#351 Live!  Foot and Ankle Pain with Dr. Joan Ritter

August 22, 2022 | By Paul Williams

Video

The Thrill of Victory and the Agony of the Feet

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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Credits

• Writer and Producer: Paul Williams MD, FACP
• Show Notes and Infographic: Paul WIlliamsMD, FACP
• Hosts: Matthew Watto MD, FACP; Paul Williams MD, FACP   
• Associate Editor: Leah Witt MD
• Showrunner: Matthew Watto MD, FACP
• Technical Production: PodPaste
• Guest: Joan Ritter MD

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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

1. Prior history of ankle injury can predispose to recurrent injury due to impaired proprioception and ligamentous laxity
2. Management of ankle sprains includes PRICE – Protection, Rice, Compression, Elevation
3. Have a low threshold to refer ankle sprains to physical therapy to prevent recurrence
4. The Thompson test should be performed on all patients with Achilles injury to rule out rupture
5. Runners with Achilles injuries should be counseled to stop running until recovered (or at least avoid hills)
6. Steroid injections are typically avoided in Achilles tendon injury
7. The “too many toes sign” can be an indicator of posterior tibial tendon dysfunction
8. Insidious midfoot pain that worsens with weight-bearing is suspicious for navicular or metatarsal stress fracture
9. 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)

Links

1. 100 Poems (book)
2. Everything Everywhere All At Once (Movie)
3. Black Monday (Television show)

Goal

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…  

1. Discuss important relevant anatomy of the foot and ankle
2. Identify and manage common foot and ankle problems in the primary care setting
3. 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.