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Lower extremity complications in persons with diabetes have become an increasingly significant public health concern in both the developed and developing world. These complications, beginning with neuropathy and subsequent diabetic foot wounds frequently lead to infection and lower extremity amputation even in the absence of critical limb ischemia. In order to diminish the detrimental consequences associated with diabetic foot ulcers, a common-sense-based treatment approach must be implemented. Many of the etiological factors contributing to the formation of diabetic foot ulceration may be identified using simple, inexpensive equipment in a clinical setting. Prevention of diabetic foot ulcers can be accomplished in a primary care setting with a brief history and screening for loss of protective sensation via the Semmes-Weinstein monofilament. Specialist clinics may quantify neuropathy, plantar foot pressure, and assess vascular status with Doppler ultrasound and ankle-brachial blood pressure indices. These measurements, in conjunction with other findings from the history and physical examination, may enable clinicians to stratify patients based on risk and help determine the type of intervention. Other effective clinical interventions may include patient education, optimizing glycemic control, smoking cessation, and diligent foot care. Recent technological advanced combined with better understanding of the wound healing process have resulted in a myriad of advanced wound healing modalities in the treatment of diabetic foot ulcers. However, it is imperative to remember the fundamental basics in the healing of diabetic foot ulcers: adequate perfusion, debridement, infection control, and pressure mitigation. Early recognition of the etiological factors along with prompt management of diabetic foot ulcers is essential for successful outcome.

Primary care physicians involved in the management of patients with diabetes are likely to encounter the diagnostic and treatment challenges of pedal neuropathic joint disease, also known as Charcot foot. The acute Charcot foot is characterized by erythema, edema and elevated temperature of the foot that can clinically mimic cellulitis or gout. Plain film radiographic findings can be normal in the acute phase of Charcot foot. A diagnosis of Charcot syndrome should be considered in any neuropathic patient, even those with a minor increase of heat and swelling of the foot or ankle, especially after any injury. Early recognition of Charcot syndrome and immobilization (often with a total contact cast), even in the presence of normal radiographs, can minimize potential foot deformity, ulceration and loss of function. Orthopedic or podiatric foot and ankle specialists should be consulted when the disease process does not respond to treatment.

1. Foot infections in patients with diabetes cause substantial morbidity and frequent visits to health care professionals and may lead to amputation of a lower extremity. 2. Diabetic foot infections require attention to local (foot) and systemic (metabolic) issues and coordinated management, preferably by a multidisciplinary foot-care team (A-II) (table 1). The team managing these infections should include, or have ready access to, an infectious diseases specialist or a medical microbiologist (B-II). Infectious Diseases Society of America—United States Public Health Service Grading System for ranking recommendations in clinical guidelines. 3. The major predisposing factor to these infections is foot ulceration, which is usually related to peripheral neuropathy. Peripheral vascular disease and various immunological disturbances play a secondary role. 4. Aerobic gram-positive cocci (especially Staphylococcus aureus) are the predominant pathogens in diabetic foot infections. Patients who have chronic wounds or who have recently received antibiotic therapy may also be infected with gram-negative rods, and those with foot ischemia or gangrene may have obligate anaerobic pathogens. 5. Wound infections must be diagnosed clinically on the basis of local (and occasionally systemic) signs and symptoms of inflammation. Laboratory (including microbiological) investigations are of limited use for diagnosing infection, except in cases of osteomyelitis (B-II). 6. Send appropriately obtained specimens for culture prior to starting empirical antibiotic therapy in all cases of infection, except perhaps those that are mild and previously untreated (B-III). Tissue specimens obtained by biopsy, ulcer curettage, or aspiration are preferable to wound swab specimens (A-I). 7. Imaging studies may help diagnose or better define deep, soft-tissue purulent collections and are usually needed to detect pathological findings in bone. Plain radiography may be adequate in many cases, but MRI (in preference to isotope scanning) is more sensitive and specific, especially for detection of soft-tissue lesions (A-I). 8. Infections should be categorized by their severity on the basis of readily assessable clinical and laboratory features (B-II). Most important among these are the specific tissues involved, the adequacy of arterial perfusion, and the presence of systemic toxicity or metabolic instability. Categorization helps determine the degree of risk to the patient and the limb and, thus, the urgency and venue of management. 9. Available evidence does not support treating clinically uninfected ulcers with antibiotic therapy (D-III). Antibiotic therapy is necessary for virtually all infected wounds, but it is often insufficient without appropriate wound care. 10. Select an empirical antibiotic regimen on the basis of the severity of the infection and the likely etiologic agent(s) (B-II). Therapy aimed solely at aerobic gram-positive cocci may be sufficient for mild-to-moderate infections in patients who have not recently received antibiotic therapy (A-II). Broad-spectrum empirical therapy is not routinely required but is indicated for severe infections, pending culture results and antibiotic susceptibility data (B-III). Take into consideration any recent antibiotic therapy and local antibiotic susceptibility data, especially the prevalence of methicillin-resistant S. aureus (MRSA) or other resistant organisms. Definitive therapy should be based on both the culture results and susceptibility data and the clinical response to the empirical regimen (C-III). 11. There is only limited evidence with which to make informed choices among the various topical, oral, and parenteral antibiotic agents. Virtually all severe and some moderate infections require parenteral therapy, at least initially (C-III). Highly bioavailable oral antibiotics can be used in most mild and in many moderate infections, including some cases of osteomyelitis (A-II). Topical therapy may be used for some mild superficial infections (B-I). 12. Continue antibiotic therapy until there is evidence that the infection has resolved but not necessarily until a wound has healed. Suggestions for the duration of antibiotic therapy are as follows: for mild infections, 1–2 weeks usually suffices, but some require an additional 1–2 weeks; for moderate and severe infections, usually 2–4 weeks is sufficient, depending on the structures involved, the adequacy of debridement, the type of soft-tissue wound cover, and wound vascularity (A-II); and for osteomyelitis, generally at least 4–6 weeks is required, but a shorter duration is sufficient if the entire infected bone is removed, and probably a longer duration is needed if infected bone remains (B-II). 13. If an infection in a clinically stable patient fails to respond to ⩾1 antibiotic courses, consider discontinuing all antimicrobials and, after a few days, obtaining optimal culture specimens (C-III). 14. Seek surgical consultation and, when needed, intervention for infections accompanied by a deep abscess, extensive bone or joint involvement, crepitus, substantial necrosis or gangrene, or necrotizing fasciitis (A-II). Evaluating the limb's arterial supply and revascularizing when indicated are particularly important. Surgeons with experience and interest in the field should be recruited by the foot-care team, if possible. 15. Providing optimal wound care, in addition to appropriate antibiotic treatment of the infection, is crucial for healing (A-I). This includes proper wound cleansing, debridement of any callus and necrotic tissue, and, especially, off-loading of pressure. There is insufficient evidence to recommend use of a specific wound dressing or any type of wound healing agents or products for infected foot wounds. 16. Patients with infected wounds require early and careful follow-up observation to ensure that the selected medical and surgical treatment regimens have been appropriate and effective (B-III). 17. Studies have not adequately defined the role of most adjunctive therapies for diabetic foot infections, but systematic reviews suggest that granulocyte colony-stimulating factors and systemic hyperbaric oxygen therapy may help prevent amputations (B-I). These treatments may be useful for severe infections or for those that have not adequately responded to therapy, despite correcting for all amenable local and systemic adverse factors. 18. Spread of infection to bone (osteitis or osteomyelitis) may be difficult to distinguish from and may but bone is for the of osteomyelitis, for the and for the antibiotic of (B-II). field has is The especially that adequately studies be to and for infection, diagnosing osteomyelitis, optimal antibiotic regimens in various and the role of in treating osteomyelitis of the Foot infections in with diabetes are a and addition to severe for the of and are the most cause of amputations Diabetic foot infections require careful attention and coordinated management, preferably by a multidisciplinary foot-care team (A-II) The team managing these infections should preferably include, or have ready access to, an infectious diseases specialist or a medical microbiologist of diabetic foot infections can the of the for and duration of and the of major limb amputation these infections are This may from a of of and insufficient to the or a of effective multidisciplinary The of is to help the medical and with diabetic foot infections. The of is on managing the diabetic patient with or foot infection, other the of the diabetic foot and diabetic foot The that the of care and the of in some clinical the of some of the and that in all care is usually more difficult to or care and This should a for treating all diabetic patients who have a foot health care be to it better and of of may the and with including those related to antibiotic wound care, surgical and adjunctive it to the of lower in with the may may be by an for foot care, (especially and vascular This is of Infectious Diseases Society of with experience and interest in diabetic foot infections, many of also have experience in guidelines. are from and other their and clinical infectious diseases clinical and of the are also of the on the Diabetic which on and Diabetic Foot Infections in an extensive the the the diabetic foot and and of of and all evidence in a of and and a of that and these as a basis for the which that based on both and of the of or other evidence in most of recommendations are based on and (table to a and to an extensive for those who to the data diabetic foot infection is most defined as any infection in a with diabetes These necrotizing and The most and is the infected diabetic foot This wound results from a of risk factors which are in 2. the with disturbances of and to to or on a foot that the of is tissues are to This wound may to and, by the infection can This of can be or especially in an especially those that may some diabetic and these likely the risk and severity of foot infections factors for foot and Aerobic gram-positive cocci are the predominant that and in the S. aureus and the and but especially are the most pathogens wounds a more including various obligate and, other gram-negative surgical and, especially, or antibiotic therapy may patients to infection with or have previously been from cases are and are with in patients with diabetic foot infections S. aureus has been in the cases of S. aureus a diabetic patient with a foot infection The necrotic or bone may as and to a role infections in patients who have not recently received antimicrobials are often with an aerobic gram-positive chronic infections are often of specimens obtained from patients with infections generally including gram-positive and gram-negative and The role of in a infection is often clinical infection and the pathogens most likely in with with various clinical Diabetic patients may many of foot wounds, any of which can should be diagnosed clinically on the basis of the presence of purulent or at least of the of or and or not all ulcers are infected an infection often to, but is not defined healing of an of diabetic foot infections and the severity of infection as the basis for the appropriate to treatment (B-II). The of osteomyelitis is particularly and and is with to treating a diabetic patient with a foot wound of the infection should at as in and the patient as a the limb or and the infected The is to determine the clinical (table and the (table of the infection, the or of the any of foot to the cause of the wound thus, to any of vascular (especially and the presence of any systemic of the or experience to any of these should appropriate Evaluating the diabetic patient who has an infected of soft-tissue specimens from an infected diabetic foot for The results of the in can be used to determine the severity of the infection and to a (B-II). the of on wound and infection of The has been used for but for the is severe and all infections a is that the issues in a diabetic foot wound are (in which tissues are and the wound is by ischemia or infection (B-II). The on the Diabetic Foot recently a on a diabetic foot ulcer for The are by the infection, and The infection includes of and or and of a systemic response is to be to all it includes a of for uninfected 2–4 are to those in 6. to treating a diabetic patient with a foot if any of the are systemic toxicity and metabolic severe or or infection, substantial necrosis or gangrene, or presence of of or and to care for or of a diabetic foot infected wounds the most important is to patients who require parenteral and empirical antibiotic therapy, and consideration of and surgical have defined these infections as Infections defined as must be from clinically uninfected lesions but are to infections as the a of wounds, some of which can be and limb have used the and with mild and but to with the various that can a The moderate and severe infections has to with the of the foot with the patient to it is This is by the that of patients with a infection not systemic signs or the in as a basis for in and (B-II). antibiotics for uninfected that many uninfected diabetic foot ulcers are a of defined as of that results in and wound healing Available evidence does not support the use of antibiotics for the of clinically uninfected to wound healing or as infection antibiotic use and may cause adverse therapy of uninfected some it is difficult to a chronic wound is as when the foot is has or a has tissue, is with or or when an ulcer fails to healing these cases, a of antibiotic therapy may be appropriate (C-III). the for is the most of treating a diabetic foot infection, and on consideration of both medical and Patients with infections that are severe or by limb ischemia should generally be patients with mild infections and more patients with moderate infections may also may be for or factors are likely to their wound care or to antibiotic the of these most patients with mild or moderate infections can be as (A-II) the to the metabolic of the patient is This may of the and of and and treatment of other patients who require should usually be to the should usually not be for after to the The of may in both the infection and healing the wound the infection may be to an antibiotic of the antibiotic regimen initially the of therapy, the of to be and the specific to and the regimen and the duration of therapy is usually empirical and should be based on the severity of the infection and on any data, as recent culture results or severe infections and for chronic moderate infections, it is to therapy with agents. These should have gram-positive cocci (including in is as as gram-negative and obligate anaerobic (B-III). ensure adequate and therapy should be at least initially (C-III). some suggest empirical therapy for most infections the of many can be with agents with a as those only aerobic gram-positive cocci (A-II) anaerobic are from many severe infections are in mild-to-moderate infections and there is evidence to support the for therapy in most infections (B-III). mild-to-moderate infections in patients without and for an oral with the appropriate is oral therapy is often especially with bioavailable agents (A-II). infected wounds with limited data support the use of therapy in effective in infected diabetic foot lesions is with the of the specific and, especially, the arterial supply to the with diabetes There are few clinical of antibiotic therapy for diabetic foot antibiotic patients with various and soft-tissue infections have some patients with diabetic foot infections. a of clinical that on therapy of diabetic foot infections, or as an of a The of among these the of of regimens The of infection severity and clinical that used in these the to a for the basis of the or of agents to be to Antibiotic agents used in clinical studies of diabetic foot infections. some empirical antibiotic regimens to the clinical severity of the infection, the data not to recommend any specific antibiotic regimen for diabetic foot infections (B-II). These agents are from clinical and experience and are not to be of all agents be depending on various and antibiotic therapy when culture and susceptibility results are (C-III). choices for patients who are not to antibiotic therapy should agents that a or of The regimens in are in of the does not by the of antibiotic agents should be selected to of the and the and the experience of the and should be on the basis of any (especially and other clinical factors. empirical antibiotic based on clinical for diabetic foot infections. to a diabetic patient with a foot infection who is not to of the for infections require surgical that from and of infected and necrotic tissues to of the lower and of soft-tissue or surgical treatment of diabetic foot infections is based on evidence that for antibiotic therapy Seek surgical consultation for or infections, as those with necrotizing gangrene, extensive soft-tissue or evidence of or those in with ischemia (A-II) surgical specialist should also patients who have foot or evidence of a infection, deep or infection in the of appropriate medical care and surgical debridement, including limited or may the for amputation especially in an can cause and patients with infections, it may be appropriate to to the of medical therapy or to determine the necrotic and The must determine the adequacy of the supply to the consider infection among foot to the deep or the and a for soft-tissue secondary or The surgical should the for healing and should to the of the of the foot addition to the must have sufficient and experience to when and to The is important or of the of the the of and infection, and experience with and for the field most the should to the patient until the infection is and the wound is healing (B-III). some cases, amputation is the or only amputation is usually required only when there is extensive necrosis or infection amputation may be for the patient who has has of foot or require or care of the of amputation must into consideration and issues the should to as of the limb as possible. a amputation that results in a more if a is may be a better a foot that is to or to all or of a foot has gangrene, it may be preferable (especially for a patient for is a to the necrotic may also be to in especially on the until to be more removed, there does not to be an of infection If the infected limb to be the patient should be to a with vascular most cases, ischemia is to to the and the to be may be amenable to or vascular Patients with ischemia those with an to of can usually be without a vascular vascular disease of the many have use of in diabetic patients a patient with a infected it is usually preferable to any needed early after the infection 1–2 to in of (and antibiotic therapy the other careful debridement of necrotic infected should not be surgical may require a The wound may require additional attention after the debridement the (table The is to and tissue, wound healing and a of pathogens may limited This can usually be as a or and without especially for a debridement with or is generally preferable to or which are and and may require and There are many products that are as to healing in various but a of these is The infected wound should be in a that and a (B-III). evidence any type of and are important of from a foot wound is crucial to the healing of can the infected but it is important to that and have many of including wound factors and therapy treatment likely has some appropriate for infected wounds, evidence is insufficient to recommend use of any of these for treatment or adjunctive granulocyte colony-stimulating factors have been in diabetic foot infections of these that does not of infection but may the for and suggest that hyperbaric oxygen therapy may be of for treatment of diabetic foot wounds, and a few recent studies have results recent that hyperbaric oxygen therapy the risk of major amputation related to a diabetic foot ulcer (B-I). additional clinical can for and with these and limited be used in the treatment of diabetic foot infections. should be used as a for proper surgical debridement and observation of the response to therapy is and should be for and perhaps initially for (B-III). The of are of local and systemic symptoms and clinical signs of inflammation. including and as the and the are of limited use for is it to and cause for when to antibiotic therapy for a diabetic patient with a foot methicillin-resistant Staphylococcus a patient is ready for or an for the should and 1. Select the antibiotic the culture and susceptibility results and any adverse related to the antibiotic a antibiotic regimen (including the treatment on the basis of the results of or other and the clinical response (C-III). is not necessary to all from S. aureus and or should be but in a infection, and may be important (B-II). If the infection has not responded to the empirical agents with all a clinically stable patient who has ⩾1 of therapy, consider discontinuing antimicrobials for a few and optimal specimens for culture (C-III). 2. the the to ensure that the infection is and that the wound is If is the for surgical evidence antibiotics for the entire that the wound remains should be used for a defined by the of the infection and by the clinical as in (A-II). If clinical evidence of infection the on the with antibiotics and for adverse factors These may the of antibiotic a an deep or of osteomyelitis, or ischemia that is more severe initially and of antibiotic therapy, by clinical 3. the off-loading and wound care the and the the consultation when 4. that and other of the metabolic are adequately with osteomyelitis is perhaps the most difficult and in the of diabetic foot infections among is that the of a of the disease the of studies and there are many but often the presence of osteomyelitis the of surgical including and the required duration of antibiotic therapy osteomyelitis healing of the wound and as a for to consider the osteomyelitis as a of any deep or extensive especially that is chronic or a osteomyelitis when an ulcer does not after at least weeks of appropriate care and ulcer in which bone is or can be with a is likely to be by osteomyelitis patients with a infection, results of a may be as sufficient for but the of have not been foot in a patient with a of foot ulceration, a a or an or should also of osteomyelitis (B-II). bone an ulcer should be to osteomyelitis a diabetic patient who has osteomyelitis of the and or be or preferably after antibiotic therapy has been for 1–2 weeks to the is usually not on radiography the early of disease and can infection, diagnosing osteomyelitis at the the patient to the can be difficult on may help in cases are more sensitive for osteomyelitis the early of but are and can be The of various of but the of bone is generally MRI is the most useful of the MRI is the most for bone infection, and it also the most of deep soft-tissue infections. The of all these are with the of osteomyelitis, and are most useful for cases The for diagnosing osteomyelitis is of from a obtained of bone to with findings of and (B-II). few of the studies that have or have treatment have used MRI is usually not needed as a in cases of diabetic foot osteomyelitis is a obtaining often If these evidence of pathological findings in the patient should be for weeks for the soft-tissue If of osteomyelitis radiography 2–4 weeks If the of osteomyelitis and and and if there is of a for osteomyelitis, preferably after obtaining appropriate specimens for culture (B-III). If findings of radiography are only but not osteomyelitis, of the choices should be 1. MRI is the with preferably use or a If results of the are osteomyelitis is if results suggest osteomyelitis, consider bone is needed 2. antibiotic therapy for 2–4 weeks and to determine have suggest 3. an appropriate as defined of a of a or is if the remains in after or if osteomyelitis is likely but the etiologic or antibiotic are not also specimens of most or these are more difficult to and more often lead to a the an can the should preferably be or if possible. patients with may be of as by and and by have been specimens if at least for culture and for it may only be to a few of of foot bone and consider it to be a (B-II). of bone specimens more data those of soft-tissue specimens for patients with osteomyelitis medical and surgical have that a bone with chronic osteomyelitis for some have the for surgical Definitive surgical to osteomyelitis, as and may risk of the in and additional of and systemic of infection may make osteomyelitis for the who may for at medical management. these diabetic may also bone with or in infection, additional bone or soft-tissue and a These have some health care professionals to diabetic foot osteomyelitis with or surgical intervention on treatment with a of antibiotics have clinical in of cases these often to a of osteomyelitis, patients patients or and debridement of bone The of which patients are for as as duration of antibiotic therapy is needed, are important for there are cases in which of osteomyelitis be (B-II). 1. There is surgical of the infection cause of 2. The patient has ischemia by vascular disease but to 3. is to the and there is soft-tissue 4. The patient and health care that surgical risk or is not appropriate or therapy for osteomyelitis consider the is there necrotic or infected bone or surgical that should be or the selected antibiotic regimen likely the and adequate in and it for a sufficient the to bone infection the cause of the wound an usually in consultation with a patients may from antibiotics in or hyperbaric oxygen therapy, or may or antibiotic in some cases, an antibiotic The most appropriate duration of therapy for any type of diabetic foot infection has not been defined is important to consider the presence and of any or infected bone and the of the a infected tissue, antibiotic therapy is needed (B-II). if infected bone or despite treatment is osteomyelitis, some parenteral therapy may be especially if an with is used (C-III). therapy may be in the recommendations for duration of therapy are based on the clinical and are in 9. The of treating a diabetic foot infection are the of clinical evidence of infection and the of soft-tissue and a clinical response of clinical evidence of to appropriate therapy in of mild-to-moderate infections and in of severe infections or cases of osteomyelitis with a signs of systemic infection limb perfusion, osteomyelitis the presence of necrosis or gangrene an and of the infection in of especially in those with may be difficult to from a recent of of the Infections that the for treating diabetic foot osteomyelitis systematic of and patient treatment may be useful for and for multidisciplinary foot-care (B-II). patient who has foot infection is more likely to have a to with the patient of is the to prevent foot infections. the patient the of appropriate at all foot of the and any to health care professionals (A-II). can be in a few should these by patients foot care and their and Patients with severe substantial foot or ischemia should be to appropriate to with these (A-II). of the recommendations in are based on and adequately There are in which be particularly 1. a for infected foot lesions to studies of their and support to the for 2. there is a role for antibiotic therapy in managing clinically uninfected 3. optimal antibiotic regimens and for various of soft-tissue and bone infections. 4. a of osteomyelitis in the diabetic 5. and a for the and treatment of infections, especially 6. the of surgical and of of support or for and for for and and support from support or for and and for and support from and and for and of support from and for and and

The Journal of Bone and Joint Surgery. British volumeVol. 33-B, No. 4 Clinical Reviews and StudiesFree AccessA DANGEROUS TYPE OF FRACTURE OF THE FOOTWilliam GissaneWilliam GissaneSearch for more papers by this authorPublished Online:1 Nov 1951https://doi.org/10.1302/0301-620X.33B4.535AboutSectionsPDF/EPUB ToolsAdd to FavouritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InRedditEmail FiguresReferencesRelatedDetailsCited byThe Lisfranc Injury: A Literature Review of Anatomy, Etiology, Evaluation, and Management20 August 2020 | Foot & Ankle Specialist, Vol. 14, No. 5Surgical Trends in the Treatment of Lisfranc Injuries Using the American Board of Orthopaedic Surgery (ABOS) Certification Examination Database31 July 2019 | Foot & Ankle Specialist, Vol. 13, No. 5Subtle Lisfranc Injuries: A Topical Review and Modification of the Classification SystemOrthopedics, Vol. 41, No. 2Classification and Outcome of Fracture-Dislocation of the Cuneiform BonesThe Journal of Foot and Ankle Surgery, Vol. 55, No. 6Résultats des arthrorises entre le deuxième métatarsien et le cunéiforme médial dans les luxations tarsométatarsiennes. 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Foot complications are among the most serious and costly complications of diabetes mellitus. Amputation of the lower extremity or part of it is usually preceded by a foot ulcer. A strategy that includes prevention, patient and staff education, multidisciplinary treatment of foot ulcers, and close monitoring can reduce amputation rates by 49–85%. Therefore, several countries and organizations, such as the World Health Organization and the International Diabetes Federation, have set goals to reduce the rate of amputations by up to 50%. The basic principles of prevention and treatment described in these guidelines are based on the International Consensus on the Diabetic Foot. Depending on local circumstances, these principles have to be translated for local use, taking into account regional differences in socio-economics, accessibility to health care, and cultural factors. These practical guidelines are aimed at healthcare workers involved in the care of people with diabetes. For more details and information on treatment by specialists in foot care, the reader is referred to the International Consensus document. Although the spectrum of foot lesions varies in different regions of the world, the pathways to ulceration are probably identical in most patients. Diabetic foot lesions frequently result from two or more risk factors occurring together. In the majority of patients, diabetic peripheral neuropathy plays a central role: up to 50% of people with diabetes with type 2 diabetes have neuropathy and at-risk feet. Neuropathy leads to an insensitive and sometimes deformed foot, often with an abnormal walking pattern. In people with neuropathy, minor trauma – caused, for example, by ill-fitting shoes, walking barefoot, or an acute injury – can precipitate a chronic ulcer. Loss of sensation, foot deformities, and limited joint mobility can result in abnormal biomechanical loading of the foot. Thickened skin (callus) forms as a result. This leads to a further increase of the abnormal loading and, often, subcutaneous haemorrhage. Whatever the primary cause, the patient continues walking on the insensitive foot, impairing subsequent healing (Figure 1). Peripheral vascular disease, usually in conjunction with minor trauma, may result in a painful, purely ischaemic foot ulcer. However, in patients with both neuropathy and ischaemia (neuro-ischaemic ulcer), symptoms may be absent, despite severe peripheral ischaemia. Microangiopathy should not be accepted as a primary cause of an ulcer. All people with diabetes should be examined at least once a year for potential foot problems. Patients with demonstrated risk factor(s) should be examined more often – every 1–6 months. The absence of symptoms does not mean that the feet are healthy; the patient might have neuropathy, peripheral vascular disease, or even an ulcer without any complaints. The patient's feet should be examined with the patient lying down and standing up, and their shoes and socks should also be inspected. After examination of the foot, each patient can be assigned to a risk category, which should guide the subsequent management (Figure 2). Education, presented in a structured and organized manner, plays an important role in the prevention of foot problems. The aim is to enhance motivation and skills. People with diabetes should learn how to recognize potential foot problems and be aware of the steps they need to take in response. The educator must demonstrate the skills, such as how to cut nails appropriately. Education should be provided in several sessions over time, preferably using a mixture of methods. It is essential to evaluate whether the person with diabetes has understood the messages, is motivated to act, and has sufficient self-care skills. An example of instructions for the high-risk patient and family is given in the succeeding part of this article. Furthermore, physicians and other healthcare professionals should receive periodic education to improve care for high-risk individuals. Inappropriate footwear is a major cause of ulceration. Appropriate footwear should be used both indoors and outdoors and should be adapted to the altered biomechanics and deformities – essential for prevention. Patients without loss of protective sensation can select off-the-shelf footwear by themselves. In patients with neuropathy and/or ischaemia, extra care must be taken when fitting footwear – particularly when foot deformities are also present. The shoe should not be too tight or too loose (Figure 4). The inside of the shoe should be 1–2 cm longer than the foot itself. The internal width should be equal to the width of the foot at the site of the metatarsal phalangeal joints, and the height should allow enough room for the toes. The fit must be evaluated with the patient in standing position, preferably at the end of the day. If the fit is too tight because of deformities or if there are signs of abnormal loading of the foot (e.g. hyperaemia, callus, ulceration), patients should be referred for special footwear (advice and/or construction), including insoles and orthoses. In a high-risk patient, callus and nail and skin pathology should be treated regularly, preferably by a trained foot care specialist. If possible, foot deformities should be treated nonsurgically (e.g. with an orthosis). A standardized and consistent strategy for evaluating wounds is essential and will guide further therapy. The following items must be addressed. Ill-fitting shoes are the most frequent cause of ulceration, even in patients with ‘pure’ ischaemic ulcers. Therefore, shoes should be examined meticulously in all patients. Most ulcers can be classified as neuropathic, ischaemic, or neuro-ischaemic. This will guide further therapy. Assessment of the vascular tree is essential in the management of a foot ulcer. If one or more pedal pulses are absent, or if an ulcer does not improve despite optimal treatment, more extensive vascular evaluation should be performed. As a first step, the ankle brachial pressure can be measured. An ankle brachial pressure index less than 0.9 is a sign of peripheral arterial disease. However, ankle pressure might be falsely elevated because of calcification of the arteries. Preferably, other tests, such as measurements of toe pressure or transcutaneous pressure of oxygen (TcPo2), should be used. Figure 5 gives an estimate of the chance of healing using the tests. If a major amputation is being contemplated, the option of revascularization should be considered first. Noninvasive evaluation and estimate of probability of healing: Neuropathic ulcers frequently occur on the plantar surface of the foot or in areas overlying a bony deformity. Ischaemic and neuro-ischaemic ulcers are more common on the tips of the toes or the lateral border of the foot. The depth of an ulcer can be difficult to determine because of the presence of overlying callus or necrosis. Therefore, neuropathic ulcers with callus and necrosis should be debrided as soon as possible. This debridement should not be performed in ischaemic or neuro-ischaemic ulcers without signs of infection. In neuropathic ulcers, debridement can usually be performed without (general) anaesthesia. Infection of the foot in a person with diabetes presents a serious threat to the affected limb and should be evaluated and treated promptly. Infection is diagnosed by the presence of signs and/or symptoms of inflammation, but these may be blunted by neuropathy or ischemia, and systemic findings (e.g. fever, increased white blood count) are often absent. Infections should be classified as mild (superficial with minimal cellulitis), moderate (deeper or more extensive), or severe (accompanied by systemic signs of sepsis). If not properly treated, infection can spread to underlying tissues, including the bone. Patients with a diabetic foot infection should be assessed for the presence of osteomyelitis. When there is a deep wound overlying the bone, especially if it is longstanding and it is possible to touch the bone with a sterile probe, osteomyelitis is likely. Properly obtained specimens for Gram stain and culture of deep tissue are advised; avoid superficial swabs. Mild (superficial and limited) infection is usually caused by aerobic Gram-positive cocci, especially Staphylococcus aureus. Chronic infections and infections that are more severe are often polymicrobial with aerobic Gram-negative rods and anaerobes. If treatment is based on the principles outlined in the succeeding part of this article, healing can be achieved in the majority of patients. Optimum wound care cannot compensate for continuing trauma to the wound bed or for ischaemia or infection. Patients with an ulcer deeper than the subcutaneous tissues should be treated intensively, and, depending on local resources and infrastructure, hospitalization must be considered. In all countries, at least three levels of foot care management are needed: Setting up a multidisciplinary foot care team has been found to be accompanied by a drop in the number of amputations. If it is not possible to create a full team from the outset, this should be built up step by step, introducing the various different disciplines at different stages. This team must work in both primary and secondary care settings. Ideally, a foot care team would consist of a diabetologist, surgeon, podiatrist, orthotist, educator, and plaster technician, in close collaboration with an orthopaedic, podiatric and/or vascular surgeon, and dermatologist. Neuropathy can be detected using the 10-g (5.07 Semmes–Weinstein) monofilament, tuning fork (128 Hz), and/or cotton wisp. Easy-to-use foot screening assessment sheet for clinical examination None declared.

BACKGROUND: MRI is being used with increasing frequency and seems to have become more popular as a screening tool rather than as an adjunct to narrow specific diagnoses or plan operative interventions. Our hypothesis was that the rising accessibility of this test may be resulting in its overuse. METHODS: We retrospectively reviewed 221 consecutive patients referred over a 3-month period for treatment of a lower extremity problem to determine: (1) the number of patients who presented with an MRI already obtained from an outside source, (2) the number of patients who obtained an MRI from the foot and ankle specialist after referral, and (3) the number of times the foot and ankle specialist used these studies or found them helpful in the care of the patient. Fractures (20) were excluded. RESULTS: Of the 201 patients without fractures included in the study, 19.9% (40 of 201) had MRI scans during the course of their treatment; 15.4% (31 of 201) presented to their initial visit with an MRI scan from an outside source, and 4.5% (9 of 201) received MRI scans as ordered by the foot and ankle specialist. Eighty-seven percent (27 of 31) of the pre-referral MRI scans were thought to be unnecessary, and 48.4% (15 of 31) had radiographic interpretations that were considered either immaterial to the patient's pertinent clinical diagnosis or inconsistent with the specialist's interpretations. All nine MRI scans ordered by the specialist were useful in the care of the patient. Therefore, of the 221 consecutive patients, the foot and ankle specialist would have ordered MRI scans in only 5.9% (13 of 221). CONCLUSIONS: This study suggests that many of the pre-referral foot or ankle MRI scans obtained before evaluation by a foot and ankle specialist are not necessary. Further studies need to be performed to determine the role of MRI in the screening of foot and ankle disorders.

Background. The goal of this systematic review is to determine the most commonly used outcome measurement tools used by foot and ankle specialists and determine their limitations, such as whether they are validated, have floor/ceiling effects, and so on. Methods. A literature search was conducted to identify primary publications between January 1, 2012 and July 1, 2017 that concern care of the foot and ankle and use any established grading criteria to evaluate patients. Results. In 669 publications, 76 scoring systems were used. The 10 most common were American Orthopaedic Foot and Ankle Score (AOFAS), visual analog scale (VAS), Short Form–36 (SF-36), Foot Function Index (FFI), Foot and Ankle Outcome Score (FAOS), Foot and Ankle Ability Measure (FAAM), SF-12, Short Musculoskeletal Function Assessment (SMFA), Ankle Osteoarthritis Scale (AOS), and Foot and Ankle Disability Index (FADI). AOFAS was used in 393 articles, VAS in 308, and SF-36 in 133 publications. AOFAS, VAS, and SF-36 were used to evaluate 23,352, 20,759, and 13,184 patients respectively. AOFAS and VAS were used simultaneously in 172 publications. Conclusion. While there are many different scoring systems available for foot and ankle specialists to use to assess or demonstrate the effectiveness of treatments, the AOFAS, while it is an unvalidated scoring system, is the most commonly used scoring system in this review. Clinical Relevance. This review presents data about commonly used patient reported outcomes systems in foot and ankle surgery. Levels of Evidence: Level III: Systematic review.

Importance: Approximately 18.6 million people worldwide are affected by a diabetic foot ulcer each year, including 1.6 million people in the United States. These ulcers precede 80% of lower extremity amputations among people diagnosed with diabetes and are associated with an increased risk of death. Observations: Neurological, vascular, and biomechanical factors contribute to diabetic foot ulceration. Approximately 50% to 60% of ulcers become infected, and about 20% of moderate to severe infections lead to lower extremity amputations. The 5-year mortality rate for individuals with a diabetic foot ulcer is approximately 30%, exceeding 70% for those with a major amputation. The mortality rate for people with diabetic foot ulcers is 231 deaths per 1000 person-years, compared with 182 deaths per 1000 person-years in people with diabetes without foot ulcers. People who are Black, Hispanic, or Native American and people with low socioeconomic status have higher rates of diabetic foot ulcer and subsequent amputation compared with White people. Classifying ulcers based on the degree of tissue loss, ischemia, and infection can help identify risk of limb-threatening disease. Several interventions reduce risk of ulcers compared with usual care, such as pressure-relieving footwear (13.3% vs 25.4%; relative risk, 0.49; 95% CI, 0.28-0.84), foot skin measurements with off-loading when hot spots (ie, greater than 2 °C difference between the affected foot and the unaffected foot) are found (18.7% vs 30.8%; relative risk, 0.51; 95% CI, 0.31-0.84), and treatment of preulcer signs. Surgical debridement, reducing pressure from weight bearing on the ulcer, and treating lower extremity ischemia and foot infection are first-line therapies for diabetic foot ulcers. Randomized clinical trials support treatments to accelerate wound healing and culture-directed oral antibiotics for localized osteomyelitis. Multidisciplinary care, typically consisting of podiatrists, infectious disease specialists, and vascular surgeons, in close collaboration with primary care clinicians, is associated with lower major amputation rates relative to usual care (3.2% vs 4.4%; odds ratio, 0.40; 95% CI, 0.32-0.51). Approximately 30% to 40% of diabetic foot ulcers heal at 12 weeks, and recurrence after healing is estimated to be 42% at 1 year and 65% at 5 years. Conclusions and Relevance: Diabetic foot ulcers affect approximately 18.6 million people worldwide each year and are associated with increased rates of amputation and death. Surgical debridement, reducing pressure from weight bearing, treating lower extremity ischemia and foot infection, and early referral for multidisciplinary care are first-line therapies for diabetic foot ulcers.

Abstract Objective: To summarise the evidence on accuracy of the Ottawa ankle rules, a decision aid for excluding fractures of the ankle and mid-foot. Design: Systematic review. Data sources: Electronic databases, reference lists of included studies, and experts. Review methods: Data were extracted on the study population, the type of Ottawa ankle rules used, and methods. Sensitivities, but not specificities, were pooled using the bootstrap after inspection of the receiver operating characteristics plot. Negative likelihood ratios were pooled for several subgroups, correcting for four main methodological threats to validity. Results: 32 studies met the inclusion criteria and 27 studies reporting on 15 581 patients were used for meta-analysis. The pooled negative likelihood ratios for the ankle and mid-foot were 0.08 (95% confidence interval 0.03 to 0.18) and 0.08 (0.03 to 0.20), respectively. The pooled negative likelihood ratio for both regions in children was 0.07 (0.03 to 0.18). Applying these ratios to a 15% prevalence of fracture gave a less than 1.4% probability of actual fracture in these subgroups. Conclusion: Evidence supports the Ottawa ankle rules as an accurate instrument for excluding fractures of the ankle and mid-foot. The instrument has a sensitivity of almost 100% and a modest specificity, and its use should reduce the number of unnecessary radiographs by 30-40%. What is already known on this topic Although most patients with ankle sprains who present to emergency departments undergo radiography, less than 15% have a fracture The Ottawa ankle rules is a clinical decision aid designed to avoid unnecessary radiography What this paper adds The Ottawa ankle rules is highly accurate at excluding ankle fractures after sprain injury

BACKGROUND: The main surgical treatments for end stage ankle arthritis are arthrodesis and total ankle replacement (TAR). In Europe, there are now more than 11 different prostheses, most with limited outcome data. This study aimed to determine the number and types of implants used in the United Kingdom. MATERIALS AND METHODS: A questionnaire based survey was sent to all Consultant members of the British Orthopaedic Foot & Ankle Society (n = 180). RESULTS: Sixty-eight percent completed the questionnaires. Thirty percent of respondents were not performing ankle joint replacements at the time of the survey. The mode number of ankle replacements carried out per year by Foot and Ankle Specialists was eight. CONCLUSION: The UK has a population of 60 million and surgeons are implanting at least 800 ankle replacements per year. More surgeons are beginning to perform ankle replacements in small numbers and a UK National Joint Registry for Ankle Replacements is in development. Currently, none of the fixed bearing implants being used in the United States are being used in the United Kingdom and although the number of ankle replacements implanted in the United States is unknown, it is predicted that this type of surgery could have a significant impact on insurers and healthcare providers in the future.

STUDY DESIGN: Review of selected literature describing the outcomes related to the management of acute Charcot foot arthropathies in patients with diabetes mellitus. OBJECTIVE: To familiarize the rehabilitation specialist with the general principles of nonsurgical management for patients with acute neuropathic arthropathies of the foot and ankle. BACKGROUND: Neuropathic (Charcot) arthropathy of the foot or ankle is the most destructive and disabling chronic complication of all diabetic foot disease. METHODS AND MEASURES: We discuss the clinical presentation and the role that orthopaedic and sports physical therapists may have in identifying and preventing complications and the long-term disability associated with these arthropathies. We summarize the outcomes of 15 published reports from 1985-1999 located using the MEDLINE database from 1966-present. Studies were selected and included if the authors reported on (1) 2 or more patients with diabetes mellitus and acute Charcot arthropathies; (2) the short-term or long-term outcomes, including the length of follow-up; and (3) the pattern or location of the arthropathy. The short-term outcomes (percentage of patients healed, average time to healing) and long-term outcomes (percentage in whom treatment failed, amputation, disability) after treatment by immobilization alone or immobilization after surgery were reviewed and summarized. RESULTS: The prognosis for an individual with severe neuropathic skeletal foot deformities is poor. Eleven deaths (3.65%) in 301 patients were reported within the average follow-up period of 2.5 years after treatment for Charcot arthropathy. Partial or complete foot amputation occurred in 20 (6.6%) of 301, whereas 83 (28%) of 301 patients reviewed had mobility limitations or required ankle-foot orthoses or permanent bracing or assistive devices for ambulation at the time of follow-up. CONCLUSION: Rehabilitation specialists can improve the short-term outcomes and limit the long-term disabilities in patients with diabetes mellitus and peripheral neuropathy. Early recognition and prompt immobilization are the basic principles of nonsurgical management that influence therapeutic outcome.

OBJECTIVE: To examine the relative effects of footwear and an ankle-foot orthosis (AFO) on hemiplegic gait. DESIGN: A case series with three contrasting conditions: walking without footwear, with footwear alone, and with footwear and an AFO. Spatio-temporal parameters reflecting walking performance were analysed using an analysis of variance (ANOVA). PATIENTS: Five patients with hemiplegia and reduced mobility following stroke. SETTING: A specialist rehabilitation centre. INTERVENTION: Wearing either footwear alone, or footwear with an AFO. MEASURES: Video recordings of gait were subjected to a kinematic analysis to determine spatio-temporal parameters. RESULTS: Stride length was increased by an average of 5 cm when wearing footwear. An additional 5-cm increase was also observed when wearing an AFO. Swing velocity was also affected by the manipulation. CONCLUSIONS: The appropriate comparative baseline for assessing the efficacy of an AFO is subjects walking with existing footwear and not barefoot.

Adults with an acquired flatfoot deformity may present not with foot deformity but almost uniformly with medial foot pain and decreased function of the affected foot (for a list of causes of an acquired flatfoot deformity in adults, see box 1).1 Patients whose acquired flatfoot is associated with a more generalised medical problem tend to receive their diagnosis and are referred appropriately. However, in patients whose “adult acquired flatfoot deformity” is a result of damage to the structures supporting the medial longitudinal arch, the diagnosis is often not made early.2 These patients are often otherwise healthier and tend to be relatively more affected by the loss of function resulting from an acquired flatfoot deformity. The most common cause of an acquired flatfoot deformity in an otherwise healthy adult is dysfunction of the tibialis posterior tendon, and this review provides an outline to its diagnosis and treatment. We seached PubMed for publications by using the keywords “flatfoot” and “tibialis posterior dysfunction”. ### Tibialis posterior dysfunction: a common condition Tibialis posterior dysfunction is well recognised by orthopaedic surgeons specialising in foot and ankle surgery and by podiatrists. However, greater general awareness of this condition is required,2 as most patients presenting to a general practitioner receive a diagnosis of ankle sprain or arthritis. By the time most patients present to a specialist foot and ankle clinic they have had the condition for several years and have consulted numerous doctors.3 Even general orthopaedic surgeons and physiotherapists often miss the diagnosis.3 However, tibialis posterior dysfunction need not remain a “specialist diagnosis” as it is usually diagnosed without any investigations, from a history and physical examination.2 Many patients benefit from relatively simple treatment, such as orthotic devices.4 Population based studies to identify the prevalence of tibialis posterior dysfunction are under way. In elderly people the condition …

BACKGROUND: The incidence and potential life-threatening complications of thromboembolic disease after major orthopaedic surgery has been extensively studied. However, there are two studies pertaining to the incidence of thromboembolic disease after foot and ankle surgery, the findings of which suggest that the incidence is too low to justify routine thromboprophylaxis. METHODS: This is a retrospective study identifying the incidence of thromboembolic disease after foot and ankle surgery in the practices of two foot and ankle specialists. The purpose of the study was to evaluate the risk factors for the development of thromboembolic disease and to examine the issue of routine thromboprophylaxis. Six hundred and two patients were included in this study. RESULTS: There was a 4% incidence (24 patients) of postoperative thromboembolic complications. Risk factors identified for postoperative thromboembolic disease were a history of rheumatoid arthritis, a recent history of air travel, previous deep vein thrombosis or pulmonary embolism, and limb immobilization. CONCLUSIONS: The incidence of thromboembolic disease after foot and ankle surgery could be higher than that previously reported particularly if a patient has certain risk factors. Prospective randomized clinical trials are needed to establish the true incidence of thromboembolic disease after foot and ankle surgery and to define the indications for routine thromboprophylaxis.

Recommendations Classification/diagnosis Diabetic foot infection must be diagnosed clinically, based on the presence of local or systemic signs or symptoms of inflammation (strong; low). Assess the severity of any diabetic foot infection using the Infectious Diseases Society of America/International Working Group on the Diabetic Foot classification scheme (strong; moderate). Osteomyelitis For an infected open wound, perform a probe‐to‐bone test; in a patient at low risk for osteomyelitis, a negative test largely rules out the diagnosis, while in a high‐risk patient, a positive test is largely diagnostic (strong; high). Markedly elevated serum inflammatory markers, especially erythrocyte sedimentation rate, are suggestive of osteomyelitis in suspected cases (weak; moderate). A definite diagnosis of bone infection usually requires positive results on microbiological (and, optimally, histological) examinations of an aseptically obtained bone sample, but this is usually required only when the diagnosis is in doubt or determining the causative pathogen's antibiotic susceptibility is crucial (strong; moderate). A probable diagnosis of bone infection is reasonable if there are positive results on a combination of diagnostic tests, such as probe‐to‐bone, serum inflammatory markers, plain X‐ray, magnetic resonance imaging (MRI) or radionuclide scanning (strong; weak). Avoid using results of soft tissue or sinus tract specimens for selecting antibiotic therapy for osteomyelitis as they do not accurately reflect bone culture results (strong; moderate). Obtain plain X‐rays of the foot in all cases of non‐superficial diabetic foot infection (strong; low). Use MRI when an advanced imaging test is needed for diagnosing diabetic foot osteomyelitis (strong; moderate). When MRI is not available or contraindicated, consider a white blood cell‐labelled radionuclide scan, or possibly single‐photon emission computed tomography (CT) and CT (SPECT/CT) or fluorine‐18‐fluorodeoxyglucose positron emission tomography/CT scans (weak; moderate). Assessing severity At initial evaluation of any infected foot, obtain vital signs and appropriate blood tests, debride the wound and probe and assess the depth and extent of the infection to establish its severity (strong; moderate). At initial evaluation, assess arterial perfusion and decide whether and when further vascular assessment or revascularization is needed (strong; low). Microbiological considerations Obtain cultures, preferably of a tissue specimen rather than a swab, of infected wounds to determine the causative microorganisms and their antibiotic sensitivity (strong; high). Do not obtain repeat cultures unless the patient is not clinically responding to treatment, or occasionally for infection control surveillance of resistant pathogens (strong; low). Send collected specimens to the microbiology laboratory promptly, in sterile transport containers, accompanied by clinical information on the type of specimen and location of the wound (strong; low). Surgical treatment Consult a surgical specialist in selected cases of moderate, and all cases of severe, diabetic foot infection (weak; low). Perform urgent surgical interventions in cases of deep abscesses, compartment syndrome and virtually all necrotizing soft tissue infections (strong; low). Consider surgical intervention in cases of osteomyelitis accompanied by spreading soft tissue infection, destroyed soft tissue envelope, progressive bone destruction on X‐ray or bone protruding through the ulcer (strong; low). Antimicrobial therapy While virtually all clinically infected diabetic foot wounds require antimicrobial therapy, do not treat clinically uninfected wounds with antimicrobial therapy (Strong; Low) Select specific antibiotic agents for treatment based on the likely or proven causative pathogens, their antibiotic susceptibilities, the clinical severity of the infection, evidence of efficacy of the agent for diabetic foot infection and costs (strong; moderate). A course of antibiotic therapy of 1–2 weeks is usually adequate for most mild and moderate infections (strong; high). Administer parenteral therapy initially for most severe infections and some moderate infections, with a switch to oral therapy when the infection is responding (strong; low). Do not select a specific type of dressing for a diabetic foot infection with the aim of preventing an infection or improving its outcome (strong; high). For diabetic foot osteomyelitis, we recommend 6 weeks of antibiotic therapy for patients who do not undergo resection of infected bone and no more than a week of antibiotic treatment if all infected bone is resected (strong; moderate). We suggest not using any adjunctive treatments for diabetic foot infection (weak; low). When treating a diabetic foot infection, assess for use of traditional remedies and previous antibiotic use and consider local bacterial pathogens and their susceptibility profile (strong; low).

Lateral ankle sprain injury is the most common musculoskeletal injury incurred by individuals who participate in sports and recreational physical activities. Following initial injury, a high proportion of individuals develop long-term injury-associated symptoms and chronic ankle instability. The development of chronic ankle instability is consequent on the interaction of mechanical and sensorimotor insufficiencies/impairments that manifest following acute lateral ankle sprain injury. To reduce the propensity for developing chronic ankle instability, clinical assessments should evaluate whether patients in the acute phase following lateral ankle sprain injury exhibit any mechanical and/or sensorimotor impairments. This modified Delphi study was undertaken under the auspices of the executive committee of the International Ankle Consortium. The primary aim was to develop recommendations, based on expert (n=14) consensus, for structured clinical assessment of acute lateral ankle sprain injuries. After two modified Delphi rounds, consensus was achieved on the clinical assessment of acute lateral ankle sprain injuries. Consensus was reached on a minimum standard clinical diagnostic assessment. Key components of this clinical diagnostic assessment include: establishing the mechanism of injury, as well as the assessment of ankle joint bones and ligaments. Through consensus, the expert panel also developed the International Ankle Consortium Rehabilitation-Oriented ASsessmenT (ROAST). The International Ankle Consortium ROAST will help clinicians identify mechanical and/or sensorimotor impairments that are associated with chronic ankle instability. This consensus statement from the International Ankle Consortium aims to be a key resource for clinicians who regularly assess individuals with acute lateral ankle sprain injuries.

BACKGROUND: Ankle sprains are a common and potentially disabling injury. Successful prediction of susceptibility to ankle sprain injury with a simple test could allow ankle sprain prevention protocols to be initiated and help prevent disability in the athletic population. OBJECTIVE: To investigate the ability of the single leg balance (SLB) test, carried out at preseason physical examination, to predict an ankle sprain during the autumn sports season. DESIGN: Prospective cohort study SETTING: High school varsity athletics and intercollegiate athletics. MAIN OUTCOME MEASURE: Ankle sprains in athletes with positive SLB tests. RESULTS: The association between a positive SLB test and future ankle sprains was significant. Controlling for confounding variables, the relative risk for an ankle sprain with a positive SLB test was 2.54 (95% confidence interval, 1.02 to 6.03). Athletes with a positive SLB test who did not tape their ankles had an increased likelihood of developing ankle sprains. The relative risk for ankle sprain for a positive SLB test and negative taping was 8.82 (1.07 to 72.70). A history of previous ankle injury was not associated with future ankle sprains in this study. The kappa value for interrater reliability for the SLB test was 0.898 (p<0.001). CONCLUSIONS: An association was demonstrated between a positive SLB test and ankle sprain. In athletes with a positive SLB test, not taping the ankle imposed an increased risk of sprain. The SLB test is a reliable and valid test for predicting ankle sprains.