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HelkaKoivu

Painful Conditions of the Ankle and Foot in Adults

  • Painful conditions of the ankle and foot are very common and significantly affect mobility. Osteoarthritis explains some of the symptoms but symptoms may also be due to malposition or to a functional problem.
  • All treatment should be based on good clinical examination completed with any imaging required to make an exact diagnosis.
  • In case of acute or subacute pain after an accident, definitive treatment should be started as soon as possible. For other, benign short-term symptoms, symptomatic treatment should be tried first.
  • If the diagnosis is not clear, a foot orthopaedist should be consulted, as far as possible, to define the correct treatment approach before any further measures are taken.

States of pain due to injury

  • Pain of sudden onset is often due to injury. Persistent heel or foot pain after injury is very often due to poor functional recovery or osteoarthritis developing in joints as a result of the injury.
  • Nerve damage associated with an injury or former surgery may sometimes cause chronic foot pain syndrome.

Other states of pain

  • Most states of pain are not due to injury and in that case the condition may have developed slowly over several years. Factors predisposing the patient to stress-induced or degenerative conditions include, in addition to a history of injury, factors such as heavy, physically demanding work, overexertion from sports or physical exercise, joint malposition, being overweight and smoking.
  • Faulty strain due to malposition of the ankle or foot may lead to strain-induced pain.
  • Osteoarthritis usually develops slowly over several years, and the symptoms do not always correlate with the radiological findings. Typical symptoms include joint pain on exertion and joint stiffness, and in more advanced disease also pain at rest.
  • Any underlying inflammatory or other systemic disease, such as rheumatoid arthritis, psoriatic arthropathy, gout or diabetes, should be excluded.

Examination of a patient with foot pain

  • In addition to the symptoms, find out about any history of injury or strain, gait disturbances, shoes and use of aids.
  • Assess gait visually and examine the ankle and foot clinically with the patient both standing and on the examination table.
  • Applicable examinations include, of imaging studies, X-ray, CT and MRI, and more rarely ENMG, as well as laboratory tests to supplement clinical examination. Ultrasonography is not indicated in examining the ankle or foot.

Osteoarthritis

  • Idiopathic osteoarthritis of the ankle or foot is rare except in the centre of the foot. Osteoarthritis of the talocrural joint, for example, is almost always due to recurrent sprains or ankle/tibial fracture. More advanced osteoarthritis can be seen on X-ray but MRI is significantly more sensitive. Conservative treatment of osteoarthritis does not differ from other treatment of osteoarthritis and consists of wearing suitable footwear, normal use of the joint, analgesics and glucocorticoid injections.
  • Osteoarthritis of the talocrural joint (TC joint, tibiotalar joint) is nearly always a secondary occurrence. Depending on its severity, it can be treated surgically by arthroscopic debridement, osteotomy (tibia and calcaneus), distraction arthroplasty (not commonly used everywhere), an endoprosthesis or arthrodesis. The long-term results of endoprosthesis and arthrodesis are similar, and such last-resort treatment should be chosen individually for each patient.
  • Osteoarthritis of the talocalcaneal (subtalar) joint develops readily after calcaneal fracture. Pain and oedema typically occur laterally underneath the malleolus, and symptoms get worse when moving on uneven ground. Surgically, such osteoarthritis can be treated by arthrodesis, today mainly arthroscopically.
  • In the central foot, tarsometatarsal (TMT) osteoarthritis is very common and can be seen fairly well on X-ray. The typical symptom is pain occurring in the central foot, often also in the sole of the foot, that gets worse when pushing off the foot. Surgical treatment consists of arthrodesis of the affected joints.
  • Osteoarthritis of the first metatarsophalangeal (MTP) joint is called hallux rigidus. There the range of joint motion is gradually restricted, and an osteophyte ridge grows on top of the joint. Surgical treatment can be considered if difficult symptoms persist despite conservative treatment. Depending on the severity of the disease, either arthroscopic debridement, osteotomy shortening the first metatarsal bone, endoprosthesis or arthrodesis can be used.
  • Surgical treatment of osteoarthritis of other MTP joints consists of open debridement, osteotomy of metatarsal bones and endoprostheses. Distal osteotomy of metatarsal bones or arthrodesis should not normally be used. The most common form of osteoarthritis of small MTP joints is a sequela of Freiberg's disease most commonly occurring in the second ray.
  • Osteoarthritis of the small toe joints (IP joint of the hallux, PIP or DIP joints of other toes) is rare and can be treated surgically by arthrodesis.

Painful forefoot (anterior metatarsalgia)

  • Metatarsalgia is a symptom, not a diagnosis, and it may have several different causes. Pain at the ball of the foot is a very common reason for seeing a doctor. In addition to clinical examination, at the very least X-ray and also MRI are often needed for differential diagnosis.
  • Problems associated with overloading the first ray of the foot, such as hallux valgus Hallux Valgus, cause what is called transfer metatarsalgia, i.e. pain on bearing weight on the ball of the foot.
  • A cavovarus foot, or foot with a high arch, is often associated with placing excessive weight on the ball of the foot and hammer toe malposition.
  • Inflammatory disorders cause synovitis and destruction of MTP joints but pain and oedema of the second MTP joint, in particular, is often due to strain and sometimes to osteoarthritis.
  • Stress fractures of metatarsal bones are fairly common and may develop from very little strain or very little change in the level of strain.
  • Morton's neuroma (neuralgia) means entrapment of interdigital nerves most commonly occurring between the third and fourth and, more rarely, second and third metatarsal bones. It is not a true neuroma, and the aetiology of entrapment is unclear. The most common symptom is electric shock-like pain at the ball of the foot that gets worse with strain and from wearing shoes, and often radiates to the toes. The condition often gets gradually worse over the years. The diagnosis is made by ENMG. Glucocorticoid injections can be tried but the only effective treatment is surgical excision of the affected nerve. This will lead to reduced cutaneous sensation in the affected toes.
  • Pain at the front of the foot hardly ever stems from tendons, except in people with rheumatic diseases.

Malposition and pain

  • There is normally quite extensive individual variation in the shape of the ankle and the foot. Therefore, speaking about malposition is slightly misleading. However, the shape of the foot defines how the load is distributed and must therefore be considered when examining patients with foot pain. The shape of the foot may be very clearly visible but, in some cases, only a standing X-ray will give a definite idea of its shape.
  • In a cavovarus foot with a high arch, the line of the back of the foot is in the varus position and the longitudinal arch is high. In a cavovarus foot, the load is typically distributed into the area of the heel, ball of the foot and lateral foot. Examples of typical conditions include recurrent ankle sprains, strain on the peroneal tendons, Achilles tendon and heel pain, pain at the ball of the foot, stress fractures of lateral metatarsal bones, and hammer toes. In case of major malposition, in particular, hereditary neuropathy may be involved, and ENMG should therefore be carried out. In case of neuropathy, the malposition is progressive.
  • In planovalgus, or flat foot, the back of the foot is in a pronounced valgus position, the longitudinal arch is low, and the front of the foot is abducted, i.e. turned outward. Instead of planovalgus, the name progressive collapsing foot deformity (PCFD) is now recommended for symptomatic cases. The most common symptoms are pain and oedema of the ankle and medial foot, as medial structures, often the posterior tibial tendon, are strained.

Possible causes of pain in the ankle area listed by location

LocationDiagnosisNotes
LateralTenosynovitis, tendinosis and degenerative tears of peroneal tendonsSymptoms consist of pain and oedema laterally in the ankle along the peroneal tendons. There may sometimes be a history of ankle sprain associated with a tendon tear. The diagnosis can be made by MRI. Treatment is primarily conservative (such as reducing the strain, cold therapy and, for varus ankles, also insoles) but patients with difficult symptoms should be referred for assessment for operative treatment.
Osteoarthritis of the subtalar jointSee here.
Stress fractures of the calcaneusPain, oedema and heat laterally in the heel. The diagnosis is evident even clinically due to the clear symptoms. The development of this condition requires a history of clear strain.
CoalitionGrowth disturbances with an abnormal coalition developing between two bones. May cause restriction of movement or pain in the talocalcaneal joint. Coalition is most commonly situated between the calcaneus and the navicular bone, with symptoms typically occurring laterally in the area of the tarsal sinus. Treatment consists of surgical removal of the coalition.
MedialStrain symptoms associated with flat foot, including tenosynovitis, tendinosis and tears of the posterior tibial tendonSee here.
Medial instability of the ankleA sequela of deltoid and/or spring ligament injury. Causes medial pain particularly when pushing off the foot. Clinically, the affected ankle can be found to ‘give way' medially under strain more than the healthy ankle. Surgical treatment should be considered.
Tarsal tunnel syndrome, or syndroma canalis tarsiTibial nerve entrapment. Causes pain and numbness medially in the ankle and in the sole of the foot. There is tenderness along the course of the nerve, and Tinel's test may produce electric shock sensations. The entrapment is usually found by ENMG and treated surgically. See also Heel Pain.
Os tibiale externumAn accessory bone developing during growth at the attachment of the posterior tibial tendon at the medial aspect of the navicular bone. Very common and often asymptomatic. The symptoms, pain and friction symptoms, may start from trauma or without a cause in adulthood. Symptomatic bones can be removed surgically.
PosteriorAchilles tendon problemsSee Achilles Tendinopathy and Tendon Rupture.
Impingement or narrowness of the posterior ankleOften posteromedial pain or snapping particularly when extending the ankle. Sometimes restricted range of movement of the big toe as the flexor hallucis longus tendon is entrapped at the back of the ankle. There may be an accessory bone called os trigonum. May cause symptoms without a reason (common in dancers) or as a result of trauma, particularly one involving overextension of the ankle. Can be treated surgically by arthroscopic debridement and excision of the accessory bone.
AnteriorTalocrural joint problems
Damaged cartilage
OCD
Osteoarthritis
Anterior impingement after trauma, for example
Osteoarthritis of the talonavicular jointSee here.
Tenosynovitis and tendinosis of the anterior tibial tendonFairly rare. Anteromedial pain and oedema extending to the distal tendon. Spontaneous total rupture is possible, the distal end of the tendon withdrawing to the level of the ankle joint and forming a resistance there. The ankle dorsiflexor loses strength, the foot starting to slap. Usually requires surgical correction.

    References

    • Choudhary S, McNally E. Review of common and unusual causes of lateral ankle pain. Skeletal Radiol 2011;40(11):1399-413. [PubMed]
    • Coughlin MJ, Saltzman CL, Anderson RP (Editors). Mann's surgery of the foot and ankle. 9th Edition. Elsevier Saunders 2014. ISBN:978-0-323-07242-7.
    • Myerson MS, Thordarson DB, Johnson JE et al. Classification and Nomenclature: Progressive Collapsing Foot Deformity. Foot Ankle Int 2020;41(10):1271-1276. [PubMed]
    • Ruiz R, Hintermann B. Clinical Appearance of Medial Ankle Instability. Foot Ankle Clin 2021;26(2):291-304. [PubMed]
    • Sharpe BD, Steginsky BD, Suhling M et al. Posterior Ankle Impingement and Flexor Hallucis Longus Pathology. Clin Sports Med 2020;39(4):911-930. [PubMed]

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