This is the current release of the guideline.

This guideline updates a previous version: Ankle and foot complaints. Elk Grove Village (IL): American College of Occupational and Environmental Medicine (ACOEM); 2004. 27 p. [47 references]

Ankle and foot disorders

Adults with potentially work-related ankle and foot disorders seen in primary care settings

Diagnosis/Evaluation

1. X-ray
2. Magnetic resonance imaging (MRI)
3. Computed tomography (CT)
4. Single-photon emission CT (SPECT)
5. Ultrasound
6. Electrodiagnostic studies
7. Bone scans

Note: Arthrography and MR arthrography were considered but not recommended.

Management/Treatment

1. Activity modification/exercise
   • Eccentric exercises
   • Stretching and loading exercises
   • Early weight bearing
   • Rest/non weight bearing
   • Balance/proprioception training
2. Medications
   • Acetaminophen
   • Non-steroidal anti-inflammatory drugs (topical or systemic)
   • Glyceryl trinitrate
   • Opioids
   • Systemic glucocorticosteroids
   • Glycosaminoglycan
   • Polidocanol
   • Botulinum toxin A
   • Local anesthesia
   • Lidocaine patches
   • Antibiotic prophylaxis
3. Physical methods
   • Cryotherapy
   • Heat therapy
   • Extracorporeal shockwave therapy
   • Iontophoresis
   • Laser therapy
   • Night splints and walking boots
   • Functional splinting
   • Casting
   • Orthotic devices
   • Heel taping
   • Intracorporeal pneumatic shock therapy
   • Ice/heat
   • Bracing
   • Pneumatic compression
4. Surgery (closed reduction, open repair, ligament reconstruction)
5. Prophylaxis for deep vein thrombosis
6. Physical/occupational therapy
7. Patient education
8. Return-to-work programs

The following databases were searched from 1966 to 2010:

• The National Library of Medicine's MEDLARS database (Medline) (www.nlm.nih.gov )
• EBM Online (www.bmjjournals.com )
• The Cochrane Central Register of Controlled Trials (http://www.thecochranelibrary.com/view/0/index.html )
• TRIP Database (www.tripdatabase.com )
• CINAHL (nursing, allied health, physical therapy, occupational therapy, social services: http://www.cinahl.com/wpages/login.htm )
• EMBASE (www.embase.com/ )
• PEDro (www.pedro.fhs.usyd.edu.au/ )

Ranking and Preliminary Screening of Studies

Primary sources selected for inclusion in the evidence base for American College of Occupational and Environmental Medicine (ACOEM) products and services are limited to those with the strongest apparent study design, pending quality rating. The strength and quality of study design are determined by ranking and rating of the studies according to accepted methods. Generally accepted ranking of study design for diagnostic testing and clinical treatment methods were modified by the Guideline Methodology Committee (GMC). Systematic reviews in general are not ranked as the best design in reality, as most reviews located during pilot testing of the Methodology, with the exception of many (but not all) Cochrane reviews, did not use systematic searches or quality assessments of included studies. The GMC also excluded level 4 evidence from consideration (case series, poor-quality cohort studies, poor-quality case-control studies, expert opinion without explicit critical appraisal, and expert opinion based on physiology, bench research, first principles). The focus was on the best-designed original studies, pending quality grading. For example, studies of diagnostic tests are generally limited to those compared to an acceptable gold standard, and those reporting sensitivity and specificity. Studies of clinical treatment methods are generally limited to randomized controlled trials or crossover trials. Additional literature was also reviewed when there was a paucity of higher-grade literature or if it was brought to the Evidence-based Practice Panel's (EBPP's) attention from interested parties.

To narrow the data discovered in the search to that which will be acceptable for further analysis and quality rating, researchers use additional preliminary screening criteria for original research.

Criteria for Inclusion in Study Rating and Critical Analysis of Studies of Diagnosis/Clinical Assessment Methods

1. Evaluate the efficacy (i.e., clinical accuracy) of the assessment method (i.e., the "test") in a group that contains subjects both with and without the condition the test is intended to assess.
2. Be a prospective cohort study or an arm of a randomized controlled trial (RCT).
3. Compare the findings of the assessment method (test) to an adequate reference standard for all subjects (not just subjects who tested positive).

Criteria for Inclusion in Study Rating and Critical Analysis of Studies of Treatment Efficacy

1. Evaluate a group of subjects with a representative spectrum of the clinical condition of interest.
2. Be an RCT evaluating clinical outcomes in a group receiving the intervention compared to a comparison group receiving either no intervention or a different intervention.
3. Evaluate functional outcomes that are important to a patient's overall health or well being or are important to society.

Searches are documented, listing the database searched, the search terms, article type and limits, the time frame searched (in this case, all years in the databases), the number of studies found, the number reviewed in detail, and the number included in the systematic analysis. Despite multiple database searches, many additional studies are discovered in exhaustive manual searches of article reference lists.

Not stated

Strength of Evidence Ratings

A = Strong evidence-base: Two or more high-quality studies*

B = Moderate evidence-base: At least one high-quality study or multiple lower-quality studies** relevant to the topic and the working population

C = Limited evidence-base: At least one study of intermediate-quality

I = Insufficient Evidence: Evidence is insufficient or irreconcilable

*For therapy and prevention, randomized controlled trials (RCTs) with narrow confidence intervals and minimal heterogeneity. For diagnosis and screening, cross sectional studies using independent gold standards. For prognosis, etiology or harms, prospective cohort studies with minimal heterogeneity.

**For therapy and prevention, well-conducted cohort studies. For prognosis, etiology or harms, well conducted retrospective cohort studies or untreated control arms of RCTs.

Study Assessment and Quality Rating

Studies are first abstracted into evidence tables for easier assessment. See Appendix B in the methodology companion (see the "Availability of Companion Documents" field) for a sample of an evidence table for treatment studies. Each study is formally graded for quality using a modification of the most recent assessment scheme proposed by the Cochrane Collaboration Back Group, as shown in the table below. The studies are quality rated using a 0, 0.5, 1 grade for each item, where 0 = does not fulfill the requirement; 0.5 = partially fulfills the requirement and 1 = entirely fulfills the requirement. A study with a score less than 4.0 is rated as a poor-quality study; a study with a score between 4.0 and 7.5 is rated as a moderate-quality study. A study with a score of 8.0 or greater is rated as a high-quality study.

Rating Criteria for Randomized Controlled Trials of Treatment Studies

Each recommendation includes citations of the specific scientific literature which supports the recommendation. The recommendations explicitly consider the health benefits, side effects, and risks of the proposed recommendation. Recommendations include the data elements described below.

Content of Recommendations for Diagnostic Testing or Treatment

1. The diagnoses for which the test or treatment is indicated
2. The specific indications for the test or treatment
3. The point in the time course of the problem for which it is appropriate
4. Prior conservative treatment that should be tried first
5. Relative and absolute contraindications to the test or procedure
6. The number of tests or procedures that are appropriate at a given time in the course of the problem
7. The potential benefits of the test or procedure
8. The potential harms, including effects on disability and return to work

The Evidence-based Practice Panels (EBPPs) for each topic area review and discuss draft practice recommendations from the research staff that includes a review of the quality evidence, evidence tables, and summaries. The strength of evidence rating is confirmed by the EBPP responsible for the topic, with review by the Guideline Methodology Committee (GMC). EBPP members may present additional comments related to their clinical opinions and experience for panel consideration. If a unanimous decision is not possible, an EBPP may vote on the rating of the strength of the evidence to determine a consensus. Dissenters to the consensus may draft minority opinions about the strength of evidence. In practice, this has not happened as recommendations have been unanimous.

Formulation of recommendations requires clinical judgment as well as a full evaluation and consideration of the available high-quality evidence. To aid in framing recommendations, the GMC developed a list of "First Principles" based on the Hippocratic Oath ("First Do No Harm"), medical logic, appropriate sequencing and case management, shared decision-making, support of functional recovery, and relative cost-effectiveness. The First Principles are defined in Table 7 in the methodology companion (see the "Availability of Companion Documents" field). When there is insufficient high-quality evidence of effectiveness or efficacy, or the high-quality evidence is conflicting, and to guide recommendations for alternative tests or treatments when there are several options, these principles are used to guide group decision-making.

The EBPPs then assign a Strength of Recommendation to each recommendation. If a consensus cannot be reached on the recommendation or strength of recommendation, the EBPPs may use nominal group voting if agreement is not possible in the discussion. Once a consensus is reached, the EBPPs will finalize the language and strength rating of the recommendation. If needed and material, a minority opinion can be appended to the recommendation.

Strength of Recommendations

The guideline developers reviewed published cost analyses.

Internal Quality Review

The Guideline Methodology Committee (GMC) assigns a committee member to each Evidence Based Practice Panel (EBPP) as a methodology consultant to assist with adherence to this methodology. The GMC reviews all recommendations for which there are questions about consistency with the defined methodology. If the GMC determines that the approved methodology has not been followed, leading to illogical or untenable recommendations, the GMC engages in direct discussions with the EBPP to reach agreement on revision. If there is no agreement or revision, then the matter will be considered by the American College of Occupational and Environmental Medicine (ACOEM) Board of Directors when the document is submitted for Board review.

External Review

ACOEM conducts external peer review of the ACOEM Occupational Medicine Practice Guidelines (APGs) and periodic revisions to 1) assure that all relevant high-quality scientific literature has been found, 2) assure that the important evidence from the relevant scientific literature has been accurately interpreted, 3) solicit opinions on whether the findings and recommendation statements are appropriate and consistent with the evidence, and 4) obtain general information on the conclusions and presentation of materials from external topic experts. Professional and patient organizations, as well as panel members, ACOEM Board of Directors, etc., are invited to nominate external peer reviewers.

Peer reviewers are asked to comment on the completeness of the scientific literature evaluation in their topic area, the clarity and technical accuracy of the APGs evaluation and summary of the evidence, and the appropriateness of the Guideline findings and recommendation statements.

Stakeholder Input

In a cyclical manner, ACOEM will seek stakeholder input to understand the needs and preferences of those who may utilize or be affected by the use of clinical practice guidelines in workplace settings and in the workers' compensation system. ACOEM solicits input from clinicians, health care systems, workers or patients, employers, utilization reviewers, case managers, insurers and third party administrators, attorneys, regulators, and policy makers through a variety of mechanisms. Stakeholders will be asked for comments about their experience using existing clinical practice guidelines and related products and their suggestions for future improvements. They are also asked for input on the use of clinical practice guidelines in clinical care, case management, claim administration, claim adjudication, and in the development of policies and regulations.

To ensure editorial independence in the development process, the stakeholder groups will be asked for input about the APGs, but will not be informed of panel deliberations or shown drafts of practice recommendations before the formal release of the documents. In some cases, a member of a stakeholder group may participate as a member of a Guideline EBPP or may participate in peer review or pilot testing. However, all individuals involved in the APGs development, peer review, and pilot testing are asked to keep all information about the panel's deliberations and conclusions confidential until the APGs are formally released.

Pilot Testing

The guidelines are pilot tested to determine if the recommendations are clear, easy to use, and are generally useful. Pilot testers are not asked if they think the recommendations or process for development was appropriate.

Review by the GMC and the ACOEM Board of Directors

During the entire evidence-based product development process, the GMC will work with the Panels, editors, and research staff to ensure that the evidence-based product methodology is being followed, both in the literature evaluation process and development of conclusion and recommendation statements. The Board of Directors has an opportunity to comment on the Guidelines during the external review period. Their comments are reviewed by the Panel and any necessary changes are made to the Guidelines.

Definitions for the strength of evidence ratings (A, B, C, and I) and the criteria for evidence-based recommendations are presented at the end of the "Major Recommendations" field.

Summary Tables: Recommendations and Evidence

Table 1 summarizes the recommendations from the Evidence-based Practice Ankle and Foot Panel for diagnostic testing for ankle and foot disorders. Table 2 is a summary of recommendations for managing these disorders. Recommendations are based on critically appraised higher quality research evidence and on expert consensus, observing First Principles when higher quality evidence was unavailable or inconsistent. The reader is cautioned to utilize the more detailed indications, specific appropriate diagnoses, temporal sequencing, prior testing or treatment, and contraindications that are elaborated in more detail for each test or treatment in the body of this Guideline in using these recommendations in clinical practice or medical management. These recommendations are not simple "yes/no" criteria, and the evidence supporting them is in nearly all circumstances developed from typical patients, not unusual situations or exceptions.

Recommendations are made under the following categories:

• Strongly Recommended, "A" Level
• Moderately Recommended, "B" Level
• Recommended, "C" Level
• Insufficient-Recommended (Consensus-based), "I" Level
• Insufficient-No Recommendation (Consensus-based), "I" Level
• Insufficient-Not Recommended (Consensus-based), "I" Level
• Not Recommended, "C" Level
• Moderately Not Recommended, "B" Level
• Strongly Not Recommended, "A" Level

Table 1. Summary of Recommendations for Diagnostic and Other Testing for Ankle and Foot Disorders

Table 2. Summary of Recommendations for Managing Ankle and Foot Disorders

Definitions:

Strength of Evidence Ratings

A = Strong evidence-base: Two or more high-quality studies*

B = Moderate evidence-base: At least one high-quality study or multiple lower-quality studies** relevant to the topic and the working population

C = Limited evidence-base: At least one study of intermediate-quality

I = Insufficient Evidence: Evidence is insufficient or irreconcilable

*For therapy and prevention, randomized controlled trials (RCTs) or crossover trials with narrow confidence intervals and minimal heterogeneity. For diagnosis and screening, cross sectional studies using independent gold standards. For prognosis, etiology or harms, prospective cohort studies with minimal heterogeneity.

**For therapy and prevention, well-conducted cohort studies. For prognosis, etiology or harms, well conducted retrospective cohort studies or untreated control arms of RCTs.

Strength of Recommendations

The following clinical algorithms are provided in the original guideline document:

• ACOEM Guidelines for Care of Acute and Subacute Ankle and Foot Disorders
• Initial Evaluation of Ankle and Foot Disorders
• Initial and Follow-up Management of Ankle and Foot Disorders
• Initial and Follow-up Management of Achilles Tendinopathy
• Management of Achilles Tendon Rupture
• Management of Plantar Heel Pain
• Management of Tarsal Tunnel Syndrome
• Management of Acute Ankle Sprains
• Management of Ankle and Foot Fractures

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

The American College of Occupational and Environmental Medicine (ACOEM) provides this segment of guidelines for practitioners and notes that decisions to adopt particular courses of actions must be made by trained practitioners on the basis of the available resources and the particular circumstances presented by the individual patient. Accordingly, the ACOEM disclaims responsibility for any injury or damage resulting from actions taken by practitioners after considering these guidelines.

An implementation strategy was not provided.

Not applicable: The guideline was not adapted from another source.

American College of Occupational and Environmental Medicine

Evidence-based Practice Ankle and Foot Panel

Panel Members: Nelson S. Haas, MD, MPH, FACOEM (Chair); Patrick J. Beecher, MD, MPH, MBA, FACOEM; Mark Easley, MD; Hannah Edwards, MD, MPH; Harold Hoffman, MD, FRCPC; Steven Mandel, MD, FACOEM; RobRoy L. Martin, PhD, PT, CSCS; James L. Thomas, DPM, FACFAS; Pete Thomas, DPM, QME

Nelson S. Haas, MD, MPH, FACOEM

Director, Occupational Medicine Clinic, North Country Hospital; Director, Occupational Medicine Clinic, Northeastern Vermont Regional Hospital

National, Regional, Local Committee Affiliations—Member, External Affairs Committee, American College of Occupational and Environmental Medicine (ACOEM); Delegate, New England College of Occupational and Environmental Medicine

Guidelines Related Professional Activities—None reported

Research Grants/Other Support—None

Financial/Non-Financial Conflict of Interest—None

Patrick J. Beecher, MD, MPH, MBA, FACOEM

The Beecher Advisory Group

National, Regional, Local Committee Affiliations—Past President, Michigan Occupational and Environmental Medicine Association; Past President, Detroit Occupational Physicians Association

Guidelines Related Professional Activities—Past Member, Health Services Policies, Procedures, Programs and Guidelines Review and Development Committee, General Motors Corporation; Past Member of Public Health Committee, Ingham County Medical Society; Past Member, Board of Trustees of the Michigan Mid-South Health Systems Agency; Past Member, Project Review Committee and Public Information Committee of Michigan Mid-South Health Systems Agency

Research Grants/Other Support—None

Financial/Non-Financial Conflict of Interest—None

Mark Easley, MD

Duke Health Center

National, Regional, Local Committee Affiliations—None

Guidelines Related Professional Activities—None

Research Grants/Other Support—None reported

Financial/Non-Financial Conflict of Interest—None reported

Hannah Edwards, MD, MPH

Assistant Professor, University of Utah, Rocky Mountain Center for Occupational and Environmental Health; Medical Director, University of Utah Occupational Medicine Clinic; Supervising Physician, ARUP Family Health Clinic

National, Regional, Local Committee Affiliations—None

Guidelines Related Professional Activities—Activities related to the ACOEM Practice Guidelines Research

Research Grants/Other Support—Training grants and research grants primarily on the epidemiology of musculoskeletal disorders (e.g., CTS, shoulder tendinosis, LBP)

Financial/Non-Financial Conflict of Interest—Honoraria: Teaching honoraria from courses, ACPM and ACOEM-related; Consulting regarding how to reduce work-related injuries, causation and apportionment of injuries, work restrictions and work-relatedness injuries, and practice guidelines compliance; Clinical: Primary, secondary and tertiary clinical management of occupational injuries and diseases

Harold Hoffman, MD, FRCPC

Specialist in Occupational and Environmental Medicine, HE Hoffman Professional Corporation; Adjunct Associate Professor, Department of Public Health Sciences, Faculty of Medicine and Dentistry, University of Alberta; Clinical Consultant, Trace Element Laboratory, Division of Biochemistry Department of Laboratory Medicine and Pathology, University of Alberta Hospital, Edmonton; and Consultant: Occupational and Environmental Medicine Clinic, University of Alberta; Great West Life Insurance Company; Appeals Commission of Workers' Compensation Board of Alberta; and several industries

National, Regional, Local Committee Affiliations—None

Guidelines Related Professional Activities—Member, Practice Guidelines Committee, ACOEM (2nd Edition); Medical Advisory Board Member/Contributor, Medical Disability Advisor

Research Grants/Other Support—None

Financial/Non-Financial Conflict of Interest—None

Steven Mandel, MD, FACOEM

Professor of Neurology, Jefferson Medical College; Professor of Anesthesiology, Jefferson Medical College; Adjunct Clinical Professor of Psychology, Institute for Graduate Clinical Psychology, School of Human Service Professions of Widener University; Adjunct Clinical Professor, Temple University's School of Podiatric Medicine, Department of Podiatric Medicine & Orthopedics

National, Regional, Local Committee Affiliations—Medical Reviewer for following journals: Journal of Voice, Academy of Neurology Practice Guidelines; AADEP Disability Newsletter; Expert Opinion Editor, Practical Neurology; Member, Occupational Health Subcommittee, Philadelphia County Medical Society

Guidelines Related Professional Activities—Developed evidence-based guidelines for laryngeal EMG in most peer-reviewed journals

Research Grants/Other Support—None

Financial/Non-Financial Conflict of Interest—None

RobRoy L. Martin, PhD, PT, CSCS

Associate Professor, Duquesne University; Staff Physical Therapist, Centers for Rehab Services, Center for Sports Medicine; Fee-for-Service Home Care Physical Therapist, University of Pittsburgh Medical Center/Jefferson Regional Home Health Representative, American Physical Therapy Association

National, Regional, Local Committee Affiliations—Vice President, Foot and Ankle Special Interest Section, American Physical Therapy Association; Member of Clinical Outcome Measures Task Force, American Orthopaedic Society for Sports Medicine; Member of Orthopaedic Section Clinical Research Agenda Task Force, American Physical Therapy Association; Grant Reviewer, Orthopaedic Section, American Physical Therapy Association; Reviewer for following journals: Journal of Athletic Training, BioMed Central Musculoskeletal Disorders, Journal of Epidemiology, and Arthritis Care & Research

Guidelines Related Professional Activities—Clinical Practice Guideline on Heel Pain – Plantar Fasciitis for Orthopaedic Section of the American Physical Therapy Association; Clinical Practice Guideline on Achilles Tendinopathy for Orthopaedic Section of the American Physical Therapy Association; Team Leader, Orthopaedic Section, American Physical Therapy Association's International Classification of Functioning and Disability Project

Research Grants/Other Support—Co-Investigator, "Ankle Proprioception after Total Ankle Replacement," DePuy Research Grant

Financial/Non-Financial Conflict of Interest—None

James L. Thomas, DPM, FACFAS

West Virginia University

National, Regional, Local Committee Affiliations—None

Guidelines Related Professional Activities—ACFAS Clinical Practice Guidelines

Research Grants/Other Support—None reported

Financial/Non-Financial Conflict of Interest—None reported /p>

Pete Thomas, DPM, QME

Podiatric Surgeon, Coastline Podiatry Group; Qualified Medical Examiner for the State of California

National, Regional, Local Committee Affiliations—Member of Medical Executive Committee, Vista Hospital of Riverside; Co-Chair of Surgery Committee, Vista Hospital of Riverside

Guidelines Related Professional Activities—None

Research Grants/Other Support—None

Financial/Non-Financial Conflict of Interest—None

This is the current release of the guideline.

This guideline updates a previous version: Ankle and foot complaints. Elk Grove Village (IL): American College of Occupational and Environmental Medicine (ACOEM); 2004. 27 p. [47 references]

Electronic copies: To order a subscription to APG-I, the online version of the Guidelines, call 847-818-1800 or visit http://www.acoem.org/apg-i.aspx .

Print copies are available from ACOEM, 25 Northwest Point Boulevard, Suite 700, Elk Grove Village, IL 60007 by calling 847-818-1800 or order online at http://www.acoem.org/PracticeGuidelines.aspx .

Subscriptions to ACOEM's Practice Guidelines app are available for iPad and iPhone. Visit http://www.acoem.org/PracticeGuidelinesiOSApp.aspx .

The following is available:

• Methodology for the update of the occupational medicine practice guidelines, 2nd edition. Elk Grove Village (IL): American College of Occupational and Environmental Medicine (ACOEM); 2008. Available from the ACOEM Web site .

None available

This NGC summary was completed by ECRI on May 31, 2006. The information was verified by the guideline developer on November 3, 2006. This NGC summary was updated by ECRI Institute on July 20, 2012. The updated information was verified by the guideline developer on August 6, 2012.

The American College of Occupational and Environmental Medicine, the signator of this license, represent and warrant that they are the publisher of the guidelines and/or possess all rights necessary to grant the license rights to AHRQ and its agents. Download and reproduce only with explicit permission from the American College of Occupational and Environmental Medicine.