ANKLE AND FOOT PAIN

ANKLE PAIN
Foot and ankle pain are common problems seen by physicians. The sprained ankle is the most common injury causing pain in the ankle. The most sever injury is the fracture dislocation.

DIFFERENTIAL DIAGNOSIS:

• Fractures (tibia, fibula)
• Ankle sprain
• Arthritis
• Complex Regional Pain Syndrome Type I (RSD)
• Nerve entrapment
• Osteochondritis dissecans

HISTORY:

• Exact location of pain (quality, timing, aggravating and relieving features)

• Spontaneous onset of pain (no injury)
• Pain with movement
• Pain out of proportion to injury 

• How injury occurred (if injury)
• Any previous foot or ankle injury
• Occupation, athletic activity
• Arthritis
• Is there swelling or discoloration
• Is there popping, snapping, or instability
• Is individual able to walk

CLINICAL FINDINGS:

• Appearance of the skin (swelling, redness, mottled)
• Is there tenderness to palpation anywhere
• Check range of motion
• Neurological examination
• Vascular examination
• Deformity

TESTS:

• X-rays of ankle (AP, lateral, oblique)
• Bone scan(?) (if stress fracture suspected)
• CT-scan (if osteochondritis suspected)
• MRI (soft tissue pathology)

MANAGEMENT:

• Pain medication (NSAID, acetaminophen)
• Acute injury

• Ice several times per day 20 minutes
• Elevation
• Compression wrap
• Surgery

• Complex Regional Pain Syndrome (CRPS), (RSD)

• Sympathetic blocks (lumbar sympathetic blocks, epidural sympathetic blocks, Bier blocks)
• Pain medication
• Anticonvulsants
• Antidepressants

• Physical therapy (non-weight bearing exercises during acute phase to improve motion, strength and flexibility
• Peroneal tendon dysfunction (stretching, heel wedge, ankle brace, injection with steroids) 

HEEL PAIN
The normal foot is pain free, has normal muscle balance, no contractures, central heel with three-point weight bearing and straight mobile toes. Most painful foot conditions originate in soft tissue: ligaments, tendons muscle, nerves and blood vessels.

DIFFERENTIAL DIAGNOSIS:

• Foot strain
• Metatarsalgia
• Plantar fasciitis
• Nerve entrapment
• March Fracture
• Arthritis
• Painful heel pad
• Dupuytren's contracture
• Posterior calcaneal bursitis
• Lumbar radiculopathy
• CRPS Type I 
• Tendinitis (Achilles, posterior tibial)
• Ruptured Achilles tendon
• Bursitis
• Tarsal tunnel
• Fractures
• Referred pain

HISTORY:

• Acute injury Where? When? How?
• Description of the pain (sharp stabbing, burning, stinging etc.)
• When does pain occur?
• Is pain related to activity? What activity?
• Occupational or athletic history
• History of low back pain, injury (radiculopathy)

CLINICAL FINDINGS:

• Palpate for pain and tenderness
• Observe for swelling and discoloration
• Are pulses present?
• Palpate Achilles tendon. Can patient plantar flex foot?
• Check Tinel's sign (tarsal tunnel syndrome)
• Lumbar back examination
• Neurologic examination including, sensation to heat, cold and touch
• Ambulation

MANAGEMENT:

• Arthritis (conservative treatment, occasionally surgery)
• Supportive shoes (arch support, heel pad, firm heel counter)
• Plantar fasciitis (heel wedge pad, PT, steroid injections, splints, surgery)
• Painful heel pad (usually self -limiting, insertion of sponge rubber heel pad, local anesthetic steroid injection.
• Dupuytren's contracture (surgical)
• Achilles paritendonitis (immobilization cast, steroid injection deep to tendon)
• Ruptured Achilles tendon (surgical)

FOREFOOT PAIN:
The general rule that applies to all musculoskeletal dysfunction applies to the foot; that is pain and dysfunction can occur from abnormal stress on a normal structure of normal stress on and abnormal structure.

DIFFERENTIAL DIAGNOSIS:

• Foot Strain
• Metatarsalgia
• Bunion
• Sesamoiditis
• Arthritis
• Neuropathy (diabetic or other)
• CRPS 's Type I and II
• Infection
• Fractures
• Sprain
• Nerve entrapment

HISTORY:

• Description of the pain

• Is the pain better with shoe off? Does message make pain better? Is pain burning, sharp, stabbing, electric shock?
• Is there numbness or tingling in the toes?
• Is pain confined to the great toe? Is there swelling? Is it hot?
• Is there pain a rest? With activity?
• Is there stocking distribution of the pain?
• If injury, is the pain out of proportion to the injury?
• What is occupation? Athletic activity?
• If trauma, what type?

• Observe foot wear (high heels or narrow toe shoes)

CLINICAL FINDINGS:

• Evaluate footwear for: wear, correct fit, etc.
• Examine for tenderness, swelling, warmth, acute pain
• Look for deformities of the foot (protuberances, bunion's etc.)
• Allodynia, hyper or hypoesthesia
• Is patient able to platarflex and dorsiflex foot
• Palpate for masses on plantar aspect, dorsum and sides of foot
• Evaluate sensation (heat, cold, touch, pinprick, vibration)

TESTS:

• Radiographs of foot
• EMG/NCV if suspected Neurologic problem
• Possible joint aspiration (gout, joint infection)

MANAGEMENT:

• Rest, ice, compression, elevation
• NSAID for pain.
• Proper fitting footwear
• Consultation for fractures, peroneal tendon dislocation, Osteochondritis dissecans
• Warts (TCA, salicylic acid), cryosurgery, fulguration
• Calluses (remove hyperkeratosis with scalpel, insoles or orthotics to relieve friction)
• PT after acute stage