American Orthopaedic Foot & Ankle Society

Five Things Physicians and Patients Should Question

Released September 17, 2014; Revised January 15, 2021

  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 at least 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 the possibility of post-operative complications with continued pain.

  4. 4

    Avoid non-weightbearing X-ray evaluation of the foot and ankle when patients are able to stand.

    The functional position of the foot and ankle is one of weightbearing. Foot and ankle deformity may be decreased or absent on non-weightbearing x-rays as compared to weightbearing x-rays. Therefore, foot and ankle disorders including flatfeet, ligamentous injuries of the midfoot, ankle arthritis, bunions, and hammertoes that are well-demonstrated on weightbearing x-rays may be underestimated or not appreciated at all on non-weightbearing x-rays. Therefore, when possible, weightbearing x-rays of the foot and ankle are preferred in order to give the most accurate assessment of the functional bony anatomy of the foot and ankle.

  5. 5

    Due to recently published evidence related to alcohol injections for Morton’s neuroma, the AOFAS has withdrawn this recommendation. The topic of alcohol injections remains somewhat controversial with conflicting reports in the literature. Some of the more recent studies are moderately supportive, but long term efficacy remains a concern. Therefore, the AOFAS does not have a formal position as to whether alcohol injections for Morton’s neuroma are efficacious or should be avoided.

  6. 6

    Avoid use of orthopaedic therapeutic biologics including platelet rich plasma and stem cell treatment for foot and ankle problems without first considering established, conventional treatment options.

    Orthopaedic therapeutic biologics (orthobiologics) comprise a variety of tissue grafts and autologous blood products that include platelet rich plasma (PRP) and mesenchymal stem cell treatment. Surgeons bear responsibility to offer their patients efficacious, safe and cost-effective treatments. Orthobiologic treatment can be costly and may not be covered by insurance. Patients can become financially vulnerable especially when pursuing orthobiologic treatment that extends beyond its intended use, scientific support, or regulatory approval. Surgeons should be well-versed in the scientific basis, techniques, potential risks, and regulatory status of orthobiologic treatments. Furthermore, surgeons should review the risks, benefits, and anticipated efficacy of orthobiologic therapy with patients in advance. Orthobiologic treatment options represent a rapidly expanding area of interest for both patients and providers, but remain relatively new and understudied. There is ongoing need for investigative research.

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) is a medical specialty society of more than 2,400 orthopaedic surgeons and allied health practitioners who specialize in the diagnosis and treatment of injuries, diseases, and other conditions of the foot and ankle. As the premier global organization for foot and ankle care, AOFAS delivers exceptional events and resources for continuous education, funds and promotes innovative research, and broadens patient understanding of foot and ankle conditions and treatments. AOFAS is proud to partner with the Choosing Wisely® campaign, as it complements the Society’s 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 to prepare an initial list of topics for the Choosing Wisely website. 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. The finalized list was then reviewed and approved by the AOFAS Board of Directors.

For more information, visit www.aofas.org.

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 feet [internet] Rosemont (IL): American Orthopaedic Foot & Ankle Society. Available from: https://www.footcaremd.org/foot-ankle-health/adult-feet

    Lehman DE. Salvage of complications of hallux valgus surgery. Foot Ankle Clin. 2003;8(1):15–35.

    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 Orthop 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.

  2. Banwell HA, Mackintosh S, Thewlis D. Foot orthoses for adults with flexible pes planus: a systematic review. J Foot Ankle Res. 2014;7(1):23. doi:10.1186/1757-1146-7-23.
    Dare DM, Dodwell ER. Pediatric flatfoot: cause, epidemiology, assessment, and treatment. Curr Opin Pediatr. 2014;26(1):93–100.
    Evans AM, Rome K. A Cochrane review of the evidence for non-surgical interventions for flexible pediatric flat feet. Eur J Phys Rehabil Med. 2011;47(1):69–89.
    Kitaoka HB, Luo ZP, Kura H, An KN. Effect of foot orthoses on 3-dimensional kinematics of flatfoot: a cadaveric study. Arch Phys Med Rehabil. 2002;83(6):876–9.
    Rome K, Ashford RL, Evans A. Non-surgical interventions for paediatric pes planus. Cochrane Database of Systematic Reviews 2010, Issue 7. Art. No.: CD006311.
    DOI: 10.1002/14651858.CD006311.pub2.
    Staheli LT, Chew DE, Corbett M. The longitudinal arch. A survey of eight hundred and eighty-two feet in normal children and adults. J Bone Joint Surg Am. 1987;69(3):426–8.
    Sullivan JA. Pediatric flatfoot: evaluation and management. J Am Acad Orthop Surg. 1999;7(1):44–53.

  3. Davies MS, Weiss GA, Saxby TS. Plantar fasciitis: how successful is surgical intervention? Foot Ankle Int. 1999;20(12):803–7.
    Landorf K. Plantar heel pain and plantar fasciitis. BMJ Clin Evid. 2015 Nov 25;2015:1111.
    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. Boszczyk A et al, Non-weightbearing compared with weightbearing x-rays in hallux valgus decision-making. Skeletal Radiology. 2020; 49:1441–1447.
    de Cesar Netto C et al, Consensus for the Use of Weightbearing CT in the Assessment of Progressive Collapsing Foot Deformity. Foot Ankle Int. 2020;41(10):1277-1282.
    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 osteoarthritis with physical performance. Osteoarthritis and cartilage / OARS,
    Osteoarthritis Research Society. 2011;19(6):634–8.
    Shelton T et al, The Influence of Percentile Weight Bearing on Foot Radiographs. Foot and Ankle Specialist. 2019; Aug;12(4):363-369
    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. American Academy of Orthopaedic Surgeons. Position Statement: Innovation and Novel Technologies in Orthopaedic Surgery. Position Statement 1185 – Revised September 2020. 1185—innovation-and-novel-technologies-in-orthopaedic-surgery-updated2020.pdf (aaos.org)

    American Academy of Orthopaedic Surgeons. Position Statement: Use of Emerging Biologic Therapies. Position Statement 1187 – Revised September 2020. 1187-use-ofemerging-biologic-therapies-updated2020.pdf (aaos.org)