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Referral Guidelines

Dr Mark Nelson

Foot & Ankle Specialist

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Referral Guidelines for Primary Care Physicians

These guidelines were developed by the American Podiatric Medical Association in conjunction with the actuarial firm of Milliman & Robertson, Inc., updated June 1999.

Topics:
Ingrown Toenail, Paronychia and Onychia
Mycotic Nail
Foot Orthoses
Heel Pain
Bunion Deformity
Hammertoe Deformity
Diabetic Foot Ulcer

Ingrown Toenail, Paronychia and Onychia

An ingrown toenail (ICD-9: 703.0) is an extremely common condition characterized by pain, tenderness, and swelling at the nail borders. More advanced cases may demonstrate drainage, malodor, erthyema, abscess, paronychia (ICD-9: 681.11), onychia (ICD-9: 681.11) and pyogenic granuloma. A non-healing chronically infected nail may, in some cases, lead to osteomyelitis. Generally, improper cutting of the toenails is the primary cause. Poorly fitting shoes, obesity, biomechanical disturbances, trauma, sports injuries and hyperhidrosis may be contributing factors. If a toenail is cut too short or otherwise inappropriately, a portion of the nail may puncture the periungual skin. This can cause a foreign body reaction leading to inflammation, infection and reactive reparative process. Ingrown toenails have a tendency to recur. In these cases, it may be necessary to perform a partial nail avulsion in conjunction with a matricectomy. All nail surgery must be supported by appropriate postoperative care. Analgesics and/or antibiotics may occasionally be necessary. The use of systemic antibiotics alone, may reverse the infectious process temporarily, but it will fail to cure the ingrown toenail.

The primary care physician should:

  1. Diagnose and treat the majority of painful ingrown toenails by removal of offending portion of nail. In some instances, the toe will need to be anesthetized. In cases of extensive infection, loosening of the nail or significant deformity of the nail, the entire nail may need to be excised and/or the use of antibiotics may be necessary.
  2. Treat the ingrown toenail by recommending specific changes in footwear, hygiene and advising on proper cutting of toenails.
  3. Seek consultation from a podiatrist or orthopedic surgeon when the ingrown toenail is chronic, recurring, involves osteomyelitis, or the patient fails to respond to treatment.  
  4. Seek consultation from a podiatrist, orthopedic surgeon and/or vascular surgeon in a patient with diabetes mellitus, poor vasculature, compromised immune system and any other disease that places the patient at risk.

Mycotic Nail

Mycotic nail or onychomycosis (ICD-9: 110.1) is a primary or secondary fungal infection of the nails seen more commonly on the feet than on the hands. Many of these are asymptomatic even when the nail is deformed. The infections are caused by both dermatophytic and nondermatophytic fungi, as well as yeast. There are four clinical types of onychomycosis, each determined by the area of involvement on the nail plate: distal subungual, white superficial, proximal subungual, and Candida onychomycosis. The manifestations are changes in the nail plate, including thickening, loosening, and alterations in texture, shape, and color. The adjacent periungual tissues are often hyperkeratotic and filled with debris. The differential diagnosis includes psoriasis, lichen planus, onychauxis, traumatic nail hypertrophy and a long list of relatively rare cutaneous genodermatoses. The features of onychomycosis are increased in the lower extremity due to the occlusive effects of shoes, socks and hosiery which create sweat and heat. Mycotic nails are commonly found in individuals who are diabetic or who have a compromised immune system.

Mycotic nails may occasionally present with a variety of problems. Due to the thickness and bulk of the nails, people may experience pain and tenderness upon ambulation and in conventional shoe gear. Occasionally, there is a subungual abscess, ulceration, pyogenic granuloma or bone spur present due to the constant pressure of the thickened nail. Additionally, onychomycosis may serve as a nidus of infection for tinea pedis and pedal intertrigo. Mycotic nails are sometimes a contributing factor in ingrown nails.

The primary care physician should:

  1. Diagnose the mycotic nail through clinical appearance, as well as performing a KOH prep, if necessary, prior to initiation treatment. Fungal culture will occasionally be necessary. Many mycotic nails are asymptomatic, require no treatment and do not require diagnostic testing.  
  2. Treat the mycotic nail by debridement and use of topical and/or oral antifungal medication. Oral antifungal agents are known to have systemic complications and should be used only when symptoms warrant. Recommend specific changes in footwear, hygiene and advise on proper cutting of nails. If treated early, they may respond to topical antifungal lotions or creams if they are constantly applied daily after bathing. The key is consistency of treatment which must be for four to six weeks.  
  3. Seek consultation from a podiatrist, dermatologist or orthopedic surgeon when the mycotic nail is difficult to cut, involves a secondary bacterial infection, in a patient with diabetes mellitus, poor vasculature, compromised immune system and any other disease state that places the patient at risk, with persistent pain, or if the nail fails to respond to adequate treatment.

Foot Orthoses

Foot orthoses are devices used to support, align, balance and improve function. Each of the many types of devices available serves a unique purpose. Although commonly used to correct compensatory joint motion with its associated symptoms, they also delay or prevent deformity. They may also preclude surgery or prevent recurrences of deformities after surgery in some cases. Foot orthoses may be over-the-counter arch supports or custom fabricated from casts.

Foot orthoses allow the body to function more efficiently and effectively. They may help resolve soft tissue inflammatory conditions, such as: plantar fasciitis (ICD-9: 728.71), and shin splints (ICD-9:844.91). The high arch foot (cavus foot type), such as seen in Charcot-Marie-Tooth (ICD-9: 356-1) and the flattened arch (pes planus - ICD-9: 736.79) may benefit from the shock accommodation and absorption properties as well as or better than over-the-counter arch supports in many patients.

Prominent plantar bones often cause painful keratotic lesions, joint pain and progressive degenerative joint disease. These common problems are often associated with structural limitation of shock absorption in the lower extremities. Foot orthoses may help control these symptoms by providing mechanical control and accommodation.

The primary care physician should:

  1. Diagnose and treat acute inflammatory conditions with the appropriate combination of rest, ice, analgesics, non-steroidal anti-inflammatory drugs, splints, steroid and/or other injections (if appropriate), and stretching exercises.  
  2. Recommend over-the-counter arch support devices or insole products, when appropriate. Advise on specific changes in footwear.
  3. Seek consultation from a podiatrist or orthopedic surgeon for possible fabrication of custom foot orthoses after failure of over-the-counter arch supports used with the appropriate regimens of therapy and exercise to resolve the problem.  
  4. Seek consultation from a podiatrists, orthopedic surgeon and/or vascular surgeon for possible fabrication of custom foot orthoses to avoid problems or complications such as: ulcerations, infections or intractable symptoms for a patient with diabetes mellitus, neuropathy, poor vasculature, compromised immune system and other disease states that places the patient at risk.

Heel Pain

Heel pain is a common condition characterized by pain tenderness and discomfort at the plantar and/or posterior aspect of the heel, which can radiate to other areas of the foot. There are many different mechanical and systemic causes of heel pain. The differential diagnosis may include inflammatory conditions such as: plantar fasciitis with or without calcaneal spur (ICD-9: 728.71), fasciitis, unspecified (ICD-9: 729.4), calcaneal stress fracture (ICD-9: 825.0), foreign body (ICD-9: 729.6), tarsal tunnel syndrome (ICD-9: 355.5), rheumatoid arthritis (rare) (ICD-9: 714.0), or enthesopathy (ICD-9: 726.90).

Clinical manifestations may include pain at the plantar aspect of the heel upon initial ambulation in the morning, continuous and/or progressive pain throughout the day, pain or discomfort upon palpation at the plantar and/or posterior aspect of the heel which may radiate to the arch area and edema and/or erythema at the plantar and/or posterior aspect of the heel. Pain due to achilles tendonitis is a different symptom complex, and is not included in this discussion. Radiographic findings may include osseous spurring or lipping at the plantar and/or posterior aspect of the calcaneus. Laboratory studies should be considered if there is a suspicion of infection or a systemic disorder such as vascular disease, metastatic disease or primary malignancy.

As there are numerous mechanical causes of heel pain, an examination should be performed on every patient who presents with these symptoms. Inappropriate footwear is also a contributing factor to heel pain. Conservative management may consist of changes in footwear, over-the-counter arch support devices, heel cups, non-steroidal anti-inflammatory drugs, stretching exercises, orthoses, steroid injection, physical therapy, immobilization by casting or splinting or non-weight bearing with use of crutches for a short period of time. Padding, strapping and night splints might be recommended by specialists following initial failure of treatment. Whatever the diagnosis, the great majority of patients can expect significant improvement within eight weeks with conservative management.

Surgical intervention for some causes of heel pain may occasionally be indicated in individuals who have pain, disability, and fail to respond to conservative therapy. Many therapeutic failures are due to non-compliance by the patient.

The primary care physician should:

  1. Diagnose the etiology of the heel pain by clinical symptoms, appearance and radiographic examination (when necessary), as well as treat acute inflammatory conditions with the appropriate combination of non-steroidal anti- inflammatory drugs, heel cups, stretching and possibly a visit to physical therapy. Request laboratory studies, when appropriate.
  2. Recommend over-the-counter heel cup, arch support devices or insole products when appropriate. Advise on specific changes in footwear.  
  3. Seek consultation from a podiatrist or orthopedic surgeon for possible fabrication of custom foot orthoses after no improvement from using over-the-counter supports for several weeks.
  4. Seek consultation from a podiatrist or orthopedic surgeon if unable to properly diagnose the etiology of the heel pain.  
  5. Seek consultation from a podiatrist or orthopedic surgeon if patient fails to respond to conservative management. Surgical intervention will occasionally be indicated.

Bunion Deformity

Bunion (ICD-9: 727.1) or hallux valgus (ICD-9:735.0) is a deformity of the first metatarsophalangeal joint involving a medial prominence at the first metatarsal head and a lateral deviation of the hallux. Radiographic examination is rarely appropriate or necessary in a primary care setting. Osseous changes, usually at the first metatarsal head, occur and are seen in moderate, severe, and chronic deformity. Clinically, individuals may present with complaints of pain, inflammation, callus formation, stiffness or inability to wear conventional footgear with comfort. Bunions have a strong hereditary basis and seem to be more common among women than men. Certain foot types (especially flexible flat foot) predispose to the development of hallux valgus and are considered the primary etiology of bunion deformities. Other contributing factors include inappropriate shoegear.

Range of motion at the first metatarsophalangeal joint may be restricted due to arthritic changes in the joint and osseous changes. Bursitis, tendinitis, ulceration or abscess formation may occur secondary to the bunion deformity. As the bunion deformity progresses, the hallux may over or underlap the second toe. This may interfere with walking and balance, especially in older patients.

Surgical correction of the bunion deformity may be indicated in individuals that have pain, disability, and fail to respond to conservative management, such as changes in shoegear, padding and strapping, stretching, orthoses, and physical therapy.

The primary care physician should:

  1. Diagnose the bunion through clinical examination.  Acute inflammatory conditions should be treated with the appropriate combination of stretching exercises, non-steriodal anti-inflammatory drugs, padding and stretching, and physical therapy.
  2. Recommend over-the-counter arch support devices or insole products, when appropriate.  Advise on specific changes in footwear.  
  3. Seek consultation from a podiatrist or orthopedic surgeon for possible fabrication of custom foot orthoses if over-the-counter arch supports fail.
  4. Seek consultation from a podiatrist or orthopedic surgeon when the bunion deformity continues to be painful, even with changes in shoegear, involves an ulceration or abscess, or in an individual with diabetes mellitus, poor vasculature, compromised immune system and any other disease that places the patient at risk.  
  5. Seek consultation from a podiatrist or orthopedic surgeon when patient fails to respond to conservative treatment and surgical correction may be indicated.

Hammertoe Deformity

Hammertoe (ICD-9: 735.4) is a sagittal plane flexion contracture of the toe at the proximal and/or distal interphalangeal joint. In absence of a neuromuscular disorder, a hammertoe is caused by an imbalance of the extensor and flexor digitorum longus or brevis tendons of the foot, and may over time become a rigid or static deformity. Radiographic findings include osseus changes and may confirm the flexion contracture at the proximal and/or distal interphalangeal joint. Clinical manifestations commonly include thickening of the skin at the joint area, along with occasional erythema and edema. If symptoms are present they are increased due to the pressure effects of improper shoegear. Conditions associated with hammertoe deformity include bursitis, neuroma and arthritis.

Due the irritation of shoegear a hammertoe may present with pain with or without ambulation and may have a buildup of callus (hyperkeratotic) tissue at the area of the deformity. There also may be an abscess or ulceration present due to the constant pressure from the shoe.

Patients with hammertoe deformities who are asymptomatic or have minimal symptoms require only advice concerning appropriate footwear. For symptomatic patients, conservative therapy with change of shoegear, appropriate padding and strapping, and debridement of callus (hyperkeratotic) tissue is appropriate. Surgical correction of the hammertoe deformity may be indicated in individuals that have pain and who fail to respond to appropriate conservative therapy.

The primary care physician should:

  1. Diagnose the hammertoe through clinical appearance. X-rays are generally not necessary in a primary care setting. Underlying erythema or edema should be treated.
  2. Treat the hammertoe by recommending specific change in footwear and appropriate padding of callus (hyperkeratotic) tissue, if present.
  3. Seek consultation from a podiatrist or orthopedic surgeon if pain continues despite the conservate measures. Consultation is also indicated if the symptoms involve callus (hyperkeratotic) tissue formation, a local ulceration or abscess, on in an individual with diabetes mellitus, poor vasculature, compromised immune system and any other disease that places the patient at risk.  
  4. Seek consultation from a podiatrist or orthopedic surgeon when patient fails to respond to conservative treatment and surgical correction may be indicated.

Diabetic Foot Ulcer

The complications of diabetes mellitus (ICD-9: 250.0) such as peripheral arterial disease, peripheral neuropathy, immunopathy, and kidney disease, can lead to malformation in the foot, including chronic pain, ulceration, infection, gangrene and amputation. Diabetic foot ulcers (ICD-9: 250.8) occur frequently and are caused by tissue breakdown in the presence of an aggravating force, biomechanical stress, or mechanical pressure, such as shoe irritation, a wrinkled sock, a boney prominence and/or deformity, foreign body or peripheral vascular disease. Callus formation may or may not be present preceding ulceration.

Diabetic peripheral neuropathy may involve the motor, sensory and/or autonomic systems and can lead to deformities of the soft tissue, joints or bones. This loss of sensation makes the foot vulnerable to ulceration secondary to painless and unrecognized trauma. Impaired blood flow caused by peripheral arterial disease may prevent or delay wound healing of the ulcer. An ulcer can become a portal of entry for fungi and/or bacteria, which can lead to infection of the bone (osteomyelitis) and soft tissue. Unsuccessfully treated, an infected ulcer can lead to gangrene and amputation.

Management of diabetic foot ulcers is complex and often requires a multispecialty team approach consisting of primary care physicians; endocrinologists; as well as podiatric, general, orthopedic, plastic and vascular surgeons. Primary focus is on prevention by routine examination of the feet of patients with diabetes and early recognition of neuropathy, vascular insufficiency, and musculoskeletal deformity. A patient education program should address self-examination, use of appropriate hosiery and footwear, and the consequences of ignoring foot problems. Once ulceration has become apparent, treatment is directed toward reducing mechanical trauma using padding, total contact casts, orthoses, and/or therapeutic footwear designed for pressure reduction and improved function and maintaining an optimal wound healing environment by blood glucose control, recognition and treatment of infection, careful removal of non-viable tissue, and if appropriate, vascular reconstruction.

Wound care centers, physicians/surgeons, and hospitals that specialize in the treatment of these complex management problems report good results combining the above therapeutic modalities with frequent visits and, in some cases, the use of platelet derived growth factors.

The primary care physician should:

  1. Perform routine examination of the feet on all patients with diabetes to determine the status of pedal pulses, presence or absence of neuropathy, and identify any pre-ulcer signs such as callus formation or erythema.  
  2. Educate the patient on preventive and regular foot care, and daily foot inspections. Advise on specific changes in footwear and hosiery.
  3. Diagnose the ulceration through clinical appearance. Take wound cultures and request radiographic examinations, if necessary. Apply appropriate wound care dressing. Prescribe medications when necessary. Consider laboratory and vascular studies in concert with members of the consulting team.  
  4. Seek consultation from a podiatrist, orthopedist, general surgeon, plastic surgeon, or vascular surgeon when the diabetic foot ulcer requires wound debridement or any other invasive treatment.  
  5. Seek consultation from a podiatrist, orthopedist, general surgeon, plastic surgeon, or vascular surgeon if the diabetic foot ulcer fails to respond to treatment.
  6. Seek consultation from a podiatrist or orthopedist for possible fabrication of custom foot orthoses ankle-foot orthoses (AFO), and/or therapeutic footwear when appropriate.

These guidelines were provided by the American Podiatric Medical Association (APMA).  Any questions or comments regarding them should be addressed to the APMA.

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