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Probability diagnosis

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Acute or chronic foot strain

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Sprained ankle

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Osteoarthritis (esp. great toe – hallux rigidus)

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Plantar fasciitis

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Achilles tendonopathy

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Tibialis posterior tendonopathy

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Wart, corn or callus

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Ingrowing toenail/paronychia

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Serious disorders not to be missed

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Vascular insufficiency:

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  • small vessel disease

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Neoplasia/cancer:

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  • osteoid osteoma

  • osteosarcoma

  • synovial sarcoma

  • acral lentiginous melanoma

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Infection (rare):

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  • septic arthritis

  • actinomycosis

  • osteomyelitis

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Rheumatoid arthritis

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Peripheral neuropathy

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Complex regional pain syndromes

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Ruptured Achilles’ tendon

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Ruptured tibialis posterior tendon

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Pitfalls (often missed)

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Foreign body (especially children)

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Gout

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Nerve syndromes:

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  • Morton neuroma

  • tarsal tunnel syndrome

  • deep peroneal nerve

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Chilblains

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Stress fracture (e.g. navicular)

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Erythema nodosum

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Rarities:

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  • spondyloarthropathies

  • osteochondritis: navicular (Köhler), metatarsal head (Freiberg), calcaneum (Sever)

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Glomus tumour (under nail)

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Paget disease

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Masquerades checklist

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Diabetes

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Drugs

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Spinal dysfunction

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Is the patient trying to tell me something?

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A non-organic cause warrants consideration with any painful condition.

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Key history

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Ask about the quality of the pain, its distribution, mode of onset, periodicity, relationship to weight-bearing and associated features such as swelling or colour change. Enquire about pain in other joints including sacroiliac joints.

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Key examination

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  • Follow the inspection, palpation, movement and test function approach

  • Test active and passive movements of the ankle (talar) joint, hindfoot (subtalar) joint and mid-foot (midtarsal) joint

  • Check the peripheral circulation and perform a neurological examination including sensation, motor strength and reflexes

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Key investigations

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Consider:

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  • FBE

  • ESR/CRP

  • rheumatoid arthritis tests

  • blood glucose

  • uric acid

  • nerve conduction studies and imaging (e.g. plain X-ray—compare both sides)

  • ultrasound

  • MRI

  • radionuclide scans.

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Diagnostic tips

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  • Good quality plain X-rays are important if there is doubt about the diagnosis of a painful foot.

  • Foot strain is probably the commonest cause of podalgia.

  • All the distal joints of the foot may be involved in arthritic disorders.

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