Foot and ankle pain

Last updated: July 21, 2026

Summary

Foot and ankle pain can be caused by a wide range of common musculoskeletal and nonmusculoskeletal conditions. Etiologies include overuse, infections, and underlying systemic diseases such as osteoarthritis and gout. Skin conditions that commonly affect the feet include warts and dermatophyte infections. Diagnosis is usually clinical, based on history and physical examination; imaging (e.g., x-rays for suspected musculoskeletal etiologies) and laboratory studies (e.g., inflammatory markers, serum uric acid level) may be performed in selected cases. Treatment is tailored to the specific condition (e.g., activity modification, appropriate footwear, physical therapy, analgesia).

Congenital and acquired foot deformities (e.g., pes planus, clubfoot, calcaneal spur) are discussed elsewhere.

Etiology

Musculoskeletal ^[1]^[2]^[3]^[4]^[5]^[6]

Ankle
- Ankle sprain
- Chronic lateral ankle instability
- Osteochondral lesion of the talus
- Ankle impingement syndromes
Hindfoot
- Plantar
  - Plantar fasciitis
  - Calcaneal and talar stress fractures
  - Heel pad syndrome
  - Heel spur
- Posterior
- Other/deep: tarsal coalition
Midfoot
- Osteoarthritis
- Tendinopathy (e.g., posterior tibial, flexor digitorum longus, peroneal)
- Tarsal tunnel syndrome
- Sinus tarsi syndrome
- Symptomatic accessory ossicles
- Navicular stress fracture, avascular necrosis (Kohler disease)
- Jones fracture
- Lisfranc fracture
Forefoot
- Metatarsalgia
- Hallux rigidus
- Hallux valgus
- Metatarsal stress fracture
- Sesamoiditis
- Plantar plate injury
- Intermetatarsal bursitis
- Metatarsal avascular necrosis

Osteoarthritis of the foot most commonly affects bones in the forefoot and midfoot. ^[7]^[8]

Nonmusculoskeletal ^[1]^[4]

Inflammatory
Infectious
- Cellulitis, erysipelas ^[10]
- Osteomyelitis
- Septic arthritis ^[11]
Neurologic
- Diabetic peripheral neuropathy ^[12]
- Lumbar radiculopathy
- Charcot neuroarthropathy ^[13]
- Complex regional pain syndrome ^[5]
- Morton neuroma
- Entrapment neuropathy (e.g., of the lateral plantar nerve)
Vascular ^[14]^[15]
- Peripheral artery disease
- Chronic venous disease
Dermatologic
Neoplastic
- Benign bone tumors (e.g., osteoid osteoma)
- Primary malignant bone tumors (e.g., Ewing sarcoma, chondrosarcoma)

Clinical evaluation

Focused history ^[4]^[16]^[17]

Inciting factor or injury
Functional impairment (e.g., inability to weight-bear)
Associated symptoms (e.g., swelling, stiffness, claudication, numbness)
Fluoroquinolone use ^[1]
Constitutional symptoms
Past medical history
- Osteoarthritis
- Systemic illness (e.g., diabetes, gout)
- Previous foot or ankle surgery

Focused physical examination ^[4]^[16]^[17]

Skin, nail, and neurovascular examination
Toe or foot deformities (e.g., hallux varus, pes planus)
Focused examination of sensation (e.g., monofilament test)
ROM and muscle strength assessment
Examination of gait

Diagnostics

Imaging ^[3]^[5]
- Acute trauma
  - Assess the need for imaging using Ottawa ankle and foot rules.
  - See also "Sports injuries" and "Management of trauma patients."
- Chronic pain: Consider imaging based on the suspected etiology.
Laboratory studies: Obtain based on clinical suspicion. ^[18]^[19]^[20]^[21]
- Inflammatory markers (e.g., WBC, CRP, ESR): for suspected osteomyelitis or gout
- Blood cultures: for suspected osteomyelitis
- Serum uric acid level: for suspected gout
- Blood glucose, HbA1c: for diabetic foot
- Diagnostics in polyneuropathy

X-rays are usually appropriate as an initial study in chronic foot and/or ankle pain of unknown cause. ^[3]^[5]

Common causes

Muskuloskeletal

Common causes of musculoskeletal foot and ankle pain ^[4]
Location	Condition	Characteristic clinical features	Diagnostics	Management
Forefoot	Bunions (hallux valgus) ^[22]	Lateral deviation of the first toe at the MTP joint Prominent first metatarsal head Pain and swelling over the first MTP joint	Clinical diagnosis X-rays: angulation of the first metatarsal and first phalanx	Footwear with a wide toe box Analgesia Surgery if conservative management is unsuccessful See "Hallux valgus" in "Toe deformities."
	Hammer toes ^[23]	Proximal interphalangeal joint flexion ± distal interphalangeal joint extension or MTP joint hyperextension	Clinical diagnosis Weight-bearing x-rays: to assess for other foot deformities	Extra-depth footwear Management of concurrent conditions (e.g., diabetes mellitus, PAD) Surgery if conservative management is unsuccessful or to prevent skin complications See "Hammer toes" in "Diabetic foot."
	Hammer toes ^[23]
Forefoot and midfoot	Osteoarthritis (e.g., hallux rigidus) ^[7]^[8]	Pain worsened by weight-bearing and push-off during walking Joint stiffness and reduced ROM Swelling	Clinical diagnosis X-rays (for atypical features or diagnostic uncertainty): irregular joint space narrowing, osteophytes, subchondral sclerosis See "Diagnosis of osteoarthritis."	Avoidance of exacerbating activities (e.g., running, jumping) Rigid orthotic inserts and/or stiff-soled shoes Analgesia See "Treatment of osteoarthritis."
Midfoot	Tarsal tunnel syndrome ^[1]^[24]	Neuropathic pain, paresthesias, numbness in the area innervated by the posterior tibial nerve Symptoms worsen with standing and activity.	Clinical diagnosis Provocative tests Tinel sign Dorsiflexion with eversion of the foot X-rays: to evaluate for underlying bony etiology Ultrasound or MRI: to confirm compression of the posterior tibial nerve or its branches See "Diagnosis of tarsal tunnel syndrome."	Activity modification Physical therapy Orthotic shoes Analgesia (e.g., topical or oral NSAIDs) Ultrasound-guided corticosteroid injections Surgery if conservative management is unsuccessful See "Treatment of tarsal tunnel syndrome."
Hindfoot	Plantar fasciitis ^[25]^[26]	Stabbing, nonradiating pain at the heel and sole of the foot Pain worsens after inactivity. Tenderness at the calcaneal insertion of the plantar aponeurosis	Clinical diagnosis Provocative test: windlass test Imaging, e.g., x-rays, ultrasound, MRI (for diagnostic uncertainty): may show bone spurs, plantar fascia thickening, and/or edema at the calcaneal insertion See "Diagnosis of plantar fasciitis."	Stretching and strengthening exercises Orthotic insoles and heel cups Analgesia Extracorporeal shockwave therapy, corticosteroid injections, and/or surgery if conservative management is unsuccessful See "Treatment of plantar fasciitis."
	Achilles tendinopathy ^[26]^[27]^[28]	Posterior heel pain that worsens with load-bearing activity Swelling along the tendon Thickening and tenderness of the tendon on palpation	Clinical diagnosis Provocative test: Royal London test, positive arc sign Imaging, e.g., x-rays, ultrasound, MRI (for diagnostic uncertainty): may show tendon thickening and/or calcifications at tendon insertion	Relative rest and ice Physical therapy Orthotic braces Analgesia (e.g., topical or oral NSAIDs) See "Achilles tendinopathy."
	Achilles tendinopathy ^[26]^[27]^[28]
Ankle	Ankle sprain ^[2]	Soft tissue swelling and tenderness Reduced ROM Increased joint laxity and prominent talus Impaired weight-bearing and/or antalgic gait Possible hematoma	Ligament integrity tests: e.g., ankle anterior drawer test Imaging X-rays (based on Ottawa ankle rules): normal or soft tissue swelling around the ankle MRI: for persistent symptoms and/or chronic instability	POLICE principle Analgesia Functional support (e.g., ankle brace) or immobilization depending on severity See "Ankle sprains."

Nonmusculoskeletal

Common causes of nonmusculoskeletal foot and ankle pain
Condition	Characteristic clinical features	Diagnostics	Management
Gout (podagra) ^[19]^[29]	Sudden-onset severe pain, typically at night Erythema, warmth, swelling at the first MTP joint Reduced range of motion (ROM) Possibly risk factors for gout (e.g., consumption of purine-rich foods or alcohol)	Clinical diagnosis: diagnostic rule for acute gout Synovial fluid analysis (for diagnostic uncertainty and/or to rule out septic arthritis): monosodium urate crystals Blood tests: hyperuricemia, ↑ inflammatory markers Imaging Ultrasound: acute joint inflammation, bone erosions, tophi X-rays: normal in acute gout; punched-out lytic bone lesions in chronic gout See "Diagnosis of gout."	Rest and ice Pharmacological treatment for acute gout (e.g., NSAIDs, colchicine, glucocorticoids) Lifestyle modifications Consideration of urate-lowering therapy See "Treatment of gout."
Polyneuropathy ^[20]^[30]	Neuropathic pain, paresthesias (e.g., burning feet syndrome) Sensory loss in stocking-glove distribution Possible ulceration and/or infection	Monofilament testing: ↓ sensation Nerve conduction studies: abnormal See "Diagnosis of polyneuropathy."	Treatment of underlying conditions (e.g., optimization of glycemic control) Analgesia for peripheral neuropathy See "Management of diabetic peripheral neuropathy" and "Treatment of polyneuropathy."
Peripheral arterial disease (PAD) ^[14]	Intermittent claudication Rest pain (in advanced disease) Trophic changes in PAD Absent or diminished pulses Arterial ulcers	Provocative test: positive Buerger sign Ankle-brachial index (ABI): ↓ Additional testing (e.g., for nondiagnostic ABI) Exercise ABI Toe-brachial index with waveforms Measures of tissue perfusion Imaging, e.g., MR angiography with IV contrast (for diagnostic uncertainty or planned intervention): arterial stenosis See "Differential diagnosis of leg ulcers" and "Diagnosis of PAD."	Management of ASCVD, including antithrombotic therapy Structured exercise therapy Wound management If insufficient improvement: cilostazol and/or revascularization See "Treatment of PAD."
Chronic venous disease ^[15]	Lower limb pruritus, tingling, and/or numbness Peripheral edema Yellow-brown or red-brown skin pigmentation Varicose veins Venous ulcers	Venous duplex ultrasound Evidence of venous reflux Ultrasound features of DVT Additional studies (for complications, diagnostic uncertainty, and/or planned interventions) Thrombophilia panel Venous plethysmography Abdominal/pelvic ultrasound; CT or MR venography See "Differential diagnosis of leg ulcers" and "Diagnosis of chronic venous disease."	Lifestyle modifications Venous compression therapy Interventional therapies (for symptomatic varicose veins, edema, skin changes, and/or ulceration) Vein ablation therapies Surgery (e.g., ambulatory phlebectomy) Endovascular recanalization See "Treatment of chronic venous disease."
Dermatophyte infections (e.g., tinea pedis, tinea unguium) ^[31]^[32]	Pruritic, erythematous scaling and erosions between the toes and/or on the soles Thickened, discolored, brittle nails	Clinical diagnosis Confirmatory studies include: KOH test: hyphae, spores Fungal culture NAAT See "Diagnosis of dermatophyte infections."	Foot hygiene Topical antifungal therapy for dermatophyte infections Severe infection and/or tinea unguium: systemic antifungal therapy for dermatophyte infections See "Tinea pedis" and "Tinea unguium" in "Dermatophyte infections."
Morton neuroma ^[26]	Burning pain and numbness on plantar surface between involved metatarsal heads Worsens with constrictive footwear, weight-bearing, and/or toe stretching Sensation of walking on a pebble	Clinical diagnosis Provocative tests: Mulder sign, Tinel sign Imaging, e.g., ultrasound or MRI (for diagnostic uncertainty): well-circumscribed, hypoechoic mass at the metatarsal head See "Diagnosis of Morton neuroma."	Activity modification Properly fitting footwear with padding Orthotics Corticosteroid injections or surgical excision if conservative management is unsuccessful See "Treatment of Morton neuroma."
Corns and calluses ^[4]^[33]	Corns Circumscribed horny papule or nodule with a lighter-colored cone-shaped keratin center Tender to palpation Calluses Poorly defined areas of thickened skin Possibly painful cracks and/or fissures	Clinical diagnosis Biopsy (for diagnostic uncertainty) See "Diagnosis of corns and calluses."	Warm water soaks followed by exfoliation Moisturizing lotions, creams, and/or emollients Topical keratolytics Large and/or painful lesions: surgical management See "Treatment of corns and calluses."
Plantar warts ^[4]^[34]	Hyperkeratotic papules or plaques on the soles of the feet	Clinical diagnosis Biopsy (for diagnostic uncertainty) See "Diagnosis of cutaneous warts."	Consider watchful waiting. Topical salicylic acid Cryotherapy Dermatology referral if refractory See "Treatment of cutaneous warts."

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