Diagnostic Approach to Foot Pain

Initial Evaluation and Imaging

The American College of Radiology recommends starting with plain radiographs of the foot as the initial imaging study for any chronic foot pain of unknown etiology, as this is the most cost-effective approach that identifies the majority of structural causes 1, 2
Standard three-view radiographs (anteroposterior, oblique, lateral) should be obtained as the first imaging study for any chronic foot pain, with radiographs having 80-100% sensitivity for tarsal coalitions and 80-100% sensitivity for toe fractures, but only 12-56% sensitivity for stress fractures 1, 5

Plantar fasciitis is the most common cause of plantar heel pain, presenting with pain on weight-bearing and when transitioning from sitting to standing 3
Plantar fascia tear should be considered with acute onset of severe pain 2
Baxter's neuropathy (inferior calcaneal nerve entrapment) manifests as denervation changes of the abductor digiti minimi muscle and causes burning heel pain 2
Tarsal coalitions (calcaneonavicular or talocalcaneal) can be detected on radiographs with 80-100% sensitivity for calcaneonavicular and 100% sensitivity for talocalcaneal coalitions 1
Occult stress fractures of the navicular, cuboid, or cuneiform bones require high clinical suspicion 2

Diabetic foot infection requires evaluation for at least 2 classic signs of inflammation (erythema, warmth, tenderness, pain, induration) or purulent secretions 6
Osteomyelitis is often difficult to diagnose and requires high clinical suspicion 6
Charcot arthropathy requires specialized evaluation 1

For suspected stress fractures or CRPS, order MRI foot without IV contrast or 3-phase bone scan as equivalent next-step options 2
For plantar fasciitis or plantar fascia tear, order MRI foot without IV contrast or ultrasound foot as equivalent options 2
For entrapment syndromes (Baxter's neuropathy), order MRI foot without IV contrast to demonstrate denervation changes in the abductor digiti minimi muscle, or ultrasound foot to visualize the nerve 2

Point tenderness location is critical: palpate the Achilles insertion, lateral malleolus, posterior superior calcaneus, lateral calcaneal wall, and calcaneofibular ligament course 4
Calcaneal squeeze test (medial-to-lateral compression) suggests stress fracture 4
Rapid onset of swelling suggests acute ligamentous injury or fracture 4
Pain relieved when walking barefoot but worsened by shoes suggests Haglund's deformity or bursitis 4, 3

Overlooking small avulsion fractures on radiographs requires careful systematic review 5
Failing to obtain weight-bearing views when indicated can miss subtle deformities 5
Reexamining too early: always reexamine 3-5 days post-injury, as excessive swelling and pain can limit the initial examination within 48 hours 4
Missing stress fractures: patients often report increased walking activity before symptom onset, and radiographs may initially be negative 4
Underestimating proper footwear impact on symptom management 5
Missing foreign bodies in cases of penetrating trauma 5