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Probability diagnosis

Acute or chronic foot strain

Sprained ankle

Osteoarthritis (esp. great toe – hallux rigidus)

Plantar fasciitis

Achilles tendonopathy

Tibialis posterior tendonopathy

Wart, corn or callus

Ingrowing toenail/paronychia

Serious disorders not to be missed

Vascular insufficiency:

  • small vessel disease


  • osteoid osteoma

  • osteosarcoma

  • synovial sarcoma

  • acral lentiginous melanoma

Infection (rare):

  • septic arthritis

  • actinomycosis

  • osteomyelitis

Rheumatoid arthritis

Peripheral neuropathy

Complex regional pain syndromes

Ruptured Achilles’ tendon

Ruptured tibialis posterior tendon

Pitfalls (often missed)

Foreign body (especially children)


Nerve syndromes:

  • Morton neuroma

  • tarsal tunnel syndrome

  • deep peroneal nerve


Stress fracture (e.g. navicular)

Erythema nodosum


  • spondyloarthropathies

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

Glomus tumour (under nail)

Paget disease

Masquerades checklist



Spinal dysfunction

Is the patient trying to tell me something?

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

Key history

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.

Key examination

  • 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

Key investigations


  • FBE


  • rheumatoid arthritis tests

  • blood glucose

  • uric acid

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

  • ultrasound

  • MRI

  • radionuclide scans.

Diagnostic tips

  • 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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