yes

Guideline quality • Rigour of development: 4 • Evidence (n=4): 0 yes

• Clarity of presentation: 69 • Developers (n=2): 1 yes

• Applicability: 0 • Purpose and end users (n=1): 0 yes

• Editorial independence: 0 • Easy to read (n=1): 0 yes

The samples studied in the body of evidence may be similar to the target population of the
Generalisability guideline; however, this was not explicitly stated

The recommendations for the non-surgical management (particularly padding, orthotic devices
Applicability or shoe insole modiications, debridement of hyperkeratotic lesion(s), taping, footwear changes)
are directly applicable to the Australian podiatry context

Additional There was a paucity of information provided in the published article regarding the methodology
information used to develop the recommendations. Litle evidence was used to justify recommendations

* Of proximal or distal interphalangeal joint(s)

A Podiatry Perspective
 Chapter 3
10. THOMAS J ET AL (2009) – CENTRAL METATARSALGIA9

Publication date 2009

Thomas J, Blitch E, Chaney D, Dinucci K, Eickmeier K, Rubin L, Stapp M, Vanore J (2009)

Availability Diagnosis and treatment of forefoot disorders. Section 2: central metatarsalgia. The Journal of
Foot and Ankle Surgery 48(2): 239-250. doi:10.1053/j.jfas.2008.12.004

End users Not stated

Capsulitis, metatarsal abnormality, metatarsal • Examination

stress fracture or other causes:
• Diferential diagnosis
Content • Signs and symptoms
• Treatment options including surgical
• Radiologic indings and non-surgical management

Basis of Consensus of current clinical practice and review of the clinical literature
recommendations

Search period Not stated

Sources of evidence Not stated

Strength of
recommendation Not stated that strength of evidence descriptors were used to formulate recommendations
descriptors

Summary of Capsulitis and metatarsal abnormality

recommendations
• Non-surgical treatment, e.g. padding, orthotic devices, shoe modiications, injections, non-
steroidal anti-inlammatories
61
• Surgical treatment, e.g. synovectomy, capsuloligamentous repair, metatarsal abnormality
repair, metatarsophalangeal arthroplasty, partial metatarsectomy

Metatarsal stress fracture

• Non-surgical treatment, e.g. immobilisation, of-loading, orthotics, assess biomechanical faults

• Surgical treatment is rare; however, may be required if it is a complete fracture, has failed
to heal or if malunion occurs.

Other causes (e.g. 2nd metatarsal phalangeal instability, avascular necrosis, tu-
mour, foreign body, infection)

• Pathology dependent

• Based upon proper diagnosis

• Surgical consultation as needed

AGREE II score (Table 3.3) iCAHE summary (Table 3.4)

• Scope and purpose: 14 • Information (n=3): 1 yes

• Stakeholder involvement: 28 • Currency (n=3): 0 yes

Guideline quality • Rigour of development: 3 • Evidence (n=4): 0 yes

• Clarity of presentation: 64 • Developers (n=2): 1 yes

• Applicability: 0 • Purpose and end users (n=1): 1 yes

• Editorial independence: 0 • Easy to read (n=1): 0 yes

The samples studied in the body of evidence may be similar to the target population of the
Generalisability
Results

guideline; however, this was not explicitly stated

Clinical Guidelines For Localised Musculoskeletal Foot Pain

The recommendations for the non-surgical management (particularly padding, orthotic devices,
Applicability shoe modiications, of loading) are directly applicable to the Australian podiatry context

Additional There was a paucity of information provided in the published article regarding the methodology
information used to develop the recommendations. Litle evidence was used to justify recommendations

11. THOMAS J ET AL (2009) – MORTON’S INTERMETATARSAL NEUROMA10

Publication date 2009

Thomas J, Blitch E, Chaney D, Dinucci K, Eickmeier K, Rubin L, Stapp M, Vanore J (2009)

Availability Diagnosis and treatment of forefoot disorders. Section 3: Morton’s intermetatarsal neuroma. The
Journal of Foot and Ankle Surgery 48(2): 251-256. doi:10.1053/j.jfas.2008.12.005

End users Not stated

• Signs and symptoms

• Diferential diagnosis
Content • Radiologic indings
• Treatment options including surgical
• Examination and non-surgical management

Basis of Consensus of current clinical practice and review of the clinical literature
recommendations

Search period Not stated

Sources of evidence Not stated

Strength of
recommendation Not stated that strength of evidence descriptors were used to formulate recommendations
descriptors

• Non-surgical treatment, e.g. padding, injection therapy, footwear alteration

Summary of
recommendations • Surgical management, e.g. decompression, injection therapy, and others, such as cryogenic
neuroablation

AGREE II score (Table 3.3) iCAHE summary (Table 3.4)

• Scope and purpose: 11 • Information (n=3): 1 yes

• Stakeholder involvement: 28 • Currency (n=3): 0 yes

Guideline quality • Rigour of development: 5 • Evidence (n=4): 0 yes

• Clarity of presentation: 64 • Developers (n=2): 1 yes

• Applicability: 0 • Purpose and end users (n=1): 1 yes

• Editorial independence: 0 • Easy to read (n=1): 0 yes

The samples studied in the body of evidence may be similar to the target population of the
Generalisability guideline; however, this was not explicitly stated

The recommendations for the non-surgical management (particularly pads and footwear
Applicability alteration) are directly applicable to the Australian podiatry context

Additional There was a paucity of information provided in the published article regarding the methodology
A Podiatry Perspective

information used to develop the recommendations. Litle evidence was used to justify recommendations
 Chapter 3
12. THOMAS J ET AL (2009C) – TAILOR’S BUNION11

Publication date 2009

Thomas J, Blitch E, Chaney D, Dinucci K, Eickmeier K, Rubin L, Stapp M, Vanore J (2009)

Availability Diagnosis and treatment of forefoot disorders. Section 4: Tailor’s bunion. The Journal of Foot and
Ankle Surgery 48(2): 257-263. doi:10.1053/j.jfas.2008.12.006

End users Not stated

• Signs and symptoms • Diferential diagnosis

Content • Radiologic indings • Treatment options including surgical

and non-surgical management
• Examination

Basis of Consensus of current clinical practice and review of the clinical literature
recommendations

Search period Not stated

Sources of evidence Not stated

Strength of
recommendation Not stated that strength of evidence descriptors were used to formulate recommendations
descriptors

• Non-surgical treatment, e.g. debridement of hyperkeratotic lesions, padding, footwear

Summary of alterations, injections, orthotic devices/ insoles
recommendations
• Surgical treatment, e.g. exostectomy, osteotomy, metatarsal head resection

AGREE II score (Table 3.3) iCAHE summary (Table 3.4)

63
• Scope and purpose: 6 • Information (n=3): 1 yes

• Stakeholder involvement: 28 • Currency (n=3): 0 yes

Guideline quality • Rigour of development: 3 • Evidence (n=4): 0 yes

• Clarity of presentation: 64 • Developers (n=2): 1 yes

• Applicability: 0 • Purpose and end users (n=1): 0 yes

• Editorial independence: 0 • Easy to read (n=1): 0 yes

The samples studied in the body of evidence may be similar to the target population of the
Generalisability guideline; however, this was not explicitly stated

The recommendations for the non-surgical management (particularly debridement of

Applicability hyperkeratotic lesions, padding, footwear alterations, and orthotic devices/ insoles) are directly
applicable to the Australian podiatry context

Additional There was a paucity of information provided in the published article regarding the methodology
information used to develop the recommendations. Litle evidence was used to justify recommendations

13. THOMAS J ET AL (2009) – TRAUMA12

Publication date 2009

Thomas J, Blitch E, Chaney D, Dinucci K, Eickmeier K, Rubin L, Stapp M, Vanore J (2009)

Availability Diagnosis and treatment of forefoot disorders. Section 5: trauma. The Journal of Foot and Ankle
Surgery 48(2): 264-272. doi:10.1053/j.jfas.2008.12.007
Results
Clinical Guidelines For Localised Musculoskeletal Foot Pain

End users Not stated

• Signs and symptoms • Examination

Content • Radiologic evaluation • Treatment options including surgical
and non-surgical management

Basis of Consensus of current clinical practice and review of the clinical literature
recommendations

Search period Not stated

Sources of evidence Not stated

Strength of
recommendation Not stated that strength of evidence descriptors were used to formulate recommendations
descriptors

Summary of recommendations

Non-surgical treatment

1. Fractures 3. Sot tissue injury (negative diagnosis of fracture or

• Immobilisation for non-displaced fractures dislocation)
• Wound care and tetanus prophylaxis
2. Dislocation for puncture wounds
• Closed reduction • Irrigation of nail bed injuries

Surgical treatment

1. Fractures 3. Sot tissue injuries

• Closed or open reduction for displaced fractures, • Resection of the bone to proximal level for degloving
arthroplasty for signiicant intra-articular fractures injuries of the nail bed and distal phalanx. This allows
2. Dislocation for adequate sot tissue coverage

• Open reduction where there is sot tissue interposition • Open repair of tendon lacerations

• Late repair and balancing of capsuloligamentous • Surgical decompression of compartment syndrome

tissues is rarely necessary

Guideline quality AGREE II score (Table 3.3) iCAHE summary (Table 3.4)

• Scope and purpose: 14 • Information (n=3): 1 yes

• Stakeholder involvement: 28 • Currency (n=3): 0 yes

• Rigour of development: 3 • Evidence (n=4): 0 yes

• Clarity of presentation: 53 • Developers (n=2): 1 yes

• Applicability: 0 • Purpose and end users (n=1): 0 yes

• Editorial independence: 0 • Easy to read (n=1): 0 yes

The samples studied in the body of evidence may be similar to the target population of the
Generalisability guideline; however, this was not explicitly stated

The recommendations for the non-surgical management (particularly for sot tissue injuries) are
Applicability directly applicable to the Australian podiatry context

Additional There was a paucity of information provided in the published article regarding the methodology
information used to develop the recommendations. Litle evidence was used to justify recommendations
A Podiatry Perspective
 Chapter 3
14. WORK LOSS DATA INSTITUTE (2013) – ODG INTEGRATED TREATMENT/
DISABILITY DURATION GUIDELINES – OCCUPATIONAL DISORDERS OF THE
FOOT AND ANKLE20

Publication date 2013

• Summary is publicly available from the National Guideline Clearinghouse

Availability • Full guideline is available in electronic form to subscribers from the Work Loss Data
Institute website. Print copies are also available from the Work Loss Data Institute, 169
Saxony Road, Suite 210, Encinitas, CA 92024, USA www.worklossdata.com

Treating physicians, allied health care providers, insurance claims professions, nurse case
End users managers, workers compensation authorities, employee representatives, to improve outcomes
for any claim that might be seen in a jurisdictional workers’ compensation system

99% of foot and ankle conditions. Recommendations include

• Evaluation including imaging

Content
• Treatment codes for automated approval
• Return to work pathways

Basis of Review of the clinical literature and consensus

recommendations

Search period 1993 – 2013

MEDLINE, Cochrane Library, MD Consult, CINAHL, e Medicine, other relevant treatment

Sources of guidelines (e.g. National Guideline Clearinghouse), conference proceedings in Occupational
evidence
Health, and disability evaluation

Strength of recommendation descriptors 65

1. Acknowledges that diferent study designs and
strength of recommendation descriptors are used for
intervention, prognostic, diagnostic and economic
studies. Therefore, a strength of recommendation
framework is not used in these guidelines. Instead,
investigations and techniques are classiied as
“recommended”, “not recommended” or “under study”
2. Evidence is ranked according to type of evidence:
1) systematic review/ meta analysis; 2) controlled
trial – randomised or controlled; 3) cohort study
– prospective or retrospective; 4) case series; 5)
unstructured review; 6) nationally recognised
treatment guideline (from www.guidelines.gov);
7) state treatment guideline; 8) other treatment
guideline; 9) textbook; 10) conference proceedings/
presentation slides; 11) case reports and descriptions
3. The quality of evidence is ranked
within each type of evidence:
• High quality: 1) Sample size: generally over 300, but at
least 100, depending on other factors below; 2) Conlict of
interest: authors and researchers had no inancial interest
in the product or service being studied; 3) Study design:
ideally blinded, and no identiiable bias, including recall
bias, confounding factors, selection bias, compliance bias,
non-response bias, or measurement bias. If a case series,
should be a case control series; 4) Statistical signiicance:
99% conidence level that the outcomes likelihood ratio
• Medium quality: 1) Sample size: from 20-50 up to
100-300, depending on other factors below; 2) Conlict
of interest: authors and researchers had no inancial
interest in the product or service being studied; 3)
Study design: no signiicant bias, including recall bias,
confounding factors, selection bias, compliance bias,
non-response bias, or measurement bias. If a case
series, should be a case control series; 4) Statistical
signiicance: 95% conidence level that the outcomes
likelihood ratio will not cross 1.0 (i.e. the p value is 0.05)
• Low quality: 1) Sample size: generally under 20-50,
depending on other factors below, but no less than 10; 2)
Conlict of interest: authors and researchers may have
had some inancial interest in the product or service being
studied, even if the sample size was large; 3) Study design:
some obvious bias, including recall bias, confounding
factors, selection bias, compliance bias, non-response bias,
or measurement; 4) Statistical signiicance: does not meet
the 95% conidence level that the outcomes likelihood
ratio will not cross 1.0 (i.e. the p value is 0.05)
Results

will not cross 1.0 (i.e. the p value is 0.01)

Clinical Guidelines For Localised Musculoskeletal Foot Pain

Summary of recommendations

Achilles tendinopathy

• Recommendation: Eccentric exercise • Not recommended: Extracorporeal shockwave therapy

Achilles tendon rupture

• Recommendation: Early motion irrespective of whether the rupture is managed conservatively or surgically

Hallux valgus and hallux varus

• Recommendations

1. Cold packs for acute injuries for 24-48 hours and with continued swelling

2. Apply heat before any stretching exercises

3. Osteotomy is more beneicial than orthoses or no treatment, but no osteotomy technique is superior

Hammer toe

• Recommendations: see Thomas J et al (2009) – Digital deformities8, table on p60

Lateral ankle sprain

• Recommendations

1. Early mobilisation and partial weight-bearing

2. NSAIDs for pain relief

3. Immobilisation of ankle, plus active or passive therapy, for 4-6 weeks if joint is unstable

4. Lace-up support to decrease swelling in the short term but slower return to work

5. Semi-rigid orthoses and pneumatic braces may assist in preventing subsequent sprains during high risk sporting activities

• Not recommended

Cast or brace (immobilisation) if a severe ankle sprain

Morton’s neuroma

• Recommendations • Conlicting or no supporting evidence

1. Avoid high-heeled and narrow shoes 1. Insoles

2. Corticosteroid injections
2. Reduce pressure using a metatarsal pad orthotic device
3. Transposition of the transected plantar digital nerve
3. Surgery (excision of nerve, 82% report excellent or good
• Not recommended: none
post-operative results)

Plantar fasciitis and heel spur

• Recommendations • Conlicting results

1. Conservative management Extracorporeal shockwave therapy

2. Heel pads and stretching in combination (as more • Not recommended
efective than either technique alone)
1. Iontophoresis
3. Orthotics, especially for people who stand for more
2. Insoles with magnetic foil
than 8 hours per day
3. Ultrasound
4. Plantar fascia stretches
A Podiatry Perspective

4. Botulinum toxin
5. Night splints with ankle in dorsilexion
5. Surgical management
6. Tension night splints used in combination with heel
pads, stretching program and NSAIDs
7. Corticosteroids
 Chapter 3
AGREE II score (Table 3.3) iCAHE summary (Table 3.4)

• Scope and purpose: 61 • Information (n=3): 3 yes

• Stakeholder involvement: 81 • Currency (n=3): 2 yes

Guideline quality • Rigour of development: 94 • Evidence (n=4): 4 yes

• Clarity of presentation: 78 • Developers (n=2): 2 yes

• Applicability: 71 • Purpose and end users (n=1): 1 yes

• Editorial independence: 100 • Easy to read (n=1): 0 yes

Generalisability The samples studied in the body of evidence tend to be similar to the target population of the guideline

The recommendations for non-surgical management are directly

Applicability applicable to the Australian podiatry context

This guideline is web based, which increases the ease of navigation, compared with a printed copy.
Updated monthly based on new sources of evidence. Includes a large number of foot and ankle
Additional diagnoses, all of which contain treatment codes for automated approval and return to work pathways.
information However, evidence-based recommendations are diicult to ind, as this requires the user to select
and read through each code for automated approval. Moreover, although these recommendations are
linked to research evidence, the evidence is not synthesised but rather linked to individual studies

67

Results
Clinical Guidelines For Localised Musculoskeletal Foot Pain
3.6
1. Academy of Ambulatory Foot and Ankle Surgery
(2003a) Hallux abductovalgus. Philadelphia (PA):
Academy of Foot and Ankle Surgery.
2. Academy of Ambulatory Foot and Ankle Surgery
(2003b) Hallux limitus and hallux rigidus. Philadelphia
(PA): Academy of Foot and Ankle Surgery.
3. Academy of Ambulatory Foot and Ankle Surgery
(2003c) Hammertoe syndrome. Philadelphia (PA):
Academy of Foot and Ankle Surgery.
4. Academy of Ambulatory Foot and Ankle Surgery
(2003d) Heel spur syndrome. Philadelphia (PA):
Academy of Foot and Ankle Surgery.
5. Academy of Ambulatory Foot and Ankle Surgery
(2003e) Intermetatarsal neuroma. Philadelphia (PA):
Academy of Foot and Ankle Surgery.
6. Academy of Ambulatory Foot and Ankle Surgery
(2003f) Metatarsalgia / intractable plantar keratosis
/ Tailor’s bunion. Philadelphia (PA): Academy of Foot
and Ankle Surgery.
7. American Academy of Orthopaedic Surgeons (2009)
The diagnosis and treatment of acute Achilles tendon
rupture: guideline and evidence report. Rosemont
(IL): American Academy of Orthopaedic Surgeons.
8. Thomas J, Blitch EL, Chaney D, Dinucci K, Eickmeier
K, Rubin L, Stapp M, Vanore J (2009) Diagnosis and
treatment of forefoot disorders. Section 1: Digital
deformities. The Journal of Foot and Ankle Surgery
48(2): 418e1-e9.
9. Thomas J, Blitch EL, Chaney D, Dinucci K, Eickmeier
K, Rubin L, Stapp M, Vanore J (2009) Diagnosis and
treatment of forefoot disorders. Section 2: Central
metatarsalgia. The Journal of Foot and Ankle Surgery
48(2): 239-250.
10. Thomas J, Blitch EL, Chaney D, Dinucci K, Eickmeier
K, Rubin L, Stapp M, Vanore J (2009) Diagnosis and
treatment of forefoot disorders. Section 3: Morton’s
intermetatarsal neuroma. The Journal of Foot and
Ankle Surgery 48(2): 251-256.
11. Thomas J, Blitch EL, Chaney D, Dinucci K, Eickmeier
K, Rubin L, Stapp M, Vanore J (2009) Diagnosis and
treatment of forefoot disorders. Section 4: Tailor’s
bunion. The Journal of Foot and Ankle Surgery 48(2):
257-263.
A Podiatry Perspective
REFERENCES
12. Thomas J, Blitch EL, Chaney D, Dinucci K, Eickmeier
K, Rubin L, Stapp M, Vanore J (2009) Diagnosis and
treatment of forefoot disorders. Section 5: trauma.
The Journal of Foot and Ankle Surgery 48(2): 264-272.
13. Thomas J, Christensen J, Kravitz S, Mendicino R,
Schulerth J, Vanore J, Weil L, Zlotof H, Bouche R,
Baker J (2010) The diagnosis and treatment of heel
pain: a clinical practice guideline – revision 2010.
The Journal of Foot and Ankle Surgery 49: S1-S19.
doi:10.1053/j.jfas.2010.01.001
14. American College of Occupational and
Environmental Medicine (2011) Ankle and
foot disorders. Illinois: American College of
Occupational and Environmental Medicine.
15. McPoil TG, Martin RL, Cornwall MW, Wukich DK,
Irrgang JJ, Godges JJ. Heel pain-plantar fasciitis:
clinical practice guidelines linked to the International
Classiication of Function, Disability, and Health from
the Orthopaedic Section of the American Physical
Therapy Association. Journal of Orthopaedic and
Sports Physical Therapy 38(4):A1-18. doi:10.2519/
jospt.2008.0302
16. Carcia C, Martin R, Houck J, Wukich D (2010) Achilles
pain, stifness, and muscle power deicits: Achilles
tendinitis, clinical practice guidelines linked to the
International Classiication of Functioning, Disability
and Health from the Orthopaedic Section of the
American Physical Therapy Association. Journal of
Orthopaedic Sports and Physical Therapy 40(9): A1-
A26. doi:10.2519/jospt.2010.0305
17. Koninklijk Nederlands Genootschap voor Fysiotherapie
(2009) KNGF – guideline for physical therapy in
patients with acute ankle sprain. Amstfoort: Koninklijk
Nederlands Genootschap voor Fysiotherapie.
18. Institute for Clinical Systems Improvement (2006)
Ankle sprain. Bloomington (MN): Institute for Clinical
Systems Improvement.
19. National Institute for Health and Care Excellence
(2009) Interventional procedures program –
Interventional procedure overview of extracorporeal
shockwave therapy for refractory plantar fasciitis.
London, UK: National Institute for Health and Care
Excellence: London.
20. Work Loss Data Institute (2011) Ankle and foot (acute
and chronic). Encinitas (CA): Work Loss Data Institute.
 Chapter 1
Chapter 4 69

Discussion

Background
Clinical Guidelines For Localised Musculoskeletal Foot Pain
Chapter 4
4.1
This is the irst study, known to the authors, that has
systematically identiied and critically appraised the quality of
clinical guidelines for localised musculoskeletal foot and ankle
pain. We found 14 clinical guidelines on the management of
localised musculoskeletal foot and ankle conditions that are
current and relevant to podiatry practice in the Australian
health care context. This volume of knowledge is considerably
smaller compared with other musculoskeletal and medical
guidelines. For example, over a decade ago Grimmer et
al1 found nine publicly available clinical guidelines relevant
to the physiotherapy management of low back pain. The
search strategy they used was more speciic compared with
the search used in this study. MacDermid2, in 2003, found
44 upper limb clinical guidelines that were relevant to hand
therapists. Moreover, Buchan et al3, who sourced clinical
guidelines from 179 Australian health-related organisations,
found that clinical guidelines were developed in the key
health care areas of drugs and alcohol, infectious diseases,
mental health, renal disease, pregnancy and childbirth,
cardiovascular disease and cancer. At the time of their study,
in 2006, more than 15 guidelines were identiied in each of
these key health care areas.
In addition to the 14 clinical guidelines included in this review,
a further six foot and ankle guidelines were identiied by
our search strategy.4-9 However, these guidelines were not
publicly available nor did the developers wish to provide
information for the purposes of this study. Therefore, users of
guidelines need to be mindful that relevant information may
exist but not be accessible to use in clinical decision-making.
Moreover, permission was gained from the developers of two
guidelines10,11 to access information for this study. Normally,
individuals and organisations would have to pay for this
access. This may potentially limit the use of these guidelines
in clinical decision-making.
The smaller volume of foot and ankle clinical guidelines,
compared with other musculoskeletal and medical clinical
guidelines, may be attributed to the relative paucity
of systematic reviews and primary studies in this area.
Systematic reviews, which are a systematic identiication
and synthesis of research evidence, have been cited as
a critical step in formulating recommendations found in
clinical guidelines.12,13 Moreover, it is acknowledged that
in the absence of evidence, recommendations may be
developed based on group consensus. The Guidelines
International Network recommends that the method used
to gain consensus must be clearly described in detail. This
includes the process for choosing group members, the chair,
and the processes used by the group to deliberate about
the evidence and formulate recommendations.13 We found
that 12 of the 14 foot and ankle clinical guidelines identiied
in this study used both evidence and consensus opinion to
A Podiatry Perspective
formulate recommendations.6,10,11,14-23 However, often the
search strategy used to identify the relevant evidence or
the methods used to gain consensus were not provided in
suicient detail for the reader to gain an understanding of
the key components of the methodology used in guideline
INTERPRETATION OF RESULTS
development. This information is often used to assist in
describing the quality of clinical guidelines.
Less than half (42%) of the guidelines included in this study
were developed by podiatrists,18-23 yet all the guidelines
identiied and appraised in this study are relevant to the
practice of podiatry in Australia. In the absence of relevant
research evidence, expert opinions from relevant health
professionals, such as podiatrists, add a signiicant body of
knowledge to conservative treatment options for people
with musculoskeletal foot and ankle conditions worldwide.
Therefore, opportunities exist for podiatrists to be involved
in the development of future foot and ankle clinical
guidelines for musculoskeletal foot and ankle conditions.
Future guidelines could be: 1) profession-speciic and focus
on podiatric assessment or management techniques; or 2)
condition-speciic and involve input from a range of relevant
health professionals, including expert podiatrists, which
mirrors service provision in the Australian health care context.
The results of this systematic review demonstrate that there
is a need to improve the guideline development process
and reporting of the search strategy, selection of research
evidence and quality rating(s) used, and the methods used
to formulate the strength of the recommendations. The
quality of the foot and ankle clinical guidelines identiied in
this study varied greatly. The AGREE II domain scores were
variable across ive of the six domains: Scope and purpose
(range = 621 – 9410), Stakeholder involvement (range = 2819-22 –
8310), Rigour of development (range = 4217 – 9410), Applicability
(range = 018-22 – 10010,24) and Editorial independence (range
= 014,16,18-22 – 10011,23). The Clarity of presentation domain
tended to be rated consistently more highly in comparison.
This observation of the variable quality of foot and ankle
clinical guidelines highlights that readers should not simply
accept and implement guideline recommendations but
consider these recommendations in light of the quality of
the guideline. Moreover, it must also be noted that according
to AGREE II scoring instructions,25 low domain scores are a
product of no relevant information found. This means that
the six domains on the AGREE II provide a quality rating of the
reporting contained within a clinical guideline, rather than an
indication of guideline quality per se.
It has been noted by other research groups that the
development of clinical guidelines has become more rigorous
in more recently developed guidelines.26 This observation
was present in the clinical guidelines identiied in this study,
with those developed in the last four years10,11,27 having higher
AGREE II ratings than those developed earlier. Moreover,
two clinical guidelines identiied15,24 were developed more
than ive years ago, which is outside the period of time in
which guidelines are recommended to be updated. This
means that the research evidence in which the guidelines
are contained, and on which recommendations are based,
may be superseded by more up-to-date evidence.28 Users of
clinical guidelines, therefore, must be mindful not only of the
method of guideline development but also the currency of
guideline development.

In this study, we identiied that diferent methodologies were
used to rate the strength of recommendations. For example,
strength of evidence recommendations could be based on:
1) study design;16,24,24 2) number and quality of studies;15 3)
beneits versus harm plus the strength of evidence;10,27 and 4)
a combination of other criteria, such as sample size, conlict
of interest, study design and statistical signiicance.11 As a
4.2 RECOMMENDATIONS FOR CLINICAL PRACTICE
This work aimed to systematically identify and critically
appraise existing clinical guidelines that address
musculoskeletal sources of foot and ankle pain. The
recommendations from these guidelines were extracted
and interpreted with respect to their generalisability to the
Australian podiatry context. Based on the indings of this
study, recommendations from clinical guidelines should be
used to assist in the operationalisation of evidence-based
practice; that is “integrating the best available evidence
with practitioner expertise and other resources, and with
the characteristics, state, needs, values and preferences
of those who are afected. This is done in a manner that
is compatible with the environmental and organizational
context”.31 We therefore recommend that podiatrists
practising in Australia should:
4.3
This study illustrates the paucity of involvement of the
podiatry profession in the development of musculoskeletal
clinical guidelines for foot and ankle conditions. This lack
of involvement, however, highlights the opportunity for
the podiatry profession in Australia to make a signiicant
contribution to the development of future podiatry clinical
guidelines, which can be used both within Australia and
internationally. This signiicant opportunity may assist
to further legitimise the podiatry profession in Australia
to external stakeholders, such as potential patients and
insurance companies.26,27 This is often diicult to achieve
in a small profession such as podiatry, which comprised
less than 3,500 registered podiatrists in Australia in April
2011, compared with approximately 29,000 registered
psychologists, 26,000 registered pharmacists, 22,000
registered physiotherapists and 18,000 registered dental
practitioners.34 Speciically, we recommend that:
4.4
This systematic review of foot and ankle clinical guidelines
for localised musculoskeletal disorders identiied 14 clinical
guidelines which can be applied to the Australian podiatry
context. These guidelines range in quality based on the
4.5
1. Grimmer K, Milanese S, Bialocerkowski A (2003)
Clinical guidelines for low back pain: physiotherapy
perspective. Physiotherapy Canada 55: 185-194.
Chapter 4
consequence, a synthesis of guideline recommendations per
condition could not be undertaken, using the methodology
as described by Koes et al.29 Another limitation of this study
is that only English-language guidelines were sourced.
However, more than 80% of Australians speak English at
home30 and English is the primary language of health service
provision in Australia.
1. Use the recommendations made in the highest
quality, up-to-date clinical guidelines to inform
evidence-based decision-making
2. Use evidence and consensus-based summaries made
in the highest quality, up-to-date clinical guidelines
to provide patients with accurate information on
the evidence base underpinning treatment options,
including beneits versus harm
3. Incorporate recommendations from moderate quality,
up-to-date clinical guidelines in clinical decision-
making, while ensuring that patients understand the
evidence base underpinning treatment options.
These recommendations will assist in increasing the
transparency of podiatry clinical practice in Australia.32,33
IMPLICATIONS FOR RESEARCH
1. Systematic reviews should be conducted to
identify evidence that underpins the most efective 71
interventions for the most prevalent conditions
treated by podiatrists in Australia
2. In the absence of high quality evidence, primary studies
should be conducted which investigate the efectiveness
of various types of interventions for the most prevalent
conditions treated by Australian podiatrists
3. In the absence of high quality evidence, consensus-
based research, such as studies that use the
Delphi technique, should be undertaken to identify
assessment techniques and interventions that should
be considered for use in the management of clients
who present to podiatrists in Australia.
These recommendations are based on a thorough
understanding of the type and prevalence of conditions that
present for podiatric management in Australia.
CONCLUSION
AGREE II and iCAHE Guideline Checklist. It is recommended
that Australian podiatrists use moderate and high quality,
up-to-date clinical guidelines in clinical decision making, to
provide the best possible care to their patients.
REFERENCES
Discussion
2. MacDermid J (2005) The quality of clinical practice
guidelines in hand therapy. Journal of Hand Therapy
17: 200-209.
Clinical Guidelines For Localised Musculoskeletal Foot Pain
3. Buchan H, Currie K, Lourey E, Duggam G (2010)
Australian clinical practice guidelines – a national
study. Medical Journal of Australia 192: 490-494.
4. Academy of Ambulatory Foot and Ankle Surgery
(2003a) Hallux abductovalgus. Philadelphia (PA):
Academy of Ambulatory Foot and Ankle Surgery.
5. Academy of Ambulatory Foot and Ankle Surgery
(2003b) Hallux limitus and hallux rigidus. Philadelphia
(PA): Academy of Ambulatory Foot and Ankle Surgery.
6. Academy of Ambulatory Foot and Ankle Surgery
(2003c) Hammertoe syndrome. Philadelphia (PA):
Academy of Ambulatory Foot and Ankle Surgery.
7. Academy of Ambulatory Foot and Ankle Surgery
(2003d) Heel spur syndrome. Philadelphia (PA):
Academy of Ambulatory Foot and Ankle Surgery.
8. Academy of Ambulatory Foot and Ankle Surgery
(2003e) Intermetatarsal neuroma. Philadelphia (PA):
Academy of Ambulatory Foot and Ankle Surgery.
9. Academy of Ambulatory Foot and Ankle Surgery
(2003f) Metatarsalgia / intractable plantar keratosis
/ Tailor’s bunion. Philadelphia (PA): Academy of
Ambulatory Foot and Ankle Surgery.
10. American College of Occupational and
Environmental Medicine (2011) Ankle and
foot disorders. Illinois: American College of
Occupational and Environmental Medicine.
11. Work Loss Data Institute (2011) Ankle and foot (acute
and chronic). Encinitas (CA): Work Loss Data Institute.
12. Chung K, Shauver M (2009) Crafting practice
guidelines in the world of evidence-based medicine.
Plastic and Reconstructive Surgery 124: 1349-1354.
13. Qaseem A, Forland F, Macbeth F, Ollenschlager
G, Phillips S, van der Wees P (2012) Guidelines
International Network: toward international
standards for clinical practice guidelines. Annals of
Internal Medicine 156: 525-531.
14. Carcia C, Martin R, Houck J, Wukich D (2010) Achilles
pain, stifness, and muscle power deicits: Achilles
tendinitis, clinical practice guidelines linked to the
International Classiication of Functioning, Disability
and Health from the Orthopaedic Section of the
American Physical Therapy Association. Journal of
Orthopaedic Sports and Physical Therapy 40(9):A1-
A26. doi:10.2519/jospt.2010.0305
15. Koninklijk Nederlands Genootschap voor Fysiotherapie
(2009) KNGF – guideline for physical therapy in
patients with acute ankle sprain. Amstfoort: Koninklijk
Nederlands Genootschap voor Fysiotherapie.
16. McPoil TG, Martin RL, Cornwall MW, Wukich DK,
Irrgang JJ, Godges JJ (2008) Heel pain--plantar
fasciitis: clinical practice guidelines linked to the
International Classiication of Function, Disability,
and Health from the Orthopaedic Section of the
American Physical Therapy Association. Journal of
Orthopaedic and Sports Physical Therapy 38(4): A1-18.
doi:10.2519/jospt.2008.0302
17. National Institute for Health and Care Excellence (2009)
Interventional procedures program – Interventional
A Podiatry Perspective
procedure overview of extracorporeal shockwave
therapy for refractory plantar fasciitis. London, UK:
National Institute for Health and Care Excellence.
18. Thomas J, Blitch EL, Chaney D, Dinucci K, Eickmeier
K, Rubin L, Stapp M, Vanore J (2009) Diagnosis and
treatment of forefoot disorders. Section 1: Digital
deformities. The Journal of Foot and Ankle Surgery
48(2): 418e1-e9.
19. Thomas J, Blitch EL, Chaney D, Dinucci K, Eickmeier
K, Rubin L, Stapp M, Vanore J (2009) Diagnosis and
treatment of forefoot disorders. Section 2: central
metatarsalgia. The Journal of Foot and Ankle Surgery
48(2): 229-250.
20. Thomas J, Blitch EL, Chaney D, Dinucci K, Eickmeier
K, Rubin L, Stapp M, Vanore J (2009) Diagnosis and
treatment of forefoot disorders. Section 3: Morton’s
neuroma. The Journal of Foot and Ankle Surgery
48(2): 251-256.
21. Thomas J, Blitch EL, Chaney D, Dinucci K, Eickmeier
K, Rubin L, Stapp M, Vanore J (2009) Diagnosis and
treatment of forefoot disorders. Section 4: Tailor’s
bunion. The Journal of Foot and Ankle Surgery 48(2):
257-262.
22. Thomas J, Blitch EL, Chaney D, Dinucci K, Eickmeier
K, Rubin L, Stapp M, Vanore J (2009) Diagnosis and
treatment of forefoot disorders. Section 5: trauma.
The Journal of Foot and Ankle Surgery 48(2): 264-272.
23. Thomas J, Christensen J, Kravitz S, Mendicino R,
Schuberth J, Vanore J, Weil L, Zlotof H, Bouche R,
Baker J (2010) The diagnosis and treatment of heel
pain: a clinical practice guideline – revision 2010. The
Journal of Foot and Ankle Surgery 49: S1-S19.
24. Institute for Clinical Systems Improvement (2006)
Ankle sprain. Bloomington (MN): Institute for Clinical
Systems Improvement.
25. AGREE II manual
26. Graham I, Beardall S, Carter A, Tetroe J, Davies
B (2003) The state of the science and art of
practice guidelines development, dissemination
and evaluation in Canada. Journal of Evaluation in
Clinical Practice 9: 195-202.
27. American Academy of Orthopaedic Surgeons (2009)
The iagnosis and treatment of acute Achilles tendon
rupture: guideline and evidence report. Rosemont
(IL): American Academy of Orthopaedic Surgeons.
28. Grimmer-Somers K and Luker J (2010) Upgrading
/ updating a guideline. In Grimmer-Somers K and
Worley A. Practical tips for using and developing
guidelines: an allied health primer. Manila: UST
Publishing House, pp. 53-68.
29. Koes B, van Tulder M, Ostelo R, Burton K, Waddell
G (2001) Clinical guidelines for the management
of low back pain in primary care: an international
comparison. Spine 26: 2504-2513.
30. Australian Bureau of Statistics. Relecting a
nation – stories from the 2011 census 2012-
2013, www.abs.gov.au/ausstats/abs@.nsf/
Lookup/2071.0main+features902012-2013
31. Evidence-based Behavioral Practice, www.ebbp.org
32. Eddy D (1990) Clinical decision making from theory
to practice: guidelines for policy statements – the
explicit approach. Journal of the American Medical
Association 263: 2239-2240, 2243.
33. Grimshaw J, Hutchinson A (1995) Clinical practice
guidelines: do they enhance value for money in
health care? British Medical Bulletin 51: 927-940.
34. Podiatry Board of Australia. Snapshot of National
Registers, www.podiatryboard.gov.au/News/
Snapshot-of-national-registers-Media-Release.aspx
 Chapter 1
Appendix 73

AGREE II score calculations

Background
Clinical Guidelines For Localised Musculoskeletal Foot Pain

Appendix AGREE II SCORE CALCULATIONS

AN EXAMPLE BASED ON THE GUIDELINE DEVELOPED BY THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS

Domain 1: Scope and purpose

Appraiser Item 1 Item 2 Item 3 Total

1 7 2 6 15

2 7 7 7 21

Total 14 9 13 36

Maximum possible score 7 (strongly agree) x 3 (items) x 2 (appraisers) = 42

Minimum possible score 1 (strongly disagree) x 3 (items) x 2 (appraisers) = 6

Domain score Obtained score – minimum possible score

Maximum possible score – minimum possible score
= [(36-6) / (42-6)]*100 = 83%

Domain 2: Stakeholder involvement

Appraiser Item 4 Item 5 Item 6 Total

1 7 1 7 15

2 7 4 7 18

Total 14 5 14 33

Maximum possible score 7 (strongly agree) x 3 (items) x 2 (appraisers) = 42

Minimum possible score 1 (strongly disagree) x 3 (items) x 2 (appraisers) = 6

Obtained score – minimum possible score

Domain score Maximum possible score – minimum possible score
= [(33-6) / (42-6)]*100 = 75%

Domain 3: Rigour of development

Appraiser Item 7 Item 8 Item 9 Item 10

1 7 7 5 7

2 7 7 7 7

Total 14 14 12 14

Item 11 Item 12 Item 13 Item 14 Total

6 7 7 1 47

6 7 7 1 49
A Podiatry Perspective

12 14 14 2 96

Maximum possible score 7 (strongly agree) x 8 (items) x 2 (appraisers) = 112

Minimum possible score 1 (strongly disagree) x 8 (items) x 2 (appraisers) = 16

 Appendix
Domain score Obtained score – minimum possible score
Maximum possible score – minimum possible score
= [(96-16) / (112-16)]*100 = 83%

Domain 4: Clarity of presentation

Appraiser Item 15 Item 16 Item 17 Total

1 7 6 7 20

2 7 6 7 20

Total 14 12 14 40

Maximum possible score 7 (strongly agree) x 3 (items) x 2 (appraisers) = 42

Minimum possible score 1 (strongly disagree) x 3 (items) x 2 (appraisers) = 6

Domain score Obtained score – minimum possible score

Maximum possible score – minimum possible score
= [(40-6) / (42-6)]*100 = 94%

Domain 5: Applicability

Appraiser Item 18 Item 19 Item 20 Item 21 Total

1 2 2 1 1 6

2 6 6 7 6 25

Total 8 8 8 7 31
75

Maximum possible score 7 (strongly agree) x 4 (items) x 2 (appraisers) = 56

Minimum possible score 1 (strongly disagree) x 4 (items) x 2 (appraisers) = 8

Domain score Obtained score – minimum possible score

Maximum possible score – minimum possible score
= [(31-8) / 56-8)]*100 = 48%

Domain 6: Editorial independence

Appraiser Item 22 Item 23 Total

1 7 7 14

2 7 7 14

Total 14 14 28

Maximum possible score 7 (strongly agree) x 2 (items) x 2 (appraisers) = 28

Minimum possible score 1 (strongly disagree) x 2 (items) x 2 (appraisers) = 4

Obtained score – minimum possible score

Domain score Maximum possible score – minimum possible score
= [(28-4) / (28-4)]*100 = 100%