Foot and Ankle Pain
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When approaching foot and ankle complaints, first be certain to rule out missed fractures or incomplete rehabilitation of a previous ankle sprain.
Common causes of ankle pain include plantar fasciitis, acute and chronic ankle sprain, chronic lateral ankle pain (due to tendonitis and/or incomplete rehabilitation of an old ankle sprain), Achilles tendonitis, lateral ankle pain due to peroneal tendonitis, medial ankle pain due to shin splints and posterior tibial tendonitis (also called tarsal tunnel syndrome), bunions, and gout. Uncommon causes include missed medial or lateral malleolus fracture, unhealed fifth metatarsal fractures, and navicular fractures.
Pain on plantar surface, usually at the calcaneal insertion of plantar fascia, pain increased upon initial weight bearing, especially in the morning or on initiation of walking after prolonged rest.
Due to degenerative change of plantar fascia at origin on medial tuberosity of calcaneus, and related to obesity, flat feet (pes planus), tight heel cord, and/or lack of mobility of tibialis anterior and in the lower leg from fascial adhesion.
Soft Tissue Mobilization of Plantar Fascia
Tibialis Anterior Mobilization
Palpate just lateral to the tibia (along tibialis anterior) for tender points.
Using your hand or a ball, hold the tender point in place, and ask the patient to plantar flex and dorsiflex the foot 10 times.
Repeat this process just medial to the tibia.
If this movement causes any distal paresthesias, apply less pressure before continuing.
Active Release for Plantar Fasciitis
The patient sits with the leg straight.
While you apply pressure to the tender spots on the distal calcaneus and plantar fascia, ask the patient to bend the toes down, or plantar flex the toes, while keeping the knee flat on the table.
Hold the toes in resistance while asking the patient to dorsiflex the toes, then relax.
Move gradually along the plantar fascia repeating the process of toe plantar flexion, holding pressure on the tender spots, then dorsiflexion against resistance.
Navicular Sling for Plantar Fasciitis
Have the patient keep the foot and ankle relaxed.
Anchor athletic tape just inferior to the lateral malleolus, then apply it to the plantar aspect of the foot along the calcaneus.
While grasping the calcaneus, move the foot into inversion as far as you can without causing pain, and pull with the tape, moving the foot into further inversion.
Attach the tape over the medial aspect of the foot and then across the anterior aspect of the mid foot.
Repeat the process with a second length of tape covering the first piece of tape, again by inverting the foot and pulling the foot into inversion with the tape.
Self-massage with a frozen bottle of water
Weight reduction if body mass index is greater than 25
Orthotics and plantar fasciitis straps: beneficial in combination with a short course of nonsteroidal anti-inflammatory drugs (NSAIDs)
Night splints: can be initially uncomfortable; better tolerated over time
Foam roller or tennis ball to areas just lateral and medial to tibia
ACUTE LATERAL ANKLE SPRAIN
Inversion injury of the ankle is the most common ankle sprain, involving the anterior talofibular ligaments. X-rays are not needed unless it meets the requirements of the Ottawa Rules.
Ottawa Rules. For those aged 18 to 50 years, an ankle x-ray series is required only if there is:
Bone tenderness at the posterior edge or tip of the lateral malleolus
Bone tenderness at the posterior edge or tip of the medial malleolus
Bone tenderness at the base of the fifth metatarsal
Bone tenderness at the navicular
An inability to bear weight both immediately after the injury and in the emergency department for four steps (Figure 13-1)
Spiral Tape for Acute Inversion Sprain
Cut a strip of athletic tape 1½ times around the ankle.
Place the foot in a neutral position.
Apply the tape starting anterior to and just superior to the lateral malleolus, having the malleolus visible inferior to the tape.
Mobilize the distal fibula posteriorly and up with your thumb.
Pull the tape superiorly at 45-degree angle, then posteriorly up and around the ankle and secure it to the anterior leg just above the ankle, but do not let the tape contact the beginning end.
Rub the tape to help the adhesive attach.
Apply a second piece of tape over the first, again starting at the lateral side of the ankle.
Mobilize the distal fibula posteriorly and up, and pull on the tape while applying it again over the first piece of tape.
Painful inflammation of Achilles tendon (Figure 13-2) and its sheath due to chronic degenerative tendinosis and tearing
Pain and swelling along tendon with noninsertional pain and tenderness are most common.
Calf Stretch for Achilles Tendonitis or Peroneal Tendonitis