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• Foot and ankle disorders (FAD) are highly prevalent in the general population and are one of the leading motivations for primary care visits.
• Many physicians consider FAD diagnostically challenging and the management daunting.
• On initial approach, the goal is to establish a historical database to characterize the problem, infer the structures involved, and assess prognosis.
• A history should elucidate symptoms, chronicity, pathomechanics, and relevant past medical conditions.
• Epidemiologic factors, such as age, gender, employment, and activities, are of great diagnostic value and help individualize the history, physical examination, and treatment.
• Physical examination findings should be interpreted in the context of overall health, vital signs, and symptoms.
• A head-to-toe inspection is the first step in the physical examination.
• Failing to expose the lower extremities sufficiently is a mistake; patients should be in a gown with shoes and socks removed.
• Footwear patterns provide valuable information and shoes should be evaluated for appropriate fit.
• Plantar foot—typical locations of injury symptoms and selected anatomic structures include plantar fat pad, plantar fasciitis, avulsion fracture of the fifth metatarsal, Jones fracture, stress fracture of the third metatarsal, stress fracture of the second metatarsal, metatarsalgia, sesamoiditis.
• Shoes have not been conclusively linked to injuries.
• A standard radiographic series of the ankle includes an anterior-posterior view, a mortise view, and a lateral view.
• Single events are not significant enough to cause acute problems but the culmination of microscopic damage from repetitive application of force will eventually result in a serious injury.
• Damage occurs from relative overload due to an increased tissue demand but inadequate recovery.
• The elderly are also at increased risk for injuries such as stress fractures due to osteopenia or osteoporosis.
• A very common injury that is frequently missed or mismanaged is the navicular stress fracture (NSF).
• Edema and ecchymosis are usually absent.
• Despite a typically insidious onset, overuse injuries may become abruptly aggravated and misdiagnosed as an acute trauma.
• Dorsal foot and ankle—typical locations of injury symptoms and selected anatomic structures include anterior ankle impingement, osteochondritis dissecans of the lateral talar dome, the N spot—NSF, Lisfranc sprain, anterior tarsal tunnel syndrome, bunionette, bunion, hallux rigidus, avascular necrosis of second metatarsal head (Freiberg infarction), interdigital neuroma (Morton neuroma), and paronychia.
• Underlying medical conditions may increase injury risk, particularly in female patients.
• Patients will experience increased pain with passive eversion, active inversion, toe hopping, and toe standing.
• Female patients should be evaluated for “the Triad” of anorexia, amenorrhea, and osteoporosis.
• All tissue types are susceptible to this mechanism; some common examples include navicular, calcaneal, or metatarsal stress fractures, apophysitis, plantar fasciitis, and Achilles tendinopathies.
• NSF symptoms include a gradual onset of vague, aching pain in the dorsal midfoot that radiates to the medial arch.
• There are 11 target sites on the ankle where fractures occur including the medial and lateral malleoli, anterior tibial tubercle, posterior tibial malleolus, talar dome, lateral talar process, tubercles of the posterior talus process, dorsal to the talonavicular joint, anterior calcaneus process, calcaneal insertion of the extensor digitorum brevis, and the base of the fifth metatarsal bone.
• Most overuse injuries lead to chronic localized pain.
• Ankle sprains are acute and the most frequent injury sustained by young athletes, but most injuries in general are due to chronic overuse.
• A thorough physical examination examines structural integrity through palpation, mobility, and strength testing.
• Many disorders mimic each other on initial presentation and provocative tests help differentiate them.
• Knowledge of common foot and ankle complaints can be diagnosed and managed effectively in the primary care setting.
• Foot and ankle disorders require a thorough and structured history and physical examination with attention to the patient as a whole.
• Knowledge of foot and ankle anatomy and biomechanics is key in successful clinical evaluation and therapeutic considerations.
• Pain, swelling, and dysfunction can originate from disruption of any of these components.
• Areas of reported pain should be assessed last to avoid patient discomfort.
• Deformity, asymmetry, crepitus, tenderness, elasticity, and texture of the palpated structures should be noted.
• Reproduction of symptoms through provocation is necessary to make a diagnosis.
• Knowledge of anatomy is crucial in diagnosing foot and ankle disorders.
• The foot has a minimum of 26 key bones in addition to at least 2 sesamoids, many ligaments stabilizing the joints, fascia, as well as intrinsic and extrinsic musculature.
• Most patients with foot and ankle complaints present with regional pain or discomfort.
• The definitive diagnosis of Charcot-Marie-Tooth disease is made by nerve biopsy or genetic testing.