Don’t fear foot pain! Learn how to evaluate the painful foot and ankle, what needs imaging, and who needs rehab. We are joined by Dr. Joan Ritter (Walter Reed National Military Medical Center) for a special live Curbsiders episode!
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Show Segments
Intro, disclaimer, guest bio
Guest one-liner, Picks of the Week*
Case from Kashlak
Relevant anatomy
Ankle sprains
Achilles tendon rupture and tendonitis
Plantar fasciitis
Posterior tibial tendon dysfunction
Midfoot pain
Morton’s neuroma
Audience questions
Outro
Foot and Ankle Pain Pearls
Prior history of ankle injury can predispose to recurrent injury due to impaired proprioception and ligamentous laxity
Management of ankle sprains includes PRICE – Protection, Rice, Compression, Elevation
Have a low threshold to refer ankle sprains to physical therapy to prevent recurrence
The Thompson test should be performed on all patients with Achilles injury to rule out rupture
Runners with Achilles injuries should be counseled to stop running until recovered (or at least avoid hills)
Steroid injections are typically avoided in Achilles tendon injury
The “too many toes sign” can be an indicator of posterior tibial tendon dysfunction
Insidious midfoot pain that worsens with weight-bearing is suspicious for navicular or metatarsal stress fracture
Morton’s neuroma occurs in the 2nd or 3rd interspace of the toes, and occurs in the setting of wearing shoes with a narrow toe-box
Foot and Ankle Pain – Notes
Ankle pain – sprains
Anatomy
Dr. Ritter breaks the foot and ankle down into the ankle, hindfoot, and midfoot
The ankle is comprised of the fibula, tibia, and talus
Lateral ankle sprain is often caused by inversion of the foot and eversion of the ankle
Potentially disrupted structures include lateral malleolus, anterior talofibular ligament, calcaneofibular ligament, and posterior talofibular ligament
If the mechanism of injury is a fall from a height, fractures of the calcaneus, lateral malleolus, or fifth metatarsal fracture should be considered
Evaluation
Obtaining a history of prior ankle injury is important
Patients with prior injury may have impaired proprioception or ligamentous laxity, predisposing to recurrent injury (Herzog et al 2019)
The physical examination should be done with the shoes and socks removed
Inspection should be done to evaluate for bruising or swelling
Assess the ankle to ensure the foot is neurovascularly intact
Palpation should include the medial and lateral malleolus, midfoot, base of the fifth metatarsal, navicular bone, calcaneus, and length of the Achilles tendon
The squeeze test is compression of the tibia and fibula at the mid-calf to assess for high ankle sprain
Functional assessment includes anterior drawer testing and the talar tilt test
The Ottawa ankle rules can guide whether imaging is necessary–imaging is performed if:
Malleolar tenderness to palpation
Midfoot tenderness to palpation
Inability to bear weight at the time of injury or take four steps upon evaluation
Management
Management of ankle sprains guided by PRICE mnemonic – Protection plus RICE (Ivins 2006)
Protection includes support or assistance for pain-free ambulation
Patients may not require any protection if their pain is minor
They may benefit from lace-up or stirrup splints for more significant pain
More significant pain may require a walking boot for 7-10 days
RICE is Rest, Ice, Compression, and Elevation
Rehab exercises should be done as soon as possible, and include Achilles stretches and tracing the letters of the alphabet with their toes
Maintain a low threshold for referral to formal physical therapy
Dr. Ritter favors nonsteroidals over acetaminophen, if not contraindicated
Consider helping the patient obtain a handicap parking placard, if warranted
Bimalleolar, trimalleolar, and high ankle sprains should be referred to orthopedists
Heel Pain – Achilles tendon rupture and tendonitis
Anatomy
Heel includes calcaneus, Achilles tendon, and subcutaneous and retrocalcaneal bursae
Posterior tibial tendon can also be implicated in more medial pain
Evaluation
Achilles tendon rupture presents with abrupt pain, and is often very dramatic
Heel pain that is worse while wearing shoes may represent retrocalcaneal bursitis or Haglund’s deformity (bony enlargement at the Achilles tendon insertion)
Achilles tendonitis may be more painful with the first steps taken after waking up as the Achilles stretches with dorsiflexion of the foot
Examination includes palpation along the length of the Achilles tendon
Bursae can be palpated laterally and medially to the tendon
The Thompson squeeze test should be performed on all patients with Achilles pain
Excellent sensitivity and specificity for rupture (Maffulli 1998)
The patient lies prone on the exam table with their feet hanging off the edge
The patient’s calf is squeezed, which should cause plantarflexion of the foot
Absence of plantarflexion suggests Achilles tendon rupture
Management
Runners with Achilles tendon injuries should be instructed to stop running, or stop running up hills at a minimum
Have a low threshold for referral to physical therapy, which includes Achilles stretches
A heel lift can alleviate pain in some patients with Achilles tendonitis (Rabusin et al 2019)
Steroid injections in the Achilles can increase the risk of rupture
Heel pain – Plantar fasciitis
Anatomy
Achilles tendon fibers contribute to the plantar fascia
Plantar fasciitis caused by unsupported arch and tightening of the plantar fascia
Evaluation
Patients typically present with plantar pain that is worse in the morning
There may be tenderness to palpation over the plantar fascia
The Windlass test creates direct stretching of the plantar aponeurosis and can replicate plantar fasciitis pain
Imaging is typically not needed for straightforward cases (Motley 2021)
Management
Most plantar fasciitis goes away after about a year
Stretching can be helpful, and the patient can be advised to roll a cold can of soda under the foot, or a frozen water bottle
Wrapping a towel around the foot and pulling the toes towards the head may also help
Heel pain – Posterior tibial tendon dysfunction
Anatomy
Posterior tibial tendon runs around the medial malleolus
Supports the arch of the foot
Evaluation
Classically seen in middle-aged women, being overweight and wearing poorly supportive shoes are additional risk factors
Presents with burning, medial ankle pain that radiates up the leg
Patient may demonstrate the “too many toes sign”
The patient stands barefoot facing away from you
A positive sign is more than 2 ½ toes seen laterally “peeking out” from behind the leg
Management
Conservative management involves activity modification and NSAIDs
More severe cases may be referred for PT, or potentially orthopedic surgery (Yao et al 2015)
Midfoot pain – Stress fractures
Anatomy
Midfoot pain with weight-bearing raises concern for navicular or metatarsal stress fracture
Presents as insidious pain near a bony structure that worsens with exertion
Occurs in the setting of repetitive stress
Evaluation and management
Begin with plain-film imaging if there is concern for a stress fracture
For metatarsal stress fractures, Dr. Ritter may utilize a post-op shoe
She avoids boots, which may immobilize the Achilles and cause more problems
Activity modification is also important, which includes avoiding running while recovering
Navicular fractures are at risk for non-healing, so have a low threshold for cross-sectional imaging with CT and MRI (Monteagudo 2022)
Navicular fractures should also be promptly referred to orthopedic surgery
Forefoot pain – Metatarsalgia
Anatomy
Conditions that can impact the forefoot include avascular necrosis of the head of the metatarsal, osteoarthritis, stress fracture, or Morton’s neuroma
As you age, you lose fat on the plantar aspect of the foot, and are more prone to metatarsalgia
Morton’s neuroma arises from thickening of the tissue around a nerve of the foot
“Neuroma” is actually a misnomer; it’s a compression neuropathy of the interdigital nerve
Generally arises from the foot being forced into footwear with a narrow toe-box, or with hyperextension of the toes in high-heeled shoes
Commonly arises in the second or third interspace of the toes
Evaluation and management
With forefoot pain, Dr. Ritter will typically get AP and lateral plain films of the foot
If these are normal, she will recommend general metatarsalgia treatment
Patients with Morton’s neuroma may describe sensation of walking on a pebble or marble
They may also note tingling or burning-type pain
Supportive treatment for Morton’s neuroma includes wearing shoes with a wider toe-box, use of metatarsal bars, and NSAIDs
Steroid injection or surgical evaluation can be considered for refractory cases (Bahtia and Thomson 2020)
Listeners will develop a framework for the evaluation and management of common foot and ankle complaints that may present in a primary care setting.
Learning objectives
After listening to this episode listeners will…
Discuss important relevant anatomy of the foot and ankle
Identify and manage common foot and ankle problems in the primary care setting
Recognize indications for imaging and referral with foot and ankle pain
Disclosures
Dr. Ritter reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.
Citation
Williams PW, Ritter J, Watto MF. “#351 Foot and Ankle Pain”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list August 22, 2022.
CME Partner
The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit.
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