Musculoskeletal problems of the foot
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
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History and Symptoms
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
- 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
- Fracture of 5th Metatarsal (MT)
- Dancer’s 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
- Dancer’s Fracture
- 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
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)
- 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)
- Morton’s 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
- 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), Reiter’s)
- 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, Reiter’s)
- 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 mvmt
- Posterior tibial nerve compressed in tarsal tunnel
- Referred pain (subtalar arthritis, lumbosacral (LS) radiculopathy)
- Plantar fasciitis
- 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 Reiter’s 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
- Achilles tendinitis
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
- 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)
- Gout
- 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
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)
- Morton’s 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 (Mulder’s 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
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
- Infracalcaneal Bursitis
- 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
- Calcaneal Spurs
- 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
- Tarsal Tunnel Syndrome
- Reproduction of symptoms with percussion or pressure over flexor retinaculum (Tinel’s sign)
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
- 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
- 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
- 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
- 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
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
- 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
- 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)
- Fracture of 5th Metatarsal
- Dancer’s 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
- Dancer’s Fracture
- 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
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)
- 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)
- Morton’s Neuroma
- Wide-toe-box shoes
- Soft, padded insoles with cotton or rubber spacer between involved toes
- 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
- 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
- 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 weightbearing 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
- Surgery may be beneficial, especially if anatomic deformity, e.g. ganglion
- Plantar Fasciitis
- 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
- Persistent tendinitis requires ortho referral (may need injection, 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
- 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
- Achilles Tendinitis
References
Acknowledgements
The content on this page was first contributed by: Rebecca Cunningham, M.D.
List of contributors: