The victim goes to bed and sleeps in good health. About two o’clock in the morning he is awakened by a severe pain in the great toe; more rarely in the heel, ankle, or instep … The part affected cannot bear the weight of the bed clothes nor the jar of a person walking in the room. The night is spent in torture.
THOMAS SYDENHAM (1624–89) ON GOUT
Pain in the foot (podalgia) and ankle problems are common occurrences in general practice. Various characteristics of the pain can give an indication of its cause, such as the description of gout by Thomas Sydenham. There are many traumatic causes of podalgia and ankle dysfunction, especially fractures and torn ligaments, but this chapter will focus mainly on everyday problems that develop spontaneously or through overuse. Forefoot pain is common especially in the elderly. The forefoot comprises the toes to the middle of the metatarsals and all of the supporting structures. Metatarsalgia is a term used to describe pain in the distal aspect of one or more of the metatarsal bones during weight-bearing.1
Key facts and checkpoints
Foot deformities such as flat feet (pes planus) are often painless.
Foot strain is probably the commonest cause of podalgia.2
A common deformity of the toes is hallux valgus, with or without bunion formation.
Osteoarthritis is a common sequel to hallux valgus.
Osteoarthritis affecting the ankle is relatively uncommon.
All of the distal joints of the foot may be involved in arthritic disorders.
Many foot and ankle problems are caused by unsuitable footwear and lack of foot care.
Ankle sprains are the most common injury in sport, representing about 25% of injuries.
Severe sprains of the lateral ligaments of the ankle due to an inversion force may be associated with various fractures.
Bunions and hammer toes are generally best treated by surgery.
A summary of the diagnostic strategy model is presented in TABLE 68.1.
Table 68.1The painful foot and ankle: diagnostic strategy model |Favorite Table|Download (.pdf) Table 68.1 The painful foot and ankle: diagnostic strategy model
Acute or chronic foot strain
Osteoarthritis (esp. great toe)
Tibialis posterior tendonopathy
Wart, corn or callus
Serious disorders not to be missed
Severe infections (rare):
Complex regional pain syndromes
Ruptured Achilles tendon
Ruptured tibialis posterior tendon
Pitfalls (often missed)
Foreign body (esp. children)
Tarsal tunnel syndrome
Deep peroneal nerve entrapment
Stress fracture (e.g. navicular)
osteochondritis: navicular (Köhler), metatarsal head (Freiberg), calcaneum (Sever)
glomus tumour (under nail)
Seven masquerades checklist
Is the patient trying ...