the painful foot

see also:

• orthopaedics in the ED
• the injured foot
• ankle injuries and fractures

• there are many common causes to foot pain
• emergent causes to be considered include:
  • osteomyelitis - common in children as haematogenous spread, in others compound fracture is a more common cause
  • septic arthritis
  • acute gout
  • cellulitis
  • gas gangrene
  • ischaemic foot - see peripheral vascular disease (PVD or PAD)
  • the the diabetic foot - infection or foot ulcers
    • 15% of cases of necrotizing fasciitis may be due to foot ulcerations and infections associated with diabetes
  • fracture
  • snake bite - although often minimal pain at bite site from Australian snakes
  • foreign body / penetrating injury

• bunion pain
• blisters, corns and calluses
• papilloma
• tinea pedis
• cellulitis
• septic arthritis
• osteomyelitis
• metatarsalgia:
  • OA MTP jts from chronivc progressive clawing of 2nd-4th toes
  • MTP joint inflammatory arthritis - gout, rheumatoid arthritis, psoriasis
  • MTP joint osteoarthritis - usually of 1st MTP and is commonly associated with primary nodal OA of DIPjts of hands
  • intermetatarsal bursitis
  • Freiberg's disease - osteochondritis of a metatarsal head (usually the 2nd or 3rd) in adolescents
  • sesamoiditis
• foreign body
• ingrown toenail
• Morton's neuroma
• stress fracture metatarsal

• cellulitis
• septic arthritis
• osteomyelitis
• foreign body
• chronic pronation causes:
  • OA of tarsal joints
• fractures:
  • stress fracture:
    • NB. early stages are “stress reactions” and will need MRI or bone scan to detect
    • base metatarsal
    • cuboid (isolated stress fractures of the cuboid are rare)
      • less common than fractures in other tarsal bones such as calcaneus and navicular because the cuboid is not a weight-bearing bone but may be a result of overuse affecting athletes or military recruits, or in those with oesteoporosis
      • may be associated with lateral foot pain especially with push off when walking but may have no obvious clinical signs - a vibrating tuning fork placed on area of maximal tenderness may increase pain intensity and may be a diagnostic aid, while XRay +/- CT and /or MRI may be needed to diagnose it ¹⁾
      • the “Nutcracker” provocation test in which the examiner stabilizes the calcaneus while the forefoot is abducted, compressing the cuboid between the calcaneus and the base of the fourth and fifth metatarsals may produce pain is specific for this injury ²⁾
  • fracture base 5th MT / Jone's fracture, LisFranc fracture
  • navicular fracture
• cuboid syndrome
  • due to subluxation of the midtarsal joint; mainly dancers and athletes, sports where there are lots of side-to-side movements, esp. in those with pronated feet; overuse (climbing stairs, poorly fitted shoes) or following an inversion injury of the ankle;
• dorsal foot ganglion
  • usually only uncomfortable but can be painful due to their size (1.5-4cm in diameter), pressure issues with shoes as well as close proximity to medial branch of the deep peroneal nerve which may result in local pain or paraesthesiae of the first interdigital cleft

• cellulitis
• septic arthritis
• osteomyelitis
• foreign body
• plantar fasciitis
• Achilles tendonitis
• Haglund syndrome
• tibialis posterior tenosynovitis
• flexor hallucis longus tenosynovitis
• peroneal tendonitis
• tarsal tunnel syndrome
• Sever's disease (esp. 9-12 yr olds)
• chronic pronation causes:
  • rear foot subluxation and degenerative disease
• fractures
  • calcaneum
  • talus

• around the ankle region
  • lipoma
  • ganglion
  • neuroma
  • CT histiocyte reaction
• calcaneal region
  • rheumatoid nodule
  • schwannoma
  • viral wart
  • cavernous haemangioma
  • calcific tendonitis
  • angioleiomyoma
• dorsum of foot
  • ganglion
  • rarely others such as angioleiomyoma, chondroma, fibroma, inclusion cyst, lipoma, fibrous histiocytoma
• arch of foot
  • plantar fibromatosis
  • neuroma
  • rheumatoid nodule
  • cavernous haemangioma
  • adventitious bursa
• toes
  • ganglion
  • fibroma
  • keratinous horn
  • mucoid cyst
  • neuroma
  • subungal exostosis
  • epidermal cyst
  • neurofibroma
  • osteoid osteoma
  • osteophyte
  • plexiform fibrohistiocytic tumour
  • tenosynovial giant cell tumour
  • tophaceous gout
  • intradermal naevus
  • spindle lipoma
  • chondroma
• see https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1964714/

• see localised rashes