Foot Pain

Aka: Foot Pain

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II. History

  1. Mechanism of foot injury
  2. Pain location (as well as timing and character)
  3. Associated swelling or Ecchymosis
  4. Neurologic symptoms (foot weakness, Paresthesias)
  5. Provocative activities
  6. Prior foot injury or surgery
  7. Inability to bear weight on affected foot

III. Exam

  1. Compare with opposite, unaffected foot
  2. Inspection
    1. Deformity
    2. Ecchymosis
    3. Focal soft tissue swelling
    4. Skin Discoloration
    5. Wounds (e.g. Lacerations or scars)
  3. Palpation over bony landmarks
    1. Proximal fifth Metatarsal
    2. Tarsal Navicular Bone
    3. Joint margins (interphalangeal joints and lis franc joint)
  4. Function
    1. Active and passive foot range of motion
  5. Neurologic Exam
    1. Muscle Strength against resistance
      1. Plantar flexion and dorsiflexion
      2. Foot Inversion and eversion
    2. Sensation
      1. orthoLegFootPlantarNeuroSegmentalGrayBB834.gif Lewis (1918) Gray's Anatomy 20th ed (in public domain at Yahoo or BartleBy)
  6. Vascular Exam
    1. Dorsalis pedis pulse
    2. Posterior Tibial pulse
    3. Capillary Refill

IV. Causes: Acute Foot Pain

  1. Soft Tissue Injuries
    1. First Metatarsophalangeal Joint Sprain (Turf Toe)
    2. Foot Blister
  2. Fractures
    1. See Foot Fracture
    2. Stress Fractures (see below, under chronic Foot Pain causes)
    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)
      2. Foot Phalanx Fracture
      3. Toe Fracture
      4. Sesamoid Fracture

V. Causes: Chronic Foot Pain

  1. See Foot Associated Rheumatologic Conditions
  2. Common causes
    1. Foot Arthritis
    2. Hallux Rigidus
    3. Hallux Valgus (Bunion)
    4. Morton's Neuroma
    5. Plantar Fasciitis
    6. Lisfranc Fracture Dislocation
    7. Stress Fracture
      1. Metatarsal Stress Fracture
      2. Calcaneus Stress Fracture
      3. Tarsal Navicular Stress Fracture
  3. Uncommon causes
    1. Accessory Bone Pain
    2. Reflex Sympathetic Dystrophy
    3. Tarsal Tunnel
    4. Metatarsalgia
    5. Peroneal Tendinopathy (lateral ankle and foot)
    6. Posterior Tibial Tendinopathy (medial ankle and foot)
    7. Insertional Achilles Tendinopathy (posterior heel)
    8. Flexor Hallucis Longus Tendinopathy (great toe)
  4. Rare causes
    1. Avascular Necrosis of the Metatarsal Head (Freiberg's Disease)
    2. Tarsal Coalition

VI. Imaging

  1. XRay Indications (Anteroposterior, Lateral and Oblique views)
    1. See Foot Fracture
    2. See Foot XRay in Osteoarthritis
    3. Foot XRay is first-line imaging in nearly all cases of Foot Pain
    4. Ottawa Ankle Rule may be used to direct imaging in Ankle Sprain
      1. However, protocol does not apply to direct foot Trauma
    5. Additional views to consider (beyond standard anteroposterior, lateral and oblique views)
      1. Weight bearing (e.g. suspected Lisfranc Fracture)
      2. Canale View (talar neck)
      3. Harris View (Calcaneal Fracture)
  2. CT Indications (when XRay is not diagnostic)
    1. Subtle Fractures (esp. midfoot)
    2. Stress Fracture (follow-up to demonstrate healing)
    3. Tarsal Coalition
  3. MRI Indications (when XRay is not diagnostic)
    1. Morton's Neuroma (minimum of 5 mm lesion and corresponding clinical findings)
    2. Accessory Bone Pain
    3. Plantar Fasciitis
    4. Stress Fracture
    5. Tarsal Tunnel Syndrome
  4. Ultrasound (when XRay is not diagnostic, operator dependent)
    1. Morton's Neuroma
    2. Plantar Fasciitis
    3. Tarsal Tunnel Syndrome
  5. Bone scan Indications (when XRay is not diagnostic)
    1. Reflex Sympathetic Dystrophy

VII. References

  1. Feden and Kiel (2017) Crit Dec Emerg Med 31(11): 3-10
  2. Ahn (2007) Am Fam Physician 76(7):975-83 [PubMed]

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