Ankle and Foot Pain

Nonarticular foot and ankle pain is best approached with a consideration of the region affected: the forefoot, midfoot, or hindfoot [see Figure 3].

Figure 3. Causes of Foot Pain. In the anterior foot, hallux valgus may cause diffuse pain, whereas Morton neuroma is usually localized. Tarsal tunnel syndrome causes paresthesias over the medial and plantar aspect. Plantar fasciitis and Achilles tendinitis are common causes of posterior foot pain.

Forefoot Pain

Hallux valgus is the leading cause of forefoot pain. It is a common deformity that causes pain because of direct pressure over the first metatarsophalangeal joint resulting from footwear or because of pressure over the lateral toe joints caused by crowding of the toes. In the lateral toes, hammer toe (i.e., plantar flexion of the proximal interphalangeal joint), claw toe (i.e., plantar flexion of the proximal and distal interphalangeal joints), or mallet toe (i.e., isolated flexion contracture of the distal interphalangeal joint) may be associated with a dorsiflexion contracture of the metatarsophalangeal joint. Initial treatment of these problems should begin with adequate footwear that allows ample width for the metatarsal heads, individualized orthoses, and surgical correction (reserved for patients with persistent pain). Morton neuroma is an entrapment neuropathy of the interdigital nerve, with or without an associated plantar neuroma, that is most commonly seen between the third and fourth metatarsal heads. Patients report pain and paresthesia radiating into the affected toes; tenderness between the metatarsal heads that reproduces the described symptoms will also be found. Orthoses to decrease pressure in the area, local glucocorticoid injection, or surgical excision of the neuroma may be needed to relieve symptoms.

Midfoot Pain

Midfoot pain is usually the result of deformities of the arch of the foot or arthritic changes of the midfoot joints. Patients with a cavus foot deformity, peripheral neuropathies, or previous ligamentous injuries from sprains may be predisposed to excessive stresses on the midfoot and early osteoarthritic changes. Tarsal tunnel syndrome is caused by entrapment of the posterior tibial nerve under the flexor retinaculum on the medial side of the ankle. Symptoms of pain and paresthesia over the plantar and distal foot and toes are usually present, and the Tinel sign may be positive. Tarsal tunnel syndrome is much less common and more difficult to diagnose than carpal tunnel syndrome in the wrist. Treatment consists of splinting and NSAIDs. Local glucocorticoid injection and surgical decompression are not as predictably successful as in carpal tunnel syndrome.

Hindfoot Pain

Plantar fasciitis is one of the most common causes of hindfoot pain. Patients report pain over the plantar aspect of the heel and midfoot that worsens with walking. Localized tenderness along the plantar fascia or at the insertion of the calcaneus is helpful in diagnosis. Plantar fasciitis is associated with obesity, pes planus, and activities that stress the plantar fascia and may also be seen in systemic arthropathies such as ankylosing spondylitis and Reiter syndrome. Although radiographic spurs in the affected area are common, they may also be seen in asymptomatic persons and are therefore not diagnostic. Orthoses, heel cord stretching exercises, NSAIDs, and local glucocorticoid injection may be helpful, whereas surgery is seldom indicated. Posterior heel pain is usually caused by Achilles tendinitis or by bursitis of the bursae that lie superficial or deep to the insertion of the Achilles tendon at the calcaneus. Although usually associated with overactivity, Achilles tendinitis may also be part of ankylosing spondylitis and Reiter syndrome. NSAIDs and orthoses designed to reduce stress on the tendon (e.g., heel lifts) are usually helpful. In most cases, glucocorticoid injections in the Achilles tendon area should be avoided because of the risk of tendon rupture.

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