Resident Editor: Juliana Macri, MD

Faculty Editor: Paul Nadler, MD

History

• Typical questions such as: character, onset, location, duration, exacerbating/relieving factors, severity, frequency, prior episodes, progression, associated symptoms
• Antecedent trauma/mechanism of injury, change in activity level, specific activities (e.g. running), footwear
• Red flags: nighttime pain may suggestion infection, bone tumor, neuropathy

 

Evaluation (see ankle exam as well)

Examination

• Inspection:
  • Look for deformities, nodules, swelling, calluses, or corns
  • With patient standing, look for pes planus (flatfoot) by noting if medial plantar surface touches the floor
• Palpation: with your thumbs, palpate the following areas:
  • Heel: posterior and inferior calcaneus, plantar fascia, achilles tendon for tenderness
  • Midfoot/Forefoot: heads of metatarsals, grooves between metatarsals, compress the forefoot between the thumb and fingers just proximal theads of 1st and 5th metatarsals

Imaging

• Ottawa Ankle Rule* – Clinical prediction tool that is 99% sensitive, 58% specific for detecting fracture as the cause of ankle pain (+LR 2.4l, -LR 0.02). Validated in children and adults

Obtain a foot x-ray series only if there is pain in the midfoot AND either of the following:

Inability tbear weight both immediately after injury and in ED/clinic (four steps) Bony tenderness at the navicular or the base of the fifth metatarsal

• Obtain AP, lateral and oblique views

 

Differential Diagnosis

 

Plantar fasciitis

• The most common cause of outpatient foot pain. Affects patients whrun (especially when increasing intensity or wearing new shoes), stand for prolonged periods, have high arches, tight Achilles tendons and the obese.
• History – severe, burning or lancinating pain on the bottom of the foot at the arch or inferior heel. Often the pain is worse in the morning on arising and after period of inactivity. It improves with walking, though may return later in the day.
• Exam – palpation over the plantar fascia's insertion on the calcaneus (anteromedial heel) elicits pain. If the pain worsens when the examiner dorsiflexes the foot while palpating, the diagnosis is more specific. Radiographs dnot aid in the diagnosis (heel spurs may be seen but itself dnot contribute tpain).
• Differential -- calcaneal stress fracture, nerve entrapment, neuroma, heel pad syndrome
• Treatment– Most importantly, rest for several days treduce inflammation. Stretch, strengthen, ice, massage and NSAIDs as first line. Arch supports tunload the fascia and heel cups for cushioning. Nighttime splints tkeep ankle at 90 degrees, arch taping and PT may alshelp. Weight loss if obese.
  • Consider corticosteroid injection -- 25-gauge needle or smaller intthe most tender spot. Dninject more that 1.5 ml tlimit acute discomfort. Risk of fascial rupture and fat pad atrophy
  • 80% resolve within 1 year regardless of therapy. If fails trespond tconservative therapy or nighttime pain, refer tfoot/ankle specialist. May consider extracorporeal shock wave therapy or plantar fasciotomy.

 

Hallux Valgus Deformity (Bunion)

• Lateral deviation of 1^st toe on 1^st metatarsal. Common. Women > men. Easily diagnosed by exam. Radiographs can assess for damage tarticular surfaces of 1^st MTP joint but are not necessary.
• Differential: May have concomitant bursitis (of bursa at the medial aspect of the bunion, brought on by tight-fitting shoes), osteoarthritis. Consider gout and septic arthritis of MTP as well
• Treatment – Poor evidence for conservative management, but experts recommend first trying shoe modification (wide, low-heeled shoes), orthoses tsupport alignment, night splinting tcorrect alignment, medial bunion pads, ice after activity, acetaminophen or NSAIDs for pain relief. Surgical referral is based on patient symptoms, signs of deformity, and lack of improvement with conservative measures.

 

Interdigital (Morton’s) Neuroma

• Entrapment of one of the common digital nerves; most commonly between 3^rd and 4^th toes. Rarely between 2^ndand 3^rd or 4^th and 5^th toes. Women > men (8:1). Triggered by overpronation and high heels, especially with a pointed and narrow toe box, as they compress the forefoot while transferring weight forward.
• History –Classically burning pain or numbness during weight bearing radiating distally from base of affected toe like “walking on a pebble”. May alscomplain of cramping, or progressive sharp, shooting pain in the ball or between toes,
• Exam –Tenderness with direct palpation between affected metatarsal heads, especially when compressing foot mediolaterally. Compression alone may cause pain. “Metatarsal Shift Test”- pain reproduced when holding the metatarsal heads of twadjacent toes and moving them in the opposite direction. Mulder’s sign (clicking sensation while palpating interspace and squeezing metatarsal joints). Plain films trule out stress fracture but only 10-14 days after onset of symptoms. Conservative treatment prior tMRI (MRI is positive in 1/3 of asymptomatic individuals).
• Differential: synovitis, capsulitis, plantar fat pad atrophy, and metatarsal stress fracture, avascular necrosis
• Treatment –Should resolve in weeks with avoidance of high-heeled, pointed-toed shoes, in favor of low-heeled shoes with wide toe box +/- bilateral shoe insert/pads under metatarsal heads. NSAIDs not very beneficial. Consider glucocorticoid/anesthetic injections if there is very high diagnostic certainty. Surgical referral if not improved with 9-12 months of conservative measures, if very severe pain, or protracted course.

 

Metatarsalgia

• General term for pain in ball of foot. Usually due trunning or ill-fitting shoes.
• Diagnosis -- Symptoms similar tinterdigital neuroma, but tenderness on exam is just proximal tmetatarsal head, not interdigital. Get radiographs trule out stress fracture.
• Treatment – metatarsal pads placed proximal tarea of tenderness.

 

Acute Metatarsal Fractures

• Usually caused by direct axial blows (for shaft fractures) or twisting forces (for proximal fifth metatarsal fractures). Initial evaluation should try tidentify conditions that require emergent referral: neurovascular compromise, open fractures.
• History – Pain, swelling, severe ecchymosis, difficulty walking. Consider early compartment syndrome if disproportionate pain.
• Exam – Neurovascular exam including capillary refill, pulses, sensation; Inspect for wounds, devitalized skin, tenting of skin over displaced fracture; Palpate for point tenderness. Radiographs are essential. Get AP, lateral, and oblique view (3 views) radiographs.
• Treatment– Depends on type of fracture
  • Non-emergent but prompt referral is required for:
    • Intra-articular or displaced fractures (>3 mm), multiple fractures, fracture-dislocations, significant angulation (>10 degrees) 1^st metatarsal fracture, “Jones Fracture” (fracture of the diaphysis of the fifth metatarsal; especially for very active patients, given delayed healing, risk of non-union) or Lisfranc injury (see below).
  • Conservative treatment for non-displaced fractures
    • Metatarsal shaft fractures (2^nd-5^th) – posterior splint, non-weight bearing, follow up in 3-5 days (heal time 6 weeks)
    • 5^th metatarsal tuberosity avulsion fracture -- compressive dressing, weight bearing and ROM as tolerated, follow up in 4-7 days (heal time of 4-8 weeks)
    • Follow up appointment for all:
      • At 1 week: Repeat radiographs tensure alignment. If unchanged radiographs, transition tshort leg walking boot, progressive weight bearing, PT
      • At 4-6 weeks: Repeat radiographs tensure alignment and healing (visible callus). If there is visible healing and resolution of point-tenderness, foot protection can be discontinued.

 

Metatarsal Shaft Stress Fractures

• History – Stress fractures tend toccur in the setting of an abrupt increase in activity or chronic overload.
• Exam – Point tenderness over the fracture, pain at fracture site with axial loading of metatarsal head. Stress fractures are rarely visible on plain radiographs until symptoms have been present for 2-6 weeks. MRI unnecessary if high suspicion on clinical grounds. Treat presumptively.
• Treatment – Stress fractures of metatarsal shaft are treated with rest and avoidance of the causative activity for 4-8 weeks and dnot require immobilization. If significant pain, can dpartial weightbearing with crutches for a few weeks.

 

Tarsal Tunnel Syndrome

• Entrapment of the posterior tibial nerve as it crosses behind the medial malleolus. Caused by trauma/fracture (typically) but alsspace-occupying lesions, systemic disease (e.g. RA) and poor biomechanics
• History –Numbness, paresthesias, burning pain in the posteromedial ankle and heel, and sometimes in the distal foot and toes. Antecedent foot trauma almost always present. Worse with activity, improved with rest.
• Exam – Percussion over the path of the nerve elicits symptoms as above (Tinel sign). Provoked by dorsiflexion-eversion test or plantar flexion-inversion test. Sensory loss. Motor findings rare. MRI preferred, but EMG and ultrasound can be considered.
• Treatment – NSAIDs, activity modification. shoe modification/orthotics. If nresponse, can dcorticosteroid injection, neuromodulator medications. Surgical decompression if failed conservative therapy.

 

Lisfranc Fracture (Injury)

• The 2^nd metatarsal head is “keystoned” between 1^st and 3^rd metatarsal heads and cuneiforms. Lisfranc injury is due taxial load on foot that causes rupture of the ligament that holds the 2^nd metatarsal head in place.
• History – Mid-foot pain after axial load injury.
• Exam – Ecchymosis in plantar midfoot is highly suggestive. Most common signs are point tenderness in the midfoot and pain with twisting of the forefoot while stabilizing the calcaneus. Neurovascular exam is important because injury can result in compromise of the dorsalis pedis artery. Important torder weightbearing AP films.
• Treatment – Lisfranc injury requires prompt orthreferral as treatment includes casting versus internal fixation depending on the type/severity of the injury.

 

Charcot arthropathy of the foot or ankle

• History: Minimal pain, though may report warmth, redness, and swelling. Suspect in patients with peripheral neuropathy from any cause (most commonly DM)
• Exam: Intact pulses, hyperemia, erythema, and occasionally joint crepitus. Plain films are normal or show osteopenia. Findings on MRI or bone scan can be difficult tdistinguish from osteomyelitis.

Differential: Cellulitis, osteomyelitis, gout. Consider in every patient with peripheral neuropathy as well as exam showing red, hot, swollen foot.

• Treatment – Failure trecognize may result in joint destruction or development of rocker-bottom foot if the patient continues tbear weight on affected foot. Make patient strictly non-weight bearing and urgently refer tfoot and ankle specialist for definitive treatment. Antibiotics may be given if infection cannot be ruled out.

 

References

Ahn JM, El-Khoury GY. Occult Fractures of Extremities. Radiologic Clinics of North America. 2007;45(3):561–579.

Bica D, Sprouse RA, and Armen J. Diagnosis and Management of Common Foot Fractures. Am Fam Physician. 2016. 93(3): 183-191. 

Goff J, Crawford R. Diagnosis and Treatment of Plantar Fasciitis. Am Fam Physician. 2011;84(6):676–682.

Tu, P. Heel Pain: Diagnosis and Management. Am Fam Physician. 2018 Jan 15;97(2):86-93.

Gould J. Tarsal Tunnel Syndrome. Foot and Ankle Clinics of North America. 2011;16(2):275–86.

Page N and Nouvong A. The Top 10 Things Foot and Ankle Specialists Wish Every Primary Care Physician Knew. MayClin Proc. June 2006;81(6):818-822.

Tu, P. Heel Pain: Diagnosis and Management. Am Family Physician 2018; 97(2): 86-93.