Choose an answer, then open any option to work its reasoning.
MUSCULOSKELETAL / LOWER EXTREMITY
Adult Heel and Forefoot Pain: Plantar, Morton, Flatfoot, and the Bunion
The first-step stab, the third-webspace burn, the arch that collapses, and the bunion that changes shoes. Four forefoot and heel complaints that own the ambulatory boards.
What this page makes you able to do
- Apply the first-step pain clock to plantar fasciitis and leave the incidental calcaneal spur out of the diagnosis
- Localize forefoot pain by webspace and metatarsal head: Morton neuroma, Freiberg, stress fracture, and podagra
- Recognize posterior tibial tendon dysfunction by the too-many-toes sign and the failed single heel rise
- Split posterior heel pain into mid-portion versus insertional Achilles disease, and localize the numb foot by nerve geography
- Dr. Fatima Ali, DOPsychiatry residentPrimary reviewer
Last reviewed
From the Attending:
Heel pain that is worst with the first steps and then eases is plantar fasciitis until proven otherwise. The spur on the film is never the diagnosis; the clock is.
Prove it
Opening question
A 46-year-old recreational runner comes to the office because of left heel pain for 4 months. The pain is worst with the first steps out of bed in the morning, eases after a few minutes of walking, and returns after she sits for 30 minutes. She denies numbness and back pain. Examination shows point tenderness at the inferomedial heel, and dorsiflexing the toes reproduces the pain. Radiographs show a small calcaneal spur with no fracture line.Which of the following is the most likely diagnosis?
- Why this is rightFirst-step pain that eases and then returns after rest is the plantar fascia clock: the tissue is tight overnight, and the first stretch is the most painful. The calcaneal spur is an incidental finding, not the cause.
- Why this failsA stress fracture hurts with weight bearing and worsens through the day; it does not ease with walking. The first-step clock belongs to the fascia.
- Why this failsTarsal tunnel is a tibial nerve entrapment: burning pain and numbness in the sole with a Tinel sign behind the medial malleolus. There is no numbness here.
- Why this failsAchilles disease sits behind the ankle, not under the heel, and its pain does not follow the first-step clock.
Work the reasoning
The plantar fascia shortens overnight, and the first weight-bearing stretch of the morning pulls on it hardest. That is why the pain is worst at step one and eases as the tissue warms.
Dorsiflexing the toes wraps the plantar fascia around the metatarsal heads and reproduces the heel pain. A positive test points at the fascia, not the spur.
MORNING IS THE TELL
The First-Step Stab: Plantar Fasciitis
Inferomedial heel pain, worst at step one, better after a few minutes, back again after sitting. The clock, not the X-ray, makes the diagnosis.
Plantar fasciitis is a degenerative overload of the plantar fascia at its calcaneal origin, inferomedial. It hits runners, standing workers, and feet that pronate.
The signature is post-static dyskinesia: pain after rest, not after use. First steps in the morning are the worst, the pain eases with a few minutes of walking, and it returns after sitting.
The windlass test dorsiflexes the toes, tightening the fascia around the metatarsal heads and reproducing the heel pain. Radiographs are for exclusion, and a calcaneal spur is an incidental finding, present in many pain-free feet.
Treatment starts with gastrocnemius-soleus and plantar fascia stretching, activity modification, and orthotics or arch support. Refractory pain earns shockwave therapy or a corticosteroid injection; surgery is the last rung.
Red flags reset the clock. Bilateral heel pain with inflammatory back stiffness points to spondyloarthropathy, and numbness or burning points to tarsal tunnel, not the fascia.
From the Attending
The spur is the photo bomb, not the villain. Every stem hands you the same clock: first steps worse, then better, worse again after sitting. When the pain obeys that clock, the spur on the film is an incidental finding and the plantar fascia is the diagnosis. Treat the fascia, ignore the spur. Know your clock. Every time.
Work the morning heel pain case one hint at a time.
MULDER CLICKS
The Third Webspace: Morton Neuroma
Burning forefoot pain that shoots into the toes, a click when you squeeze the foot, and shoes that are too narrow. An interdigital neuroma, not arthritis.
Morton neuroma is a benign perineural fibrosis of the interdigital nerve, classically in the third webspace between the third and fourth toes. It favors women and narrow, high-heeled shoes.
The pain is burning or shooting into the toes, worse with forefoot squeeze and relieved by removing the shoe. The Mulder click, a palpable click with metatarsal squeeze, is the exam signature.
Ultrasound or MRI confirms an interdigital hypoechoic mass when the exam is unclear. First line is wide shoes, metatarsal pads, and an ultrasound-guided corticosteroid injection; refractory pain earns surgical neurectomy.
The differential is a forefoot geography problem. Metatarsalgia aches under the metatarsal heads without toe radiation, and a metatarsal stress fracture is point-tender on the bone with load-related pain.
Compare the forefoot pain syndromes.
TOO MANY TOES
The Collapsing Arch: Posterior Tibial Tendon Dysfunction
Medial ankle pain and swelling behind the malleolus, an arch that drops, and a heel that cannot rise. Adult acquired flatfoot, and it is progressive.
Posterior tibial tendon dysfunction (PTTD) is adult acquired flatfoot: the tendon that holds up the arch fails, and the arch collapses. It favors middle-aged women and follows a step up in activity.
Early disease is medial ankle pain and swelling behind the medial malleolus, worse with activity. From behind, the too-many-toes sign appears as the hindfoot falls into valgus.
The defining test is the single heel rise: the tibialis posterior cannot invert the hindfoot, so the heel never comes off the ground. Pain migrating to the lateral ankle means the deformity is fixed and impingement has started.
Flexible flatfoot in a child is physiologic and painless; an adult arch that collapses is disease. Early PTTD gets orthotics, PT, and a brace; a fixed deformity earns hindfoot fusion.
Put the PTTD progression in order.
The vignette below runs the whole collapse: Dana's long school day, the arch that gave way, and the heel that stopped rising.
The Arch Collapse
DANA REYES
54. School nurse. Medial ankle pain after a long day on her feet.
Six hours of standing, and the medial ankle aches behind the malleolus. The tendon is strained but the arch still holds. Stage one: tendon strain.
THE ARCH DROPS
Six months later. The single heel rise fails.
From behind, more toes show on the right. On the single heel rise, the heel never leaves the ground. Stage two: the arch drops.
FIXED FLATFOOT
The deformity is no longer reducible.
RouteTendon strain behind the medial malleolus, then arch drop with too-many-toes and hindfoot valgus, then failed single heel rise, then fixed flatfoot with lateral pain. Orthotics and PT early; hindfoot fusion when fixed.
PatternMedial ankle swelling plus a dropped arch plus too-many-toes plus a failed single heel rise equals PTTD in the adult.
PearlThe single heel rise is the test: if the heel cannot leave the ground, the tibialis posterior has lost the lever, and the clock is running on the arch.
Pain now sits on the lateral ankle where the sinus tarsi impinges. Stage three: fixed flatfoot, and surgery enters the discussion.
MID-PORTION VS INSERTIONAL
The Achilles Pair: Two Tendinopathies, One Rupture
Pain 2 to 6 cm above the heel is mid-portion disease. Pain at the insertion with a bump and spurs is insertional disease. A positive Thompson is neither.
Mid-portion Achilles tendinopathy strikes runners, sits 2 to 6 cm above the insertion, and responds to eccentric loading: slow, loaded lengthening of the calf, with isometrics for pain.
Insertional tendinopathy sits exactly at the bone, carries spurs and a Haglund bump on X-ray, responds less to eccentric work, and often needs activity modification and shoe change first.
Achilles rupture is the emergency in the differential: a pop, a palpable gap, and a positive Thompson test (no plantar flexion with calf squeeze). It is managed with early functional bracing or surgery, and its full workup lives on the soft-tissue-trauma page.
Posterior heel pain that sits behind the medial malleolus with a dropped arch is not Achilles disease at all; it is posterior tibial tendon dysfunction wearing a similar costume.
Split the posterior heel pain by location and exam.
A patient has posterior leg and heel pain. Which door fits which presentation?
HALLUX VALGUS, HAMMERS, AND CLAWS
The Bunion and the Toes
The big toe leans, the second toe bends, the claw curls everything. Footwear drives the first; nerves drive the last.
Hallux valgus is lateral deviation of the hallux at the first MTP joint with a medial eminence (the bunion) whose bursa can inflame. It favors women and narrow, pointed shoes.
Radiographs quantify the hallux valgus angle; over about 15 degrees the deformity is measurable, and preserved joint space separates it from arthritis. First line is wide shoes, orthotics, and activity modification; refractory pain earns a chevron osteotomy.
Hammer toe is PIP flexion with a neutral MTP, classically the second toe crowding against the bunion. Claw toe is MTP hyperextension with PIP and DIP flexion, and it signals a neurologic or neuropathic cause.
The tailor's bunion is the fifth toe mirror: a painful lateral eminence at the fifth MTP joint. Same footwear logic, opposite side of the foot.
Tap the letters to unlock each toe deformity.
HCB: HAMMER, CLAW, BUNION
HHammer toe: PIP flexion, MTP neutral. The second toe bends at the middle joint, often crowding against a bunion. Stretch the extensor, pad the toe box.
CClaw toe: MTP hyperextension plus PIP and DIP flexion. The whole toe curls, and the pattern flags a neuropathic or neurologic cause.
BBunion: first MTP valgus with a medial eminence. Wide shoes first, orthotics, then a chevron osteotomy for refractory pain.
TINEL BEHIND THE MALLEOLUS
The Tarsal Tunnel and the Numb Foot
Burning in the sole, worse at night, Tinel behind the medial malleolus: the tibial nerve is trapped. Numbness has a geography, and the geography names the nerve.
Tarsal tunnel syndrome is entrapment of the tibial nerve behind the medial malleolus: burning pain and numbness over the sole and heel, worse at night and with standing, with a positive Tinel sign.
Nerve conduction studies confirm slowed tibial conduction at the ankle. Rest, activity change, and orthotics come first; injection or surgical release follows for refractory entrapment.
Numbness that follows a dermatome from the back is lumbosacral radiculopathy, and a stocking-glove pattern in a diabetic is peripheral neuropathy. The full radiculopathy localizer lives in the neurology section, and the diabetic foot workup lives on the diabetic-foot-charcot page.
From the Attending
Numbness has a geography. Confined to the sole with a Tinel behind the malleolus: tarsal tunnel. Following a dermatome down from the back: radiculopathy. Stocking-glove in a diabetic: neuropathy. The stem tells you which nerve is trapped, and the exam tells you where to look. One question: where does the numbness start?
Localize the numb foot.
A 52-year-old woman has burning pain and numbness confined to the sole of the right foot, worse at night, with a Tinel sign behind the medial malleolus and normal toe extension strength. Which of the following is the most likely diagnosis?
Tarsal tunnel syndrome. Numbness confined to the sole with a Tinel behind the medial malleolus is tibial nerve entrapment at the ankle. L5 radiculopathy. L5 disease runs lateral leg and foot dorsum numbness with weak toe extension, and it starts in the back. Common peroneal neuropathy. The peroneal nerve supplies the dorsum and lateral leg with foot drop; the sole is tibial territory. S1 radiculopathy. S1 runs down the posterior leg to the lateral foot with a depressed ankle reflex; the whole sole is tibial. Rule: sole numbness plus Tinel at the malleolus equals tarsal tunnel.
FREIBERG, STRESS, AND GOUT
The Forefoot Red-Flag Split
Second metatarsal head pain in a young runner, point tenderness on a bone, or one hot swollen MTP joint. Three different clocks, three different workups.
Freiberg infraction is avascular necrosis of the second metatarsal head in young, active women. Radiographs show flattening and sclerosis of the head; rest, activity change, and orthotics are first line.
A metatarsal stress fracture is point-tender on the shaft, hurts with impact, and hides on early X-rays; MRI finds it when the film is negative. Loading is the trigger, rest is the treatment.
Podagra, first MTP gout, is the hot red joint that cross-refs to the gout page. A hot swollen single joint with fever is septic arthritis until proven otherwise, and the msk-infections page owns that workup.
On rounds, your attending stops at the next bed, a 19-year-old runner pointing at the second metatarsal head.
Attending
The X-ray is negative and she wants to keep training. What is the one question that ends the argument?
You
Is the pain reproduced by hopping on that foot? Point tenderness on the bone with load-related pain is a stress fracture, and a negative film does not clear it.
Attending
Then the bone is the story, not the film. Rest the load and image with MRI when you need proof.
The exam beats the X-ray. Point tenderness plus load pain is a stress fracture until proven otherwise.
Tick the forefoot red flags before you move on.
HEEL, FOREFOOT, MIDFOOT, OR BACK
The One-Screen Discriminator
Location first, then the clock. The heel belongs to the fascia, the third webspace to the neuroma, the medial arch to the tibialis posterior, and the posterior heel to the Achilles.
Run the screen in order. Inferomedial heel with first-step pain: plantar fasciitis. Burning in the third webspace with a click: Morton neuroma. Medial ankle swelling with too-many-toes and a failed single heel rise: PTTD. Pain at the Achilles insertion with a bump: insertional tendinopathy.
Numbness follows the nerve, not the bone: sole plus Tinel is tarsal tunnel, dermatome from the back is radiculopathy, and stocking-glove is neuropathy. Trauma with an inversion mechanism belongs to the Ottawa rules and the soft-tissue-trauma page.
Match each foot pain location to its diagnosis.
Prove it
Walkthrough: Heel and forefoot pain in seven cases
Original practice scenarios, one at a time. Choose an answer, then open any option to work its reasoning.
Clinical walkthrough
