Family medicine
Foot And Ankle Pain
Foot and ankle pain is a common musculoskeletal complaint arising from traumatic, degenerative, inflammatory, or biomechanical disorders affecting the bones, joints, tendons, ligaments, or soft tissues of the foot and ankle complex.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding |
|---|---|---|---|
| Probability Diagnosis | Plantar fasciitis [1][2] | First-step heel pain in morning, improves with walking, tenderness at medial calcaneal tuberosity | 「朝早起身落地頭幾步最痛，行開咗好返？」(First-step pain?) |
| Ankle sprain (lateral ligament) [2] | Inversion injury, swelling/tenderness anterior to lateral malleolus | 「有冇扭親腳？邊度腫？」(Inversion injury history + ATFL tenderness) | |
| Gout (1st MTP) [5] | Acute onset, exquisitely tender, red, swollen 1st MTP, ± history of hyperuricaemia | 「大腳趾公突然又紅又腫又痛？以前有冇驗過尿酸高？」 | |
| Achilles tendinopathy [2] | Gradual posterior ankle pain, worse with activity, tender 2–6 cm above calcaneal insertion | 「腳跟後面痛？行路或者跑步痛啲？」(Posterior heel, activity-related) | |
| Serious Not To Miss | Fracture (stress or acute) | Bony tenderness, unable to weight-bear (Ottawa rules) [2] | 「㩒骨度痛唔痛？企得起嚟行四步嗎？」(Ottawa ankle rules) |
| Septic arthritis / Osteomyelitis [1] | Fever + hot swollen joint + unable to move; risk if DM or immunocompromised | 「有冇發燒？隻腳關節又紅又腫又唔郁得？」 | |
| Peripheral arterial disease [4] | Claudication, rest pain, absent pulses, trophic changes, ABI ≤ 0.9 | 「行路行一段小腿痛，停低好返？腳趾有冇變色？」 | |
| Achilles tendon rupture [2] | Sudden pop + inability to plantarflex, Thompson test positive | 「有冇聽到「啪」一聲？之後踮唔到腳尖？」 | |
| DVT [6] | Unilateral calf swelling, warmth, tenderness; risk factors | 「一隻腳突然腫晒？有冇坐長途飛機或者做完手術？」 | |
| Pitfalls | Morton's neuroma [5] | Forefoot pain between 3rd/4th toes, numbness, worse in tight shoes | 「第3、4隻腳趾中間痛？著窄鞋痛啲？有冇痺？」(Squeeze test +ve) |
| Tarsal tunnel syndrome | Medial ankle burning/tingling radiating to sole; Tinel's at tarsal tunnel | 「腳眼內側有冇痺或者火燒感覺？去到腳底？」 | |
| Posterior tibialis tendon dysfunction (pes planus) [2] | Progressive flat foot, medial ankle pain, unable to single-leg heel rise | 「隻腳有冇越嚟越扁？可唔可以單腳踮起腳尖？」 | |
| Osteochondral lesion of talus [2] | Persistent deep ankle pain after sprain, locking/catching | 「扭親之後一直好唔返？有冇鎖死嘅感覺？」 | |
| Masquerades | Diabetic neuropathy / Diabetic foot [3][7] | Bilateral burning/numbness in stocking distribution, monofilament loss, foot ulcer | 「有冇糖尿病？兩隻腳底有冇痺痺哋或者冇感覺？」 |
| Lumbar radiculopathy (L5/S1) | Back pain radiating to foot, dermatomal numbness, positive SLR | 「有冇腰痛？痛有冇由腰去到腳？」 | |
| Drug-related | Fluoroquinolone → Achilles rupture; diuretics → gout | 「最近有冇食過抗生素（如左氧氟沙星）？」 | |
| Trying to Tell Me Something? | Work/financial stress | Pain preventing work, fear of job loss, compensation claim | 「隻腳痛有冇影響到返工或者收入？」 |
| Health anxiety | Fear of serious disease (cancer, amputation in DM patient) | 「你最擔心呢個痛係咩原因？」 |
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Friendly opening, rapport, agenda setting | 「你好呀！我係今日幫你睇症嘅醫生。你點稱呼呀？」「今日咩嘢唔舒服呀，可以講畀我聽嗎？」 | Interpersonal marks: greeting, using patient's name, open question |
| 0:30–2:00 | HPI: symptom analysis – site, onset, character, radiation, severity, aggravating/relieving factors, timing, associated symptoms | 「隻腳邊度痛呀？幾時開始？」「痛係點樣痛？痺定係𢲱住痛？」「行路會唔會痛啲？著地嗰下最痛定行耐咗先痛？」「有冇扭親過？有冇聽到「啪」一聲？」 | Captures chief complaint and HPI for Case Report; discriminates mechanical vs inflammatory vs vascular |
| 2:00–3:00 | Red flags + targeted systems review – trauma, infection, vascular, neuro, systemic | 「隻腳有冇腫？有冇紅？有冇發燒？」「有冇試過著地行唔到？」「腳趾有冇痺或者無感覺？」「有冇糖尿病或者痛風？」 | Rules out serious disorders; marks for red flags |
| 3:00–3:45 | PMH, Drug Hx, Allergy, FHx, Social Hx | 「你有冇其他長期病？食緊咩藥？有冇藥物敏感？」「屋企人有冇痛風或者關節問題？」「你做咩工作㗎？有冇做運動？」 | Completeness of history; occupational/functional impact for biopsychosocial |
| 3:45–4:30 | ICE + Hidden agenda ("Why today?") | 「你自己覺得呢個痛係咩原因呢？」(Ideas)「你最擔心啲咩？」(Concerns)「你嚟睇醫生最想我幫到你啲咩？」(Expectations)「點解揀今日嚟睇？係咪最近有啲嘢令你特別擔心？」 | Direct marks for ICE; uncovers hidden agenda (e.g. fear of gout/cancer/unable to work) |
| 4:30–5:15 | Focused physical exam description / offer exam | 「我想幫你檢查下隻腳，可以除鞋襪畀我睇下嗎？」「我會輕輕㩒下，痛就同我講。」 | Shows clinical method; identifies supporting physical sign |
| 5:15–6:00 | Summarise, safety-net, close | 「咁即係你隻腳底痛咗兩個禮拜，朝早起身落地最痛，我覺得最大機會係足底筋膜炎。我建議你…」「如果隻腳突然腫好多、又紅又熱、或者發燒，就要即刻返嚟睇急症。」「你有冇嘢想問我？」 | Summarising scores interpersonal marks; safety-net prevents missing serious pathology |
Hidden agenda tip: For foot/ankle pain, common hidden agendas include: fear of gout recurrence, worry about diabetes complications (diabetic foot), concern that they need surgery, inability to work/exercise affecting livelihood, or fear of cancer (bone tumour). Always ask 「點解揀今日嚟睇？」 and 「你最驚係咩嘢？」
| Domain | English Question | Cantonese Question | Why It Matters | If Positive, Think Of |
|---|---|---|---|---|
| Site | Where exactly is the pain? Sole/heel/top/ankle/toes? | 「隻腳邊度痛？腳踭、腳底、腳趾、腳眼位定係腳背？」 | Localises pathology | Heel → plantar fasciitis; 1st MTP → gout; ankle → sprain/OA; forefoot → Morton's neuroma |
| Onset | When did it start? Sudden or gradual? Any injury? | 「幾時開始痛？突然間痛定慢慢嚟？有冇扭親或者撞親？」 | Trauma vs atraumatic; acute vs chronic | Sudden + trauma → fracture/sprain; sudden + no trauma → gout; gradual → overuse/OA |
| Character | What does the pain feel like? Sharp/dull/burning/throbbing? | 「痛係點痛？痺痺哋、實實哋、定係好似火燒咁？」 | Neuropathic vs mechanical vs inflammatory | Burning/tingling → neuropathy; throbbing → gout/infection; aching → OA/overuse |
| Radiation | Does the pain go anywhere else? Up the leg? | 「個痛有冇去到其他位？有冇上到小腿？」 | Referred pain from lumbar spine | Radiating to foot → L5/S1 radiculopathy |
| Severity/function | How bad is it 0–10? Can you walk/work normally? | 「痛到幾分，0分唔痛10分最痛？行到路嗎？返到工嗎？」 | Functional impact → biopsychosocial | Inability to weight-bear → fracture/rupture/severe gout |
| Aggravating | Worse with walking/morning first steps/rest/at night? | 「行路痛啲定休息痛啲？朝早起身頭幾步最痛？夜晚痛唔痛？」 | First-step pain → plantar fasciitis; rest/night pain → red flag (tumour/infection/ischaemia) | Morning stiffness > 30min → inflammatory arthritis; night pain → tumour/ischaemia |
| Relieving | What makes it better? Rest/shoes/painkillers? | 「做啲咩會好啲？休息有冇用？食止痛藥有冇幫到？」 | Response to NSAIDs helps distinguish inflammatory vs mechanical | Good NSAID response → gout/inflammatory; poor response → consider other Dx |
| Swelling/redness | Any swelling, redness, warmth? | 「有冇腫？有冇紅或者熱？」 | Signs of inflammation/infection | Swollen + red + hot → gout, septic arthritis, cellulitis |
| Trauma/MOI | Did you twist your ankle? Hear a pop? | 「有冇扭親？有冇聽到「啪」一聲？」 | Ligament sprain vs Achilles rupture vs fracture [2] | Pop + unable to heel-raise → Achilles rupture |
| Locking/giving way | Does your ankle give way or lock? | 「隻腳有冇試過突然軟低或者鎖死咗？」 | Instability vs loose body | Giving way → chronic ankle instability; locking → osteochondral lesion |
| Numbness/tingling | Any numbness or pins-and-needles in feet? | 「腳趾有冇痺或者針拮嘅感覺？」 | Neuropathy → DM, tarsal tunnel, radiculopathy [3] | Glove-stocking → diabetic peripheral neuropathy |
| Red flags: fever | Any fever or chills? | 「有冇發燒或者打冷震？」 | Septic arthritis, osteomyelitis | Fever + hot swollen joint → urgent referral |
| Red flags: weight loss | Any unexplained weight loss? | 「有冇無啦啦瘦咗好多？」 | Malignancy | Night pain + weight loss → bone tumour |
| Claudication | Pain in calf when walking that goes away when you stop? | 「行路行一段小腿會唔會痺痛，停低就好返？」 | Peripheral arterial disease [4] | Claudication distance → PAD |
| PMH | Any diabetes, gout, high uric acid, RA, psoriasis? | 「你有冇糖尿病、痛風、類風濕、或者銀屑病？」 | Guides DDx enormously | DM → diabetic foot/neuropathy; gout → acute monoarthritis |
| Drug Hx | Taking any medications? Diuretics? Fluoroquinolones? | 「食緊咩藥？有冇食去水丸、抗生素（如沙星類）？」 | Diuretics → precipitate gout; fluoroquinolones → Achilles tendon rupture [2] | |
| Occupation | What work do you do? Standing all day? | 「你做咩工作？需唔需要企成日或者行好多路？」 | Occupational overuse; functional impact | Prolonged standing → plantar fasciitis; manual labour → unable to work |
| Exercise/sport | Do you play sports? Running? | 「你有冇做運動？跑步？打波？」 | Overuse injuries, stress fracture | Running → stress fracture, Achilles tendinopathy |
| Footwear | What shoes do you wear? Any new shoes? | 「你著咩鞋？有冇著高踭鞋或者新鞋？」 | Poor footwear → plantar fasciitis, metatarsalgia [1] | |
| Alcohol | Do you drink alcohol? How much? | 「你飲唔飲酒？飲幾多？」 | Alcohol → gout precipitant | |
| Family Hx | Any family history of gout or arthritis? | 「屋企人有冇痛風或者關節炎？」 | Genetic predisposition | |
| Psych/stress | Any stress or low mood? Sleep affected? | 「最近有冇壓力大或者心情唔好？瞓得好嗎？」 | Biopsychosocial; chronic pain → depression |
Case Report Form Answer Builder
High-yield points to capture:
- Symptom: foot/ankle pain – specify exact site (heel/sole/1st MTP/lateral ankle/posterior ankle)
- Duration & onset: acute vs chronic; traumatic vs atraumatic
- Character: sharp/dull/burning/throbbing
- Severity: 0–10 scale; functional limitation (walking, stairs, work)
- Aggravating: weight-bearing, first steps in morning, exercise, specific shoes
- Relieving: rest, ice, NSAIDs, elevation
- Associated: swelling, redness, warmth, numbness, locking, giving way, fever
- Previous episodes: recurrent → gout, chronic instability
- PMH: DM, gout, RA, psoriasis, PAD
- Drug Hx: diuretics, fluoroquinolones, anticoagulants
Likely RFC examples:
- "Pain affecting daily activities/work"
- "Worried about gout recurrence"
- "Concerned about diabetes-related foot problem"
- "Wants to know if needs X-ray or specialist referral"
How to phrase: State as the single overriding reason, e.g., "The patient presented because of worsening heel pain over 2 weeks that is now affecting her ability to stand at work, and she is worried it may be a fracture."
| Component | Likely Examples | Exact Wording to Write |
|---|---|---|
| Ideas | "Thinks it might be gout / bone spur / arthritis" | "Patient thinks the pain is due to a bone spur (骨刺) from wearing high heels." |
| Concerns | "Worried about needing surgery / unable to work / DM amputation" | "Patient is concerned the pain may indicate a serious problem requiring surgery." |
| Expectations | "Wants X-ray / pain relief / referral / reassurance" | "Patient expects an X-ray and effective pain medication so she can return to work." |
Choose based on the stem clues. The most common diagnoses for foot/ankle pain in FM primary care:
| If the Stem Shows… | Most Likely Diagnosis | Minimum Supporting Evidence |
|---|---|---|
| Heel pain, first-step pain in AM, gradual onset, tenderness medial calcaneal tuberosity | Plantar fasciitis [1][2] | First-step pain + tenderness at plantar fascia origin |
| Inversion injury, lateral ankle swelling/bruising | Lateral ankle sprain [2] | Mechanism + ATFL tenderness + able to weight-bear (Ottawa –ve) |
| Acute 1st MTP swelling/redness/exquisite tenderness, ♂, alcohol/seafood | Acute gout [5] | Podagra + risk factors ± raised uric acid |
| Gradual posterior heel pain, runner/sport, tender Achilles | Achilles tendinopathy [2] | Activity-related posterior heel pain + tenderness 2–6 cm above insertion |
| DM patient with foot numbness/ulcer | Diabetic foot / neuropathy [3][7] | Stocking-distribution sensory loss + monofilament abnormality |
(Adapt to the scenario. Below is a generic set for plantar fasciitis as most likely Dx):
| DDx | One Key Discriminator |
|---|---|
| 1. Calcaneal stress fracture | Squeezing calcaneus laterally produces pain (calcaneal squeeze test); pain does NOT improve with walking |
| 2. Achilles tendinopathy | Pain is posterior (not plantar), worse during/after activity, tender 2–6 cm above insertion [2] |
| 3. Tarsal tunnel syndrome | Burning/tingling radiating to sole, Tinel's sign at tarsal tunnel, may have nocturnal symptoms |
| Domain | Example Problem |
|---|---|
| Biological | Plantar fasciitis causing significant heel pain and difficulty with weight-bearing |
| Psychological | Anxiety about the diagnosis (fears fracture/surgery/cancer); sleep disturbance from pain |
| Social/Functional | Unable to perform prolonged standing required for occupation (e.g. teacher, retail); reduced exercise/social activities |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports This Diagnosis |
|---|---|---|---|
| Plantar fasciitis | Tenderness at medial calcaneal tuberosity (plantar fascia origin) | Dorsiflex great toe → palpate plantar fascia from calcaneal tuberosity distally [2][5] | Reproduces the patient's pain at the classic anatomical origin of plantar fascia; Windlass test may reproduce pain |
| Lateral ankle sprain | Tenderness anterior to lateral malleolus over ATFL | Palpate ATFL; anterior drawer test (laxity) [2] | Localises injury to lateral ligament complex |
| Acute gout (1st MTP) | Swollen, erythematous, exquisitely tender 1st MTP joint | Inspect and gently palpate 1st MTP [5] | Classic podagra presentation |
| Achilles tendinopathy | Focal tenderness 2–6 cm above calcaneal insertion; may have fusiform swelling | Palpate Achilles tendon with ankle in slight dorsiflexion [2] | The "watershed zone" of relative hypovascularity is the typical site |
| Achilles rupture | Positive Thompson (Simmonds') test | Squeeze calf with patient prone — no plantarflexion [2][5] | Pathognomonic for complete Achilles tendon rupture |
| Calcaneal stress fracture | Positive calcaneal squeeze test | Squeeze calcaneus from medial and lateral sides simultaneously | Pain reproduced; plantar fasciitis does NOT produce pain with this manoeuvre |
| Morton's neuroma | Mulder's click / squeeze test | Compress forefoot between 1st and 5th metatarsal heads while pressing up from sole at 3rd/4th interspace [5] | Reproduces shooting pain/click between 3rd-4th toes |
| PAD | Absent dorsalis pedis/posterior tibial pulse; trophic changes | Palpate dorsalis pedis (lateral to EHL tendon) and posterior tibial (behind medial malleolus) [4] | Absent pulses + trophic changes confirm arterial insufficiency |
| Diabetic neuropathy | Loss of 10g monofilament sensation | Apply monofilament to plantar surface of foot [3][7] | Loss of protective sensation confirms peripheral neuropathy |
Top Traps That Lose Marks
- Forgetting Ottawa Ankle Rules — if there is bony tenderness at the posterior 6 cm of malleolus or inability to weight-bear 4 steps, you must mention XR is indicated [2]
- Missing gout in a "sprain" presentation — acute 1st MTP pain without trauma is gout until proven otherwise
- Not asking about DM — diabetic foot/neuropathy is a masquerade; always ask about DM and check sensation
- Confusing plantar fasciitis with Achilles tendinopathy — plantar = inferior heel, worst on first steps; Achilles = posterior, worst during/after activity
- Forgetting to ask about medications — fluoroquinolones → Achilles rupture; diuretics → gout [2]
- Not eliciting ICE — this is a direct-marks item; you MUST ask all three
- Not identifying the hidden agenda — "Why today?" may reveal fear of DM amputation or work inability
- Writing > 1 main reason for consultation — the form asks for ONE; pick the most important
Must-Not-Miss Red Flags — Urgent Referral
- Septic arthritis/osteomyelitis: Fever + hot swollen joint + immunocompromise → A&E referral, joint aspiration
- Acute limb ischaemia (6 Ps): Pain, Pallor, Pulselessness, Paraesthesia, Paralysis, Perishingly cold → emergency vascular referral [4]
- Achilles tendon rupture: Sudden pop + positive Thompson test → orthopaedic referral within days [2]
- Fracture (Ottawa +ve): Bony tenderness + unable to weight-bear → XR + orthopaedic review
- Compartment syndrome: Severe pain out of proportion, pain on passive stretch, tense swelling → surgical emergency
- Cauda equina syndrome: Bilateral foot numbness/weakness + urinary retention + saddle anaesthesia → emergency MRI
Key GC Lecture Points from "GC 234. Common Foot and Ankle Conditions" [1]:
- Plantar fasciitis is the most common cause of infracalcaneal pain (80%) [1][2]
- Ottawa Ankle Rules determine need for XR in ankle injuries [1][2]
- Morton's neuroma: entrapment of digital nerve between 3rd-4th metatarsals; Mulder's click [1][5]
- Hallux valgus: most common forefoot deformity; assess intermetatarsal angle on XR [1]
- Achilles tendinopathy: tender 2–6 cm above insertion (watershed zone); risk with fluoroquinolones [1][2]
- Diabetic foot: multifactorial (neuropathy + PVD + poor healing); annual foot screening in all DM patients [1][7]
Shortest safe management & safety-net line (for consultation close): "Based on your history, the most likely cause is plantar fasciitis. I'd recommend supportive shoes, stretching exercises, and paracetamol/ibuprofen for now. If the pain hasn't improved in 4–6 weeks, or if you develop fever, sudden worsening, numbness, or inability to walk, please come back immediately or go to A&E."
High Yield Summary
What to ASK: Site-specific pain analysis (heel/ankle/forefoot/toes), trauma history, first-step pain, red flags (fever, weight loss, night pain, numbness, inability to weight-bear), DM/gout/RA history, medications (fluoroquinolones, diuretics), occupation/footwear, ICE, and "Why today?"
What to WRITE: Precise chief complaint with site + duration + character; ONE main RFC; all three ICE components; most likely Dx with ONE supporting sign; three DDx with discriminators; three biopsychosocial problems covering biological (the diagnosis), psychological (anxiety/sleep), and social (work/functional impact).
What NOT to MISS: Ottawa Ankle Rules for fracture; gout masquerading as sprain; diabetic neuropathy/foot in any DM patient; Achilles rupture (Thompson test); septic arthritis (fever + hot joint); peripheral arterial disease (absent pulses); and the hidden agenda behind the visit.
Active Recall - Family Medicine Clinical Test
[1] Lecture slides: GC 234. Common Foot and Ankle Conditions.pdf [2] Senior notes: Maksim Surgery Notes.pdf (Section 8.3–8.5: F&A trauma, soft tissue injury, diabetic foot) [3] Senior notes: Ryan Ho Endocrine.pdf (p98–99: Diabetic peripheral neuropathy, diabetic foot) [4] Senior notes: Ryan Ho Cardiology.pdf (p200–214: PAD, intermittent claudication, rest pain, ABI) [5] Senior notes: Ryan Ho Rheumatology.pdf (p23: Ankle and foot examination) [6] Senior notes: Ryan Ho Haemtology.pdf (p131: DVT clinical features) [7] Senior notes: Maksim Medicine Notes.pdf (p89: Diabetic foot)
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