Foot Pain

Differential Diagnosis

Common Diagnoses

Occasional Diagnoses

Rare Diagnoses

  • March Fracture
  • Sever’s Disease (Apophysitis of the Calcaneus), Usually a Problem of Adolescence
  • Osteochondritis: Navicular = Köhler’s Disease; Head of Second or Third Metatarsal = Freiberg’s Disease
  • Osteomyelitis and Septic Arthritis
  • Erythromelalgia and Painful Polyneuropathy
  • Ischaemia

Ready Reckoner

Key distinguishing features of the most common diagnoses

GoutVerrucaBunionIGTNPlantar Fasciitis
Forefoot PainYesPossibleYesYesNo
Very Tender Joint(s) YesNoPossibleNoNo
Pain at RestYesNoNoPossibleNo
Tender HeelNoPossibleNoNoYes
Sudden OnsetYesNoNoPossiblePossible

Possible Investigations

Likely:None.

Possible:Urinalysis, FBC, ESR/CRP, rheumatoid factor/anti-CCP antibodies, uric acid, X-ray.

Small Print:Bone scan, angiography.

  • Urinalysis may reveal glycosuria in previously undiagnosed diabetic with neuropathy (suspicion of neuropathy may in itself require further investigations).
  • FBC/ESR/CRP: Raised WCC and ESR/CRP in infection and severe inflammation.
  • Rheumatoid factor: Of prognostic help if foot pain is part of clinical diagnosis of rheumatoid arthritis (consider anti-CCP antibodies if negative).
  • Uric acid: If gout suspected, especially with recurrent attacks and if considering prophylaxis.
  • X-ray useful if suspect possible arthritis, osteomyelitis, march fracture, osteochondritis, radio-opaque foreign body. If clinical suspicion high and X-ray unhelpful, bone scan may be more useful.
  • Angiography: If ischaemic foot with rest pain.

Top Tips

  • The vast majority of causes are obvious from the history or from a cursory examination. The harder you have to think, the more likely that there may be an obscure cause requiring investigation.
  • It can be difficult to distinguish gout from a severely inflamed bunion. With gout, the patient may have had previous episodes, the onset tends to be sudden, the joint is extremely tender and joint movements are very limited.
  • Important pointers can be picked up in the history, especially for some of the less common causes. Thus, Morton’s neuroma causes a sharp pain often radiating to the third and fourth toes, relieved by removing the shoe; plantar fasciitis is described as ‘walking on a pebble’, especially after resting; and a march fracture results in a pain which initially comes on predictably with exercise and which then becomes continuous, with local bony tenderness and possibly a lump.

Red Flags

  • If a known arteriopath complains of pain in the ball of the foot disturbing sleep then the diagnosis is probably critical ischaemia. Refer urgently.
  • Fever and systemic illness with localised extreme bone pain and signs of local infection is acute osteomyelitis or septic arthritis until proved otherwise. Admit.
  • Pain with no obvious signs – particularly tenderness – in the foot suggests ischaemia, neuropathy or an L5/S1 nerve root lesion.
  • If no cause is evident but the patient has very localised sole tenderness away from the heel, consider a foreign body.

Published: 2nd August 2022 Updated: 10th April 2024

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Based on the best-selling book Symptom Sorter, Nursing in Practice Reference is designed to help nurses working in primary and community care make sense of patient presentations. Written by GPs and adapted by nurses, it covers the vast majority of symptoms seen in primary care to inform different nursing disciplines with a range of responsibilities. Each symptom is organised into common, occasional or rare differentials, with distinguishing features, possible investigations and key points. It also provides guides on managing more than 350 conditions. The perspective is very much grass roots primary care, informed by the latest evidence and guidance.

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Disclaimer

Nursing in Practice Reference is based on the best-selling book Symptom Sorter. The experts behind Nursing in Practice Reference are Marilyn Eveleigh who is Nursing in Practice’s editorial advisor and a primary care nurse in East Sussex, Dr Keith Hopcroft who is the co-author of Symptom Sorter, a GP in Essex and Pulse editorial advisor and Dr Poppy Freeman, a GP in Camden and also a clinical advisor to Pulse.