Toe Pain — Assessment & Management

Safety

Red Flags — Diabetic Foot Emergency, Malignancy & Ischaemia

Done

Toe pain + erythema + warmth + systemic illness in a diabetic patient — or cellulitis spreading from toe wound Diabetic foot infection → classify severity. Refer immediately to hospital and inform the multidisciplinary foot service if sepsis/systemic illness, limb ischaemia, gangrene, suspected deep soft-tissue or bone infection, or other limb- or life-threatening features; other active diabetic foot problems → multidisciplinary foot service within 1 working day. Start antibiotics as soon as infection is suspected (per NICE NG19 and local guidance). A positive probe-to-bone test or X-ray changes increase the likelihood of osteomyelitis but do not establish it, and negative results do not exclude it — MRI if suspicion remains.

Toe pain + cold, pale, pulseless, painful, numb toe + acute onset Acute limb/digital ischaemia — arterial embolism or thrombosis. A toe can be ischaemic despite a palpable proximal pulse: check capillary refill, temperature, colour, sensation and motor function. → 999 — acute limb or digital ischaemia is a vascular emergency (immediate vascular assessment). No compression; do not delay vascular referral for routine investigations.

Painful swollen great toe + fever + rapidly spreading erythema beyond the joint + systemically unwell Septic arthritis of first MTP joint or necrotising fasciitis of foot. → 999 if signs of sepsis (NICE NG253), septic shock or suspected necrotising fasciitis; otherwise same-day hospital assessment. Do not assume gout without excluding septic arthritis — first MTP septic arthritis is uncommon but limb-threatening and may mimic podagra. Joint aspiration + Gram stain + culture when infection is possible or the diagnosis is uncertain.

Subungual pigmented lesion (longitudinal melanonychia) in a great toe nail + widening + Hutchinson's sign on nail fold Subungual melanoma. → dermatology suspected cancer pathway referral. See the nail disorders protocol.

Hot, swollen foot in a person with neuropathy (even if painless) — or a deep neuropathic ulcer with visible bone or deep tissue Suspected acute Charcot foot or deep ulcer. → Suspected Charcot: stop weight-bearing, provide appropriate immobilisation/offloading and refer urgently to the multidisciplinary foot service within 1 working day; weight-bearing X-ray of foot and ankle, MRI if X-ray is normal but suspicion remains. Definitive total-contact casting by the specialist foot service only. Deep ulcer / suspected deep infection → immediate hospital assessment.

Toe pain + bone erosion on X-ray + weight loss + known or suspected malignancy Metastatic bone lesion — rare in phalanges but documented (lung, renal, thyroid most commonly metastasise to distal extremities). → CT staging + urgent orthopaedic oncology referral (suspected cancer pathway).

The probe-to-bone test (gently probing the ulcer base with a sterile blunt metal probe; hard, gritty bone = positive) increases the likelihood of osteomyelitis, particularly in a deep or chronic ulcer, but does not establish the diagnosis alone — and a negative test does not exclude it. NICE NG19 warns that osteomyelitis may be present despite normal inflammatory markers, normal X-rays or a negative probe-to-bone test. Use clinical assessment and a plain X-ray first (bony changes may support the diagnosis but can be late or non-specific), MRI if osteomyelitis is still suspected, and a deep tissue or bone specimen for microbiology where appropriate, ideally after debridement. A deep ulcer or positive test needs specialist confirmation through the diabetic foot pathway.

Diagnose

Classification of Toe Pain — Anatomical Framework

Done

Forefoot pain (toes and metatarsal heads)

Hallux valgus (bunion): lateral deviation of great toe + medial MTP joint prominence — ill-fitting footwear, genetic predisposition, RA. Morton's neuroma: plantar interdigital burning/numbness between 3rd/4th toes (most common) — a Mulder's click supports the diagnosis but is not diagnostic in isolation. Metatarsalgia: pain under metatarsal heads on weight-bearing — callus formation, Morton's, stress fracture. Sesamoiditis: pain under 1st MTP joint — sesamoid bones injured by repetitive loading.

Toe joint disorders

Gout: first MTP joint (podagra — the most common site for gout) — acute onset, intensely painful, erythematous, hot, unable to bear weight. OA of toes: great toe MTP and IP joints — stiff, bony, pain on movement. Hammer toe / claw toe: PIP fixed flexion + DIP hyperextension (claw toe) — callus over PIPJ dorsum, ulceration risk in neuropathy. Ingrown toenail: lateral nail fold pain, granulation tissue.

Nail disorders

Onychomycosis: yellow-brown thickened nails — see the nail disorders protocol. Subungual haematoma: painful blood under nail (trauma — evacuation with hot needle). Onychogryphosis (ram's horn nail): severely thickened curved nail — elderly, neglect, neuropathy. Paronychia: nail fold infection (acute bacterial or chronic candidal). Subungual SCC or melanoma: suspected cancer pathway referral.

Structural and sports-related

Hallux rigidus: OA of first MTP — dorsiflexion severely restricted, stiff toe, pain on push-off. Plantar fasciitis (heel + toe): inferior heel pain worst first steps of morning — affects toe mechanics. Turf toe: hyperextension injury of first MTP (sports). Freiberg's infarction: avascular necrosis of 2nd-4th metatarsal head (adolescent girls) — X-ray fragmented metatarsal head.

Morton's neuroma management in primary care is frequently inadequate because the diagnosis is missed — the neuroma (actually a perineural fibrosis, not a true neuroma) forms in the common digital nerve between the metatarsal heads, most commonly between the 3rd and 4th toes. The presenting symptoms: burning, sharp, or shooting pain in the forefoot radiating into the affected toes (particularly the 3rd and 4th), often described as 'walking on a pebble,' worsened by tight footwear and high heels, relieved by removing shoes and massaging the foot. The key examination finding: Mulder's click sign — with one hand compressing the metatarsal heads laterally (squeezing the forefoot) while the other hand's thumb and index finger palpate the interspace from above and below, a palpable and audible 'click' produced by moving the neuroma suggests the diagnosis but is not diagnostic in isolation. The clinical approach: wide-toe-box footwear + metatarsal pad (raises the metatarsal arch, reducing nerve compression) is first-line. Consider image-guided corticosteroid injection or specialist podiatry/orthopaedic assessment if symptoms persist despite footwear and offloading. Surgery is reserved for persistent, function-limiting symptoms after appropriate conservative treatment and specialist review.

Diagnose

Assessment — History, Examination & Investigations

Done

History

Pain location: great toe (gout, hallux valgus, hallux rigidus, sesamoiditis), interdigital (Morton's neuroma), under metatarsal heads (metatarsalgia, plantar plate tear), toenail (onychomycosis, paronychia, melanoma, ingrown). Onset: sudden (gout, fracture, acute ischaemia) vs gradual (OA, hallux valgus, hammer toe, Morton's). Character: burning/electric (Morton's — neuropathic), throbbing (gout, infection), dull ache on walking (OA, metatarsalgia, hallux rigidus). Footwear: narrow toe box, high heels (hallux valgus, Morton's, hammer toe). Activities: running (stress fracture, plantar fasciitis, turf toe), prolonged standing (metatarsalgia). Diabetes (neuropathy, Charcot foot, osteomyelitis), gout history, inflammatory arthritis.

Examination

Weight-bearing gait observation. Footwear inspection (wear pattern). Great toe: alignment (hallux valgus angle), range of dorsiflexion (restricted in hallux rigidus). All toe deformities (hammer, claw, mallet toe). Interdigital spaces: Mulder's click (Morton's). Neuropathy screen: 10g monofilament to plantar surface + vibration (128 Hz tuning fork) — absent sensation in diabetes = Charcot/ulcer risk. Skin: callus (pressure areas), ulcer (neuropathic), erythema, cellulitis. Vascular: dorsalis pedis + posterior tibial pulses, capillary refill, temperature and colour. ABPI can be unreliable in diabetes (arterial calcification) — absent pulses or suspected ischaemia in a diabetic foot need urgent vascular/diabetic-foot assessment (toe pressures or Doppler waveforms via the specialist pathway).

Investigations

Not routinely needed for clinically typical Morton's neuroma, metatarsalgia, hallux valgus or uncomplicated gout. X-ray foot (weight-bearing) (structural deformity, arthritis, fracture or surgical planning; hallux valgus angle, gout erosions 'punched out' with overhanging edge, stress fracture, Freiberg's, OA joint space) · Serum urate (does not confirm gout alone; may be below 360 µmol/L during a flare — repeat at least 2 weeks after it settles if suspicion remains) · HbA1c + eGFR (diabetes + CKD — gout risk, neuropathy) · USS foot (selected soft-tissue conditions, e.g. Morton's neuroma or tendon tears — not mandatory) · MRI foot (reserved for suspected osteomyelitis, Charcot foot, stress fracture, avascular necrosis, plantar plate injury or other significant pathology) · ABPI (peripheral arterial disease — may be falsely reassuring in diabetes)

The 10g Semmes-Weinstein monofilament test for diabetic foot neuropathy is the most important screening examination for identifying feet at risk of neuropathic ulceration — it should be performed at every annual diabetic foot check and at any consultation where a diabetic patient presents with a foot complaint. The technique: press the monofilament perpendicular to the skin surface with enough force to bend it (the calibrated monofilament applies 10g of force when buckled). Test four sites on each foot: plantar aspect of hallux, plantar first, third, and fifth metatarsal heads. Ask the patient to say 'yes' when they feel it (eyes closed). A patient who cannot feel the monofilament at one or more sites has significant peripheral neuropathy — their foot cannot generate protective pain, meaning they can sustain tissue-damaging pressure without awareness. These patients need: enhanced foot protection education, footwear advice, regular podiatry, and review frequency set by their NICE NG19 risk category and the local foot-protection service.

Diagnose

Gout of the Foot, Ingrown Toenail & Hallux Valgus

Done

Podagra (gout of first MTP joint)

The most common presentation of gout. Onset: typically nocturnal (patient woken from sleep by severe pain). Features: excruciating pain, erythema (may be mistaken for cellulitis), hot, markedly swollen, extremely tender to even light touch (sheet contact intolerable). Systemic: mild fever (38°C), elevated WBC. Course: untreated resolves in 7-14 days (faster with treatment). Diagnosis is clinical (typical history plus risk factors: male, hyperuricaemia, renal impairment, alcohol, diet, diuretics, aspirin). A serum urate level does not confirm gout in isolation and may be below 360 µmol/L during a flare — repeat at least 2 weeks after the flare has settled if suspicion remains. Aspirate for microscopy if the diagnosis is uncertain or infection is possible (NICE NG219).

Ingrown toenail (onychocryptosis)

Lateral nail edge penetrating into the nail fold — great toe most common. Stages: (1) erythema + swelling (no infection); (2) granulation tissue (± discharge); (3) chronic infection with thick granulation. Causes: incorrect nail cutting (should cut straight across, not curved), tight footwear, trauma. Conservative management (stages 1-2): soak foot in warm salt water, elevate the nail edge with a cotton wick (gently tease cotton under the lateral nail edge) — not in significant diabetes, neuropathy, peripheral arterial disease or poor healing without podiatry advice. Antibiotics only for clear cellulitis or infection — not for inflammation or granulation caused by the nail edge. Surgical (stage 3 or recurrent): nail avulsion ± phenolisation of lateral nail matrix (wedge excision — permanent prevention). Assess for diabetes, vascular disease and neuropathy first. Refer to podiatry, or primary-care minor surgery only by clinicians with documented competence under a governed local protocol.

Hallux valgus management

Conservative: wide-toe-box footwear (most important — tight footwear drives progression), toe separators (silicone — reduce friction between hallux and 2nd toe), bunion pads (protect MTP prominence), orthoses only where helpful and acceptable. Exercises or toe separators may ease symptoms or pressure but do not correct the deformity. OT referral for shoe fittings. Surgery (osteotomy — bunionectomy) is the only structural correction. Refer to orthopaedics based on pain and functional limitation, failure of appropriate conservative management, patient preference and clinical/radiographic findings — no fixed conservative trial is required when symptoms are severe or function is substantially affected.

Nail avulsion with phenolisation of the matrix is an effective option for recurrent ingrown toenail, but procedural detail belongs in a governed local minor-surgery protocol. It should only be performed by clinicians with documented competence, appropriate consent, aseptic technique, local governance and follow-up arrangements. Cautions/contraindications: significant peripheral arterial disease, neuropathy or high-risk diabetic foot, poor wound healing, anticoagulation or bleeding disorder, unclear diagnosis or possible melanoma/SCC, and extensive cellulitis. Warn patients that discharge is expected during healing, which takes several weeks.

Refer

Referral Pathways

Done

999 / emergency

Acute limb/digital ischaemia · Necrotising infection, suspected sepsis (NICE NG253) or septic shock · Septic arthritis with systemic instability · Pulmonary embolism symptoms with instability

Immediate diabetic foot / ED assessment

Diabetic foot infection with sepsis, gangrene, limb ischaemia or suspected deep soft-tissue/bone infection (refer immediately to hospital and inform the multidisciplinary foot service) · Deep ulcer or positive probe-to-bone test needing specialist confirmation · Any rapidly deteriorating diabetic foot problem

Urgent — within 1 working day

Multidisciplinary foot service (local triage): suspected acute Charcot foot (stop weight-bearing and offload meanwhile) · Any active diabetic foot ulcer · Local diabetic foot infection without systemic instability · Suspected osteomyelitis without systemic illness · High-risk painful ingrown toenail or pressure lesion

Podiatry

Ingrown toenail stage 3 (chronic granulation) · Onychogryphosis causing pain or pressure · Callus causing pain or risk of breakdown in high-risk foot

Orthopaedics

Hallux valgus causing pain + significant functional limitation, failed conservative management or patient preference · Morton's neuroma with persistent, function-limiting symptoms despite footwear, offloading ± image-guided injection (specialist podiatry/orthopaedic assessment) · Hallux rigidus severe (marked loss of dorsiflexion) · Hammer/claw toe causing ulceration or failed conservative management

GP management

Typical gout after septic arthritis has been considered: NSAID, colchicine or a short course of oral corticosteroid (NICE NG219). Mild uncomplicated ingrown toenail without cellulitis or high-risk comorbidity: salt soaks ± cotton wick. Typical hallux valgus, hallux rigidus or metatarsalgia. Typical Morton's neuroma after assessment for alternative diagnoses. Tinea pedis: clotrimazole 1% cream BD x 4 weeks (treat before onychomycosis develops). Metatarsalgia: metatarsal pad + wide footwear + physiotherapy.

Charcot neuroarthropathy is a serious complication of diabetic peripheral neuropathy and is frequently missed in primary care — acute Charcot presents as a unilateral warm, swollen, often erythematous foot in a patient with neuropathy, easily mistaken for cellulitis, gout or DVT. Pain may be minimal or absent because of the neuropathy, so suspect Charcot even when the foot does not hurt, or when 'cellulitis' is not improving with antibiotics. Stop weight-bearing, provide appropriate immobilisation/offloading and refer urgently (within 1 working day) to the multidisciplinary foot service; arrange a weight-bearing X-ray of the foot and ankle, with MRI if the X-ray is normal but suspicion remains. Definitive total-contact casting is provided by the specialist foot service. Delay risks midfoot or hindfoot collapse (rocker-bottom deformity), ulceration and amputation.

Treat

Gout, Morton's Neuroma & Toe Conditions

Done

Acute gout — first MTP joint

NICE NG219 first-line: an NSAID (with PPI), colchicine, or a short course of oral corticosteroid — choose by renal function, gastrointestinal and cardiovascular risk, anticoagulants, age and interactions, and check doses in the SPC and your local formulary. Colchicine needs particular caution in renal impairment, older age, with statins and with strong CYP3A4/P-glycoprotein inhibitors (especially clarithromycin). Ice, rest and elevation; avoid pressure on the joint. Intra-articular steroid only after infection has been considered and, where clinically indicated, after aspiration. ULT: ordinarily offered 2–4 weeks after the flare settles, but it can be started during a flare if flares are frequent; target serum urate below 360 µmol/L (consider below 300 µmol/L for tophi, chronic gouty arthritis or ongoing frequent flares).

Morton's neuroma management

Metatarsal pad (placed proximal to metatarsal heads — raises the arch and separates the metatarsal heads). Wide-toe-box footwear. Activity modification; physiotherapy or orthoses where appropriate. Silicone interdigital spacer may help. If symptoms persist despite footwear and offloading: consider image-guided corticosteroid injection or specialist podiatry/orthopaedic assessment. Surgery is reserved for persistent, function-limiting symptoms after appropriate conservative treatment and specialist review.

Metatarsalgia conservative management

Metatarsal dome pad (placed proximal to metatarsal heads — redistributes weight). Footwear modification: low heel, wide toe box. Orthotic insoles (custom or over-the-counter — Dr Scholl's, Superfeet). Physiotherapy: intrinsic foot muscle strengthening, toe-spread exercises, calf stretching. NSAIDs topical (diclofenac gel) for acute flares. If plantar plate tear on MRI: orthopaedic referral (strapping, boot, or surgical repair).

Colchicine dosing has moved away from older high-dose regimens because of gastrointestinal toxicity. Current practice uses low-dose colchicine (EULAR; colchicine is a first-line flare option in NICE NG219) — follow the current SPC and local formulary for dose, maximum per course and repeat-course interval. Reduce the dose or avoid in renal impairment per the SPC, and take particular care in older people and with statins. Clarithromycin and other strong CYP3A4 or P-glycoprotein inhibitors can greatly increase colchicine levels and cause life-threatening toxicity (myopathy, pancytopenia) — avoid the combination or seek advice.

Treat

Diabetic Foot Management & Nail Procedures

Done

Diabetic foot infection — antibiotic principles

Start antibiotics as soon as diabetic foot infection is suspected; take a deep tissue or bone specimen where possible before, or close to, starting. Classify severity. Oral antibiotics first line if the patient is clinically stable and able to take oral treatment; IV only for severe infection, inability to take oral therapy or inadequate oral coverage — review IV treatment at 48 hours and switch to oral where possible. Choose agents by severity per NICE NG19 (antimicrobial prescribing, 2019) and local antimicrobial guidance, considering local resistance, renal function, allergy and previous microbiology — there is no universal combination. Treat for at least 7 days, up to 6 weeks for osteomyelitis, depending on clinical response and specialist advice. Children and young people: seek specialist advice. Osteomyelitis is confirmed through the specialist pathway (X-ray, MRI, bone specimen). Offloading per the foot service. Vascular assessment via the specialist pathway (ABPI may be unreliable in diabetes; toe pressures or Doppler waveforms).

Ingrown toenail nail surgery

Partial nail avulsion ± phenolisation should follow a governed local minor-surgery protocol and be performed only by clinicians with documented competence, appropriate consent, aseptic technique, local governance and follow-up. Assess for diabetes, vascular disease and neuropathy first. Cautions/contraindications: significant peripheral arterial disease, neuropathy or high-risk diabetic foot, poor wound healing, anticoagulation or bleeding disorder, unclear diagnosis or possible melanoma/SCC, extensive cellulitis — refer to podiatry instead.

Onychomycosis treatment for toe nails

Do not start oral terbinafine solely on the appearance of a dystrophic toenail — obtain nail clippings or an appropriate mycological sample and confirm fungal infection before systemic therapy. Before terbinafine: check the current SPC, review liver disease and interacting medicines, obtain baseline LFTs, and use the licensed/product-specific duration and local formulary guidance; monitor per the product information and local protocol, and stop if significant adverse effects or liver toxicity are suspected. Alternatives (e.g. itraconazole for non-dermatophyte infection) and topical amorolfine for mild distal disease per SPC/local formulary.

Next steps: see Morton's neuroma · Gout · Nail disorders · Fungal skin infection · Peripheral arterial disease

Oral terbinafine kills the fungus during the course, but visible improvement lags many months behind because healthy nail must grow out slowly from the matrix. Counsel patients to complete the licensed course (per the current SPC) even if the nail looks unchanged, that clearance may take months after treatment ends, and that recurrence is common. Review adherence and adverse effects; monitor LFTs per the current SPC and local protocol, and stop if liver toxicity is suspected.

Lifestyle

Foot Care, Footwear & Diabetic Foot Education

Done

Nail cutting technique and prevention of ingrown toenail Cut nails straight across — never curved or into the corners. Do not cut down the sides of the nail. Cut after bathing (softer). Leave nails at or just beyond the free edge (not too short). Use proper nail scissors or clippers (not scissors with curved blades). Patients with reduced manual dexterity, poor vision, neuropathy, or thickened nails: refer to NHS podiatry — do not self-cut with these risk factors.

Diabetic foot daily inspection Every diabetic patient with peripheral neuropathy should inspect both feet every day: check between all toes, soles, heels, and around nails for: cuts, blisters, calluses, erythema, swelling, or wounds. Use a mirror for sole inspection if unable to bend. Check footwear before putting on (foreign objects in shoes — neuropathic patient cannot feel a stone). Any wound needs prompt assessment, especially with neuropathy, ischaemia, deformity or previous ulcer/amputation: contact the GP or diabetic foot team the same day (do not wait for the scheduled appointment).

Footwear for foot health Wide toe box: no compression of toes (hallux valgus, hammer toe, Morton's all worsened by narrow shoes). Low heel for daily use. Cushioned sole: reduces metatarsal head loading. Gradual break-in: never wear new shoes all day without breaking in (blisters + ulcers in neuropathic patients). Diabetic footwear: NICE NG19 — the foot protection service assesses the need for specialist footwear and orthoses in people at moderate or high risk (prescribed via podiatrist or orthotist).

Gout lifestyle advice Support a healthy weight, reduce excess alcohol (particularly beer and spirits) and sugary drinks, maintain adequate hydration and address cardiovascular risk factors. Dietary advice should not replace treat-to-target urate-lowering therapy.

Circulation and Raynaud's in toes Secondary Raynaud's of toes: consider SSc, lupus, MCTD, vibration injury. Nifedipine is the first-line drug for troublesome attacks: prescribe the exact modified-release product, start low and titrate per the SPC and local formulary. Foot warmers, thermal socks, heated insoles. Avoid cold immersion. Smoking cessation (vasoconstrictor — significantly worsens digital ischaemia). Regular moderate aerobic exercise (walking, cycling — improves peripheral circulation and microvascular density).

Morton's neuroma footwear and activity advice Avoid narrow shoes with high heels completely during recovery — these compress the transverse metatarsal arch and impinge the neuroma. Trainers with a wide toe box and a well-cushioned sole are ideal (New Balance wide-fit, Hoka). Metatarsal dome pad (available OTC in pharmacies) under the ball of the foot, placed proximal to the metatarsal heads — correctly positioned, this is highly effective for symptom relief. Activities: reduce high-impact running or jumping during acute phases.

Hallux valgus exercise programme Hallux valgus cannot be corrected without surgery; exercises and toe separators may ease symptoms or reduce pressure but do not correct the deformity. Toe separation and spreading exercises: sit with feet flat on floor, spread toes apart and hold for 5 seconds, repeat 10 times twice daily. Towel curling: use toes to gather a towel on the floor (strengthens intrinsic muscles). Marble pickup: use toes to pick up and drop marbles (1 min daily). Ankle resistance band exercises: eversion + inversion strengthening. These exercises may help comfort and function.

Posture and weight management for foot pain Excess weight increases forefoot loading; weight loss may reduce plantar pressures and symptoms in metatarsalgia, hallux valgus and Morton's neuroma. NICE NG246 weight management pathway for BMI ≥30.

The metatarsal dome pad placement is critically important for its effectiveness — it must be placed PROXIMAL to (just behind) the metatarsal heads, not under them. A correctly positioned metatarsal dome pad lifts the metatarsal shaft (like a keystone under an arch), spreading the transverse metatarsal arch and separating the metatarsal heads, thereby decompressing the interdigital nerves. If placed directly under the metatarsal heads (the intuitive but incorrect position), it increases rather than decreases pressure on the nerve. The correct placement: the pad sits just behind the metatarsal heads (the ball of the foot). Many patients and podiatrists use pre-fabricated metatarsal pads without explaining this positioning detail, resulting in ineffective treatment and unnecessary escalation to steroid injection or surgery. GPs advising patients on metatarsal pads should demonstrate placement on an anatomical model or clear diagram.

Safety

Follow-Up & Diabetic Foot Safety-Net

Done

Annual diabetic foot review

Vascular assessment (DP + PT pulses; ABPI can be unreliable in diabetes — specialist vascular testing if ischaemia is suspected). Neuropathy screen (10g monofilament + vibration). Skin + nail inspection. Footwear. Classify risk (NICE NG19): low risk (no risk factors except callus alone) = annual; moderate risk (deformity, neuropathy or peripheral arterial disease) = every 3-6 months; high risk (previous ulcer or amputation, renal replacement therapy, neuropathy with peripheral arterial disease, or neuropathy or peripheral arterial disease with callus and/or deformity) = every 1-2 months, or every 1-2 weeks if there is immediate concern (check intervals against the local diabetic-foot pathway). Any active foot problem → multidisciplinary foot service within 1 working day.

Gout follow-up

Check serum urate at least 2 weeks after the flare has settled. Offer ULT per NICE NG219 — ordinarily 2–4 weeks after a flare, but it can be started during a flare if flares are frequent — with flare prophylaxis (e.g. colchicine) when starting. Treat to target: serum urate below 360 µmol/L; consider below 300 µmol/L for tophi, chronic gouty arthritis or ongoing frequent flares. Monitor urate per NICE NG219 once stable. Lifestyle reinforcement.

Morton's neuroma and hallux valgus

Morton's: review after any injection; persistent function-limiting symptoms → specialist podiatry/orthopaedic review. Hallux valgus: refer on pain, functional limitation, failed conservative management, patient preference and clinical/radiographic findings — no mandatory fixed conservative trial when symptoms are severe.

Same-day / 999

Hot swollen joint with fever → same-day hospital assessment (septic arthritis — aspirate, don't just treat as gout); 999 if signs of sepsis (NICE NG253) · Diabetic foot with sepsis, gangrene, ischaemia or suspected deep/bone infection → immediate hospital + inform the foot service · Acute digital ischaemia → 999 · Hot swollen foot in a neuropathic patient (possible Charcot, even if painless) → stop weight-bearing; multidisciplinary foot service within 1 working day

Safety-net — tell the patient

Call 999 if the toe or foot suddenly turns cold, pale or blue, numb or very painful, or you feel very unwell (possible sepsis). Same day (contact us or NHS 111) for a fever with a hot swollen joint, spreading redness, or any new wound, blister, swelling or colour change on a diabetic foot. Contact us if the pain worsens or is not settling.

Within 1-2 weeks

New ingrown toenail stage 2-3 → podiatry (within 1 working day if high-risk diabetic foot). Gout confirming new diagnosis → serum urate (at least 2 weeks after the flare) + renal function + review. Any diabetic foot ulcer → multidisciplinary foot service within 1 working day — do not wait 1–2 weeks.

The annual diabetic foot risk stratification and follow-up frequency is a NICE NG28 and NICE NG19 quality standard — low risk (no risk factors except callus alone) = annual review by GP or practice nurse; moderate risk (deformity, neuropathy or peripheral arterial disease) = every 3-6 months by the foot protection service; high risk (previous ulcer or amputation, renal replacement therapy, neuropathy with peripheral arterial disease, or neuropathy or peripheral arterial disease with callus and/or deformity) = every 1-2 months by the foot protection service, or every 1-2 weeks if there is immediate concern (NICE NG19). Identifying the correct risk category and ensuring the appropriate follow-up is arranged is a GP quality standard. A high-risk diabetic foot patient who is only reviewed annually (as if low risk) represents a clinical governance failure. The QOF diabetes indicators include a foot examination with neuropathy and vascular assessment at least annually — GPs should ensure this is recorded in the diabetic annual review template.