Ankle and foot pain

An approach that allows a consistent, thorough evaluation can be recommended by a mnemonic using the words ankle/foot. The maxim about foot and ankle pain is that "the good exam begins at the back and ends at the toe." During this exam, the cutaneous, vascular, and neural systems need careful evaluation. The exam is directed to the region of maximal discomfort where careful palpation should pinpoint the spot of greatest tenderness. Once this region has been localized and signs and symptoms collected, consider the differential diagnosis specific for that area. This will narrow the focus, make the number of potential pain sources manageable, and often provide the answer. When the diagnosis is still unclear, obtain standard x-rays of the area. A directed evaluation to probe the region is appropriate. This can mean a bone scan to detect early avascular necrosis, stress fractures or osteomyelitis; an EMG-NCS to assess the neural circuitry; and special x-ray views, CAT scan, NMR, or arthrogram to uncover the difficult fracture. At this point, fortunately, the primary physician is not alone. The diagnostic dilemma or the difficult management case can be referred for a second opinion or therapeutic assistance to a podiatrist, rheumatologist, or the orthopedist with a special interest in feet.