Overview of Foot and Ankle Disorders

By Kendrick Alan Whitney, DPM, Temple University School of Podiatric Medicine

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Foot and Ankle Disorders
Overview of Foot and Ankle Disorders
Achilles Tendon Enthesopathy
Anterior Achilles Tendon Bursitis
Bunion
Epiphysitis of the Calcaneus
Freiberg Disease
Hammer Toe Deformity
Inferior Calcaneal Bursitis
Interdigital Neuralgia
Medial and Lateral Plantar Nerve Entrapment
Metatarsalgia
Metatarsophalangeal Joint Pain
Plantar Fasciosis
Plantar Fibromatosis
Posterior Achilles Tendon Bursitis
Sesamoiditis
Tarsal Tunnel Syndrome
Tibialis Posterior Tendinosis and Tibialis Posterior Tenosynovitis

Most foot problems result from anatomic disorders or abnormal function of articular or extra-articular structures (see Figure: Bones of the foot.). Less commonly, foot problems reflect a systemic disorder (see Table: Foot Manifestations of Systemic Disorders).

Bones of the foot.

Foot Manifestations of Systemic Disorders

Foot Symptoms or Signs	Possible Cause
Pain at rest (feet elevated), relieved by dependency	End-stage peripheral arterial disease
Cold, red, or cyanotic feet	Advanced arterial ischemia
Episodically red, hot, very painful, burning feet	Erythromelalgia—idiopathic (most commonly) or secondary to various disorders (eg, myeloproliferative disorders, which are rare)
Foot pain that becomes severe within seconds or possibly minutes, particularly in patients with atrial fibrillation; foot often cool	Embolic arterial occlusion
Cyanosis of a single toe (blue toe syndrome)	Thromboembolic disease due to aortic-iliac stenosis, arrhythmia, or cholesterol embolization (after coronary artery bypass or catheterization) Warfarin therapy
Bilateral episodic digital discomfort, pallor, and cyanosis	Raynaud syndrome
Bilateral painless cyanosis	Acrocyanosis, drug-induced discoloration (eg, minocycline)
Bilateral edema	Renal, hepatic, or cardiac dysfunction Drugs (eg, calcium channel blockers)
Unilateral edema	Deep venous thrombosis Lymphatic obstruction
Firm nonpitting foot and leg edema	Lymphedema Systemic sclerosis
Firm, nonpitting edema with nodular appearance above the malleoli	Pretibial myxedema
Edema with hemosiderin deposition and brownish discoloration	Venous insufficiency Recurrent or prior small-vessel vasculitis
Edema of feet and toes, numbness and pain at the ankle and heel (tarsal tunnel syndrome)	Hypothyroidism Relapsing symmetric seronegative synovitis (rare)
Red, dusky patches on the dorsum with flaccid bullae (necrolytic acral erythema)	Hepatitis C Vasculitis Emboli
Isolated toe swelling and deformity (dactylitis, or sausage digits) with pain	Psoriatic arthritis Reactive arthritis Other spondyloarthropathies Crystal-induced arthritis Infection
Painful feet with paresthesias	Peripheral neuropathy (local or systemic—eg, diabetic neuropathy) Ischemia
Pain or paresthesias in the leg and foot; pain in the foot and back when the leg is extended, relieved when the knee is flexed	Sciatica
Toe, foot, or ankle pain with warmth and redness	Gout Stress fracture, such as fragility fractures associated with osteoporosis
Foot swelling, redness, and warmth with little or no pain	Neurogenic arthropathy (Charcot joints; usually in the absence of pain)
Posterior heel pain below the top of the shoe counter during ambulation Tendon tenderness at its insertion (diagnostic) Exacerbation of tendon pain by passive ankle dorsiflexion	Achilles enthesopathy associated with spondyloarthropathies (eg, ankylosing spondylitis, psoriatic arthritis)

In people with diabetes and people with peripheral vascular disease, careful examination of the feet, with evaluation of vascular sufficiency and neurologic integrity, should be done at least twice/yr. People with these diseases should examine their own feet at least once/day.

The feet are also common sites for corns and calluses and infections by fungus (see Tinea Pedis), bacteria (see Bacterial Skin Infections), and viruses (see Warts).

Table Common Foot and Ankle Disorders by Anatomic Site lists foot and ankle disorders according to anatomic site. Table Disorders Associated With Heel Pain According to Location lists common causes of heel pain according to location.

Common Foot and Ankle Disorders by Anatomic Site

Ankle (anterolateral) Meniscoid body Neuralgia of the intermediate dorsal cutaneous nerve Peroneal tenosynovitis
Ankle (medial) Tarsal tunnel syndrome Tibialis posterior tendinosis Tibialis posterior tenosynovitis
Ball of the foot Corns and calluses Freiberg disease Interdigital nerve pain (Morton neuroma) Metatarsophalangeal joint pain Sesamoiditis
Heel (plantar) Inferior calcaneal bursitis Medial or lateral plantar nerve entrapment Plantar fasciosis
Heel (posterior) Achilles tendon enthesopathy Anterior Achilles tendon bursitis Posterior Achilles tendon bursitis
Heel (sides) Epiphysitis of the calcaneus(Sever disease) Tarsal tunnel syndrome
Plantar arch (sole) Cuboid subluxation syndrome Plantar fascial sprain Plantar fibromatosis Posterior tibial tendon rupture with arch collapse
Toe Bunion Dactylitis (painful, isolated toe swelling due to inflammatory arthritis) Hallux rigidus Hammer toe Ingrown toenail Onychomycosis Paronychia

Disorders Associated With Heel Pain According to Location

Location of Pain	Associated Disorder
Plantar surface of the heel	Inferior calcaneal bursitis Plantar fasciosis (plantar fasciitis, calcaneal spur syndrome)
Medial and lateral margins of the heel	In children, epiphysitis of the calcaneus (Sever disease) Medial or lateral plantar nerve entrapment Sometimes tarsal tunnel syndrome
Anterior to the Achilles tendon at the retromalleolar space	Anterior Achilles tendon bursitis Fracture of the posterolateral talar tubercle Tarsal tunnel syndrome Tibialis posterior tendinosis
Posterior to the Achilles tendon	Posterior Achilles tendon bursitis Tendon nodules
Calcaneal insertion or body of the Achilles tendon	Achilles tendon enthesopathy Tendon tear (due to trauma or associated with fluoroquinolone use—see Achilles Tendon Tears)

Considerations for Using Corticosteroid Injections

Corticosteroid injections should be used judiciously to avoid adverse effects. Injectable corticosteroids should be reserved for inflammation (such as gout and disorders such as RA), which is not present in most foot disorders. Because the tarsus, ankle, retrocalcaneal space, and dorsum of the toes have little connective tissue between the skin and underlying bone, injection of insoluble corticosteroids into these structures may cause depigmentation, atrophy, or ulceration, especially in elderly patients with peripheral arterial disease.	Insoluble corticosteroids can be given deeply rather than superficially with greater safety (eg, in the heel pad, tarsal canal, or metatarsal interspaces). The foot should be immobilized for a few days after tendon sheaths are injected. Unusual resistance to injection suggests injection into a tendon. Repeated injection into a tendon should be avoided because the tendon may weaken (partially tear), predisposing to subsequent rupture.

Corticosteroid injections should be used judiciously to avoid adverse effects. Injectable corticosteroids should be reserved for inflammation (such as gout and disorders such as RA), which is not present in most foot disorders. Because the tarsus, ankle, retrocalcaneal space, and dorsum of the toes have little connective tissue between the skin and underlying bone, injection of insoluble corticosteroids into these structures may cause depigmentation, atrophy, or ulceration, especially in elderly patients with peripheral arterial disease.

Insoluble corticosteroids can be given deeply rather than superficially with greater safety (eg, in the heel pad, tarsal canal, or metatarsal interspaces). The foot should be immobilized for a few days after tendon sheaths are injected. Unusual resistance to injection suggests injection into a tendon. Repeated injection into a tendon should be avoided because the tendon may weaken (partially tear), predisposing to subsequent rupture.

Last full review/revision September 2016 by Kendrick Alan Whitney, DPM