Musculoskeletal problems of the foot

# Overview
Foot and ankle pain is a very common condition.  Anomalies range from osteoarthritis, ligamentous strain , nerve entrapment and peripheral neuropathy , to mechanical and postural induced abnormalities.  Most cases respond to conservative care including physical therapy, orthotics, local injection and percutaneous tenotomy .  In more recalcitrant cases surgical intervention is required.

# Associated Conditions
It is not at all uncommon for someone to present with foot or ankle pain even when the primary problem is coming from nerve root irritation in the back , venous reflux  or peripheral arterial disease . It is therefor important to keep in mind that not all foot and ankle problems arise from the foot or ankle itself.  If pain persists beyond a few weeks, it is wise to get a doctors opinion.

# History and Symptoms
The history of present illness (the facts that surround the onset of pain) and the symptoms associated with the chief complaint, can provide valuable clues as to its source.  Examples of several conditions are listed below.

## Acute Traumatic Injury
- Fracture of Proximal Phalanx of Great Toe
Usually via direct trauma or toe-stubbing injury
Usually minimal displacement; can by treated conservatively
- Usually via direct trauma or toe-stubbing injury
- Usually minimal displacement; can by treated conservatively
- Fracture of Metatarsals 1-4
Usually via direct blow to top of foot
Midfoot pain, inability to bear weight, direct tenderness
Nondisplaced
Can be treated conservatively
Displaced
Require surgical reduction
- Usually via direct blow to top of foot
- Midfoot pain, inability to bear weight, direct tenderness
- Nondisplaced
Can be treated conservatively
- Can be treated conservatively
- Displaced
Require surgical reduction
- Require surgical reduction
- Fracture of 5th Metatarsal (MT)
Dancers Fracture
Severe inversion injury--avulsion of bone from proximal metatarsal
Occurs at site of peroneus brevis insertion
Can be treated conservatively (immobilization)
Jones Fracture
Fracture of proximal tuberosity of base of metatarsal
Transverse fracture of shaft
Can be managed conservatively, but high rate nonunion
- Dancers Fracture
Severe inversion injury--avulsion of bone from proximal metatarsal
Occurs at site of peroneus brevis insertion
Can be treated conservatively (immobilization)
- Severe inversion injury--avulsion of bone from proximal metatarsal
- Occurs at site of peroneus brevis insertion
- Can be treated conservatively (immobilization)
- Jones Fracture
Fracture of proximal tuberosity of base of metatarsal
- Fracture of proximal tuberosity of base of metatarsal
- Transverse fracture of shaft
Can be managed conservatively, but high rate nonunion
- Can be managed conservatively, but high rate nonunion
- Calcaneal Fracture
Most commonly fractured tarsal bone
Usually via vertical falls or twisting injuries
Intra-articular Fractures
All require orthopedics referral; unpredictable healing
May be complicated by chronic joint pain, arthritis, nerve entrapment
Extra-articular Fractures
Most can be treated without surgery
Ortho referral for displaced posterior process fractures (Achilles disruption)
Ortho referral for nonunion of anterior process fracture
- Most commonly fractured tarsal bone
- Usually via vertical falls or twisting injuries
- Intra-articular Fractures
All require orthopedics referral; unpredictable healing
May be complicated by chronic joint pain, arthritis, nerve entrapment
- All require orthopedics referral; unpredictable healing
- May be complicated by chronic joint pain, arthritis, nerve entrapment
- Extra-articular Fractures
Most can be treated without surgery
Ortho referral for displaced posterior process fractures (Achilles disruption)
Ortho referral for nonunion of anterior process fracture
- Most can be treated without surgery
- Ortho referral for displaced posterior process fractures (Achilles disruption)
- Ortho referral for nonunion of anterior process fracture

## Nontraumatic
- Great toe
Hallux valgus (bunion)
Metatarso-phalangeal osteoarthritis (MTP OA)--painful swelling of dorsomedial aspect of 1st metatarsal head
Hallux valgus deformity associated (toe angulates laterally)
Hyperpronation (flat feet) and poor footwear contribute
Arthritic flares or bursitis can occur with ongoing pressure at medial joint line
Adventitial bursitis
Inflammation of bursal sac over medial 1st MTP joint due to friction/pressure
Dramatic erythema, edema and tenderness
Gout (podagra):
Dramatic inflammatory response to monosodium urate (MSU) crystal deposition
Can also affect tenosynovial sheaths (enthesitis) and other small joints of foot
Sesamoid disorders
Two sesamoids (medial and lateral) articulate on plantar aspect of 1st metatarsal (MT)
Inflammation or fracture can occur with chronic stress (runners, dancers)
Localized pain and swelling at plantar aspect of 1st
- Hallux valgus (bunion)
Metatarso-phalangeal osteoarthritis (MTP OA)--painful swelling of dorsomedial aspect of 1st metatarsal head
Hallux valgus deformity associated (toe angulates laterally)
Hyperpronation (flat feet) and poor footwear contribute
Arthritic flares or bursitis can occur with ongoing pressure at medial joint line
- Metatarso-phalangeal osteoarthritis (MTP OA)--painful swelling of dorsomedial aspect of 1st metatarsal head
- Hallux valgus deformity associated (toe angulates laterally)
- Hyperpronation (flat feet) and poor footwear contribute
- Arthritic flares or bursitis can occur with ongoing pressure at medial joint line
- Adventitial bursitis
Inflammation of bursal sac over medial 1st MTP joint due to friction/pressure
Dramatic erythema, edema and tenderness
- Inflammation of bursal sac over medial 1st MTP joint due to friction/pressure
- Dramatic erythema, edema and tenderness
- Gout (podagra):
Dramatic inflammatory response to monosodium urate (MSU) crystal deposition
Can also affect tenosynovial sheaths (enthesitis) and other small joints of foot
- Dramatic inflammatory response to monosodium urate (MSU) crystal deposition
- Can also affect tenosynovial sheaths (enthesitis) and other small joints of foot
- Sesamoid disorders
Two sesamoids (medial and lateral) articulate on plantar aspect of 1st metatarsal (MT)
Inflammation or fracture can occur with chronic stress (runners, dancers)
Localized pain and swelling at plantar aspect of 1st
- Two sesamoids (medial and lateral) articulate on plantar aspect of 1st metatarsal (MT)
- Inflammation or fracture can occur with chronic stress (runners, dancers)
- Localized pain and swelling at plantar aspect of 1st
- Forefoot
Metatarsalgia
Pain at any of the 2nd-5th metatarsal heads with weight-bearing
Can be related to inflammatory deformity with subluxation of MT head (right anterior)
Mortons neuroma
Chronic irritation of digital nerve running between metatarsal heads
Most commonly occurs between 3rd and 4th toes
Burning pain btwn toes; cramping; numbness along sides of 2 adjacent toes
Typically associated with poorly padded shoes, improves with forefoot massage
Metatarsal stress fracture
Microfracture of metatarsal after prolonged walking/standing (march fracture)
Usually 2nd or 3rd metatarsal
Sudden onset of pain, often without history of trauma
Military recruits, athletes, osteoporotic patients at risk
- Metatarsalgia
Pain at any of the 2nd-5th metatarsal heads with weight-bearing
Can be related to inflammatory deformity with subluxation of MT head (right anterior)
- Pain at any of the 2nd-5th metatarsal heads with weight-bearing
- Can be related to inflammatory deformity with subluxation of MT head (right anterior)
- Mortons neuroma
Chronic irritation of digital nerve running between metatarsal heads
Most commonly occurs between 3rd and 4th toes
Burning pain btwn toes; cramping; numbness along sides of 2 adjacent toes
Typically associated with poorly padded shoes, improves with forefoot massage
- Chronic irritation of digital nerve running between metatarsal heads
- Most commonly occurs between 3rd and 4th toes
- Burning pain btwn toes; cramping; numbness along sides of 2 adjacent toes
- Typically associated with poorly padded shoes, improves with forefoot massage
- Metatarsal stress fracture
Microfracture of metatarsal after prolonged walking/standing (march fracture)
Usually 2nd or 3rd metatarsal
Sudden onset of pain, often without history of trauma
Military recruits, athletes, osteoporotic patients at risk
- Microfracture of metatarsal after prolonged walking/standing (march fracture)
- Usually 2nd or 3rd metatarsal
- Sudden onset of pain, often without history of trauma
- Military recruits, athletes, osteoporotic patients at risk
- Hindfoot  Plantar Region
Plantar fasciitis
One of most common causes adult foot pain
Heel pain worse with initiation of walking/standing after inactivity
Results from strain of plantar fascia after jumping, prolonged standing
Predisposing factors
Obesity
Flat feet (pes planus) or high arches (pes cavus)
Excessive pronation
Short Achilles tendons
Can be an inflammatory process associated with systemic disease (rheumatoid arthritis (RA), Reiters)
Calcaneal spurs may coexist or develop due to inflammation (but usually asymptomatic)
Infracalcaneal bursitis
Inflammation of bursa beneath calcaneus
Pain/ache in mid-plantar aspect of calcaneus
Symptoms increase with duration of weight-bearing
Calcaneal periostitis
Bilateral pain along plantar and lateral aspects of heels
Can be due to trauma
Can be due to inflammatory disease (RA, psoriatic arthritis, ankylosing spondylitis, Reiters)
May improve with treatment of underlying disease process
Calcaneal spurs
Bony outgrowths that develop on plantar tuberosity
Usually asymptomatic
Pain can occur if large (>1 cm) with apex angled downward--pain with weight-bearing
Heel pad syndrome
Irritation of fat pad due to trauma
Pain localized to heel pad; plantar fascia not tender
Most commonly in marathon runners
Self-limited, resolves within 2-3 weeks
Tarsal tunnel syndrome
Posterior tibial nerve compressed in tarsal tunnel
(Beneath flexor retinaculum inferoposterior to medial malleolus)
Can occur via local trauma (sprain, fracture), repetitive hyperpronation
Also via inflammatory disease (RA), bony prominences, pregnancy, hypoT4
Paresthesias, plantar pain (medial/lateral plantar nerve distribution)
Symptoms often nocturnal or after standing, relieved by foot/ankle movement
Referred pain (subtalar arthritis, lumbosacral (LS) radiculopathy)
Treat the underlying condition
For example, see , , 
- Plantar fasciitis
One of most common causes adult foot pain
Heel pain worse with initiation of walking/standing after inactivity
Results from strain of plantar fascia after jumping, prolonged standing
Predisposing factors
Obesity
Flat feet (pes planus) or high arches (pes cavus)
Excessive pronation
Short Achilles tendons
Can be an inflammatory process associated with systemic disease (rheumatoid arthritis (RA), Reiters)
Calcaneal spurs may coexist or develop due to inflammation (but usually asymptomatic)
- One of most common causes adult foot pain
- Heel pain worse with initiation of walking/standing after inactivity
- Results from strain of plantar fascia after jumping, prolonged standing
- Predisposing factors
Obesity
Flat feet (pes planus) or high arches (pes cavus)
Excessive pronation
Short Achilles tendons
- Obesity
- Flat feet (pes planus) or high arches (pes cavus)
- Excessive pronation
- Short Achilles tendons
- Can be an inflammatory process associated with systemic disease (rheumatoid arthritis (RA), Reiters)
- Calcaneal spurs may coexist or develop due to inflammation (but usually asymptomatic)
- Infracalcaneal bursitis
Inflammation of bursa beneath calcaneus
Pain/ache in mid-plantar aspect of calcaneus
Symptoms increase with duration of weight-bearing
- Inflammation of bursa beneath calcaneus
- Pain/ache in mid-plantar aspect of calcaneus
- Symptoms increase with duration of weight-bearing
- Calcaneal periostitis
Bilateral pain along plantar and lateral aspects of heels
Can be due to trauma
Can be due to inflammatory disease (RA, psoriatic arthritis, ankylosing spondylitis, Reiters)
May improve with treatment of underlying disease process
- Bilateral pain along plantar and lateral aspects of heels
- Can be due to trauma
- Can be due to inflammatory disease (RA, psoriatic arthritis, ankylosing spondylitis, Reiters)
- May improve with treatment of underlying disease process
- Calcaneal spurs
Bony outgrowths that develop on plantar tuberosity
Usually asymptomatic
Pain can occur if large (>1 cm) with apex angled downward--pain with weight-bearing
- Bony outgrowths that develop on plantar tuberosity
- Usually asymptomatic
- Pain can occur if large (>1 cm) with apex angled downward--pain with weight-bearing
- Heel pad syndrome
Irritation of fat pad due to trauma
Pain localized to heel pad; plantar fascia not tender
Most commonly in marathon runners
Self-limited, resolves within 2-3 weeks
- Irritation of fat pad due to trauma
- Pain localized to heel pad; plantar fascia not tender
- Most commonly in marathon runners
- Self-limited, resolves within 2-3 weeks
- Tarsal tunnel syndrome
Posterior tibial nerve compressed in tarsal tunnel
(Beneath flexor retinaculum inferoposterior to medial malleolus)
Can occur via local trauma (sprain, fracture), repetitive hyperpronation
Also via inflammatory disease (RA), bony prominences, pregnancy, hypoT4
Paresthesias, plantar pain (medial/lateral plantar nerve distribution)
Symptoms often nocturnal or after standing, relieved by foot/ankle movement
- Posterior tibial nerve compressed in tarsal tunnel
(Beneath flexor retinaculum inferoposterior to medial malleolus)
- (Beneath flexor retinaculum inferoposterior to medial malleolus)
- Can occur via local trauma (sprain, fracture), repetitive hyperpronation
- Also via inflammatory disease (RA), bony prominences, pregnancy, hypoT4
- Paresthesias, plantar pain (medial/lateral plantar nerve distribution)
- Symptoms often nocturnal or after standing, relieved by foot/ankle movement
- Referred pain (subtalar arthritis, lumbosacral (LS) radiculopathy)
Treat the underlying condition
For example, see , , 
- Treat the underlying condition
- For example, see , , 
- Ligament Strain
Pain anywhere that ligament connects bone to bone
May be associated with swelling and skin color changes
Often due to an inciting event (such as a turned or twisted ankle)
May also be due to normal wear and tear or other forgotten injury
- Ligament Strain
Pain anywhere that ligament connects bone to bone
May be associated with swelling and skin color changes
Often due to an inciting event (such as a turned or twisted ankle)
May also be due to normal wear and tear or other forgotten injury
- Pain anywhere that ligament connects bone to bone
- May be associated with swelling and skin color changes
- Often due to an inciting event (such as a turned or twisted ankle)
- May also be due to normal wear and tear or other forgotten injury
- Hindfoot  Posterior Region
Achilles tendinitis
Inflammation and microtears near Achilles tendon insertion
Often associated with repetitive irritation (athletes)
Bilateral involvement (in absence of quinolone) suggests Reiters or spondylitis
Pain behind ankle with walking, standing, weight-bearing athletic activities
Pain worse with activity--later stiffness and swelling
Untreated cases--acute rupture (up to 10%) or chronic tendinitis
Achilles tendon rupture
Occurs after abrupt calf muscle contraction
Typically occurs in patients > 30 years old with sporadic athletic activity
Also associated with fluoroquinolone use
Audible snap followed by severe pain in calf
Partial rupture can occur without precipitating event
Posterior tibial tenosynovitis
Inflammation of tendon as it passes around the medial malleolus
Exacerbants = ankle pronation, pes planus, obesity
Can be associated w/tarsal tunnel syndrome, especially if significant pronation
Pain and swelling at inner aspect of ankle, worse wtih walking
Retrocalcaneal bursitis
Inflammation of bursa between Achilles tendon and calcaneus
Uncommon
Pain behind ankle, increased with walking (plantar flexion)
Pre-Achilles bursitis
Inflammation of bursa between Achilles tendon (calcaneal insertion) and skin
May resemble Achilles tendinitis, but less disabling; no significant risk tendon rupture
Pain and localized swelling behind the heel
Aggravated/caused by inappropriate shoes
Ligament Strain
Pain anywhere that ligament connects bone to bone
May be associated with swelling and skin color changes
Often due to an inciting event (such as a turned or twisted ankle)
May also be due to normal wear and tear or other forgotten injury
- Achilles tendinitis
Inflammation and microtears near Achilles tendon insertion
Often associated with repetitive irritation (athletes)
Bilateral involvement (in absence of quinolone) suggests Reiters or spondylitis
Pain behind ankle with walking, standing, weight-bearing athletic activities
Pain worse with activity--later stiffness and swelling
Untreated cases--acute rupture (up to 10%) or chronic tendinitis
- Inflammation and microtears near Achilles tendon insertion
- Often associated with repetitive irritation (athletes)
- Bilateral involvement (in absence of quinolone) suggests Reiters or spondylitis
- Pain behind ankle with walking, standing, weight-bearing athletic activities
- Pain worse with activity--later stiffness and swelling
- Untreated cases--acute rupture (up to 10%) or chronic tendinitis
- Achilles tendon rupture
Occurs after abrupt calf muscle contraction
Typically occurs in patients > 30 years old with sporadic athletic activity
Also associated with fluoroquinolone use
Audible snap followed by severe pain in calf
Partial rupture can occur without precipitating event
- Occurs after abrupt calf muscle contraction
- Typically occurs in patients > 30 years old with sporadic athletic activity
- Also associated with fluoroquinolone use
- Audible snap followed by severe pain in calf
- Partial rupture can occur without precipitating event
- Posterior tibial tenosynovitis
Inflammation of tendon as it passes around the medial malleolus
Exacerbants = ankle pronation, pes planus, obesity
Can be associated w/tarsal tunnel syndrome, especially if significant pronation
Pain and swelling at inner aspect of ankle, worse wtih walking
- Inflammation of tendon as it passes around the medial malleolus
- Exacerbants = ankle pronation, pes planus, obesity
- Can be associated w/tarsal tunnel syndrome, especially if significant pronation
- Pain and swelling at inner aspect of ankle, worse wtih walking
- Retrocalcaneal bursitis
Inflammation of bursa between Achilles tendon and calcaneus
Uncommon
Pain behind ankle, increased with walking (plantar flexion)
- Inflammation of bursa between Achilles tendon and calcaneus
- Uncommon
- Pain behind ankle, increased with walking (plantar flexion)
- Pre-Achilles bursitis
Inflammation of bursa between Achilles tendon (calcaneal insertion) and skin
May resemble Achilles tendinitis, but less disabling; no significant risk tendon rupture
Pain and localized swelling behind the heel
Aggravated/caused by inappropriate shoes
- Inflammation of bursa between Achilles tendon (calcaneal insertion) and skin
- May resemble Achilles tendinitis, but less disabling; no significant risk tendon rupture
- Pain and localized swelling behind the heel
- Aggravated/caused by inappropriate shoes
- Ligament Strain
Pain anywhere that ligament connects bone to bone
May be associated with swelling and skin color changes
Often due to an inciting event (such as a turned or twisted ankle)
May also be due to normal wear and tear or other forgotten injury
- Pain anywhere that ligament connects bone to bone
- May be associated with swelling and skin color changes
- Often due to an inciting event (such as a turned or twisted ankle)
- May also be due to normal wear and tear or other forgotten injury

# Presentation and Physical Exam

## 1st MTP Joint Conditions
- Hallux Valgus
Valgus deformity of MTP joint
Prominent metatarsal head, toe points laterally
First and second toe may overlap if advanced
Tenderness along medial joint line (or over whole joint if acute flare)
Joint enlargement due to subluxation, osteophytes, edema
Crepitation with passive movement of MTP joint
+/- Pain at extremes of passive plantar/dorsiflexion of toe
+/- Limited range of motion (ROM) (hallux rigidus)
- Valgus deformity of MTP joint
Prominent metatarsal head, toe points laterally
First and second toe may overlap if advanced
- Prominent metatarsal head, toe points laterally
- First and second toe may overlap if advanced
- Tenderness along medial joint line (or over whole joint if acute flare)
- Joint enlargement due to subluxation, osteophytes, edema
- Crepitation with passive movement of MTP joint
- +/- Pain at extremes of passive plantar/dorsiflexion of toe
- +/- Limited range of motion (ROM) (hallux rigidus)
- Adventitial Bursitis of 1st MTP
Erythema, swelling over medial aspect of MTP joint (focal area vs. full joint involvement with gout)
Maximal tenderness over medial joint line
Associated with hallux valgus deformity (increased friction with shoes) +/- resultant loss of ROM
Mild pain with MTP flexion/extension (vs. gout with severe pain)
Isometric toe flexion/extension against resistance painless (tendons spared)
- Erythema, swelling over medial aspect of MTP joint (focal area vs. full joint involvement with gout)
- Maximal tenderness over medial joint line
- Associated with hallux valgus deformity (increased friction with shoes) +/- resultant loss of ROM
- Mild pain with MTP flexion/extension (vs. gout with severe pain)
- Isometric toe flexion/extension against resistance painless (tendons spared)
- Gout
Significant erythema, swelling and exquisite tenderness involving entire joint
Severe pain with MTP flexion/extension
- Significant erythema, swelling and exquisite tenderness involving entire joint
- Severe pain with MTP flexion/extension
- Sesamoiditis or Fracture
Localized tenderness/swelling on plantar palpation of MTP
- Localized tenderness/swelling on plantar palpation of MTP

## Lesser MTP Forefoot Conditions
- Metatarsalgia
Maximal tenderness at the MTP heads
Plantar protrusion of metatarsal head(s) may be visible with patient lying prone
Callus often present beneath involved metatarsal(s)
Adjacent metatarsals may be hypermobile (shifting weight to involved metatarsal)
- Maximal tenderness at the MTP heads
- Plantar protrusion of metatarsal head(s) may be visible with patient lying prone
- Callus often present beneath involved metatarsal(s)
- Adjacent metatarsals may be hypermobile (shifting weight to involved metatarsal)
- Mortons Neuroma
Tenderness greatest in web space between MTP heads (vs. at MTP heads in metatarsalgia)
Pain reproduced by squeezing MTP heads from sides (electric pain to ends of adjacent 2 toes)
Click may be felt with squeeze + deep palpation in distal intermetatarsal space (Mulders sign)
Passive ROM of MTP joints painless
+/- Loss of sensation along inner aspects of 2 adjacent toes (advanced cases)
- Tenderness greatest in web space between MTP heads (vs. at MTP heads in metatarsalgia)
- Pain reproduced by squeezing MTP heads from sides (electric pain to ends of adjacent 2 toes)
- Click may be felt with squeeze + deep palpation in distal intermetatarsal space (Mulders sign)
- Passive ROM of MTP joints painless
- +/- Loss of sensation along inner aspects of 2 adjacent toes (advanced cases)
- Metatarsal Stress Fracture
Localized tenderness over metatarsal shaft
Dramatic dorsal foot swelling
Pain when metatarsals squeezed from the sides
- Localized tenderness over metatarsal shaft
- Dramatic dorsal foot swelling
- Pain when metatarsals squeezed from the sides

## Hindfoot (Plantar) Conditions
- Plantar Fasciitis
Focal point tenderness at the calcaneal origin of the plantar fascia  pain can be increased by toe dorsiflexion (stretch fascia) during palpation of medial plantar surface ~1.5 distal to posterior heel
Medial-to-lateral compression of calcaneus usually less painful than local fascial tenderness (if compression more painful, must rule out calcaneal stress fracture)
+/- Limited foot dorsiflexion (nl = 25-30) due to shortening of Achilles tendon
+/- Associated pes planus/cavus
- Focal point tenderness at the calcaneal origin of the plantar fascia  pain can be increased by toe dorsiflexion (stretch fascia) during palpation of medial plantar surface ~1.5 distal to posterior heel
- Medial-to-lateral compression of calcaneus usually less painful than local fascial tenderness (if compression more painful, must rule out calcaneal stress fracture)
- +/- Limited foot dorsiflexion (nl = 25-30) due to shortening of Achilles tendon
- +/- Associated pes planus/cavus
- Infracalcaneal Bursitis
Point tenderness directly under center of calcaneus (plantar surface)
+/- Localized warmth/swelling
- Point tenderness directly under center of calcaneus (plantar surface)
- +/- Localized warmth/swelling
- Calcaneal Periostitis
Diffuse tenderness along plantar aspect of heel and midfoot bilateral and along lateral edges of heels
Evaluation for signs underlying rheumatologic disease indicated
- Diffuse tenderness along plantar aspect of heel and midfoot bilateral and along lateral edges of heels
- Evaluation for signs underlying rheumatologic disease indicated
- Calcaneal Spurs
Usually no specific findings; prominent spur palpable through skin may require intervention
- Usually no specific findings; prominent spur palpable through skin may require intervention
- Heel Pad Syndrome
Pain localized to heel pad, aggravated by squeezing pad from side to side
Plantar fascia not tender; pain not exacerbated by toe dorsiflexion
- Pain localized to heel pad, aggravated by squeezing pad from side to side
- Plantar fascia not tender; pain not exacerbated by toe dorsiflexion
- Tarsal Tunnel Syndrome
Reproduction of symptoms with percussion or pressure over flexor retinaculum (Tinels sign)
- Reproduction of symptoms with percussion or pressure over flexor retinaculum (Tinels sign)
- Ligament Strain
Pain anywhere that ligament connects bone to bone
Swelling and skin color changes may be present
Weather sensitivity can exist
- Pain anywhere that ligament connects bone to bone
- Swelling and skin color changes may be present
- Weather sensitivity can exist

## Hindfoot (Posterior) Conditions
- Achilles Tendinitis
Tender, fusiform thickening of Achilles tendon with cobblestone texture
Pain exacerbated with resisted plantar flexion and passive stretching in dorsiflexion
Ankle ROM normal, though may be limited by pain in dorsiflexion
Preserved calf muscle strength with no palpable defects in tendon
- Tender, fusiform thickening of Achilles tendon with cobblestone texture
- Pain exacerbated with resisted plantar flexion and passive stretching in dorsiflexion
- Ankle ROM normal, though may be limited by pain in dorsiflexion
- Preserved calf muscle strength with no palpable defects in tendon
- Achilles Tendon Rupture
Weakness--patient may be unable to stand up on toes (with full rupture)
Thompson Test
Patient kneels on chair with feet hanging over edge
Squeeze of normal calf muscle foot plantar flexion
Squeeze on side with tendon rupture--no foot response
Crescent Sign
Blood tracking in soft tissues can be seen beneath malleolus or in foot/toes
- Weakness--patient may be unable to stand up on toes (with full rupture)
- Thompson Test
Patient kneels on chair with feet hanging over edge
Squeeze of normal calf muscle foot plantar flexion
Squeeze on side with tendon rupture--no foot response
- Patient kneels on chair with feet hanging over edge
- Squeeze of normal calf muscle foot plantar flexion
- Squeeze on side with tendon rupture--no foot response
- Crescent Sign
Blood tracking in soft tissues can be seen beneath malleolus or in foot/toes
- Blood tracking in soft tissues can be seen beneath malleolus or in foot/toes
- Posterior Tibial Tenosynovitis
Local tenderness/swelling inferior and posterior to medial malleolus
Swelling may obliterate normal depression inferior to malleolus
Pain exacerbated by resisted ankle inversion and plantar flexion
Passive forced eversion may worsen pain (tendon stretch)
Normal ankle ROM
+/- Pes planus, pes cavus, or ankle pronation
- Local tenderness/swelling inferior and posterior to medial malleolus
- Swelling may obliterate normal depression inferior to malleolus
- Pain exacerbated by resisted ankle inversion and plantar flexion
- Passive forced eversion may worsen pain (tendon stretch)
- Normal ankle ROM
- +/- Pes planus, pes cavus, or ankle pronation
- Retrocalcaneal Bursitis
Local tenderness and swelling in soft-tissue space between Achilles tendon and calcaneus/talus
Pain increased with forced extreme plantar flexion (compression of bursa)
Resisted ankle plantar/dorsiflexion, inversion/eversion painless (no tendon involvement)
Normal ankle ROM
+/- Significant swelling
- Local tenderness and swelling in soft-tissue space between Achilles tendon and calcaneus/talus
- Pain increased with forced extreme plantar flexion (compression of bursa)
- Resisted ankle plantar/dorsiflexion, inversion/eversion painless (no tendon involvement)
- Normal ankle ROM
- +/- Significant swelling
- Pre-Achilles Bursitis
Local midline tenderness and swelling ~1 superior to heel pad, small area of involvement
Passive stretch of Achilles tendon (dorsiflexion)  painless or minimally painful
Resisted plantar flexion painless or minimally painful (unlike Achilles tendinitis)
Normal ankle ROM
- Local midline tenderness and swelling ~1 superior to heel pad, small area of involvement
- Passive stretch of Achilles tendon (dorsiflexion)  painless or minimally painful
- Resisted plantar flexion painless or minimally painful (unlike Achilles tendinitis)
- Normal ankle ROM
- Ligament Strain
Pain anywhere that ligament connects bone to bone
Swelling and skin color changes may be present
Weather sensitivity can exist
- Pain anywhere that ligament connects bone to bone
- Swelling and skin color changes may be present
- Weather sensitivity can exist

# Management

## Acute Traumatic Injury
- Fracture of Proximal Phalanx of Great Toe  nondisplaced
Buddy tape the toe to adjacent toe
Stiff shoes or a short-leg walking cast for 2 weeks
- Buddy tape the toe to adjacent toe
- Stiff shoes or a short-leg walking cast for 2 weeks
- Fracture of Lesser Toes  nondisplaced
Buddy tape the toe to adjacent larger toe with cotton placed in toe web
Wide toe-box shoes until healed
- Buddy tape the toe to adjacent larger toe with cotton placed in toe web
- Wide toe-box shoes until healed
- Fracture of Metatarsals 1-4  nondisplaced
Ice, elevation, analgesia
Short-leg walking cast for fractures of metatarsals 2-4
First metatarsal fractures requires non-weightbearing casting for 2-3 weeks, then short-leg walking cast for 2-3 weeks more (total immobilization ~5 weeks)
- Ice, elevation, analgesia
- Short-leg walking cast for fractures of metatarsals 2-4
- First metatarsal fractures requires non-weightbearing casting for 2-3 weeks, then short-leg walking cast for 2-3 weeks more (total immobilization ~5 weeks)
- Fracture of 5th Metatarsal
Dancers Fracture
Short-leg walking cast
Immobilization for 3-4 weeks to allow tendon reattachment
Jones Fracture
Bulky Jones dressing for 24-36 hours; no weightbearing
Then short-leg walking cast for 3-4 weeks
Transverse Fracture of Shaft
Short-leg walking cast; at risk for nonunion despite immobilization
- Dancers Fracture
Short-leg walking cast
Immobilization for 3-4 weeks to allow tendon reattachment
- Short-leg walking cast
- Immobilization for 3-4 weeks to allow tendon reattachment
- Jones Fracture
Bulky Jones dressing for 24-36 hours; no weightbearing
Then short-leg walking cast for 3-4 weeks
- Bulky Jones dressing for 24-36 hours; no weightbearing
- Then short-leg walking cast for 3-4 weeks
- Transverse Fracture of Shaft
Short-leg walking cast; at risk for nonunion despite immobilization
- Short-leg walking cast; at risk for nonunion despite immobilization
- Calcaneal Fracture  extra-articular
Strict bedrest for 5-6 days with leg elevation (reduce swelling)
Jones compression dressing for 2-3 days
Short-leg walking cast
Non-weightbearing ambulation only (crutches) until union seen on follw-up X-rays  usually takes weeks
Gradual resumption of weightbearing thereafter
- Strict bedrest for 5-6 days with leg elevation (reduce swelling)
- Jones compression dressing for 2-3 days
- Short-leg walking cast
- Non-weightbearing ambulation only (crutches) until union seen on follw-up X-rays  usually takes weeks
- Gradual resumption of weightbearing thereafter
- Ligament Strain
For the first 72 hours "ICE": ice, compression and elevation
Range of Motion
Depending upon the severity of the strain, reduced activity to non weight bearing for 4-6 weeks
Use of a splint prn
Ankle and foot intrinsic strengthening and balance exercises
- For the first 72 hours "ICE": ice, compression and elevation
- Range of Motion
- Depending upon the severity of the strain, reduced activity to non weight bearing for 4-6 weeks
- Use of a splint prn
- Ankle and foot intrinsic strengthening and balance exercises

## Nontraumatic Injury
- Great Toe
Hallux Valgus (bunion)
Cotton or rubber spacer between 1st and 2nd toes
Wide-toe-box shoes
Felt ring or bunion shield to protect medial joint from shoe irritation
Ice to side/top of toe for pain relief
+/- nonsteriodal anti-inflammatory drugs (NSAIDs), elevation during flare
Steroid injection (periarticular) at 4-6 weeks if above measures fail
Podiatry/ortho referral for chronic cases (palliative bunionectomy)
Adventitial Bursitis
Wide-toe-box shoes
Felt ring or bunion shield over medial aspect of joint
Consider steroid injection for pain relief after rule out infection (caution in diabetic (DM) patients)
NSAIDs often ineffective
Gout (podagra)
Ice, elevation, NSAIDs, +/- colchicine or prednisone taper
Joint aspiration prone to confirm diagnosis and rule out infection
Steroid injection (periarticular) if other treatment contraindicated
Sesamoid Disorders
Stiff-soled, low-heeled shoe with soft innersole  reduce stress on sesamoids
Orthotics if above measures inadequate
If sesamoid fracture, short-leg walking cast for 3-4 weeks, then stiff shoes
- Hallux Valgus (bunion)
Cotton or rubber spacer between 1st and 2nd toes
Wide-toe-box shoes
Felt ring or bunion shield to protect medial joint from shoe irritation
Ice to side/top of toe for pain relief
+/- nonsteriodal anti-inflammatory drugs (NSAIDs), elevation during flare
Steroid injection (periarticular) at 4-6 weeks if above measures fail
Podiatry/ortho referral for chronic cases (palliative bunionectomy)
- Cotton or rubber spacer between 1st and 2nd toes
- Wide-toe-box shoes
- Felt ring or bunion shield to protect medial joint from shoe irritation
- Ice to side/top of toe for pain relief
- +/- nonsteriodal anti-inflammatory drugs (NSAIDs), elevation during flare
- Steroid injection (periarticular) at 4-6 weeks if above measures fail
- Podiatry/ortho referral for chronic cases (palliative bunionectomy)
- Adventitial Bursitis
Wide-toe-box shoes
Felt ring or bunion shield over medial aspect of joint
Consider steroid injection for pain relief after rule out infection (caution in diabetic (DM) patients)
NSAIDs often ineffective
- Wide-toe-box shoes
- Felt ring or bunion shield over medial aspect of joint
- Consider steroid injection for pain relief after rule out infection (caution in diabetic (DM) patients)
- NSAIDs often ineffective
- Gout (podagra)
Ice, elevation, NSAIDs, +/- colchicine or prednisone taper
Joint aspiration prone to confirm diagnosis and rule out infection
Steroid injection (periarticular) if other treatment contraindicated
- Ice, elevation, NSAIDs, +/- colchicine or prednisone taper
- Joint aspiration prone to confirm diagnosis and rule out infection
- Steroid injection (periarticular) if other treatment contraindicated
- Sesamoid Disorders
Stiff-soled, low-heeled shoe with soft innersole  reduce stress on sesamoids
Orthotics if above measures inadequate
If sesamoid fracture, short-leg walking cast for 3-4 weeks, then stiff shoes
- Stiff-soled, low-heeled shoe with soft innersole  reduce stress on sesamoids
- Orthotics if above measures inadequate
- If sesamoid fracture, short-leg walking cast for 3-4 weeks, then stiff shoes
- Forefoot
Metatarsalgia
Soft innersoles, molded shoes, or metatarsal bars to disperse weight from MT
Surgery needed in some cases, e.g. metatarsal head resection in rheumatoid arthritis (RA)
Mortons Neuroma
Wide-toe-box shoes
Soft, padded insoles with cotton or rubber spacer between involved toes
Nerve block
NSAIDs often ineffective
Steroid injection may be beneficial if no relief with above measures
Surgical neurectomy if above fails  may cause permanent toe numbness
Metatarsal Stress Fracture
Wide-toe-box shoes (decrease medial/lateral pressure)
Padded insoles, walking with shortened stride to reduce impact
Restricted weightbearing (standing/walking) till pain much improved
Short-leg walking cast if persistent symptoms
- Metatarsalgia
Soft innersoles, molded shoes, or metatarsal bars to disperse weight from MT
Surgery needed in some cases, e.g. metatarsal head resection in rheumatoid arthritis (RA)
- Soft innersoles, molded shoes, or metatarsal bars to disperse weight from MT
- Surgery needed in some cases, e.g. metatarsal head resection in rheumatoid arthritis (RA)
- Mortons Neuroma
Wide-toe-box shoes
Soft, padded insoles with cotton or rubber spacer between involved toes
Nerve block
NSAIDs often ineffective
Steroid injection may be beneficial if no relief with above measures
Surgical neurectomy if above fails  may cause permanent toe numbness
- Wide-toe-box shoes
- Soft, padded insoles with cotton or rubber spacer between involved toes
- Nerve block
- NSAIDs often ineffective
- Steroid injection may be beneficial if no relief with above measures
- Surgical neurectomy if above fails  may cause permanent toe numbness
- Metatarsal Stress Fracture
Wide-toe-box shoes (decrease medial/lateral pressure)
Padded insoles, walking with shortened stride to reduce impact
Restricted weightbearing (standing/walking) till pain much improved
Short-leg walking cast if persistent symptoms
- Wide-toe-box shoes (decrease medial/lateral pressure)
- Padded insoles, walking with shortened stride to reduce impact
- Restricted weightbearing (standing/walking) till pain much improved
- Short-leg walking cast if persistent symptoms
- Hindfoot  plantar region
Plantar Fasciitis
Padded arch supports, weight loss if obese
Soft heel pads or heel cups may relieve pain
Ice to heel, massage of heel with tennis ball or frozen water bottle
Achilles tendon stretching exercises
NSAIDs may have limited benefit (2-3 week course)
Steroid injection along plantar fascia can provide short-term relief
Judicious use of injections given risk heel pad atrophy and fascial rupture
Short-leg walking cast for 4-8 weeks may be beneficial
Percutaneous Tenotomy for recalcitrant cases{{Diagnostic musculoskeletal ultrasound]]
Open surgery rarely indicated
Infracalcaneal Bursitis
Ice, massage, NSAIDs
Soft heel pad or heel cup to reduce impact
Calcaneal Periostitis
NSAIDs, heel lifts, treat any underlying inflammatory conditions
Calcaneal Spurs
Rarely requires treatment; consider heel pad or custom orthotic
Surgery if painful spur palpable beneath heel pad
Heel Pad Syndrome
Ice during acute phase
Rubber heel cups or padded arch supports worn for 1-2 weeks
Limited weight bearing during first few days (crutches if needed)
Avoidance of hard surfaces
Ankle ROM and Achilles tendon stretching exercises during recovery
Tarsal Tunnel Syndrome
Cushioned soles, arch supports; orthoses if significant pronation
NSAIDs
Steroid injection with variable response
Nerve blocks can be  helpful
Surgery may be beneficial, especially if anatomic deformity, e.g. ganglion
Ligament Strain
Ankle and foot intrinsic strengthening exercises
Balance exercises
Therapeutic modalities
Orthotics
Prolotherapy
- Plantar Fasciitis
Padded arch supports, weight loss if obese
Soft heel pads or heel cups may relieve pain
Ice to heel, massage of heel with tennis ball or frozen water bottle
Achilles tendon stretching exercises
NSAIDs may have limited benefit (2-3 week course)
Steroid injection along plantar fascia can provide short-term relief
Judicious use of injections given risk heel pad atrophy and fascial rupture
Short-leg walking cast for 4-8 weeks may be beneficial
Percutaneous Tenotomy for recalcitrant cases{{Diagnostic musculoskeletal ultrasound]]
Open surgery rarely indicated
- Padded arch supports, weight loss if obese
- Soft heel pads or heel cups may relieve pain
- Ice to heel, massage of heel with tennis ball or frozen water bottle
- Achilles tendon stretching exercises
- NSAIDs may have limited benefit (2-3 week course)
- Steroid injection along plantar fascia can provide short-term relief
- Judicious use of injections given risk heel pad atrophy and fascial rupture
- Short-leg walking cast for 4-8 weeks may be beneficial
- Percutaneous Tenotomy for recalcitrant cases{{Diagnostic musculoskeletal ultrasound]]
- Open surgery rarely indicated
- Infracalcaneal Bursitis
Ice, massage, NSAIDs
Soft heel pad or heel cup to reduce impact
- Ice, massage, NSAIDs
- Soft heel pad or heel cup to reduce impact
- Calcaneal Periostitis
NSAIDs, heel lifts, treat any underlying inflammatory conditions
- NSAIDs, heel lifts, treat any underlying inflammatory conditions
- Calcaneal Spurs
Rarely requires treatment; consider heel pad or custom orthotic
Surgery if painful spur palpable beneath heel pad
- Rarely requires treatment; consider heel pad or custom orthotic
- Surgery if painful spur palpable beneath heel pad
- Heel Pad Syndrome
Ice during acute phase
Rubber heel cups or padded arch supports worn for 1-2 weeks
Limited weight bearing during first few days (crutches if needed)
Avoidance of hard surfaces
Ankle ROM and Achilles tendon stretching exercises during recovery
- Ice during acute phase
- Rubber heel cups or padded arch supports worn for 1-2 weeks
- Limited weight bearing during first few days (crutches if needed)
- Avoidance of hard surfaces
- Ankle ROM and Achilles tendon stretching exercises during recovery
- Tarsal Tunnel Syndrome
Cushioned soles, arch supports; orthoses if significant pronation
NSAIDs
Steroid injection with variable response
Nerve blocks can be  helpful
Surgery may be beneficial, especially if anatomic deformity, e.g. ganglion
- Cushioned soles, arch supports; orthoses if significant pronation
- NSAIDs
- Steroid injection with variable response
- Nerve blocks can be  helpful
- Surgery may be beneficial, especially if anatomic deformity, e.g. ganglion
- Ligament Strain
Ankle and foot intrinsic strengthening exercises
Balance exercises
Therapeutic modalities
Orthotics
Prolotherapy
- Ankle and foot intrinsic strengthening exercises
- Balance exercises
- Therapeutic modalities
- Orthotics
- Prolotherapy
- Hindfoot  posterior region
Achilles Tendinitis
Crutches/non-weightbearing for 7-10 days if severe, acute symptoms
+/- Short-leg walking cast or air cast for moderate/severe cases
Ice +/- NSAIDs (3-4 week course)
Daily gentle stretching in dorsiflexion after acute symptoms to improve
Padded heel cups or heel lift; double socks to decrease friction over tendon
Vigorous stretches (goal 30 painless dorsiflexion) 3-4 weeks after symptoms resolve
Local injection with either steriod, Prolotherapy
Persistent tendinitis requires ortho referral (may need surgery)
Achilles Tendon Rupture
Orthopedics referral
Posterior Tibial Tenosynovitis
Correct ankle pronation with arch supports or high top shoes
Correct pes planus with arch supports
Limit standing and walking; use Velcro pull-on ankle brace
Ice +/- NSAID (4 week course)
Persistent symptoms may require injection, rigid immobilization
Ankle stretching exercises during recovery phase
Local injection with either steriod or 
Retrocalcaneal Bursitis
Restriction of repetitive ankle motion (jogging, stair-climbing)
Ice, NSAIDs, elevation
Avoidance of high heels
Padded heel cups, shortened walking stride
+/- High top shoes or velcro ankle brace to control heel motion
Steroid injection can be very effective
Achilles tendon stretching exercises during recovery phase
Pre-Achilles Bursitis
Padded heel cups, double socks or felt ring to decrease heel friction
Avoidance of rigid-backed shoes; shortened walking/running stride
Ice for analgesia
Injection + immobilization (air or walking cast) for severe/recurrent cases
Achilles tendon stretching exercises
Ligament Strain
Ankle and foot intrinsic strengthening exercises
Balance exercises
Therapeutic modalities
Orthotics
Prolotherapy
- Achilles Tendinitis
Crutches/non-weightbearing for 7-10 days if severe, acute symptoms
+/- Short-leg walking cast or air cast for moderate/severe cases
Ice +/- NSAIDs (3-4 week course)
Daily gentle stretching in dorsiflexion after acute symptoms to improve
Padded heel cups or heel lift; double socks to decrease friction over tendon
Vigorous stretches (goal 30 painless dorsiflexion) 3-4 weeks after symptoms resolve
Local injection with either steriod, Prolotherapy
Persistent tendinitis requires ortho referral (may need surgery)
- Crutches/non-weightbearing for 7-10 days if severe, acute symptoms
- +/- Short-leg walking cast or air cast for moderate/severe cases
- Ice +/- NSAIDs (3-4 week course)
- Daily gentle stretching in dorsiflexion after acute symptoms to improve
- Padded heel cups or heel lift; double socks to decrease friction over tendon
- Vigorous stretches (goal 30 painless dorsiflexion) 3-4 weeks after symptoms resolve
- Local injection with either steriod, Prolotherapy
- Persistent tendinitis requires ortho referral (may need surgery)
- Achilles Tendon Rupture
Orthopedics referral
- Orthopedics referral
- Posterior Tibial Tenosynovitis
Correct ankle pronation with arch supports or high top shoes
Correct pes planus with arch supports
Limit standing and walking; use Velcro pull-on ankle brace
Ice +/- NSAID (4 week course)
Persistent symptoms may require injection, rigid immobilization
Ankle stretching exercises during recovery phase
Local injection with either steriod or 
- Correct ankle pronation with arch supports or high top shoes
- Correct pes planus with arch supports
- Limit standing and walking; use Velcro pull-on ankle brace
- Ice +/- NSAID (4 week course)
- Persistent symptoms may require injection, rigid immobilization
- Ankle stretching exercises during recovery phase
- Local injection with either steriod or 
- Retrocalcaneal Bursitis
Restriction of repetitive ankle motion (jogging, stair-climbing)
Ice, NSAIDs, elevation
Avoidance of high heels
Padded heel cups, shortened walking stride
+/- High top shoes or velcro ankle brace to control heel motion
Steroid injection can be very effective
Achilles tendon stretching exercises during recovery phase
- Restriction of repetitive ankle motion (jogging, stair-climbing)
- Ice, NSAIDs, elevation
- Avoidance of high heels
- Padded heel cups, shortened walking stride
- +/- High top shoes or velcro ankle brace to control heel motion
- Steroid injection can be very effective
- Achilles tendon stretching exercises during recovery phase
- Pre-Achilles Bursitis
Padded heel cups, double socks or felt ring to decrease heel friction
Avoidance of rigid-backed shoes; shortened walking/running stride
Ice for analgesia
Injection + immobilization (air or walking cast) for severe/recurrent cases
Achilles tendon stretching exercises
- Padded heel cups, double socks or felt ring to decrease heel friction
- Avoidance of rigid-backed shoes; shortened walking/running stride
- Ice for analgesia
- Injection + immobilization (air or walking cast) for severe/recurrent cases
- Achilles tendon stretching exercises
- Ligament Strain
Ankle and foot intrinsic strengthening exercises
Balance exercises
Therapeutic modalities
Orthotics
Prolotherapy
- Ankle and foot intrinsic strengthening exercises
- Balance exercises
- Therapeutic modalities
- Orthotics
- Prolotherapy