Recommendations for Ankle and Foot Disorders

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

Ankle and Foot Disorder	Treatment with Evidence Rating/Recommendation Level
	Recommended	No Recommendation	Not Recommended
Achilles Tendinopathy	Acetaminophen (I)Non-steroidal anti-inflammatory drugs (NSAIDs) for acute Achilles tendinopathy pain (C) NSAIDs for subacute or chronic Achilles tendinopathy pain or postoperative pain or inflammation (I) Topical NSAIDs for acute or subacute Achilles tendinosis (C) Topical NSAIDs for chronic Achilles tendinosis (I) Topical glyceryl trinitrate for pain in select patients with chronic Achilles tendinopathy after other conservative treatment alternatives have failed (C) Opioids for short-term use to treat pain after Achilles tendon surgery or for patients who have encountered surgical complications (I) Low-dose glucocorticosteroid injections as an alternative therapy for chronic Achilles tendinopathy and associated paratendon bursitis (I) Glycosaminoglycan polysulfate local injection as an alternative therapy for chronic Achilles tendinopathy (C) Polidocanol injection for chronic Achilles tendinopathy (C) Education (I) Eccentric exercises for chronic Achilles tendinopathy (B) Stretching and loading exercises, particularly eccentric exercises, for acute, subacute, or post-operative Achilles tendinopathy (I) Cryotherapy (I) Heat (I) Extracorporeal shockwave therapy as an adjunct to an eccentric exercise for chronic, recalcitrant Achilles tendinopathy (C) Iontophoresis with glucocorticosteroid for acute, subacute, or chronic Achilles tendinopathy (I) Low-level laser therapy for select patients with chronic Achilles tendinopathy (C) Night splints and walking boots for post-operative Achilles tendinopathy (I) Surgery for select cases of chronic Achilles tendinopathy without rupture. There is no recommendation for any particular procedure over another. (I)	Vitamins as therapeutic intervention or for prevention of Achilles tendinopathy in doses recommended by U.S. Food and Drug Administration (FDA) (I)Lidocaine patches (I) Topical glyceryl trinitrate for acute, subacute, or post-operative Achilles tendinopathy (I) Glycosaminoglycan polysulfate local injection for acute, subacute, or postoperative Achilles tendinopathy (I) Actovegin injection for acute, subacute, or chronic Achilles tendinopathy (I) Prolotherapy injections for chronic Achilles tendinopathy (I) Polidocanol injection for acute, subacute, or post-operative Achilles tendinopathy (I) High-volume image-guided injection for chronic Achilles tendinopathy (I) Night splint for acute, subacute or chronic Achilles tendinopathy (I) Orthotic devices such as heel lifts, heel pads, or heel braces (I) Acupuncture (I) Massage and tendon mobilization (I) Ultrasound (I) Iontophoresis with NSAIDs (I) Phonophoresis (I) Low-level laser therapy for acute, subacute, or post-operative Achilles tendinopathy (I) Topical NSAIDs for post-operative Achilles tendinosis (I) Iontophoresis with glucocorticosteroid for post-operative Achilles tendinopathy (I)	Oral or intramuscular (IM) steroid preparations for acute, subacute, chronic, or postoperative Achilles tendinopathy (I)Opioids for acute, subacute, or chronic Achilles tendinopathy pain (I) High doses (exceeding U.S. FDA recommendations) or expensive compounded preparation vitamins for prevention of Achilles tendinopathy (I) Low-dose glucocorticosteroid injections for acute, subacute, or post-operative Achilles tendinopathy (I) Heparin subcutaneous injection for acute or subacute Achilles tendinopathy (C) Heparin subcutaneous injection for chronic Achilles tendinopathy (I) Aprotinin injection for acute or subacute Achilles tendinopathy (I) Aprotinin injection for chronic Achilles tendinopathy (C) Platelet-rich plasma injections (B) Magnets (I) Extracorporeal shockwave therapy for acute, subacute, or post-operative Achilles tendinopathy (I) Dry needling (I) Surgery for acute or subacute Achilles tendinopathy without rupture (I)
Achilles Tendon Rupture	Acetaminophen as analgesia for pain as a result of acute Achilles tendon rupture (I)NSAIDs for pain treatment of acute and subacute Achilles tendon rupture (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. (I) Self-application of cryotherapy for acute or post-operative Achilles tendon rupture (I) Self-application of heat for acute, subacute, chronic, or post-operative Achilles tendon rupture (I) Surgical repair for ruptured Achilles tendon (C) Non-operative management with functional splinting and casting for Achilles tendon rupture (C) Open repair and percutaneous approaches for patients undergoing operative repair. There is no recommendation of one approach over the other. (C) A primarily home-based rehabilitation program (exercise and education) for Achilles tendon rupture (I) Early weight bearing for post-operative rehabilitation of Achilles tendon ruptures for functional bracing or rigid immobilization (A) Functional splinting (bracing) as primary treatment method for postoperative care of Achilles tendon ruptures (B) Prophylaxis for prevention of deep venous thrombosis (C)	Early weight bearing for non-operatively managed Achilles tendon ruptures (I)Augmented repair for chronic or neglected ruptures (I) Prophylaxis, including warfarin, heparin, low molecular weight heparin, graded compression stockings, aspirin, or Factor Xa to prevent deep venous thrombosis (I) Transcutaneous electrical nerve stimulation (TENS) as post-operative treatment for Achilles tendon rupture (I)	Opioids for treatment of pain from subacute or chronic Achilles tendon repair (I)Augmented repair for acute ruptures, unless primary repair is not possible (C)
Plantar Heel (“Plantar Fasciitis”)	Education for select patients (I)Acetaminophen (I) NSAIDs (I) Limited use of opioids for a few postoperative days for select patients (I) Topical NSAIDs for acute, subacute, or chronic plantar fascial pain syndromes (I) Botulinum toxin A injection for select chronic plantar fasciitis (C) Glucocorticosteroid injections for short-term relief of chronic plantar fasciitis (C) Cryotherapy (I) Heat (I) Prefabricated night splints for subacute or chronic plantar heel pain (I) Orthotic devices (C) Stretching exercises of plantar fascia and Achilles tendon (I) Heel taping as a short-term treatment for acute or subacute plantar fasciitis or heel pain (C) Extracorporeal shockwave therapy (ESWT) for chronic plantar fasciitis in select patients with chronic recalcitrant conditions (I) Local anesthesia in conjunction with high-energy ESWT (I) Intracorporeal pneumatic shock therapy for select chronic plantar fasciitis (B) Surgical release for select chronic recalcitrant plantar fasciitis. There is no recommendation for any particular procedure or method over another. (I)	Short-term use of vitamins for treatment or prevention (I)Lidocaine patches (I) Topical NSAIDs for post-operative plantar fasciitis (I) Hyperosmolar dextrose injections (I) Platelet rich plasma injections (I) Casting for chronic plantar fasciitis (I) Custom orthoses (I) Orthotic devices for prevention of plantar fasciitis or lower extremity disorders (I) Special fitted or shock absorbing shoes for prevention of plantar fasciitis or lower extremity disorders (I) Heel taping for chronic plantar fasciitis or heel pain (I) Acupuncture (I) Low frequency electrical stimulation (I) Local anesthesia used in conjunction with low- or medium-energy ESWT (I) Radial ESWT for chronic plantar fasciitis (I) Iontophoresis with glucocorticosteroid or acetic acid for select patients (I) Low-level laser therapy (I) Manipulation (I) Massage and tendon mobilization (I) Phonophoresis (I) Radiation therapy for chronic plantar heel pain (I) Cryosurgery for chronic plantar heel pain (I) Percutaneous calcaneus fenestration for chronic plantar heel pain (I) Radiofrequency microtenotomy for chronic plantar fasciitis (I)	Infliximab (I)Opioids for acute, subacute or chronic plantar fasciitis (I) Oral or intramuscular glucocorticosteroid (I) Wheat grass cream (B) Autologous blood injection (C) Botulinum toxin A injection for acute or subacute plantar fasciitis (I) Glucocorticosteroid injections for acute or subacute plantar fasciitis (I) Ultrasound or scintigraphy imaging techniques to guide injection (C) Magnets (A) ESWT for acute or subacute plantar fasciitis (I) Ultrasound or fluoroscopic guidance is not recommended over application of energy at point of maximal tenderness (I) Radial ESWT for acute or subacute plantar fasciitis (I) Ultrasound (C) Cryosurgery for acute or subacute plantar heel pain (I) Surgical release for acute or subacute plantar fasciitis (I)
Tarsal Tunnel Syndrome (TTS)	Self-application of ice/heat (I)Oral glucocorticosteroids for TTS patients who decline tarsal tunnel injection (I) Limited use (a few days) of opioids for select patients who have undergone recent tarsal tunnel release and have large incisions or encountered significant complications that cannot be managed with other means (I) Lidocaine patches for select cases (I) Glucocorticosteroid injections (I) 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-specific causes are otherwise expected to have mixed results and patients should be counseled regarding potential lack of benefit before considering surgery. There is no recommendation for any specific technique as there is lack of quality evidence. (I) Return-to-work programs for patients with TTS particularly those with significant lost time (I)	Rest (I)Taping (I) Acetaminophen or NSAIDs (I) Other vitamins (I) Exercises (I) Trial of nocturnal splinting (I) Orthotics (I) Acupuncture (I) Ultrasound (I) Iontophoresis (I) Phonophoresis (I) Work restrictions (I)	Diuretics (I)Routine use of opioids (I) Pyridoxine for routine treatment of TTS in patients without vitamin deficiencies (I) Insulin injections (I) Botulinum injections (I) Magnets (I) Manipulation or mobilization of the distal lower extremity (I)
Ankle Sprain	Education for select patients (I)Acetaminophen (B) NSAIDs for acute ankle sprain (A) NSAIDs for subacute, chronic, or postoperative ankle sprain (I) Limited use of opioids for no more than 1 week for select patients with severe pain related to acute ankle sprain (A) Limited use of opioids for no more than 1 week may be indicated for those that have undergone ankle ligament repair surgery or those who encountered surgical complications (I) Topical NSAIDs for acute ankle sprain (B) Early mobilization for acute ankle sprains without fracture (B) Semi-rigid pneumatic or gel ankle brace supports for acute ankle sprain, with optional use as needed for mild and moderate sprains (I) Rest or non-weight bearing as an initial intervention for acute ankle sprain for patients unable to tolerate weight (I) Cryotherapy for acute ankle sprain (I) Elevation for controlling edema of acute ankle sprains (I) Ankle support (brace, tape) for prevention (initial injury) of ankle injury (C) Ankle support (brace, tape) for prevention (recurrent injury) of ankle injury (I) Appropriate activity specific 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. (I) Balance/proprioception training for prevention of initial and recurrent ankle injury (C) Physical or occupational therapy for select patients with acute, subacute, or chronic ankle sprain (I) Physical or occupational therapy for chronic ankle instability (I) Ligament reconstruction for select cases of chronic ankle instability (I) Short-term cast immobilization with early mobilization and physical or occupational therapy for ankle instability (I)	Vitamins as therapeutic intervention or for prevention of ankle sprain in doses recommended by the U.S. FDA (I)Benzydamine (I) Medications (gels) that stimulate sensation of cold (I) Lidocaine patches (I) Topical comfrey extract (I) Movelat (I) Topical NSAIDs for subacute, chronic, or post-operative ankle sprain (I) Autologous blood injection (I) Glucocorticosteroid injection (I) Hyaluronic acid injection (I) Platelet rich plasma injection (I) Contrast baths for acute ankle sprain (I) Non-rigid support therapies (i.e., tape, elastic wrap, or tubular elastic) for acute ankle sprain (I) Walking boot for acute ankle sprain (I) Heat for acute ankle sprain (I) Immobilization by cast for severe ankle sprain as splints should be sufficient (I) Compression therapy (i.e., tape, elastic wrap, tubular elastic, or pneumatic compression devices) for acute ankle sprain (I) Magnets (I) Iontophoresis (I) Phonophoresis (I) Acupuncture (I) Manipulation or mobilization for acute or subacute ankle sprain (I) Manipulation or mobilization for chronic recurrent ankle sprain (I) Foot orthotics for prevention of ankle injury (I) Stretching or strengthening exercises for prevention of initial or recurrent ankle injury (I)	Oral proteolytic enzyme preparations (B)Oral streptokinase/streptodornase preparations (I) Oral or intramuscular steroid preparations (I) High doses (exceeding U.S. FDA recommendations) or expensive compounded preparation vitamins for prevention of ankle sprain (I) Immobilization by cast for patients with acute mild to moderate ankle sprain as splints should be sufficient. (I) Diathermy for acute ankle sprain (B) Diathermy for subacute or chronic ankle sprain (I) Low frequency electrical stimulation (C) High-voltage pulsed stimulation (I) Low-level laser therapy for acute ankle sprain (B) Low-level laser therapy for subacute or chronic ankle sprain (I) Ultrasound for acute ankle sprain (B) Ultrasound for subacute or chronic ankle sprain (I) Hyperbaric oxygen therapy for acute ankle sprain (C) Hyperbaric oxygen therapy for subacute or chronic ankle sprain (I) Surgical repair for routine lateral ligament tear associated with acute or subacute ankle sprain (I)
Ankle and Foot Fractures	Pre-operative antibiotic prophylaxis for closed or open ankle fracture surgery (I)NSAIDs and acetaminophen for analgesia of pain associated with fracture (I) Limited use of opioids for acute and post-operative pain management as adjunctive therapy to more effective treatments (I) For open fractures, update tetanus immunization status as necessary (I) Adequate analgesia (conscious sedation, intraarticular block) for performing non-operative closed reduction of ankle fractures (C) Adequate analgesia (hematoma block, general anesthesia) for performing non-operative closed reduction of ankle fractures (I) Non-operative management for nondisplaced and reduced stable ankle fractures (I) Closed reduction and immobilization for select non-comminuted closed displaced ankle fractures (I) Operative fixation for unstable closed displaced ankle fractures (C) Operative fixation for definitive management of displaced tibial shaft fracture (C) Operative fixation for distal extra-articular tibial fractures in select patients (I) Non-operative management in select circumstances for distal extra-articular tibial fractures (I) Non-operative management for tibial plafond fractures in select patients (I) Operative management for tibial plafond fractures in select patients (I) Operative fixation for unstable syndesmotic rupture (I) Non-operative management for stable syndesmotic injury (I) Operative fixation for displaced distal fibula fracture (I) Cast immobilization for management of ankle fractures (B) Early mobilization in the management of post-operative and stable non-operative ankle fractures (B) Early weight bearing of operatively fixated ankle fracture post-operatively (B) Pneumatic compression of foot and ankle to reduce swelling for patients with significant post-operative edema (C) Referral of patients with functional debilities or inability to return to work for physical or occupational therapy after cast removal (I)	Non-operative management of tibial shaft fractures (I)Arthroscopy assisted open reduction and internal fixation (ORIF) for distal fibular fractures (I) Use of a specific operative product (I) Type of post-operative care dressing (I) Electrical stimulation for prevention of muscle atrophy in ankle and foot fracture management (I) Hyperbaric oxygen (I) Hypnosis (I)	Use of nasal spray calcitonin for prophylaxis of post-fracture osteopenia (C)Performing repair of torn deltoid ligament in association with ORIF for ankle fracture (I) Surgical thigh tourniquet for surgical treatment of closed displaced ankle fractures (C) Interferential therapy for postoperative swelling following ORIF for displaced malleolar fracture (B) Manual therapy as part of an active post-ankle fracture rehabilitation program (C) Passive stretching for contractures after immobilization of ankle fractures (B) Ultrasound (B)
Hindfoot Fractures (Calcaneus, Talus)	Operative management for all displaced talar fractures – head, neck, body, lateral process (I)Non-operative management of osteochondral lesions of the talus for select patients (I) Operative intervention for osteochondral lesions of talus after initial course of conservative management. Chondroplasty, microfracture and osteochondral autograft recommended. (I) Non-operative cast immobilization for select calcaneus fractures (I) Operative management for select calcaneus fractures (I) Pneumatic compression of foot to reduce swelling for patients with significant edema after closed calcaneus fractures (C)	Non-operative management of nondisplaced talar fractures – head, neck, body (I)Diathermy for management of edema associated with calcaneus fractures (I) Calcium phosphate paste or bone graft for displaced intra-articular fracture defects (I)
Forefoot and Midfoot Fractures (Tarsal, Metatarsal, Phalangeal)	NSAIDs or acetaminophen to control pain from phalangeal or metatarsal fractures (I)Non-operative management of nondisplaced tarsal-metatarsal injury (Lisfranc) for select patients (I) Operative management for unstable tarsal-metatarsal injury – Lisfranc (I) Non-operative management for nondisplaced metatarsal fractures (I) Operative management for displaced metatarsal shaft fractures (I) Non-operative management of 5th metatarsal fractures (including Jones and Avulsion) for select patients (I) Operative management for 5th metatarsal fractures (Jones, Avulsion) for select patients (I) Immobilization for select patients with distal, middle, and proximal phalanx fractures (I) Operative management for select patients with distal, middle, and proximal phalanx fractures (I) Non-operative management for low risk lower extremity stress fracture (I)	Operative management of lower extremity stress fractures in select patients (I)

Definitions:
Strength of Evidence Ratings
A = Strong evidence-base: Two or more high-quality studies*
B = Moderate evidence-base: At least one high-quality study or multiple lower-quality studies** relevant to the topic and the working population
C = Limited evidence-base: At least one study of intermediate-quality
I = Insufficient Evidence: Evidence is insufficient or irreconcilable
*For therapy and prevention, randomized controlled trials (RCTs) or crossover trials with narrow confidence intervals and minimal heterogeneity. For diagnosis and screening, cross sectional studies using independent gold standards. For prognosis, etiology or harms, prospective cohort studies with minimal heterogeneity.
**For therapy and prevention, well-conducted cohort studies. For prognosis, etiology or harms, well conducted retrospective cohort studies or untreated control arms of RCTs.