Ankle/Heel/Foot Pain

Ottawa Ankle Rules

Ankle x-ray for pain in the malleolar zone and one of the following:

Inability to bear weight for four steps both immediately and in ED
Bone tenderness at the posterior edge or tip of the lateral and/or medial malleolus

Foot x-ray for pain in the malleolar zone and one of the following

Adult

Plantar

Plantar warts: Raised skin lesions associated with pain on palpation. Lesion shaving, topical salicylic acid, imiquimod cream, and/or cryotherapy. Consider referral to podiatry for surgical excision. Duct tape is ineffective.
Plantar fasciitis (most common etiology): Sharp/aching anterior heel pain worse with weight bearing following rest. NSAIDs, stretches, night splinting, physical therapy. Consider corticosteroid injection, platelet rich plasma injection, extracorporeal shock wave therapy for recalcitrant cases.
Often confused with plantar fasciitis:
- Heel pad syndrome: Deep mid-heel ache in worse with prolonged walking. NSAIDs, RICE, weight loss. Rigid heel cup. Consider podiatry referral.
- Calcaneal stress fracture: Sudden increase in activity with minimalist shoes followed. Pain worse in the morning and with ambulation.

Medial

Maisonneuve fracture
Posterior tibial tendon insufficiency (PTTI)
Tarsal tunnel syndrome: Almost always occurs following clear foot trauma
- Intermittent numbness and aching/burning medial/plantar foot pain worse at night and with prolonged walking
- Pes planus, pain with ankle dorsiflexion/eversion, positive triple compression test
- Ankle x-ray to rule out dislocation/fracture of talus, calcaneus, and/or medial malleolus; consider bilateral EMG to compare affected and unaffected foot
- NSAIDs, shoe modifications, and/or orthotics; consider corticosteroid injection vs. nerve decompression surgery for recalcitrant cases

Lateral

Posterior

Calcaneal fracture
Achilles tendinopathy
- Middle-age distance runners with posterior pain and palpable achilles tendon nodule
- NSAIDs and eccentric calf strengthening exercises; consider extracorporeal shock wave therapy for recalcitrant cases
- Do NOT treat with corticosteroid or platelet-rich plasma injections
- Reference: British Journal of Sports Medicine
Retrocalcaneal bursiti and other common conditions

Additional Considerations

Neuroma
Neuropathy
Inflammatory
- Acute: Gout
- Chronic: Rheumatoid arthritis, fibromyalgia
Infectious
- Diabetic foot ulcers: Stage per university of Texas System (Table 1). Address peripheral vascular disease, glycemic control, neuropathy. MRI if concern for osteomyelitis. Antibiotics if infected. Podiatry for debridement and pressure relief/offloading recommendations. Wound care consult and follow-up outpatient.
- Osteomyelitis

Pediatric

Fracture: Two-view (lateral/axial) plain film
Calcaneal apophysitis (Sever's Disease)
- Elementary/adolescent athlete s/p "growth spurt"
- Tenderness with compression of mediolateral posterior calcaneus
- NSAID, RICE, stretching, 3 to 6 weeks rest
Achilles tendonitis: Tendon inflammation in adolescent athlete

Acute
- Lisfranc fracture
- Stress fracture: Pain with walking following sudden increase in physical activity
  - Plain film and consider MRI to rule out 5th metatarsal fracture
  - Crutches (4 days) → boot (4 weeks) → re-evaluation → rigid shoe (4 weeks)
- Acute limb ischemia (embolism)
Subacute and/or chronic
- Plantar wart (see above)
- Morton’s neuroma
- Poikilothermia (cold feet): Raynaud’s phenomenon, atherosclerosis (peripheral arterial disease), neuropathy

Toe fracture: Plain radiograph with anteroposterior, lateral, and oblique views
Gout: Excess meat/liver/beer/high-fructose corn syrup, loop/thiazide diuretic
- Calculate acute gout diagnosis rule and CrCl per BMP. Definitive diagnosis with with aspiration.
- Indomethacin (CrCl > 30) vs. colchicine (CrCl < 30).