American Orthopaedic Foot & Ankle Society

Five Things Physicians and Patients Should Question

Released September 17, 2014

  1. 1

    Don’t perform surgery for a bunion or hammertoes without symptoms.

    Foot surgery for cosmetic reasons is not supported by medical research. Symptoms such as pain and limitations of activity are the most common reasons to pursue bunion or hammertoe surgery. Patients having surgery for bunions and hammertoes are at risk for a wide range of complications such as nerve damage, infection, bone healing problems and toe stiffness.

  2. 2

    Don’t use shoe inserts for symmetric flat feet or high arches in patients without symptoms.

    Symmetric flat feet or high arches are common conditions, and generally they are asymptomatic. The development of the arch is not related to external supports, and no evidence exists that any support is needed in asymptomatic patients.

  3. 3

    Don’t perform surgery for plantar fasciitis before trying six months of non-operative care.

    With six months of consistent, non-operative treatment, plantar fasciitis will resolve up to 97% of the time. Surgery has a much lower rate of success and has the added possibility of post-operative complications.

  4. 4

    Avoid X-ray evaluation of the foot and ankle without standing (weightbearing) in the absence of injury.

    The functional position of the foot and ankle is one of weightbearing. When compared to non-weightbearing X-rays, deformities of the forefoot, midfoot and hindfoot have been shown to increase on weightbearing X-rays. In addition, narrowing of the ankle joint space on standing X-rays is associated with symptoms of arthritis. Therefore, weightbearing X-rays, when possible, give the most accurate assessment of the functional bony anatomy of the foot and ankle.

  5. 5

    Don’t use alcohol injections for Morton’s neuromas.

    Alcohol can permanently damage the nerve, but without effective pain relief. At five year follow-up, alcohol injection for Morton’s neuroma has both a high recurrence rate and a high rate of complications, including bruising, scar formation, dysesthesia, severe pain and infection.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their health care provider.

The American Orthopaedic Foot & Ankle Society (AOFAS) promotes quality, ethical and cost-effective patient care through education, research and training of orthopaedic surgeons and other health care providers. It creates public awareness for the prevention and treatment of foot and ankle disorders, provides leadership in the treatment and understanding of these conditions. The AOFAS serves as a resource for government, industry and the national and international health care community. The 2,000+ AOFAS members are orthopaedic foot and ankle surgeons (MD and DO) who specializein the diagnosis, care and treatment of patients with disorders of the musculoskeletal system of the foot and ankle. AOFAS is proud to partner with theChoosing Wisely® campaign, as it complements the AOFAS public education, evidence-based medicine and patient outcomes initiatives to improve the quality of patient care.

To learn more about AOFAS, visit www.aofas.org.

How This List Was Created

In order to formulate this list, the American Orthopaedic Foot & Ankle Society Evidence-Based Medicine Committee reviewed the society position statements on foot and ankle care and solicited expert opinion from specialty leaders including the AOFAS Board of Directors to prepare an initial list of topics for the Choosing Wisely website. The Board of Directors of the AOFAS reviewed the initial list and approved five statements for further development. The Evidence-Based Medicine Committee members reviewed the scientific literature on each statement and presented draft statements with supporting evidence to the committee for discussion. Committee members also reviewed the Choosing Wisely campaign website to ensure that there was no duplication in proposed content and for proper formatting. The committee evaluated each statement and edited the statement wording and supporting references. Once consensus was reached, the 2014 list was finalized by committee members. The finalized list was then reviewed and approved by the AOFAS Board of Directors. The AOFAS disclosure and conflict of interest policies may be found at www.aofas.org/education/Pages/Education.aspx.

Evidence-Based Medicine Committee:
Sandra E. Klein, MD, Chair
Ian J. Alexander, MD
Avrill R. Berkman, MD
Patrick B. Ebeling, MD
Todd S. Kim, MD
Anthony Michael Perera, MBChB
Phinit Phisitkul, MD
Ruth L. Thomas, MD
Emilio Wagner, MD
James A. Meeker, MD

AOFAS Board of Directors:
Steven L. Haddad, MD, President
Bruce J. Sangeorzan, MD, President-Elect
Mark E. Easley, MD, Vice President
Thomas H. Lee, MD, Secretary
Jeffrey E. Johnson, MD, Treasurer
Lew C. Schon, MD, Immediate Past President
Judith F. Baumhauer, MD, MPH, Past President
Bruce E. Cohen, MD, Member-at-Large
Timothy R. Daniels, MD, Member-at-Large
Sheldon S. Lin, MD, Member-at-Large
Selene G. Parekh, MD, MBA, Member-at-Large

Sources

  1. Bunions [internet] Rosemont (IL): American Orthopaedic & Ankle Society. Available from: http://www.aofas.org/footcaremd/conditions/ailments-of-the-big-toe/Pages/Bunions.aspx

    Adult foot health [internet] Rosemont (IL): American Orthopaedic & Ankle Society. Available from: http://www.aofas.org/footcaremd/overview/Pages/Adult-Foot-Health.aspx

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    Pfeffer GB. Cosmetic foot surgery: a step in the wrong direction . Am J Orthop. 2011;40(4):174.

    Sammarco GJ, Idusuyi OB. Complications after surgery of the hallux. Clin O rthop Relat Res. 2001;(391):59–71

    Scranton PE. Jr., McDermott JE. Prognostic factors in bunion surgery. Foot Ankle Int. 1995;16(11):698–704.

    Wapner KL: Conservative treatment of the foot. In Coughlin MJ; Mann RA; Saltzman CL, eds. Surgery of the Foot and Ankle . Vol I. 8th ed. Philadelphia, PA, Mosby Elsevier, 2007, 147–148.

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  3. Davies MS, Weiss GA, Saxby TS. Plantar fasciitis: how successful is surgical intervention? Foot Ankle Int. 1999;20(12):803–7.

    Wolgin M, Cook C, Graham C, Mauldin D. Conservative treatment of plantar heel pain: long-term follow -up. Foot Ankle Int. 1994;15(3):97–102.

  4. Keim HA, Ritchie GW. Weight-bearing roentgenograms in the evaluation of foot deformities. Clin Orthop Relat Res. 1970;70:133–6.

    Kitaoka HB, Lundberg A, Luo ZP, An KN. Kinematics of the normal arch of the foot and ankle under physiologic loading. Foot Ankle Int. 1995;16(8):492–9.

    McDaniel G, Renner JB, Sloane R, Kraus VB. Association of knee and ankle ost eoarthritis with physical performance. Osteoarthritis and cartilage / OARS,Osteoarthritis Research Society. 2011;19(6):634–8.

    Tanaka Y, Takakura Y, Takaoka T. Radiographic analysis of hallux valgus in women on weightbearing and nonweightbearing. Clin Orthop Relat Res. 1997;(336):186–4.

  5. Gurdezi S, White T, Ramesh P. Alcohol injection for Morton’s neuroma: a five-year follow-up. Foot Ankle Int. 2013;34(8):1064–7.

    Rengachary SS, Watanabe IS, Singer P, Bopp WJ. Effect of glycerol on peripheral nerve: an experimental study . Neurosurgery. 1983;13(6):681–8.