Ankle and Foot Pain

Ankle pain accounts for up to 20% of cases of musculoskeletal complaints in outpatient clinics. The most common etiologies of foot and ankle pain can be categorized into arthritis, trauma, sprains, and systemic causes. The diagnosis is clinical with imaging and/or laboratory studies to confirm the suspected diagnosis. Management involves rest, ice packs, compression, elevation, and nonsteroidal anti-inflammatory drugs (NSAIDs). Surgical repair is rarely needed.

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Overview

Epidemiology

Foot pain is more common among people who wear uncomfortable shoes (usually women).

Classification

  • Acute: lasts < 2 weeks 
  • Chronic: lasts > 2 weeks

History

  • Pain history (localization, quality, time, factors that alleviate/reinforce pain) 
  • Pay attention to alarming symptoms: 
    • Severe pain, fever, warmness, and skin redness may indicate septic arthritis.
    • Inability to walk 4 steps immediately after injury → likely fractured
    • Numbness or weakness → likely fractured with compressed or injured nerve

Physical examination

Ottawa ankle and foot rules:

  • High sensitivity, poor specificity for fractures
  • Most helpful when negative → no need for an X-ray
X-ray qualify foot pain

Ottawa ankle and foot rules

Image by Lecturio.

Differential Diagnosis

The etiology of ankle or foot pain can be determined from the anatomical location of the maximum point of pain or tenderness.

Common causes of ankle pain
LocationConditionFeatures
Lateral aspectAnkle sprain (acute pain)
  • Most common cause of lateral ankle pain
  • Most commonly involved ligament is the anterior talofibular ligament
  • Mechanism is inversion of the plantar-flexed foot
  • Patient is able to walk, but with pain
  • If the patient can’t walk at all, consider the possibility of tibial or fibular fracture.
Medial aspect
  • Most common cause of medial ankle pain
  • Most commonly involved ligament is the deltoid ligament
  • Mechanism is forced eversion of the foot
  • Patient is able to walk, but with pain
  • If the patient can’t walk at all, consider the possibility of tibial or fibular fracture.
Posterior aspectAchilles tendinitis (acute pain)
  • Burning pain, stiffness, and swelling over the tendon, often 3–5 cm above insertion of calcaneus
  • Associated with a change in the intensity of training
  • Presence of a “pop”-like sound before sudden onset of the pain
Variable locationsInfectious and inflammatory conditions
  • Acute pain (< 2 weeks):
    • Septic arthritis
    • Cellulitis
    • Acute gouty arthritis
    • Disseminated gonococcal infection
  • Chronic pain (> 2 weeks):
    • Rheumatoid arthritis
    • Reactive arthritis
Common causes of foot pain
LocationConditionFeatures
Forefoot (toes + distal metatarsals)Bunions (hallux valgus)
  • Most common cause of forefoot pain
  • Pain is exacerbated by wearing shoes.
  • Diagnosis is made clinically with history of great toe pain and increasing valgus deformity.
Ingrown toenails
  • Develops when a spicule of the lateral nail plate pierces the lateral nail fold and skin causing an inflammatory reaction
  • High risk of infection
Morton neuroma
  • Commonly occurs in runners
  • Mechanism involves a mechanically induced neuropathic degeneration of the interdigital nerves.
  • Patient presents with burning pain and numbness at the third intermetatarsal space.
  • Clicking sensation, tenderness, and crepitus during palpation
Corns and calluses
  • Arise from abnormal pressure over the skin and bony prominences from shoes or foot breakdown
  • Calluses represent a diffuse thickening of the stratum corneum layer.
  • Corns develop similarly, but differ by having a central “core” that is hyperkeratotic and often painful.
Plantar warts
  • Cutaneous manifestation of human papillomavirus type 1
  • Associated with pain, discomfort, or functional impairment
  • Differentiated from corns and calluses by:
    • Absence of skin lines
    • Thrombosed capillaries that appear after scraping the hyperkeratotic surface
Metatarsal stress fractures
  • Insidious onset with history of overuse
  • Patient complains of focal pain in the metatarsal bones
  • Possible negative X-ray in the first 6 weeks
  • Risk factors include:
    • Abrupt increase in intensity of training
    • Poor running mechanics
    • Female with restrictive eating disorder (loss of estrogen resulting in reduced bone mass)
    • Inadequate calcium and vitamin D intake
    • Decreased caloric intake
Midfoot (tarsal bones, arches, and ligaments)Osteoarthritis
  • Most common form of arthritis
  • Slowly progressing joint pain and stiffness (over years)
High-arched feet (pes cavus) and flat feet (pes planus)
  • Epidemiologic studies suggest an increased risk of midfoot pain in individuals with these conditions.
  • Pes planus is normal for infants and young children due to ligamentous laxity.
  • Having pes planus in adulthood may be due to a breakdown in supporting structures (posterior tibialis tendon and spring ligament).
Navicular stress fracture
  • In navicular stress fracture, patients localize the pain to a focal point over the dorsomedial midfoot.
  • Persistent medial arch pain including pain that occurs during sleep is highly suggestive of navicular stress fracture.
Hindfoot (talus + calcaneus)Plantar fasciitis
  • Pain with first steps in the morning or after prolonged sitting
  • Pain is more medially located on the plantar surface.
  • Tenderness is elicited by palpating the fascia from the heel to the forefoot while dorsiflexing the patient’s toes.
Tarsal tunnel syndrome
  • Due to compression of the tibial nerve as it passes through the ankle
  • Usually occurs following fracture of ankle bones
  • Patients develop burning, numbness, and aching of the distal plantar surface of the foot.
  • Pain sometimes radiates up to the calf.
Calcaneal and talar stress fractures
  • Patient presents with persistent heel pain that continues to cause discomfort at night.
  • History of high-intensity activity
Calcaneal apophysitis (Sever’s disease)
  • One of the most common causes of heel pain in children and young adolescents
  • Risk factors include participation in sports or other activities that involve running or jumping.
  • Patient presents with chronic heel pain that is related to activity and has an insidious onset.
  • Heel pain tenderness is elicited by direct palpation over the apophysis or by calcaneal compression test.
  • Diagnosis is made clinically, no radiographs needed since they have low sensitivity and specificity for this condition.

Diagnostic workup:

  • General lab investigations (CBC, erythrocyte sedimentation rate [ESR], C-reactive protein [CRP]) to exclude infectious causes and autoimmune conditions
  • Imaging studies:
    • X-ray looking for fractures
    • Magnetic resonance imaging (MRI) to assess soft tissues
    • Bone scan to evaluate for osteoporosis in elderly patients
Foot pain - Sclerosis and fragmentation of the calcaneal apophysis

X-ray of the foot of an 11-year-old boy, showing sclerosis and fragmentation of the calcaneal apophysis. However, X-rays have poor sensitivity and specificity for Sever’s disease so diagnosis is usually made clinically.

Image: “Sclerosis and fragmentation of the calcaneal apophysis” by Mikael Häggström. License: CC0 1.0

Management

  • Stress fracture:
    • The mainstay of treatment is reducing weight-bearing, then immobilization for 4–6 weeks.
    • Referral to an orthopedic surgeon if there is a fracture at high risk for malunion:
      • Anterior tibial cortex
      • 5th metatarsal
  • Ankle sprain: (RICE [rest, ice, compression, elevation] is the usual prescribed therapy for the first 2-3 days, but there is no good data about its effectiveness as the sole therapy).
    • Early mobilization with a range of motion exercises.
    • Cooling
    • Compression
    • Acetaminophen/nonsteroidal anti-inflammatory drugs (NSAIDs)
    • Consider physiotherapy, particularly for patients at risk of recurrence
  • Morton neuroma:
    • Strength exercises for the intrinsic foot muscles (metatarsal support)
    • Bar or padded shoe inserts to decrease pressure on the metatarsal heads
    • A single injection of a glucocorticoid and local anesthetic if persistent
    • Surgery is usually reserved for patients who fail conservative treatment.
    • Rarely, a neuroma may recur following surgery.
  • Calluses and corns:
    • Application of salicylic acid plasters
    • Patients should be advised to avoid ill-fitting shoes.
  • Plantar warts:
    • Topical salicylic acid and cryotherapy with liquid nitrogen
  • High-arched feet (pes cavus) and flat feet (pes planus):
    • Orthotic devices
    • Shoe modifications
    • Bracing
  • Plantar fasciitis:
    • Stretching exercises for the plantar fascia and calf muscles
    • Avoid the use of flat shoes and barefoot walking.
    • Use arch supports and/or heel cups.
    • Decrease physical activities (e.g., excessive running, dancing, or jumping).
    • Short-term trial (2–3 weeks) of NSAIDs
    • If all previous measures fail, consider injecting the tender areas of the plantar region with glucocorticoids and a local anesthetic.
  • Calcaneal apophysitis (Sever’s disease):
    • Bilateral use of a heel cup or lift
    • Decreased level of participation in painful activities
    • Daily ice packs to the area for 20 minutes along with calf muscle stretching and strengthening
    • NSAIDs as needed against pain during the initial treatment stage

Clinical Relevance

The following are common conditions associated with ankle and foot pain:

  • Ankle joint: also called the talocrural joint, the ankle joint is a true hinge joint formed between the articular surfaces of the distal tibia, distal fibula, and the talus. The ankle joint functions as a hinge joint allowing plantar flexion, dorsiflexion, and a small degree of abduction, adduction, and rotation.
  • Disseminated gonococcal infection: an infection that often occurs in sexually active young patients. It may present with asymmetric polyarthralgia (often but not always associated with tenosynovitis and skin rash) or an isolated septic monoarthritis or oligoarthritis. Diagnosis requires joint aspiration and analysis and is confirmed by Gram stain of the synovial fluid, blood cultures, and genital/pharyngeal nucleic acid amplification tests for Neisseria gonorrhoeae. 
  • Rheumatoid arthritis: a chronic inflammatory systemic disease that progresses in stages. The basis of the disease is an inflammation of the synovial membrane, i.e., the inner layer of the joint capsule. Attributed to synovitis, it can lead to secondary diseases such as arthritis, bursitis, or tenosynovitis.
  • Osteoarthritis: a degenerative disorder of the articular cartilage, along with the subchondral bones and other joint structures. Osteoarthritis is the most common type of joint disease and the leading cause of disability in older adults. The main risk factors for osteoarthritis are a family history of the disease, female gender, past trauma to the involved joint, aging, and obesity.
  • Gout: defined by uric acid precipitation in the tissue (joints, tophi, and kidneys). An acute gout attack represents exacerbated hyperuricemia. A gout attack often occurs at night with monoarthritis. In 90% of cases, the gout attack affects the first metatarsophalangeal joint (podagra). Signs of acute joint gout include reddening, swelling, and extreme contact pain. Fever due to cytokine production and development of systemic inflammation may also be found.
  • Pseudogout: calcium pyrophosphate dihydrate crystals deposition in the periarticular tissues of joints and soft tissue. Pseudogout can induce remarkable damage to the affected joints. Symptoms include pain, swelling, and heat in the affected joint. Diagnosis is made by identification of positively birefringent CPP crystals by compensated polarized light microscopy in the aspirated joint fluid.
  • Anorexia nervosa: an eating disorder marked by self-imposed starvation and inappropriate dietary habits due to a morbid fear of weight gain and disturbed perception of body shape and weight. Patients have strikingly low body weight (BMI < 18.5) and diverse physiological and psychological complications. One of the common complications of anorexia nervosa is stress fractures.

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