Ankle/Foot Pain
Differential Overview
Ankle Pain
❑ Ankle sprain
❑ Fibular fracture
❑ Achilles tendinitis
❑ Acute gout
Foot Pain
❑ Plantar fasciitis
❑ Acute gout
❑ Hallux valgus (bunion)
❑ Sciatica
❑ Metatarsalgia
❑ Metatarsal stress fracture
❑ Tibialis anterior tendinitis
❑ Pes planus
❑ Calcaneal fracture
❑ Interdigital neuroma
❑ Posterior tibial nerve entrapment
❑ Compartment syndrome
Diagnostic Approach
In acute ankle injury, ability to bear weight for four steps and absence of bone tenderness at the posterior edge or the tip of either malleolus rule out a significant fracture (Ottawa ankle rule).
In acute foot injury, ability to bear weight for four steps and absence of bone tenderness at the navicular or the base of the fifth metatarsal rule out a significant midfoot fracture (Ottawa foot rule).
Clinical Findings
Ankle sprain Inversion injury is most common, stretching the calcaneofibular or anterior talofibular ligament, with pain, swelling, and exquisite tenderness over the anterolateral ankle. The anterior drawer sign is helpful in determining stability (and degree of injury), with an anterior shift of the foot on the tibia of greater than or equal to 4 mm being abnormal. The medial deltoid ligament is unlikely to be torn unless there is a fibular fracture with subluxation of the ankle joint. Comparison with the uninjured foot is helpful.
Fibular fracture Following trauma, the distal fibula is exquisitely tender, swollen, and ecchymotic. The patient may be able to bear weight despite the fracture.
Achilles tendinitis The patient presents with a tender Achilles tendon with a fusiform swelling. A common cause is athletic overuse, but it is also seen in spondyloarthropathy, rheumatoid arthritis, and familial hypercholesterolemia. With overuse, the inflammation is maximal at 2 to 6 cm from the insertion; with spondyloarthropathy, it is maximal at the insertion itself. Tendon rupture will be sudden, marked by inability to rise onto the toes, with a palpable gap in the tendon. Posterior calcaneal bursitis, arising from rubbing against the heel of the shoe, can simulate this.
Acute gout Classically, it presents as podagra (acute painful swelling, dusky redness, and exquisite tenderness of the metatarsophalangeal joint of the great toe) or unilateral ankle inflammation without a history of trauma.
Plantar fasciitis The pain is greatest with weight bearing after a period of inactivity. The medial plantar aspect of the foot (distal to the calcaneus) is tender, and pain is increased by forced dorsiflexion of the toes. It occurs more often in patients with flat feet or obesity.
Hallux valgus (bunion) A tender bursa is found over the prominence formed by lateral drift of the first metatarsal head. The arch flattens when the patient stands.
Sciatica The L4 dermatome projects to the instep, the L5 to the dorsal foot, and S1 to the heel and lateral foot. The pain is usually dysesthetic (numb or burning). There will be no palpable tenderness or swelling at the site of pain. Knee (L4) or ankle (S1) reflexes may be decreased or absent.
Metatarsalgia Pain occurs over the mid-metatarsal heads with weight bearing. There is often a callus formed over a prominent metatarsophalangeal joint, and the plantar foot is tender to pressure. Common causes include a high arch or use of high-heeled shoes.
Metatarsal stress fracture Pain and tenderness develop over the midshaft of the second or third metatarsal. This is a common injury in runners.
Tibialis anterior tendinitis Pain with exquisite point tenderness occurs at the tendon insertion onto the lateral foot and is increased with foot eversion. There is often a bulbous swelling along the tendon.
Pes planus Flat feet may produce pain in the instep after prolonged standing or walking. Signs include an absent longitudinal arch, valgus heel deviation, and a prominent navicular.
Calcaneal fracture A patient jumps or falls from a height, landing squarely on the heels. Prominent heel pain follows.
Interdigital neuroma Symptoms are burning pain and cramping of the third and fourth toes, which are relieved by rubbing the forefoot. Compressing the forefoot and pushing up in the third intermetatarsal space produces a palpable click with reproduction of the patient’s symptoms. Tenderness is maximal between the metatarsals, and a nodule may be felt.
Posterior tibial nerve entrapment Entrapment of the nerve in the tarsal tunnel produces burning and numbness from the medial malleolus, via the sole, into the toes. Risk factors include valgus heel deviation and ankle fracture. There may be a Tinel sign at the ankle.
Compartment syndrome Pain and paresthesias radiate into the foot. Compartment syndrome should be suspected in the presence of acute trauma, surgery, or ischemia to the lower leg. Anterior compartment pain is elicited on passive flexion of the toes, and there is weakness in the foot.
Pictures
Book Source Details
- Book Title: Field Guide to Bedside Diagnosis
- Author(s): David S. Smith
- Year of Publication: 2007
- Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.
Other Book Chapters Related to Foot symptoms
Read excerpts from these other book chapters related to Foot symptoms:
Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2008 Williams & Wilkins.
More About Causes of Foot symptoms
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More About This Book:
Title: Field Guide to Bedside Diagnosis
Authors: David S. Smith
Publisher: Lippincott Williams & Wilkins
Copyright: 2007
ISBN: 0-78178-165-5
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