clinical guidelines for localised musculoskeletal foot pain17111/... · stop-shop’ of current...

Clinical Guidelines for localised

Musculoskeletal Foot Pain

A Podiatry Perspective

VERONA DU TOIT | ANDREA BIALOCERKOWSKI

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Verona du Toit

Andrea Bialocerkowski

First published 2013

Designed by Sensory

sensorycreative.com.au

© 2013 Verona du Toit and Andrea Bialocerkowski

All rights reserved. No part of this report may be reprinted

or reproduced or utilised in any form or by an electronic,

mechanical, or other means, now known or hereafter

invented, including photocopying and recording, or in

any information storage or retrieval system, without

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

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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

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

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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

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FOREWORD

I am delighted to contribute the Forward to this book. The

authors are to be congratulated on this initiative, as this

book represents novel, easy-to-read and eicient access

to current best evidence for podiatric management of

patients with musculoskeletal foot and ankle conditions.

It is speciically targeted to the needs of busy podiatrists

practising in Australia. The book presents carefully

summarised clinical practice guidelines drawn from a

comprehensive range of international sources.

Evidence-based practice is the integration of best

available research evidence, clinical judgement, and

patient choices and values, within the context of

local practice. Thus clinical practice guidelines which

incorporate the best available evidence provide a ‘one-

stop-shop’ of current best evidence for assessment

and management of a clinical condition. The guidelines

presented in this book have been identiied using

unbiased, comprehensive, rigorous, transparent searching

methods. The included guidelines have then been critically

appraised, synthesised and reported in an eicient,

comprehensive and easy-to-read format. Busy podiatrists

can be conident that this book presents a comprehensive

resource of current best international information on

assessment and management of musculoskeletal foot

and ankle conditions.

Each included guideline has been summarised using

a standard reporting approach. The book presents

the guideline name, publication date, availability,

end users, content, basis of recommendations (e.g.

consensus, evidence), search period, sources of evidence,

strength of recommendation descriptors, summary of

recommendations, guideline quality (using scores from two

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:

1. choose recommendations from highest quality, most

up-to-date included clinical guidelines to inform their

clinical decision-making; and

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.

One outcome of writing this book was the identiication

of current evidence gaps. These gaps highlight directions

for future podiatric research to better inform podiatric

practice. Ways of addressing current evidence gaps include:

1. More high quality systematic reviews should be

conducted to critically appraise and synthesise

the available evidence, to provide evidence of the

most efective interventions for the most prevalent

conditions treated by podiatrists in Australia.

2. Where there is an absence of high quality systematic

reviews and primary research evidence, more

high quality primary studies should be conducted

to investigate the efectiveness of the diferent

interventions used to manage the most prevalent

conditions treated by Australian podiatrists.

3. Where there is an absence of published research

evidence, consensus based research, such as Delphi

studies, should be undertaken to identify assessment

techniques and interventions that could be used in the

management of patients who seek treatment from

podiatrists in Australia. This information could not

only inform clinical practice now, but could also inform

future better quality, targeted primary research.

Podiatrists practising in Australia are indeed fortunate

to have this resource. Whilst it presents the current best

evidence, it also is written in a format which can be readily

updated to ensure ongoing currency. Podiatrists should be

able to eiciently navigate the clinical guidelines reported

in this book, and use the information to inform equitable,

timely, safe, consumer-oriented and efective clinical

decisions and treatment plans.

Professor Karen Grimmer

Director, International Centre for Allied Health Evidence

University of South Australia

10/6/2013

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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.

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Chapter 1Background

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Chapter 1

1.1 OVERVIEW

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

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 1.2 WHY SHOULD THEY BE USED?

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

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

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.

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.

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

efectiveness of 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.

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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

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.

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

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

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

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

outcomes and cost efectiveness of patient management.18

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1.8 PODIATRY IN AUSTRALIA

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

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

1.9 AIM OF THIS WORK

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.

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.

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1.10 REFERENCES

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.

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

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/

26. Jones CL (1995) Who treats feet? Journal of the

American Podiatric Medicine Association 85: 293-294.

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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.

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/

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Chapter 2Methodology

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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

G57Mononeuropathies of

lower limbIncludes Morton’s neuroma

Morton’s neuroma

Tarsal tunnel syndrome

M20Acquired deformities of

ingers and toes

Includes hallux valgus, hallux

rigidus, hallux varus and other

hammer toes

Hallux valgus

Hallux limitus

Hallux rigidus

Hammer toes

M77 Other enthesopathies Includes plantar fasciitis,

calcaneal heel spur,

metatarsalgia, tendinitis

Plantar fasciitis

Heel spur

Metatarsalgia

Tendinopathies

S82Fracture of lower leg,

including ankle

Includes fracture of the medial

and lateral malleoli, bimalleolar

and trimalleolar fractures

Ankle fracture

S86

Injury of muscle and

tendon at the lower leg

level

Includes injury to the Achilles

tendon and other posterior,

anterior and the peroneal

muscles

Achilles tendon rupture

Achilles tendinopathy/rupture

S90Supericial injury of

ankle and foot

Includes contusion to the ankle,

toes + nail damage and other

parts of the foot

S91Open wound of the foot

and ankle

Includes open wound to the

ankle, toes + nail damage and

other parts of the foot

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S92Fracture to foot, except

ankle

Includes open and closed

fractures of the calcaneus, talus,

other tarsal bones, metatarsals

and phalanges

S93

Dislocation, sprain and

strain of joints and

ligaments at the ankle

and foot

Includes dislocation of the ankle,

toes and other parts of the foot;

rupture of ligaments at the

ankle, foot and toes

Lateral and medial ankle sprain

S94Injury to nerves at

ankle and foot level

Includes injury to the lateral and

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

S95

Injury of blood vessels

at the ankle and foot

level

Includes dorsal and plantar

arteries, dorsal veins, and other

blood vessels in the foot and

ankle area

S96

Injury to muscle and

tendon at the ankle

and foot level

Includes long lexor and extensor

muscles and tendons at the

ankle and foot levels, intrinsic

muscles, and other muscles in

the foot and ankle area

Peroneal tendinitis

S97Crushing injury of the

ankle and foot

Includes crushing injuries of the

ankle, toes and other areas of

the foot

S98Traumatic amputation

of the ankle and foot

Includes traumatic amputation

at the foot at the ankle level,

amputation of one or more toes

or other parts of the foot

S99

Other and unspeciied

injuries to ankle

and foot

Includes multiple injuries and

unspeciied injuries of the ankle

and foot

2.3 DATABASES

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

• Guidelines International Network

• National Guideline Clearinghouse (USA)

• Scottish Intercollegiate Guidelines Network (UK)

• National Health and Medical Research Council

(Australia)

• New Zealand Guidelines Group

(New Zealand)

• Canadian Medical Association (Canada)

• 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.

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TABLE 2.2 GUIDELINE SITES

SITE NAME URL & DETAILS

Guidelines International Network

www.g-i-n.net

Global network consisting of 48 countries, which supports evidence-based health care

and improved health outcomes by reducing inappropriate variation throughout the work.

Membership required to access clinical guidelines.

National Guideline Clearinghouse

www.guidelines.gov/browse.guideline_index.aspx

Supported by the Agency for Healthcare Research and Quality (in the USA). It is a publicly

available resource for evidence-based clinical practice guidelines.

Scotish Intercollegiate Guidelines Network

www.sign.ac.uk

Develops evidence-based clinical guidelines for the National Health Service in Scotland for the

acceleration of the translation of new knowledge to reduce variation in practice and improve

patient outcomes.

National Health And Medical Research Council (of Australia)

www.nhmrc.gov.au/guidelines

Australia’s peak body for supporting health and medical research, for developing health advice

for the Australian community, health professionals and government, and for providing advice

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.

New Zealand Guidelines Group

www.nzgg.org.nz/library/cfm

The New Zealand Guidelines Group was an independent not-for-proit organisation established

in 1999 to promote the use of evidence in the delivery of health and disability services. It went

into voluntary liquidation in mid-2012.

Canadian Medical Association

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

The Canadian Medical Association is the voice of physicians in Canada. It advocates access

to high quality healthcare, health promotion and disease and injury prevention policies, and

facilitates changes in health care delivery.

National Institute For Health And Care Excellence

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

Provides independent, authoritative and evidence-based guidance to support healthcare

professionals and others to make sure that the care they provide is of the best possible quality

and ofers the best value for money to prevent, diagnose and treat disease and ill-health and to

reduce inequalities and variations.

American Academy of Orthopaedic Surgeons

www.aaos.org/

Founded in 1933, the Academy is the pre-eminent provider of musculoskeletal education to

orthopaedic surgeons and others in the world.

American Academy of Family Physicians

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

The American Academy of Family Physicians is one of the largest national medical organisations,

representing 105,900 family physicians, family medicine residents, and medical students

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.

Institute For Clinical Systems Improvement

htps://www.icsi.org/

ICSI champions the use of evidence-based medicine. A cornerstone of its work is enlisting

clinicians from its membership to perform rigorous reviews of current scientiic literature and

develop evidence-based guidelines and protocols on numerous health conditions that enable

clinicians in 180 countries to practice best medicine.

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TABLE 2.3 PROFESSIONAL PODIATRIC ASSOCIATION WEBSITES

COUNTRY PROFESSIONAL BODY WEBSITE

AustraliaAustralasian Podiatry Council

Australasian Academy of Podiatric Sports Medicine

www.apodc.com.au

www.aapsm.org.au

CanadaCanadian Podiatric Medical Association

Canadian Federation of Podiatric Medicine

www.podiatrycanada.org

www.podiatryinfocanada.ca/Public

/Home.aspx

New Zealand

New Zealand Society of Podiatrists www.podiatry.org.nz

UK Society of Chiropodists and Podiatrists www.scpod.org

USAAmerican Podiatric Medical Association

American Academy of Podiatric Sports Medicine

www.apma.org

www.aapsm.org

2.4 SELECTION CRITERIA

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

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.

2.5 CRITICAL APPRAISAL

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”.

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

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TABLE 2.4 ITEMS CONTAINED IN THE AGREE II3

DOMAIN ITEM

1. Scope and purpose

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

The health question(s) covered by the guideline is (are) speciically described

The population (patients, public, etc) to whom the guideline is meant to apply is speciically

described

2. Stakeholder involvement

The guideline development group includes individuals from all relevant professions

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

The target users of the guideline are clearly deined

3. Rigour of development

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

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

4. Clarity of presentation

The recommendations are speciic and unambiguous

The diferent options for management of the condition or health issue are clearly presented

Key recommendations are easily identiiable

5. Applicability

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

The potential resource implications of applying the recommendations have been considered

The guideline presents monitoring and/or auditing criteria

6. Editorial independence

The views of the funding body have not inluenced the content of the guideline

Competing interests of guideline development group members have been recorded and addressed

Overall guideline assessment

Rate the quality of this guideline

I would recommend this guideline for use

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TABLE 2.5 ITEMS CONTAINED IN THE ICAHE GUIDELINE CHECKLIST (GRIMMER-SOMERS4 )

DOMAIN ITEM

1. Information

Is the guideline readily available in full text?

Does the guideline provide a complete reference list?

Does the guideline provide a summary of its recommendations?

2. Currency

Is there a date of completion available?

Does the guideline provide an anticipated review date?

Does the guideline provide dates for when literature was included?

3.

Finding the evidence and determining the evidence base

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

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

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

Does the guideline link the hierarchy of evidence and quality

of underlying evidence to each recommendation?

4. Developers

Are the developers of the guideline clearly stated?

Does the qualiications and expertise of the guideline developer(s) link with the purpose of

the guideline and its end users?

5. Purpose and end users

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

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

1. InformationGenerally guidelines should not be considered by end users if they are not available in full

text, do not have a full reference list and do not link evidence to recommendations.

2. CurrencyThe most up-to-date clinical guideline must be used as evidence in any particular area is rapidly

changing. Guidelines must maintain their currency through regular review and updating.

3.

Finding the evidence and determining the evidence base

Each recommendation should be referenced to the strength of evidence which underpins

it. Speciic search strategies used to locate the evidence must be provided. When

recommendations are based on expert opinion, details must be provided on the method used

to generate the recommendation.

4. DevelopersThe guideline developers must be named as well as their ailiation organisations. Any

conlict of interest must be listed together with strategies to address the conlict.

5. Purpose and end users

The purpose and end users should be clearly stated to allow clinicians to identify the relevance

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.

6. Easy to read The recommendations must be easy to read, and the guideline easily navigated.

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2.6 DATA EXTRACTION

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,

content, basis of recommendations, search period,

sources of evidence, strength of recommendation

descriptors, summary of recommendations.

2.7 DATA SYNTHESIS

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).

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.

2.8 REFERENCES

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/

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 1

21Background

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Chapter 3

3.1 OVERVIEW

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

recommendations have been synthesised to provide

clinicians with management summaries, relevant to the

practice of podiatry in Australia.

GUIDELINE SECTION 3.2 PROCESS & SEARCH YIELD

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.

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)

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FIGURE 3.1 STUDY SELECTION PROCESS AND SEARCH YIELD

Database hits

(n = 404)

Assessed for

eligibility

(n = 85)

Met selection criteria

(content, language,

date)

(n = 20)

Total number of

guidelines

(n = 14)

Guideline not

publicity available

(n = 8)

Guideline made

available

(n = 2)

Guideline excluded

due to lack of

availability

(n = 6)

Guideline publicity

available

(n = 12)

Duplicates removed

(n = 319)

Excluded based on

content, language,

date

(n = 65)

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TABLE 3.1 CLINICAL GUIDELINES WHICH MET THE SELECTION CRITERIA

Guideline developer Condition

Availability

Text publicly available

Text provided by guideline developer

Text not publicly available

Academy of Ambulatory

Foot and Ankle Surgery

(2003)

Hallux abducto

valgus1



(2003)

Hallux limitus and

hallux rigidus2



(2003)

Hammer toe

syndrome3



(2003)

Heel spur

syndrome4



(2003)

Intermetatarsal

neuroma5



(2003)

Metatarsalgia /

intractable plantar

keratosis / Tailor’s

bunion6

American Academy of

Orthopaedic Surgeons

(2009)

Acute Achilles

tendon rupture7

American College of

Foot and Ankle Surgeons

(Thomas et al 2009)

Digital deformities8

American College of


(Thomas et al 2009)

Central

metatarsalgia9

American College of


(Thomas et al 2009)

Morton’s

intermetatarsal

neuroma10

American College of


(Thomas et al 2009)

Tailor’s bunion11

American College of


(Thomas et al 2009)

Trauma12

American College of


(Thomas et al 2010)

Heel pain13

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Guideline developer Condition

Availability

Text publicly available

Text provided by guideline developer

Text not publicly available

American College of

Occupational and

Environmental Medicine

(2011)

Ankle and foot

disorders14

American Physical

Therapy Association

(McPoil et al 2008)

Plantar fasciitis15

American Physical

Therapy Association

(Carcia et al 2010)

Achilles

tendinopathy16

KNGF (2006) Acute ankle

sprain17

Institute for Clinical

Systems Improvement

(2006)

Ankle sprain18

National Institute

of Health and Care

Excellence (2009)

Plantar fasciitis19

Work Loss Data Institute

(2011)

Ankle and foot

(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

demonstrated in Tables 3.3 and 3.4. AGREE II scores for each

of the six domains varied considerably. However, based on

the AGREE II scores, the following guidelines provided high

quality information with respect to their scope and purpose,

stakeholder involvement, rigour of development, clarity of

presentation and editorial independence:

• American Academy of Orthopaedic Surgeons7

• American College of Occupational and

Environmental Medicine14

• Work Loss Data Institute20

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.

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TABLE 3.2 INCLUDED GUIDELINES AND CORRESPONDING MUSCULOSKELETAL CONDITIONS

LOCATION CONDITIONNO. OF

GUIDELINESREFERENCE

ANKLE

Achilles tendon rupture7,14,20 3

American Academy of Orthopaedic Surgeons

(2009)7

American College of Occupational and

Environmental Medicine (2011)14

Work Loss Data Institute (2011)20

Achilles tendinopathy / tendinitis13,14,16,20

4

Carcia et al (2010)16



Thomas et al (2010)13


Ankle sprain14,17,18,20 4



KNGF (2009)17

Institute for Clinical Systems Improvement

(2006)18


Tarsal tunnel syndrome*12,14,20 3





Fracture12,14,20 3





FOOT

Plantar fasciitis

Heel / calcaneal spur13-15,20

4



McPoil et al (2008)15



Metatarsalgia9,20 2Thomas et al (2009)9


Morton’s neuroma10,20 2



Tailor’s bunion11,20 2Thomas et al (2009)11

Work Loss data Institute (2011)20

Deformities of the toes8,20 2



* Conditions listed in the Work Loss Data Institute Foot and Ankle chapter, but recommendations were not linked to clinical guidelines

Chapter 3

27Results

TABLE 3.3 QUALITY OF CLINICAL GUIDELINES BASED ON AGREE II*

Domains AAOS7* ACOEM14Carcia et

al16ICSI18 KNGF17

McPoil et

al15NICE19

Thomas

et al8

Thomas

et al9

Thomas

et al10

Thomas

et al11

Thomas

et al12

Thomas

et al13WLDI20

Scope and

purpose83 94 56 67 50 61 67 25 14 11 6 14 36 61

Stakeholder

involvement75 83 72 75 75 72 50 31 28 28 28 28 47 81

Rigour of

development83 86 66 57 44 57 44 4 3 5 3 3 19 94

Clarity of

presentation94 100 89 83 97 89 42 69 64 64 64 53 61 78

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

Editorial

independence100 92 0 100 4 0 0 0 0 0 0 0 100 100

* 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

Clinical Guidelines For Localised Musculoskeletal Foot PainA Podiatry Perspective

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AAOS7 ACOEM14Carcia et

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McPoil et

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Thomas

et al8

Thomas

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Thomas et

al10

Thomas

et al11

Thomas et

al12

Thomas et

al13WLDI20

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?

Y Y Y Y Y Y Y Y Y Y Y Y Y Y

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

Chapter 3

29Results

AAOS7 ACOEM14Carcia et

al16ICSI18 KNGF17

McPoil et

al15NICE19

Thomas

et al8

Thomas

et al9

Thomas et

al10

Thomas

et al11

Thomas et

al12

Thomas et

al13WLDI20

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 Institute20

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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

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

Research/guidelines/atrguideline.asp

End usersPhysicians and orthopaedic surgeons. Professional health care practitioners and developers of

practice guidelines and recommendations

Content

1. Diagnosis of Achilles tendon

rupture, including

• Clinical tests (Thompson test, decreased

ankle plantar lexion strength, presence

of a palpable gap, increased passive ankle

dorsilexion with gentle manipulation)

• Radiology, such as magnetic

resonance imaging, ultrasonography

and radiography

2. Non-operative management, including

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

4. Post-operative management, including

• Antithrombotic treatment

• Protected weight-bearing

(limited dorsilexion)

• Protected devices (orthosis, plaster

splint or cast)

• Physiotherapy

5. Return to activities of daily living and

sports/ athletic activity

Basis of recommendations

Recommendations based on research evidence with the exception of the diagnosis recommendation

which was based on consensus gained from experts, in the absence of reliable evidence

Search period January 1966 – June 2009

Sources of evidence

PubMed, EMBASE, CINAHL, The Cochrane Library, The National Guideline Clearinghouse and

TRIP Database

Strength of recommendation descriptors

Grades of recommendation (including implications for practice)

• Strong: the beneits of the

recommended approach clearly

exceed the potential harm (or that the

potential harm clearly exceeds the

beneits in the case of a strong negative

recommendation), and that the strength

of the supporting evidence is high.

(Practitioners should follow a strong

recommendation unless a clear and

completing rationale for an alternative

approach is present.)

• Moderate: the beneits exceed the

potential harm (or that the potential

harm clearly exceeds the beneits in the

case of a negative recommendation),

but the strength of the supporting

evidence is not as strong. (Practitioners

should generally follow a moderate

recommendation but remain alert to

new information and be sensitive to

patient preferences.)

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• 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,

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

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.)

• Consensus: expert opinion supports

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)

• 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


• 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

recommendation: Moderate)

• 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)

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Return to activities of daily living/ athletic activity

• Following Achilles tendon rupture, there is

inconclusive evidence regarding when patients

can return to activities of daily living (Strength of

recommendation: Inconclusive)

• In patients who participate in sports, there is limited

evidence to suggest that the option of returning them

to sports within 3-6 months ater operative treatment

for acute Achilles tendon rupture (Strength of


• There is inconclusive evidence to recommend a

speciic time at which patients who are managed

non-operatively can be returned to athletic activity

(Strength of recommendation: Inconclusive)

Guideline quality AGREE II score (Table 3.3)

• Scope and purpose: 83

• Stakeholder involvement: 75

• Rigour of development: 83

• Clarity of presentation: 94

• Applicability: 48

• Editorial independence: 100

iCAHE summary (Table 3.4)

• Information (n=3): 3 yes

• Currency (n=3): 3 yes

• Evidence (n=4): 4 yes

• Developers (n=2): 1 yes

• Purpose and end users (n=1): 1 yes

• 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 information

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

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


Availability

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

gov/content.aspx?id=36625

• 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

Content

Foot and ankle conditions of:

• Achilles tendinopathy

• Achilles tendon rupture

• Plantar heel (plantar fasciitis)

• Tarsal tunnel syndrome

• Ankle sprain

• 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.

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Based on research evidence and consensus that was reached for some recommendations by

the Evidence-Based Practice Panel (EBPP). The EBPP explicitly considered the health beneits,

side efects, and risks of the proposed recommendation for the management of each condition/

modality.

Search period 1966 – 2010

Sources of evidence

The National Library of Medicine’s MEDLARS database (Medline), EBM Online, The Cochrane

Central Register of Controlled Trials, TRIP Database, CINAHL, EMBASE, PEDro


Grades of recommendation

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

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.


ACHILLES TENDINOPATHY

Non-operative management (physical methods and devices)

Recommended No recommendation Not recommended

Eccentric exercises for

chronic Achilles tendinopathy

(Recommendation B)

Night splint for acute, subacute

or chronic Achilles tendinopathy

(Recommendation I)

Magnets (Recommendation I)

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Low-level laser therapy for select

patients with chronic Achilles

tendinopathy (Recommendation C)

Orthotic devices such as heel

lifts, heel pads, or heel braces

(Recommendation I)

Dry needling (Recommendation I)

Extracorporeal shockwave therapy

(ESWT) as an adjunct to an

eccentric exercise for chronic,

recalcitrant Achilles tendinopathy

(Recommendation C)

Acupuncture (Recommendation I) ESWT for acute, subacute, or post-

operative Achilles tendinopathy

(Recommendation I)

Education (Recommendation I) Massage and tendon mobilisation

(Recommendation I)

Heat (Recommendation I) Ultrasound (Recommendation I)

Cryotherapy (Recommendation I) Low-level laser therapy for

acute, subacute, or post-


(Recommendation I)

Stretching and loading exercises,

particularly eccentric exercises,

for acute, subacute, or post-


(Recommendation I)

Night splints and walking boots

for post-operative Achilles

tendinopathy (Recommendation I)

Pharmacological management (including injectable agents)


Non-steroidal anti-inlammatory

drugs (NSAIDs) for acute

Achilles tendinopathy pain

(Recommendation C)

Vitamins as therapeutic

intervention or for prevention of

Achilles tendinopathy in doses

recommended by U.S. Food

and Drug Administration (FDA)

(Recommendation I)

Platelet-rich plasma injections.

(Recommendation B)

Topical NSAIDs for acute or

subacute Achilles tendinosis

(Recommendation C)

Lidocaine patches

(Recommendation I)

Aprotinin injection for


(Recommendation C)

Topical glyceryl trinitrate for pain

in select patients with chronic

Achilles tendinopathy after

other conservative treatment

alternatives have failed

(Recommendation C)

Glycosaminoglycan polysulfate local

injection for acute, subacute, or

post-operative Achilles tendinopathy

(Recommendation I)

Heparin subcutaneous injection

for acute or subacute Achilles

tendinopathy (Recommendation C)

Acetaminophen

(Recommendation I)

Actovegin injection for acute,

subacute, or chronic Achilles


Low-dose glucocorticosteroid

injections for acute, subacute, or

post-operative Achilles tendinopathy

(Recommendation I)

Topical NSAIDs for chronic Achilles

tendinosis (Recommendation I)

Prolotherapy injections for


(Recommendation I)

Oral or intramuscular steroid

preparations for acute, subacute,

chronic, or post-operative Achilles


NSAIDs for subacute or chronic

Achilles tendinopathy pain or post-

operative pain or inlammation

(Recommendation I)

Polidocanol injection for



(Recommendation I)

Heparin subcutaneous injection

for chronic Achilles tendinopathy

(Recommendation I)

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Opioids for short-term use to

treat pain after Achilles tendon

surgery or for patients who have

encountered surgical complications

(Recommendation I)

High-volume image-guided

injection for chronic Achilles

tendinopathy Recommendation I)

Aprotinin injection for acute or

subacute Achilles tendinopathy

(Recommendation I)

Low-dose glucocorticosteroid

injections as an alternative therapy


and associated paratendon bursitis

(Recommendation I)

Iontophoresis with NSAIDs

(Recommendation I)

Opioids for acute, subacute, or

chronic Achilles tendinopathy pain

(Recommendation I)

Glycosaminoglycan polysulfate local

injection as an alternative therapy


(Recommendation C)

Phonophoresis Recommendation I) High doses (exceeding U.S. FDA

recommendations) or expensive

compounded preparation

vitamins for prevention of Achilles


Polidocanol injection for


(Recommendation C)

Topical NSAIDs for post-

operative Achilles tendinosis

(Recommendation I)

Iontophoresis with

glucocorticosteroid for acute,

subacute, or chronic Achilles


Iontophoresis with

glucocorticosteroid for post-


(Recommendation I)

Topical glyceryl trinitrate for



(Recommendation I)

Surgical management


Surgery for select cases of


without rupture. There is no

recommendation for any

particular procedure over another

(Recommendation I)

Surgery for acute or subacute

Achilles tendinopathy without

rupture (Recommendation I)

ACHILLES TENDON RUPTURE



Early weight-bearing for post-

operative rehabilitation of Achilles

tendon ruptures for functional

bracing or rigid immobilisation

(Recommendation A)

Early weight-bearing for non-

operatively managed Achilles

tendon ruptures

(Recommendation I)

Functional splinting (bracing) as

primary treatment method for post-

operative care of Achilles tendon

ruptures (Recommendation B)

Transcutaneous electrical nerve

stimulation as post-operative

treatment for Achilles tendon


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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


(Recommendation I)

A primarily home-based

rehabilitation program (exercise

and education) for Achilles tendon




Prophylaxis for prevention

of deep venous thrombosis

(Recommendation C)

Prophylaxis, including warfarin,

heparin, low molecular weight

heparin, graded compression

stockings, aspirin, or factor Xa to

prevent deep venous thrombosis

(Recommendation I)

Opioids for treatment of pain from

subacute or chronic Achilles tendon

repair (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


Open repair and percutaneous

approaches for patients undergoing

operative repair. There is no

recommendation of one approach

over the other (Recommendation C)

Augmented repair for

chronic or neglected ruptures

(Recommendation I)

Augmented repair for acute

ruptures, unless primary repair is

not possible (Recommendation C)

Surgical repair for ruptured Achilles

tendon (Recommendation C)

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PLANTAR HEEL (PLANTAR FASCIITIS)



Heel taping as a short-term

treatment for acute or subacute

plantar fasciitis or heel pain

(Recommendation C)

Casting for chronic plantar fasciitis

(Recommendation I)

Ultrasound (Recommendation C)

Orthotic devices

(Recommendation C)

Acupuncture (Recommendation I) ESWT for acute or subacute plantar

fasciitis (Recommendation I)

Education for select patients

(Recommendation I)

Custom orthoses

(Recommendation I)

Radial ESWT for acute or subacute

plantar fasciitis (Recommendation I)

Heat (Recommendation I) Heel taping for chronic

plantar fasciitis or heel pain

(Recommendation I)

Ultrasound or luoroscopic guidance

is not recommended over application

of energy at point of maximal

tenderness (Recommendation I)

Prefabricated night splints for

subacute or chronic plantar heel

pain (Recommendation I)

Low frequency electrical

stimulation (Recommendation I)

Stretching exercises of plantar

fascia and Achilles tendon

(Recommendation I)

Low-level laser therapy

(Recommendation I)

Manipulation (Recommendation I)

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)

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Intracorporeal pneumatic shock

therapy for select chronic plantar

fasciitis (Recommendation B)

Cryosurgery for chronic plantar

heel pain (Recommendation I)

Magnets (Recommendation A)

Botulinum toxin A injection for

select chronic plantar fasciitis

(Recommendation C)

Hyperosmolar dextrose injections

(Recommendation I)

Wheat grass cream

(Recommendation B)

Glucocorticosteroid injections for

short-term relief of chronic plantar

fasciitis (Recommendation C)

Iontophoresis with

glucocorticosteroid or acetic acid for

select patients (Recommendation I)

Autologous blood injection

(Recommendation C)

Acetaminophen (Recommendation I) Lidocaine patches

(Recommendation I)

Ultrasound or scintigraphy imaging

techniques to guide injection

(Recommendation C)

ESWT for chronic plantar

fasciitis in select patients with

chronic recalcitrant conditions

(Recommendation I)

Local anaesthesia used in

conjunction with low- or medium-

energy ESWT (Recommendation I)

Botulinum toxin A injection for

acute or subacute plantar fasciitis

(Recommendation I)

Cryotherapy (Recommendation I) Platelet rich plasma injections

(Recommendation I)

Cryosurgery for acute or

subacute plantar heel pain

(Recommendation I)

Limited use of opioids for a few

post-operative days for select

patients (Recommendation I)

Phonophoresis (Recommendation I) Glucocorticosteroid injections for

acute or subacute plantar fasciitis.

(Recommendation I)

Local anaesthesia in conjunction

with high-energy ESWT

(Recommendation I)

Short-term use of vitamins

for treatment or prevention

(Recommendation I)

Inliximab (Recommendation I)

NSAIDs (Recommendation I) Topical NSAIDs for post-operative

plantar fasciitis (Recommendation I)

Opioids for acute, subacute

or chronic plantar fasciitis

(Recommendation I)

Topical NSAIDs for acute, subacute,

or chronic plantar fascial pain

syndromes (Recommendation I)

Oral or intramuscular or

prevention (Recommendation

I)glucocorticosteroid

(Recommendation I)

Surgical management


Surgical release for select chronic

recalcitrant plantar fasciitis. There

is no recommendation for any

particular procedure or method

over another (Recommendation I)

Augmented repair for

chronic or neglected ruptures

(Recommendation I)

Surgical release for acute or

subacute plantar fasciitis

(Recommendation I)

TARSAL TUNNEL SYNDROME (TTS)



Self-application of ice/heat

(Recommendation I)

Acupuncture (Recommendation I) Magnets (Recommendation I)

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Return-to-work programs for

patients with TTS particularly

those with signiicant lost time

(Recommendation I)

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)



Glucocorticosteroid injections

(Recommendation I)

Acetaminophen or NSAIDs

(Recommendation I)

Botulinum injections

(Recommendation I)

Lidocaine patches for select cases

(Recommendation I)

Iontophoresis (Recommendation I) Diuretics (Recommendation I)

Limited use (a few days) of

opioids for select patients who

have undergone recent tarsal

tunnel release and have large

incisions or encountered signiicant

complications that cannot be

managed with other means

(Recommendation I)

Phonophoresis (Recommendation I) Insulin injections

(Recommendation I)

Oral glucocorticosteroids for TTS

patients who decline tarsal tunnel

injection (Recommendation I)

Other vitamins (Recommendation I) Pyridoxine for routine treatment

of TTS in patients without vitamin

deiciencies (Recommendation I)

Routine use of opioids

(Recommendation I)

Surgical management


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.

(Recommendation I)

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ANKLE SPRAIN



Early mobilisation for acute

ankle sprains without fracture

(Recommendation B)

Acupuncture (Recommendation I) Diathermy for acute ankle sprain

(Recommendation B)

Ankle support (brace, tape) for

prevention (initial injury) of ankle

injury (Recommendation C)

Contrast baths for acute ankle

sprain (Recommendation I)

Low-level laser therapy for acute

ankle sprain (Recommendation B)

Balance/proprioception training for

prevention of initial and recurrent

ankle injury (Recommendation C)

Compression therapy (i.e. tape,

elastic wrap, tubular elastic,

or pneumatic compression

devices) for acute ankle sprain

(Recommendation I)

Ultrasound for acute ankle sprain

(Recommendation B)

Ankle support (brace, tape) for

prevention (recurrent injury) of

ankle injury (Recommendation I)

Foot orthotics for prevention of

ankle injury (Recommendation I)

Hyperbaric oxygen therapy

for acute ankle sprain

(Recommendation C)

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)

Heat for acute ankle sprain

(Recommendation I)

Low frequency electrical

stimulation (Recommendation C)

Education for select patients

(Recommendation I)

Immobilisation by cast for severe

ankle sprain as splints should be

suicient (Recommendation I)

Diathermy for subacute or chronic

ankle sprain (Recommendation I)

Elevation for controlling

oedema of acute ankle sprains

(Recommendation I)

Magnets (Recommendation I) High-voltage pulsed stimulation

(Recommendation I)

Physical or occupational therapy

for select patients with acute,

subacute, or chronic ankle sprain

(Recommendation I)

Manipulation or mobilisation for

acute or subacute ankle sprain

(Recommendation I)

Hyperbaric oxygen therapy for

subacute or chronic ankle sprain

(Recommendation I)

Physical or occupational therapy

for chronic ankle instability

(Recommendation I)

Non-rigid support therapies (i.e.

tape, elastic wrap, or tubular

elastic) for acute ankle sprain

(Recommendation I)

Immobilisation by cast for patients

with acute mild to moderate

ankle sprain as splints should be

suicient (Recommendation I)

Rest or non-weight-bearing as an

initial intervention for acute ankle

sprain for patients unable to tolerate

weight (Recommendation I)

Stretching or strengthening

exercises for prevention of

initial or recurrent ankle injury

(Recommendation I)

Low-level laser therapy for

subacute or chronic ankle sprain

(Recommendation I)

Semi-rigid pneumatic or gel ankle

brace supports for acute ankle

sprain, with optional use as needed

for mild and moderate sprains

(Recommendation I)

Walking boot for acute ankle sprain

(Recommendation I)

Ultrasound for subacute or chronic

ankle sprain (Recommendation I)

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Short-term cast immobilisation

with early mobilisation and

physical or occupational

therapy for ankle instability

(Recommendation I)

Cryotherapy for acute ankle sprain

(Recommendation I)



Limited use of opioids for no more

than 1 week for select patients with

severe pain related to acute ankle

sprain (Recommendation A)

Autologous blood injection

(Recommendation I)

Oral proteolytic enzyme

preparations (Recommendation B)

NSAIDs for acute ankle sprain

(Recommendation A)

Benzydamine (Recommendation I) High doses (exceeding U.S. FDA

recommendations) or expensive

compounded preparation vitamins

for prevention of ankle sprain

(Recommendation I)

Acetaminophen

(Recommendation B)

Glucocorticosteroid injection

(Recommendation I)

Oral or intramuscular steroid

preparations (Recommendation I)

Topical NSAIDs for acute ankle

sprain (Recommendation B)

Hyaluronic acid injection

(Recommendation I)

Oral streptokinase/streptodornase

preparations (Recommendation I)

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)

Iontophoresis (Recommendation I)

NSAIDs for subacute, chronic,

or post-operative ankle sprain

(Recommendation I)

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

(Recommendation I)

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Surgical management


Ligament reconstruction for select

cases of chronic ankle instability

(Recommendation I)

Surgical repair for routine lateral

ligament tear associated with

acute or subacute ankle sprain

(Recommendation I)

ANKLE AND FOOT FRACTURES



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

management of post-operative

and stable non-operative ankle

fractures (Recommendation B)

Hyperbaric oxygen

(Recommendation I)

Interferential therapy for post-

operative swelling following ORIF

for displaced malleolar fracture

(Recommendation B)

Early weight-bearing of operatively

ixated ankle fracture post-

operatively (Recommendation B)

Hypnosis (Recommendation I) Passive stretching for contractures

after immobilisation of ankle

fractures (Recommendation B)

Pneumatic compression of foot and

ankle to reduce swelling for patients

with signiicant post-operative

oedema (Recommendation C)


of tibial shaft fractures

(Recommendation I)

Ultrasound (Recommendation B)

Non-operative management for

non-displaced and reduced stable

ankle fractures (Recommendation I)

Type of post-operative care

dressing (Recommendation I)

Manual therapy as part of an active

post-ankle fracture rehabilitation

program (Recommendation B)

Non-operative management in

select circumstances for distal

extra-articular tibial fractures

(Recommendation I)

Use of a speciic operative product.

(Recommendation I)


tibial plafond fractures in select



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)

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Adequate analgesia (conscious

sedation, intra-articular block)

for performing non-operative

closed reduction of ankle fractures.

(Recommendation C)

Use of nasal spray calcitonin

for prophylaxis of post-fracture

osteopenia (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)

Surgical management


Operative ixation for unstable

closed displaced ankle fractures

(Recommendation C)

Arthroscopy assisted ORIF

for distal ibular fractures.

(Recommendation I)

Surgical thigh tourniquet for

surgical treatment of closed

displaced ankle fractures

(Recommendation C)

Operative ixation for deinitive

management of displaced tibial

shaft fracture (Recommendation C)

Performing repair of torn

deltoid ligament in association

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


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Operative ixation for

displaced distal ibula fracture

(Recommendation I)

Operative ixation for

unstable syndesmotic rupture

(Recommendation I)

HINDFOOT FRACTURES (CALCANEUS, TALUS)



Pneumatic compression of foot

to reduce swelling for patients

with signiicant oedema after

closed calcaneus fractures

(Recommendation C)

Diathermy for management of

oedema associated with calcaneus


Non-operative cast immobilization

for select calcaneus fractures

(Recommendation I)


of non-displaced talar

fractures – head, neck, body

(Recommendation I)


of osteochondral lesions of

the talus for select patients

(Recommendation I)



Calcium phosphate paste or

bone graft for displaced intra-

articular fracture defects

(Recommendation I)

Surgical management


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)

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FOREFOOT AND MIDFOOT FRACTURES (TARSAL, METATARSAL, PHALANGEAL)



Immobilisation for select

patients with distal, middle,

and proximal phalanx fractures

(Recommendation I)


low risk lower extremity stress

fracture (Recommendation I)

Non-operative management of

5th metatarsal fractures (including

Jones and avulsion) for select



non-displaced metatarsal fractures

(Recommendation I)

Non-operative management of

non-displaced tarsal-metatarsal

injury (Lisfranc) for select patients

(Recommendation I)



NSAIDs or acetaminophen to control

pain from phalangeal or metatarsal


Surgical management


Operative management for select

patients with distal, middle,

and proximal phalanx fractures

(Recommendation I)

Operative management of lower

extremity stress fractures in select


Operative management for 5th

metatarsal fractures (Jones,

avulsion) for select patients

(Recommendation I)

Operative management for

unstable tarsal-metatarsal injury

(Lisfranc) (Recommendation I)

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Guideline quality

AGREE II score (Table 3.3)














Generalisability

It is likely that the samples studied in the body of evidence would be similar to the target

population of the guideline (adults with potentially work-related ankle and foot disorders in

primary care setings); however, this was not explicitly stated

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

devices) are directly applicable to the Australian podiatry context


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

Comprehensive information is also provided with respect to assessment procedures, diagnostic

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


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

End usersUsed in the management of patients with Achilles tendinitis by orthopaedic physical therapy

clinicians, academic instructors, clinical instructors, students, interns, and residents

Content Impairment/function-based diagnoses

• Prevalence

• Pathoanatomical features

• Risk factors

• Intrinsic risk factors such as

dorsilexion range of motion, abnormal

subtalar range of motion, decreased

plantar lexion strength, pronation,

tendon structure, and comorbidity

• Extrinsic risk factors including

training errors, environmental factors,

and faulty equipment

• Diagnosis and classiication


• Signs and symptoms

• Diferential diagnosis

• Conditions listed include ruptures,

tears, bursitis, nerve and muscle

involvement

Examination

• Outcome measures such as the

• Victorian Institute of Sport

Assessment (VISA)

• Foot and Ankle Ability Measure

(FAAM)

• Activity limitation and participation

restriction measures

• Six tests of function, such as jump

tests, strength tests, and a muscular

endurance test

• Physical impairment measures

• Ankle dorsilexion and subtalar

joint range of motion, plantar lexion

strength and endurance, truncated

arch-height ratio, forefoot alignment,

Achilles tendon palpation test, arc

sign, and Royal London Hospital test

• Prognosis

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Interventions

• Eccentric loading

• Laser therapy:

• Iontophoresis

• Stretching

• Foot orthoses

• Manual therapy

• Taping

• Heel lits

• Night splints


Based on research evidence, and included the role of consensus expert opinion and basic

science research to demonstrate biological and biomechanical plausibility

Search period 1967 – February 2009

Sources of evidence

MEDLINE, CINAHL, and The Cochrane Database of Systematic Reviews



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


Impairment/ function-based diagnosis

• Intrinsic and extrinsic risk factors

(Recommendation: B, for speciic groups of individuals.

Consider abnormal ankle dorsilexion range of motion,

abnormal subtalar joint range of motion, decreased ankle

plantar lexion strength, increased foot pronation, and

abnormal tendon structure as intrinsic risk factors associated

with Achilles tendinopathy. Obesity, hypertension,

hyperlipidaemia, and diabetes are medical conditions

associated with Achilles tendinopathy. Also consider training

errors, environmental factors, and faulty equipment as

extrinsic risk factors associated with Achilles tendinopathy)


(Recommendation: C, self-reported localised pain and

perceived stifness in the Achilles tendon following a period

of inactivity [i.e. sleep, prolonged siting], lessens with an

acute bout of activity and may increase ater the activity.

Symptoms are frequently accompanied with Achilles tendon

tenderness, a positive arc sign, and positive indings on the

Royal London Hospital test.

These signs and symptoms are useful clinical indings

for classifying a patient with ankle pain into the ICD

category of Achilles bursitis or tendinitis and the associated

International Classiication of Functioning impairment-

based category of Achilles pain [b28015 Pain in lower limb],

stifness [b7800 Sensation of muscle stifness], and muscle

power deicits [b7301 Power of muscles of lower limb])


(Recommendation: F, clinicians should consider diagnostic

classiications other than Achilles tendinopathy when the

patient’s reported activity limitations or impairments of

body function and structure are not consistent with those

presented in the diagnosis/classiication section of this

guideline, or when the patient’s symptoms are not resolving

with interventions aimed at normalisation of the patient’s

impairments of body function)

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Examination

• Outcome measures

(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)

• Activity limitation and participation restriction

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

(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)

• Foot orthoses

(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


• 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


Guideline quality















GeneralisabilityIt is likely that the samples studied in the body of evidence would be similar to the target


Applicability

The recommendations pertaining to the interventions are directly applicable to the Australian

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

against research criteria and strength of evidence. This guideline scored moderately high on the

AGREE II and highly on the iCAHE Guideline Checklist

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4. INSTITUTE FOR CLINICAL SYSTEMS IMPROVEMENT (ICSI) (2006) – ANKLE SPRAIN18


Availability

Guideline can be found in the National Guideline Clearinghouse to members only or resources

available to ICSI members only. A lowchart of the ankle sprain guideline is publicly available

from www.guideline.gov/algorithm/4870/NGC-4870.pdf

End users

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

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

Content

1. Provider visit, including

• Components of a history

• Physical examination

2. Indications for x-ray

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


Based on research evidence. It is unclear how these recommendations were developed although

some references have been provided and have been graded based on study design.

Search period Not stated

Sources of evidence

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

research, included the source/ author and contact information, clearly stated revision dates or

the date the information was published, and was clear about potential biases, noting conlict of

interest and/ or disclaimers as appropriate



Classes of research reports:

A. Primary Reports of New Data Collection:

Class A: Randomised, controlled trial

Class B: Cohort study

Class C: Non-randomised trial with concurrent

or historical controls

• Case-control study

• Study of sensitivity and speciicity of a

diagnostic test

• Population-based descriptive study

Class D: Cross-sectional study

• Case series

• Case report

B. Reports that Synthesize or Relect

upon Collections of Primary Reports:

Class M: Meta-analysis

• Systematic review

• Decision analysis

• Cost-efectiveness analysis

Class R: Consensus statement

• Consensus report

• Narrative review

Class X: Medical opinion

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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

Guideline quality















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Generalisability

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

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

quality with respect to the rigour of development (on the AGREE II) and underlying evidence on

the iCAHE Guideline Checklist

5. KNGF (2006) – GUIDELINE FOR PHYSICAL THERAPY IN PATIENTS WITH ACUTE ANKLE SPRAIN17


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

guidelines-in-english

End users Physical therapists treating patients with acute ankle sprains

Content

The guideline contains background

information on the deinition of acute

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

2. The diagnostic process, including

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)

3. Therapy

• To address the four phases of healing:

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,

bandaging, tape/bracing, electrophysical

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


Based on research evidence and expert opinion.


Sources of evidence

Not stated

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Review of the evidence

1 = One systematic review (A1 quality; see

below) or at least two independent studies of

A2 quality

2 = At least two independent

studies of B quality

3 = One study of A2 or B quality, or several

studies of C quality

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

the Guideline Commitee

Quality levels (intervention and prevention)

A1 = Systematic reviews included at least

some studies of A2 quality, with results

consistent across individual studies

A2 = Randomised comparative clinical trial

of sound methodological quality (randomised

double-blind controlled trial) of suicient size

and consistency

B = Randomised comparative clinical trial

of moderate quality or insuicient size;

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


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


• 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)

• 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


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• An exercise program should be suiciently intensive and include enough repetition to train muscle endurance as well


• 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


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


• 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.

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)

Guideline quality















Generalisability

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

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

ApplicabilityThis guideline is directly applicable to the Australian podiatry context; however, it potentially

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

the inability to access the accompanying documents published in Dutch. The recommendations

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

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6. MCPOIL ET AL (2008) – HEEL PAIN: PLANTAR FASCIITIS (ORTHOPAEDIC SECTION OF THE AMERICAN PHYSICAL THERAPY ASSOCIATION) 15


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

End usersUsed in the management of patients with heel pain or plantar fasciitis by orthopaedic physical

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




• 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


• 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

• Modalities

• Manual therapy

• Stretching

• Taping

• Orthotic devices

• Night splints


Based on research evidence, and included the role of consensus expert opinion and basic science

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


Levels of Evidence

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

diagnostic studies

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

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

lll = Case-controlled studies or retrospective studies

lV = Case series

V = Expert opinion

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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


Impairment/ function-based diagnoses

• Pathoanatomical features

(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

(Recommendation: B, clinicians should consider limited

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)


(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.

The following physical examination measures may be useful

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: F, clinicians should consider diagnostic

classiications other than heel pain/ plantar fasciitis when

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


(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)

• Activity limitation measures

(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

(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

to prefabricated orthoses. There is currently no evidence to

support the use of prefabricated or custom foot orthoses for

long term [1 year] pain management or function improvement)

• Iontophoresis

(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

(Recommendation: C, calcaneal or Low-Dye taping can be

used to provide short-term [7-10 days] pain relief. Studies

indicate that taping does cause improvements in function)

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• Stretching

(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)

• Manual therapy

(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)

Guideline quality















GeneralisabilityIt is likely that the samples studied in the body of evidence would be similar to the target


Applicability

The recommendations pertaining to the interventions are directly applicable to the Australian

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 comprehensive. The information was referenced but the evidence source was not stated;

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

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7. NATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE (2009) – INTERVENTIONAL PROCEDURES PROGRAM – INTERVENTIONAL PROCEDURE OVERVIEW OF EXTRACORPOREAL SHOCKWAVE THERAPY FOR REFRACTORY PLANTAR FASCIITIS19


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

End users Not stated

Content• Eicacy

• Safety


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

Search period Prior to May 2008

Sources of evidence

Research evidence located from electronic database searches (The Cochrane Database of

Systematic reviews, Database of Abstracts of Reviews of Efects, HTA database, The Cochrane

Central Database of Controlled trials, Medline, Medline -In- Process, EMBASE, CINAHL, BLIC,

National Research Register Archive, UK Clinical Research Network Portfolio Database, Current

Controlled Trials metaRegister of Controlled Trials, Clinicaltrials.gov


Not stated


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

energy type. The results of studies (7 randomised controlled trials, 1 cross-sectional survey and

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

Guideline quality















GeneralisabilityIt is highly probable that the samples studied in the body of evidence would be similar to the

target population of the guideline

Applicability

The recommendations pertaining to the intervention are directly applicable to the Australian

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

assessment of the use of extracorporeal shockwave therapy for refractory plantar fasciitis.

There was no synthesis of evidence and therefore no summary recommendations. Moreover, a

comprehensive search of the literature was not performed

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


Availability

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

S1067251610000025

• 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


Content

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

• Prevalence

• Aetiology


• Examination

• Treatment options including padding and strapping,

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


Consensus of current clinical practice and review of the clinical literature


Sources of evidence Not stated


Levels of evidence:

I = High quality prospective randomised

controlled trial

II = Prospective comparative study

III = Retrospective case control study

IV = Expert opinion

Grades of recommendation:

A = Treatment options are supported by strong

evidence (consistent with level I or II studies)

B = Treatment options are supported by fair

evidence (consistent with level III or IV studies)

C = Treatment options are supported by either

conlicting or level IV studies

I = Insuicient evidence to make a

recommendation

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

1. Acute management (within 6 weeks

from onset of symptoms)

• Achilles and plantar fascia stretching

(Recommendation: B)

• Orthotic insoles (Recommendation: B)

• Padding and strapping (Recommendation: B)

• Oral inlammatory medication (Recommendation: I)

2. Subacute management (up to 6 months

from onset of symptoms)

• Night splint (Recommendation: B)

• 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)

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)

Guideline quality















GeneralisabilityThe samples studied in the body of evidence may be similar to the target population of the

guideline; however, this was not explicitly stated

ApplicabilityThe recommendations for the management of acute and subacute heel pain are directly

applicable to the Australian podiatry context


There was a paucity of information provided in the published article regarding the methodology

used to develop the recommendations

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


Availability

Thomas J, Blitch E, 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): 418.e1-e9 doi:10.1053/j.jfas.2008.12.003


Content


• Radiologic indings

• Examination


• Treatment options including surgical and non-surgical management






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


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

debridement of hyperkeratotic lesion(s), corticosteroid injections, taping, footwear changes

• 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

Guideline quality

















Applicability

The recommendations for the non-surgical management (particularly padding, orthotic devices

or shoe insole modiications, debridement of hyperkeratotic lesion(s), taping, footwear changes)

are directly applicable to the Australian podiatry context



used to develop the recommendations. Litle evidence was used to justify recommendations

* Of proximal or distal interphalangeal joint(s)

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10. THOMAS J ET AL (2009) – CENTRAL METATARSALGIA9


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


Content

Capsulitis, metatarsal abnormality, metatarsal

stress fracture or other causes:



• Examination


• Treatment options including surgical

and non-surgical management








Capsulitis and metatarsal abnormality

• Non-surgical treatment, e.g. padding, orthotic devices, shoe modiications, injections, non-

steroidal anti-inlammatories

• 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

Guideline quality

















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ApplicabilityThe recommendations for the non-surgical management (particularly padding, orthotic devices,

shoe modiications, of loading) are directly applicable to the Australian podiatry context




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


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


Content



• Examination











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

• Surgical management, e.g. decompression, injection therapy, and others, such as cryogenic

neuroablation

Guideline quality

















ApplicabilityThe recommendations for the non-surgical management (particularly pads and footwear

alteration) are directly applicable to the Australian podiatry context




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12. THOMAS J ET AL (2009C) – TAILOR’S BUNION11


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


Content



• Examination











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

alterations, injections, orthotic devices/ insoles

• Surgical treatment, e.g. exostectomy, osteotomy, metatarsal head resection

Guideline quality

















Applicability

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

hyperkeratotic lesions, padding, footwear alterations, and orthotic devices/ insoles) are directly





13. THOMAS J ET AL (2009) – TRAUMA12


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

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Content


• Radiologic evaluation

• Examination










Non-surgical treatment

1. Fractures

• Immobilisation for non-displaced fractures

2. Dislocation

• Closed reduction

3. Sot tissue injury (negative diagnosis of fracture or

dislocation)

• Wound care and tetanus prophylaxis

for puncture wounds

• Irrigation of nail bed injuries

Surgical treatment

1. Fractures

• Closed or open reduction for displaced fractures,

arthroplasty for signiicant intra-articular fractures

2. Dislocation

• Open reduction where there is sot tissue interposition

• Late repair and balancing of capsuloligamentous

tissues is rarely necessary

3. Sot tissue injuries

• Resection of the bone to proximal level for degloving

injuries of the nail bed and distal phalanx. This allows

for adequate sot tissue coverage

• Open repair of tendon lacerations

• Surgical decompression of compartment syndrome

Guideline quality AGREE II score (Table 3.3)
















ApplicabilityThe recommendations for the non-surgical management (particularly for sot tissue injuries) are

directly applicable to the Australian podiatry context




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14. WORK LOSS DATA INSTITUTE (2013) – ODG INTEGRATED TREATMENT/DISABILITY DURATION GUIDELINES – OCCUPATIONAL DISORDERS OF THE FOOT AND ANKLE20


Availability

• Summary is publicly available from the National Guideline Clearinghouse

• 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

End users

Treating physicians, allied health care providers, insurance claims professions, nurse case

managers, workers compensation authorities, employee representatives, to improve outcomes

for any claim that might be seen in a jurisdictional workers’ compensation system

Content

99% of foot and ankle conditions. Recommendations include

• Evaluation including imaging

• Treatment codes for automated approval

• Return to work pathways


Review of the clinical literature and consensus

Search period 1993 – 2013

Sources of evidence

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

guidelines (e.g. National Guideline Clearinghouse), conference proceedings in Occupational

Health, and disability evaluation


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

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

• 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)

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Achilles tendinopathy

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


• 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

1. Avoid high-heeled and narrow shoes

2. Reduce pressure using a metatarsal pad orthotic device

3. Surgery (excision of nerve, 82% report excellent or good

post-operative results)

• Conlicting or no supporting evidence

1. Insoles

2. Corticosteroid injections

3. Transposition of the transected plantar digital nerve

• Not recommended: none

Plantar fasciitis and heel spur

• Recommendations

1. Conservative management

2. Heel pads and stretching in combination (as more

efective than either technique alone)

3. Orthotics, especially for people who stand for more

than 8 hours per day

4. Plantar fascia stretches

5. Night splints with ankle in dorsilexion

6. Tension night splints used in combination with heel

pads, stretching program and NSAIDs

7. Corticosteroids

• Conlicting results

Extracorporeal shockwave therapy

• Not recommended

1. Iontophoresis

2. Insoles with magnetic foil

3. Ultrasound

4. Botulinum toxin

5. Surgical management

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Guideline quality















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

ApplicabilityThe recommendations for non-surgical management are directly



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

diagnoses, all of which contain treatment codes for automated approval and return to work pathways.

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

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3.6 REFERENCES

1. Academy of Ambulatory Foot and Ankle Surgery

(2003a) Hallux abductovalgus. Philadelphia (PA):

Academy of Foot and Ankle Surgery.


(2003b) Hallux limitus and hallux rigidus. Philadelphia

(PA): Academy of Foot and Ankle Surgery.


(2003c) Hammertoe syndrome. Philadelphia (PA):



(2003d) Heel spur syndrome. Philadelphia (PA):



(2003e) Intermetatarsal neuroma. Philadelphia (PA):



(2003f) Metatarsalgia / intractable plantar keratosis

/ Tailor’s bunion. Philadelphia (PA): Academy of Foot

and Ankle Surgery.


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.



treatment of forefoot disorders. Section 2: Central

metatarsalgia. The Journal of Foot and Ankle Surgery

48(2): 239-250.



treatment of forefoot disorders. Section 3: Morton’s

intermetatarsal neuroma. The Journal of Foot and

Ankle Surgery 48(2): 251-256.



treatment of forefoot disorders. Section 4: Tailor’s

bunion. The Journal of Foot and Ankle Surgery 48(2):

257-263.



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.


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.

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Chapter 4

Discussion

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Chapter 4

4.1 INTERPRETATION OF RESULTS

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

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

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.

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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

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.

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:

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

4.3 IMPLICATIONS FOR RESEARCH

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:

1. Systematic reviews should be conducted to

identify evidence that underpins the most efective

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.

4.4 CONCLUSION

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

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.

4.5 REFERENCES

1. Grimmer K, Milanese S, Bialocerkowski A (2003)

Clinical guidelines for low back pain: physiotherapy

perspective. Physiotherapy Canada 55: 185-194.

2. MacDermid J (2005) The quality of clinical practice

guidelines in hand therapy. Journal of Hand Therapy

17: 200-209.

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3. Buchan H, Currie K, Lourey E, Duggam G (2010)

Australian clinical practice guidelines – a national

study. Medical Journal of Australia 192: 490-494.


(2003a) Hallux abductovalgus. Philadelphia (PA):

Academy of Ambulatory Foot and Ankle Surgery.


(2003b) Hallux limitus and hallux rigidus. Philadelphia

(PA): Academy of Ambulatory Foot and Ankle Surgery.


(2003c) Hammertoe syndrome. Philadelphia (PA):



(2003d) Heel spur syndrome. Philadelphia (PA):



(2003e) Intermetatarsal neuroma. Philadelphia (PA):



(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



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,



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

procedure overview of extracorporeal shockwave

therapy for refractory plantar fasciitis. London, UK:

National Institute for Health and Care Excellence.



treatment of forefoot disorders. Section 1: Digital

deformities. The Journal of Foot and Ankle Surgery

48(2): 418e1-e9.



treatment of forefoot disorders. Section 2: central

metatarsalgia. The Journal of Foot and Ankle Surgery

48(2): 229-250.



treatment of forefoot disorders. Section 3: Morton’s

neuroma. The Journal of Foot and Ankle Surgery

48(2): 251-256.



treatment of forefoot disorders. Section 4: Tailor’s

bunion. The Journal of Foot and Ankle Surgery 48(2):

257-262.



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.


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.


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/[email protected]/

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

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Appendix

AGREE II score calculations

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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


1 7 1 7 15

2 7 4 7 18

Total 14 5 14 33



Domain score

Obtained 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

12 14 14 2 96



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= [(96-16) / (112-16)]*100 = 83%

Domain 4: Clarity of presentation


1 7 6 7 20

2 7 6 7 20

Total 14 12 14 40





= [(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





= [(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



Domain score

Obtained score – minimum possible score


= [(28-4) / (28-4)]*100 = 100%

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