Foot XRay

Aka: Foot XRay, Foot Radiograph

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II. Indications

  1. Foot XRay is first-line imaging in nearly all cases of Foot Pain

III. Precautions

  1. Serious foot injuries may demonstrate only subtle xray findings
  2. Foot XRay is challenging with many overlapping bony contours and soft tissue shadows
    1. Mach Bands may result in False PositiveFracture diagnoses

IV. Imaging

  1. See Foot Anatomy
  2. Standard Views
    1. Dorsoposterior (DP) or Anteroposterior (AP) View
      1. Medial structures are best visualized
      2. Metatarsal Bones 1-2
      3. Medial and Middle Cuneiforms
      4. Navicular bone
      5. Distal Talus
    2. Lateral View
      1. Metatarsal Bone to tarsal bone alignment
      2. Fifth Metatarsal base
      3. Calcaneus body
    3. Oblique View
      1. Lateral structures are best visualized
        1. Variable efficacy specific to individual patient anatomy (depends on longitudinal arch)
      2. Metatarsal Bones 3-5
      3. Lateral Cuneiform
      4. Distal Calcaneus
  3. Additional views to consider (beyond standard)
    1. Weight bearing (e.g. suspected Lisfranc Fracture)
    2. Canale View (talar neck)
    3. Harris View (Calcaneal Fracture)

V. Evaluation

  1. See Musculoskeletal XRay ABCs (for systematic approach)
  2. Alignment
    1. Dorsoposterior (DP) View
      1. Second Metatarsal medial border should align with middle Cuneiform medial border
    2. Oblique View
      1. Third Metatarsal medial border should align with lateral Cuneiform medial border
      2. Fourth Metatarsal medial border should align with Cuboid medial border
  3. Bones
    1. Start at the bottom of the XRay image (hindfoot, heel) and work upwards (to forefoot, toes)
    2. Trace each bony cortex from distal tibia through Calcaneus, tarsal bones, Metatarsals and phalanges
      1. Distinguish true Fracture lines (that stop at cortex) from Mach Bands (overlapping shadows)
  4. Cartilage (joints)
    1. Joint spacing in the midfoot should be roughly consistent
    2. Look for widening of space (diastasis, >2.7 to 3 mm) between first and second Metatarsal heads (Lisfranc Injury)
  5. Soft Tissue
    1. Radiopaque Foreign Body
    2. Subcutaneous gas

VI. Findings

  1. See Foot Pain
  2. See Foot XRay in Osteoarthritis
  3. Fractures
    1. See Foot Fracture
    2. Stress Fractures
    3. Hindfoot Fracture
      1. Calcaneus Fracture
      2. Talus Fracture
    4. Midfoot Fracture
      1. Lisfranc Fracture Dislocation
      2. Tarsal Navicular Fracture
    5. Forefoot Fracture
      1. Metatarsal Fracture (esp. Fifth Metatarsal Fracture, March Fracture)
      2. Foot Phalanx Fracture
      3. Toe Fracture
      4. Sesamoid Fracture

VII. References

  1. Tubbs and Janicki (2025) Adult Lower Extremity, Mastering Emergency Imaging, CCME, accessed 5/8/2026

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