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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Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

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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 Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain history (localization, quality, time, factors that alleviate/reinforce pain) 
  • Pay attention to alarming symptoms: 
    • Severe pain, fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever, warmness, and skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin redness may indicate septic arthritis Septic arthritis Septic arthritis is an infection of the joint due to direct inoculation, contiguous extension, or hematogenous spread of infectious organisms into the joint space. This process causes an acute, inflammatory, monoarticular arthritis. 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.

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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
Location Condition Features
Lateral aspect Ankle 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 Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures.
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 Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures.
Posterior aspect Achilles 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 Variable Variables represent information about something that can change. The design of the measurement scales, or of the methods for obtaining information, will determine the data gathered and the characteristics of that data. As a result, a variable can be qualitative or quantitative, and may be further classified into subgroups. Types of Variables locations Infectious and inflammatory conditions
  • Acute pain (< 2 weeks):
    • Septic arthritis
    • Cellulitis Cellulitis Cellulitis is a common infection caused by bacteria that affects the dermis and subcutaneous tissue of the skin. It is frequently caused by Staphylococcus aureus and Streptococcus pyogenes. The skin infection presents as an erythematous and edematous area with warmth and tenderness. Cellulitis
    • Acute gouty arthritis
    • Disseminated gonococcal infection
  • Chronic pain (> 2 weeks):
    • Rheumatoid arthritis Rheumatoid arthritis Rheumatoid arthritis (RA) is a symmetric, inflammatory polyarthritis and chronic, progressive, autoimmune disorder. Presentation occurs most commonly in middle-aged women with joint swelling, pain, and morning stiffness (often in the hands). Rheumatoid Arthritis
    • Reactive arthritis Reactive arthritis Reactive arthritis is a seronegative autoimmune spondyloarthropathy that occurs in response to a previous gastrointestinal (GI) or genitourinary (GU) infection. The disease manifests as asymmetric oligoarthritis (particularly of large joints in the lower extremities), enthesopathy, dactylitis, and/or sacroiliitis. Reactive Arthritis
Common causes of foot pain
Location Condition Features
Forefoot (toes + distal metatarsals) Bunions (hallux valgus)
  • Most common cause of forefoot pain
  • Pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of 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 Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the 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 Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of 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 Human papillomavirus Human papillomavirus (HPV) is a nonenveloped, circular, double-stranded DNA virus belonging to the Papillomaviridae family. Humans are the only reservoir, and transmission occurs through close skin-to-skin or sexual contact. Human papillomaviruses infect basal epithelial cells and can affect cell-regulatory proteins to result in cell proliferation. Papillomaviridae: HPV type 1
  • Associated with pain, discomfort, or functional impairment
  • Differentiated from corns and calluses by:
    • Absence of skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin lines
    • Thrombosed capillaries Capillaries Capillaries are the primary structures in the circulatory system that allow the exchange of gas, nutrients, and other materials between the blood and the extracellular fluid (ECF). Capillaries are the smallest of the blood vessels. Because a capillary diameter is so small, only 1 RBC may pass through at a time. 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 Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones mass)
    • Inadequate calcium and vitamin D intake
    • Decreased caloric intake
Midfoot (tarsal bones, arches, and ligaments) Osteoarthritis Osteoarthritis Osteoarthritis (OA) is the most common form of arthritis, and is due to cartilage destruction and changes of the subchondral bone. The risk of developing this disorder increases with age, obesity, and repetitive joint use or trauma. Patients develop gradual joint pain, stiffness lasting < 30 minutes, and decreased range of motion. 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 Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures
  • In navicular stress fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures, patients localize the pain to a focal point over the dorsomedial midfoot.
  • Persistent medial arch pain including pain that occurs during sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep is highly suggestive of navicular stress fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures.
Hindfoot (talus + calcaneus) Plantar fasciitis
  • Pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain with first steps in the morning or after prolonged sitting
  • Pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of 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 Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures of ankle bones
  • Patients develop burning, numbness, and aching of the distal plantar surface of the foot.
  • Pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of 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 Osteoporosis Osteoporosis refers to a decrease in bone mass and density leading to an increased number of fractures. There are 2 forms of osteoporosis: primary, which is commonly postmenopausal or senile; and secondary, which is a manifestation of immobilization, underlying medical disorders, or long-term use of certain medications. 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 X-rays X-rays are high-energy particles of electromagnetic radiation used in the medical field for the generation of anatomical images. X-rays are projected through the body of a patient and onto a film, and this technique is called conventional or projectional radiography. 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 Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures:
    • The mainstay of treatment is reducing weight-bearing, then immobilization for 4–6 weeks.
    • Referral to an orthopedic surgeon if there is a fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures 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 Acetaminophen Acetaminophen is an over-the-counter nonopioid analgesic and antipyretic medication and the most commonly used analgesic worldwide. Despite the widespread use of acetaminophen, its mechanism of action is not entirely understood. 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 Glucocorticoids Glucocorticoids are a class within the corticosteroid family. Glucocorticoids are chemically and functionally similar to endogenous cortisol. There are a wide array of indications, which primarily benefit from the antiinflammatory and immunosuppressive effects of this class of drugs. 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 Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the 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 Neisseria Neisseria is a genus of bacteria commonly present on mucosal surfaces. Several species exist, but only 2 are pathogenic to humans: N. gonorrhoeae and N. meningitidis. Neisseria species are non-motile, gram-negative diplococci most commonly isolated on modified Thayer-Martin (MTM) agar. Neisseria gonorrhoeae. 
  • Rheumatoid arthritis Rheumatoid arthritis Rheumatoid arthritis (RA) is a symmetric, inflammatory polyarthritis and chronic, progressive, autoimmune disorder. Presentation occurs most commonly in middle-aged women with joint swelling, pain, and morning stiffness (often in the hands). Rheumatoid Arthritis: a chronic inflammatory systemic disease that progresses in stages. The basis of the disease is an inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. 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 Osteoarthritis Osteoarthritis (OA) is the most common form of arthritis, and is due to cartilage destruction and changes of the subchondral bone. The risk of developing this disorder increases with age, obesity, and repetitive joint use or trauma. Patients develop gradual joint pain, stiffness lasting < 30 minutes, and decreased range of motion. Osteoarthritis: a degenerative disorder of the articular cartilage Cartilage Cartilage is a type of connective tissue derived from embryonic mesenchyme that is responsible for structural support, resilience, and the smoothness of physical actions. Perichondrium (connective tissue membrane surrounding cartilage) compensates for the absence of vasculature in cartilage by providing nutrition and support. Cartilage, along with the subchondral bones and other joint structures. Osteoarthritis Osteoarthritis Osteoarthritis (OA) is the most common form of arthritis, and is due to cartilage destruction and changes of the subchondral bone. The risk of developing this disorder increases with age, obesity, and repetitive joint use or trauma. Patients develop gradual joint pain, stiffness lasting < 30 minutes, and decreased range of motion. 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 Obesity Obesity is a condition associated with excess body weight, specifically with the deposition of excessive adipose tissue. Obesity is considered a global epidemic. Major influences come from the western diet and sedentary lifestyles, but the exact mechanisms likely include a mixture of genetic and environmental factors. Obesity.
  • Gout Gout Gout is a heterogeneous metabolic disease associated with elevated serum uric acid levels (> 6.8 mg/dL) and abnormal deposits of monosodium urate in tissues. The condition is often familial and is initially characterized by painful, recurring, and usually monoarticular acute arthritis, or "gout flare," followed later by chronic deforming arthritis. Gout: defined by uric acid precipitation in the tissue (joints, tophi, and kidneys Kidneys The kidneys are a pair of bean-shaped organs located retroperitoneally against the posterior wall of the abdomen on either side of the spine. As part of the urinary tract, the kidneys are responsible for blood filtration and excretion of water-soluble waste in the urine. 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 Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. 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 Anorexia Nervosa Anorexia nervosa is 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 BMI and diverse physiological and psychological complications. 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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