Foot PainAPPROACH

MUSCULOSKELETAL AND EXTREMITIES · 19 SECTIONS

⚲

613 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Shoulder Pain Elbow Pain Wrist Pain Hand Pain Hip Pain Knee Pain Ankle Pain Foot Pain Cast Or Splint Complication Symptoms Wound Check And Suture Related Visits Joint Swelling And Monoarthritis Suspected Septic Joint Presentation Suspected Tendon Rupture Presentation Limp Or Refusal To Bear Weight

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx111

HPI overview

›Foot pain context

›Traumatic

›Atraumatic

›Location pattern

›Forefoot

›Midfoot

›Hindfoot

›Heel

›Plantar

›Dorsal

›Mechanism and loading

›Fall from height

›Twist

›Crush

›Direct blow

›Repetitive impact

›New footwear

›New activity

›Symptom trajectory

›Sudden

›Gradual

›Progressive

›Intermittent

›Baseline function

›Usual walking tolerance

›Prior foot pain baseline

Onset

›Timing of onset

›Date of onset

›Time from onset to peak

›Context at onset

›At rest

›During activity

›After injury

›Initial severity

›Immediate inability to bear weight

›Able to continue activity

Provocation/Palliation

›Worse with

›Weight bearing

›First steps after rest

›Running

›Stairs

›Toe off phase

›Shoes

›Better with

›Rest

›Elevation

›Ice

›Compression

›Immobilization

›Diurnal pattern

›Morning stiffness

›End of day worsening

Quality

›Pain quality

›Sharp

›Dull

›Aching

›Burning

›Electric

›Neuropathic features

›Tingling

›Numbness

›Inflammatory features

›Warmth

›Redness

Region/Radiation

›Primary site

›1st metatarsophalangeal

›Metatarsals

›Navicular

›Cuboid

›Calcaneus

›Plantar fascia origin

›Radiation pattern

›To toes

›To ankle

›None

Severity

›Pain intensity

›Rest pain

›Pain with ambulation

›Functional limitation

›Unable to bear weight

›Limp

›Unable to work

›Analgesic response

›No relief with usual doses

›Partial relief

Timing

›Duration

›Less than 6 weeks

›6 to 12 weeks

›More than 12 weeks

›Course

›Improving

›Stable

›Worsening

›Recurrent episodes

›Similar prior flares

›New pattern

Associated symptoms

›Local symptoms

›Swelling

›Bruising

›Deformity

›Wound

›Drainage

›Systemic symptoms

›Fever

›Chills

›Malaise

›Neurovascular symptoms

›Cold foot

›Color change

›Weakness

›Numbness

02Alarm Features/alarm51

Immediate escalation triggers

›Limb threat triggers

›Pulseless foot

›Rapidly progressive pain

›Pain out of proportion

›New motor deficit

›Expanding hematoma

›Infection threat triggers

›Toxic appearance

›Rapidly spreading erythema

›Crepitus

›Bullae

›Skin necrosis

›Trauma threat triggers

›Open fracture

›Gross deformity

›Suspected Lisfranc instability

›Compartment syndrome concern

Vital sign danger thresholds

›Sepsis physiology

›Hypotension

›Tachycardia

›Tachypnea

›Hypoperfusion

›Altered mental status

›Cool clammy skin

High risk history features

›Immunocompromised state

›Neutropenia

›Chronic steroids

›Biologic therapy

›Diabetes with foot risk

›Neuropathy

›Prior ulcer

›Prior amputation

›Vascular risk

›Known peripheral artery disease

›Prior revascularization

›High risk injury patterns

›Fall from height

›Crush injury

›Penetrating injury

High risk exam features

›Neurovascular compromise

›Absent dorsalis pedis pulse

›Absent posterior tibial pulse

›Prolonged capillary refill

›Sensory loss in a new distribution

›Compartment syndrome features

›Pain with passive stretch

›Tense compartments

›Progressive neurologic deficit

›Septic joint features

›Severe pain with minimal range of motion

›Effusion with warmth

03Medications/meds26

Medication exposures relevant to foot pain

›Current medications

›Anticoagulants

›Antiplatelets

›Systemic corticosteroids

›Immunosuppressants

›Chemotherapy

›Recent antibiotics

›Recent course within 30 days

›Prior MRSA coverage

›Tendon risk medications

›Fluoroquinolones

›Systemic steroids

›Pain medication use

›Acetaminophen dosing pattern

›NSAID dosing pattern

›Opioid exposure

Contraindications and interaction traps

›NSAID cautions

›Chronic kidney disease

›Heart failure

›Prior GI bleed

›Acetaminophen cautions

›Liver disease

›Heavy alcohol use

›Opioid cautions

›Concurrent sedatives

›Sleep apnea risk

04Diet/diet10

Dietary exposures linked to foot pain etiologies

›Gout triggers

›Alcohol binge

›High purine intake

›Recent fasting

›Hydration pattern

›Dehydration

›Excessive diuresis

›Bone health nutrition

›Low calcium intake

›Low vitamin D intake

05Review of Systems/ros19

System screening relevant to foot pain

›Constitutional

›Fever

›Weight loss

›Skin

›Rash

›New ulcer

›Drainage

›Musculoskeletal

›Other joint pain

›Morning stiffness

›Back pain

›Neurologic

›Numbness

›Weakness

›Balance issues

›Vascular

›Claudication

›Rest pain

›Color change

06Collateral History and Family History/chafh17

Collateral and reliability

›Collateral source

›Family

›Caregiver

›Facility staff

›Reliability concerns

›Cognitive impairment

›Intoxication

›Language barrier

Family history relevant to etiologies

›Inflammatory arthritis

›Rheumatoid arthritis (M05)

›Psoriatic arthritis (L40.5)

›Gout

›Gout family history (M10)

›Early onset hyperuricemia

›Thrombosis history

›Venous thromboembolism

›Known thrombophilia

07Risk Factors/rf30

Patient level risk factors

›Diabetes complications

›Peripheral neuropathy (E11.40)

›Peripheral angiopathy (E11.51)

›Vascular disease

›Peripheral artery disease (I73.9)

›Smoking exposure

›Bone fragility

›Osteoporosis (M81)

›Prior fragility fracture

›Inflammatory disease

›Rheumatoid arthritis (M06.9)

›Spondyloarthropathy

Exposure and mechanical risks

›Overuse and training error

›Rapid increase in mileage

›Change in running surface

›Footwear and biomechanics

›Poor arch support

›High heels

›Minimalist shoes transition

›Occupational load

›Prolonged standing

›Heavy lifting

Infection and wound risks

›Skin barrier disruption

›Ulcer

›Blister

›Tinea pedis

›High risk exposures

›Puncture wound through shoe

›Fresh water exposure

›Animal bite

08Differential Diagnosis/ddx54

Life threatening

›Limb and life threats

›Acute limb ischemia (I74.3)

›Necrotizing soft tissue infection (M72.6)

›Compartment syndrome of foot (T79.A2)

›Severe infections

›Septic arthritis of foot joints (M00)

›Osteomyelitis (M86)

›High risk trauma

›Open fracture (S92 with open injury)

›Lisfranc fracture dislocation (S93.3)

Common

›Mechanical and overuse

›Plantar fasciitis (M72.2)

›Achilles tendinopathy (M76.6)

›Stress fracture metatarsal (M84.37)

›Sprain and fracture

›Metatarsal fracture (S92.3)

›Phalanx fracture (S92.5)

›Crystal and inflammatory

›Gout (M10)

›Calcium pyrophosphate disease (M11.2)

›Neuropathic and entrapment

›Morton neuroma (G57.6)

›Tarsal tunnel syndrome (G57.5)

›Skin and soft tissue infection

›Cellulitis (L03.11)

›Abscess (L02.61)

Less common

›Midfoot and hindfoot syndromes

›Navicular stress fracture (M84.37)

›Calcaneal stress fracture (M84.37)

›Neuropathic arthropathy

›Charcot neuroarthropathy (E11.610)

›Acute Charcot flare

›Vascular and hematologic

›Superficial thrombophlebitis (I80)

›Spontaneous hematoma on anticoagulation

›Tumor and referred pain

›Bone tumor

›Lumbar radiculopathy (M54.16)

Key differentiating clues

›Plantar fasciitis

›Pain with first steps after rest

›Medial calcaneal tubercle tenderness

›Stress fracture

›Point bony tenderness

›Pain with hop test

›Gout

›Sudden severe monoarthritis

›1st metatarsophalangeal involvement

›Lisfranc injury

›Midfoot swelling

›Plantar ecchymosis

›Pain with forefoot abduction stress

›Osteomyelitis in diabetes

›Chronic ulcer

›Probe to bone positive

09Past Medical History/pmh18

Relevant chronic conditions and prior events

›Diabetes related foot history

›Prior ulcer

›Prior osteomyelitis

›Vascular history

›Prior bypass or stent

›Prior acute limb ischemia

›Rheumatologic history

›Gout (M10)

›Rheumatoid arthritis (M06.9)

›Neurologic history

›Peripheral neuropathy

›Prior stroke deficits

Procedures and devices

›Prior foot and ankle surgery

›Hardware presence

›Prior fusion

›Implanted devices

›Pacemaker

›Vascular graft

10Physical Exam/exam56

General and vitals

›Overall appearance

›Toxic

›Non toxic

›Vital sign interpretation

›Fever pattern

›Hemodynamic stability

Foot inspection and palpation

›Skin and soft tissue

›Erythema distribution

›Warmth

›Ecchymosis

›Blisters

›Ulcer

›Deformity and alignment

›Arch collapse

›Toe deformities

›Focal tenderness mapping

›Metatarsal shafts

›Base of 5th metatarsal

›Navicular

›Calcaneus

›Swelling pattern

›Dorsal midfoot

›Forefoot

›Ankle associated

Range of motion and function

›Active and passive motion

›Metatarsophalangeal

›Midfoot

›Subtalar

›Gait and weight bearing

›Antalgic gait

›Unable to take 4 steps

›Strength testing

›Plantarflexion strength

›Dorsiflexion strength

Neurovascular exam

›Perfusion

›Dorsalis pedis pulse

›Posterior tibial pulse

›Capillary refill

›Sensation

›Plantar surface

›Dorsal surface

›Motor

›Toe extension

›Toe flexion

Key maneuvers

›Plantar fascia maneuvers

›Windlass test pain reproduction

›Heel squeeze tenderness

›Tendon and ligament maneuvers

›Thompson test

›Pain with resisted plantarflexion

›Forefoot maneuvers

›Mulder click

›Metatarsal squeeze pain

›Midfoot maneuvers

›Forefoot abduction stress pain

›Midfoot instability

11Lab Studies/labs21

Targeted labs by syndrome

›Infection concern labs

›CBC

›CRP

›ESR

›Blood cultures with fever

›Metabolic and diabetic assessment

›Glucose

›Creatinine

›Ketones with systemic illness

›Severe illness physiology

›Lactate with sepsis concern

›Venous blood gas with shock concern

Interpretation pearls and pitfalls

›Inflammatory markers

›ESR and CRP elevation supports infection or inflammation

›Normal ESR and CRP does not exclude early infection

›Uric acid

›Normal uric acid during acute gout flare possible

›Hyperuricemia not diagnostic of gout

›Leukocytosis

›Absence does not exclude diabetic foot infection

›Steroids may blunt response

12Imaging/img39

Scoring Systems

›Ottawa Ankle Rules and Ottawa Foot Rules

›Foot radiograph criteria

›Midfoot pain

›Bone tenderness at navicular

›Bone tenderness at base of 5th metatarsal

›Inability to bear weight

›Necrotizing infection risk tools

›LRINEC score

›Not for ruling out necrotizing infection

MRI

›Indications

›Stress fracture with negative radiographs

›Osteomyelitis evaluation

›Deep soft tissue infection extent

›Contraindications and limitations

›Non MRI compatible implants

›Motion artifact risk

›Interpretation pearls

›Bone marrow edema patterns for stress injury

›Sinus tract and marrow changes for osteomyelitis

›Indications

›Complex fracture characterization

›Suspected Lisfranc injury with equivocal radiographs

›Preoperative planning

›Contrast considerations

›Iodinated contrast allergy history

›Kidney disease risk

›Interpretation pearls

›Subtle midfoot fractures

›Joint congruity assessment

Ultrasound

›POCUS targets

›Abscess versus cellulitis

›Tendon rupture screening

›Joint effusion screening

›Limitations

›Deep space infection may be missed

›Operator dependence

›Interpretation pearls

›Compressibility and cobblestoning for cellulitis pattern

›Fluid collections with posterior enhancement for abscess

13Special Tests/spec16

Bedside maneuvers and procedural diagnostics

›Diabetic foot bedside tests

›Probe to bone test

›Monofilament sensation screening

›Vascular bedside tests

›Ankle brachial index

›Doppler signal assessment

›Arthrocentesis when joint infection concern

›Synovial WBC and differential

›Gram stain and culture

›Crystal analysis

Pitfalls and limitations

›Probe to bone

›Best for ulcers over bony prominences

›Negative test does not exclude osteomyelitis

›Arthrocentesis

›Crystals can coexist with infection

›Prior antibiotics reduce culture yield

14ECG/ecg6

When relevant in foot pain presentations

›Indications uncommon

›Sepsis physiology

›Chest pain or dyspnea with thromboembolism concern

›High risk findings to act on

›New ischemic changes

›Unstable arrhythmia

15Assessment/ax27

Problem representation and risk stratification

›Foot pain syndrome classification

›Traumatic with suspected fracture

›Atraumatic mechanical

›Inflammatory monoarthritis

›Infection suspected

›Neurovascular compromise suspected

›Severity stratification

›Non weight bearing

›Severe rest pain

›Rapid progression

›Complications to rule out

›Compartment syndrome

›Acute limb ischemia

›Septic arthritis

›Necrotizing infection

Working diagnosis examples with codes

›Plantar fasciitis (M72.2)

›Heel pain first steps pattern

›Plantar fascia insertion tenderness

›Stress fracture (M84.37)

›Overuse history

›Focal bony tenderness

›Gout (M10)

›Sudden monoarthritis pattern

›Podagra pattern

›Diabetic foot infection (E11.621)

›Ulcer plus erythema

›Purulent drainage

16Plan/plan49

Approach to the critical patient first 5 minutes

›Immediate stabilization priorities

›Airway and breathing concerns if toxic

›Cardiac monitoring with sepsis physiology

›IV access criteria

›Two large bore IV with shock concern

›Analgesia early

›Acetaminophen PO 1000 mg once

›Ibuprofen PO 400 mg once

›Avoid NSAID with kidney disease concern

›Limb threat pathway

›If pulseless or mottled foot immediate vascular surgery

›If compartment syndrome concern immediate orthopedics

Diagnostic sequencing

›Trauma pathway

›Radiographs foot 3 view

›Weight bearing radiographs with Lisfranc concern

›CT with complex fracture concern

›Infection pathway

›CBC

›CRP

›ESR

›Blood cultures with fever

›MRI with osteomyelitis concern

›Inflammatory arthritis pathway

›Arthrocentesis with effusion and severe pain

›Crystal analysis

›Culture regardless of crystals if infection concern

Therapeutics

›Immobilization and protection

›Walking boot for suspected fracture pending imaging

›Non weight bearing with Lisfranc concern

›Antibiotics for suspected severe infection

›Local protocol dependent empiric coverage

›MRSA risk based coverage decision

›Gout flare treatment options

›Naproxen PO 500 mg once

›Then naproxen PO 250 mg twice daily

›Colchicine PO 1.2 mg once

›Then colchicine PO 0.6 mg once 1 hour later

›Avoid colchicine with severe kidney disease

›Plantar fasciitis symptom control

›Relative rest

›Ice after activity

›Supportive footwear

Reassessment loop

›Time based reassessment

›Recheck pain and neurovascular status within 30 to 60 minutes after interventions

›Repeat compartment exam if worsening pain

›Escalation triggers

›Increasing pain despite analgesia

›New numbness

›Worsening perfusion signs

17Disposition/dispo25

Level of care and consultation criteria

›ICU considerations

›Septic shock physiology

›Rapidly progressive necrotizing infection concern

›Admission indications

›Septic arthritis suspected

›Osteomyelitis with systemic signs

›Acute Charcot with inability to offload safely

›Urgent consult indications

›Vascular surgery for acute limb ischemia concern

›Orthopedics for open fracture

›Orthopedics for Lisfranc instability

›Discharge criteria

›Stable vitals

›Pain controlled with oral medications

›Neurovascularly intact

›Safe ambulation plan

›Follow up plan reliable

Follow up timing

›Fracture or suspected fracture

›Orthopedics within 3 to 7 days

›Earlier if worsening pain or swelling

›Diabetic foot ulcer or infection

›Wound care or podiatry within 48 to 72 hours

›Earlier with spreading erythema

›Plantar fasciitis

›Primary care or sports medicine within 2 to 6 weeks

18Discharge Instructions/di26

Copy discharge instructions

›Summary

›Foot pain evaluation today with no immediate life threatening cause identified

›Imaging and tests reviewed based on your symptoms

›Activity

›Limit weight bearing as discussed

›Use the boot or splint as directed

›Elevate the foot when resting

›Pain control

›Acetaminophen as directed on label

›Ibuprofen as directed on label unless told to avoid

›Do not combine multiple NSAID products

›Wound and skin care if applicable

›Keep wound clean and dry

›Check skin daily if diabetes or neuropathy

›Follow up

›Follow up with primary care or specialist in the recommended time frame

›Return for reassessment if unable to arrange follow up

›Return to emergency care now for

›Fever

›Rapidly worsening redness

›New drainage

›Increasing swelling

›New numbness

›Blue or cold foot

›Inability to bear weight that is worsening

›Severe pain not controlled with medications

19References/r12

Guidelines and decision tools

›Project instructions source

›Evidence based clinical reference generator instructions

›Formatting and structure requirements

›IWGDF and IDSA guideline on diabetic foot infections 2023

›Diagnosis and treatment guidance for diabetes related foot infection

›Local protocol dependent antibiotic selection

›ACR Appropriateness Criteria Chronic Foot Pain 2020

›Imaging selection framework by clinical variant

›Reviewed annually by ACR process

›Ottawa Ankle Rules and Ottawa Foot Rules derivation 1992

›Radiography decision tool for ankle and midfoot injuries

›Validation and implementation studies followed

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.

Foot PainAPPROACH

MUSCULOSKELETAL AND EXTREMITIES · 19 SECTIONS

⚲

613 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx111

HPI overview

›Foot pain context

›Traumatic

›Atraumatic

›Location pattern

›Forefoot

›Midfoot

›Hindfoot

›Heel

›Plantar

›Dorsal

›Mechanism and loading

›Fall from height

›Twist

›Crush

›Direct blow

›Repetitive impact

›New footwear

›New activity

›Symptom trajectory

›Sudden

›Gradual

›Progressive

›Intermittent

›Baseline function

›Usual walking tolerance

›Prior foot pain baseline

Onset

›Timing of onset

›Date of onset

›Time from onset to peak

›Context at onset

›At rest

›During activity

›After injury

›Initial severity

›Immediate inability to bear weight

›Able to continue activity

Provocation/Palliation

›Worse with

›Weight bearing

›First steps after rest

›Running

›Stairs

›Toe off phase

›Shoes

›Better with

›Rest

›Elevation

›Ice

›Compression

›Immobilization

›Diurnal pattern

›Morning stiffness

›End of day worsening

Quality

›Pain quality

›Sharp

›Dull

›Aching

›Burning

›Electric

›Neuropathic features

›Tingling

›Numbness

›Inflammatory features

›Warmth

›Redness

Region/Radiation

›Primary site

›1st metatarsophalangeal

›Metatarsals

›Navicular

›Cuboid

›Calcaneus

›Plantar fascia origin

›Radiation pattern

›To toes

›To ankle

›None

Severity

›Pain intensity

›Rest pain

›Pain with ambulation

›Functional limitation

›Unable to bear weight

›Limp

›Unable to work

›Analgesic response

›No relief with usual doses

›Partial relief

Timing

›Duration

›Less than 6 weeks

›6 to 12 weeks

›More than 12 weeks

›Course

›Improving

›Stable

›Worsening

›Recurrent episodes

›Similar prior flares

›New pattern

Associated symptoms

›Local symptoms

›Swelling

›Bruising

›Deformity

›Wound

›Drainage

›Systemic symptoms

›Fever

›Chills

›Malaise

›Neurovascular symptoms

›Cold foot

›Color change

›Weakness

›Numbness

02Alarm Features/alarm51

Immediate escalation triggers

›Limb threat triggers

›Pulseless foot

›Rapidly progressive pain

›Pain out of proportion

›New motor deficit

›Expanding hematoma

›Infection threat triggers

›Toxic appearance

›Rapidly spreading erythema

›Crepitus

›Bullae

›Skin necrosis

›Trauma threat triggers

›Open fracture

›Gross deformity

›Suspected Lisfranc instability

›Compartment syndrome concern

Vital sign danger thresholds

›Sepsis physiology

›Hypotension

›Tachycardia

›Tachypnea

›Hypoperfusion

›Altered mental status

›Cool clammy skin

High risk history features

›Immunocompromised state

›Neutropenia

›Chronic steroids

›Biologic therapy

›Diabetes with foot risk

›Neuropathy

›Prior ulcer

›Prior amputation

›Vascular risk

›Known peripheral artery disease

›Prior revascularization

›High risk injury patterns

›Fall from height

›Crush injury

›Penetrating injury

High risk exam features

›Neurovascular compromise

›Absent dorsalis pedis pulse

›Absent posterior tibial pulse

›Prolonged capillary refill

›Sensory loss in a new distribution

›Compartment syndrome features

›Pain with passive stretch

›Tense compartments

›Progressive neurologic deficit

›Septic joint features

›Severe pain with minimal range of motion

›Effusion with warmth

03Medications/meds26

Medication exposures relevant to foot pain

›Current medications

›Anticoagulants

›Antiplatelets

›Systemic corticosteroids

›Immunosuppressants

›Chemotherapy

›Recent antibiotics

›Recent course within 30 days

›Prior MRSA coverage

›Tendon risk medications

›Fluoroquinolones

›Systemic steroids

›Pain medication use

›Acetaminophen dosing pattern

›NSAID dosing pattern

›Opioid exposure

Contraindications and interaction traps

›NSAID cautions

›Chronic kidney disease

›Heart failure

›Prior GI bleed

›Acetaminophen cautions

›Liver disease

›Heavy alcohol use

›Opioid cautions

›Concurrent sedatives

›Sleep apnea risk

04Diet/diet10

Dietary exposures linked to foot pain etiologies

›Gout triggers

›Alcohol binge

›High purine intake

›Recent fasting

›Hydration pattern

›Dehydration

›Excessive diuresis

›Bone health nutrition

›Low calcium intake

›Low vitamin D intake

05Review of Systems/ros19

System screening relevant to foot pain

›Constitutional

›Fever

›Weight loss

›Skin

›Rash

›New ulcer

›Drainage

›Musculoskeletal

›Other joint pain

›Morning stiffness

›Back pain

›Neurologic

›Numbness

›Weakness

›Balance issues

›Vascular

›Claudication

›Rest pain

›Color change

06Collateral History and Family History/chafh17

Collateral and reliability

›Collateral source

›Family

›Caregiver

›Facility staff

›Reliability concerns

›Cognitive impairment

›Intoxication

›Language barrier

Family history relevant to etiologies

›Inflammatory arthritis

›Rheumatoid arthritis (M05)

›Psoriatic arthritis (L40.5)

›Gout

›Gout family history (M10)

›Early onset hyperuricemia

›Thrombosis history

›Venous thromboembolism

›Known thrombophilia

07Risk Factors/rf30

Patient level risk factors

›Diabetes complications

›Peripheral neuropathy (E11.40)

›Peripheral angiopathy (E11.51)

›Vascular disease

›Peripheral artery disease (I73.9)

›Smoking exposure

›Bone fragility

›Osteoporosis (M81)

›Prior fragility fracture

›Inflammatory disease

›Rheumatoid arthritis (M06.9)

›Spondyloarthropathy

Exposure and mechanical risks

›Overuse and training error

›Rapid increase in mileage

›Change in running surface

›Footwear and biomechanics

›Poor arch support

›High heels

›Minimalist shoes transition

›Occupational load

›Prolonged standing

›Heavy lifting

Infection and wound risks

›Skin barrier disruption

›Ulcer

›Blister

›Tinea pedis

›High risk exposures

›Puncture wound through shoe

›Fresh water exposure

›Animal bite

08Differential Diagnosis/ddx54

Life threatening

›Limb and life threats

›Acute limb ischemia (I74.3)

›Necrotizing soft tissue infection (M72.6)

›Compartment syndrome of foot (T79.A2)

›Severe infections

›Septic arthritis of foot joints (M00)

›Osteomyelitis (M86)

›High risk trauma

›Open fracture (S92 with open injury)

›Lisfranc fracture dislocation (S93.3)

Common

›Mechanical and overuse

›Plantar fasciitis (M72.2)

›Achilles tendinopathy (M76.6)

›Stress fracture metatarsal (M84.37)

›Sprain and fracture

›Metatarsal fracture (S92.3)

›Phalanx fracture (S92.5)

›Crystal and inflammatory

›Gout (M10)

›Calcium pyrophosphate disease (M11.2)

›Neuropathic and entrapment

›Morton neuroma (G57.6)

›Tarsal tunnel syndrome (G57.5)

›Skin and soft tissue infection

›Cellulitis (L03.11)

›Abscess (L02.61)

Less common

›Midfoot and hindfoot syndromes

›Navicular stress fracture (M84.37)

›Calcaneal stress fracture (M84.37)

›Neuropathic arthropathy

›Charcot neuroarthropathy (E11.610)

›Acute Charcot flare

›Vascular and hematologic

›Superficial thrombophlebitis (I80)

›Spontaneous hematoma on anticoagulation

›Tumor and referred pain

›Bone tumor

›Lumbar radiculopathy (M54.16)

Key differentiating clues

›Plantar fasciitis

›Pain with first steps after rest

›Medial calcaneal tubercle tenderness

›Stress fracture

›Point bony tenderness

›Pain with hop test

›Gout

›Sudden severe monoarthritis

›1st metatarsophalangeal involvement

›Lisfranc injury

›Midfoot swelling

›Plantar ecchymosis

›Pain with forefoot abduction stress

›Osteomyelitis in diabetes

›Chronic ulcer

›Probe to bone positive

09Past Medical History/pmh18

Relevant chronic conditions and prior events

›Diabetes related foot history

›Prior ulcer

›Prior osteomyelitis

›Vascular history

›Prior bypass or stent

›Prior acute limb ischemia

›Rheumatologic history

›Gout (M10)

›Rheumatoid arthritis (M06.9)

›Neurologic history

›Peripheral neuropathy

›Prior stroke deficits

Procedures and devices

›Prior foot and ankle surgery

›Hardware presence

›Prior fusion

›Implanted devices

›Pacemaker

›Vascular graft

10Physical Exam/exam56

General and vitals

›Overall appearance

›Toxic

›Non toxic

›Vital sign interpretation

›Fever pattern

›Hemodynamic stability

Foot inspection and palpation

›Skin and soft tissue

›Erythema distribution

›Warmth

›Ecchymosis

›Blisters

›Ulcer

›Deformity and alignment

›Arch collapse

›Toe deformities

›Focal tenderness mapping

›Metatarsal shafts

›Base of 5th metatarsal

›Navicular

›Calcaneus

›Swelling pattern

›Dorsal midfoot

›Forefoot

›Ankle associated

Range of motion and function

›Active and passive motion

›Metatarsophalangeal

›Midfoot

›Subtalar

›Gait and weight bearing

›Antalgic gait

›Unable to take 4 steps

›Strength testing

›Plantarflexion strength

›Dorsiflexion strength

Neurovascular exam

›Perfusion

›Dorsalis pedis pulse

›Posterior tibial pulse

›Capillary refill

›Sensation

›Plantar surface

›Dorsal surface

›Motor

›Toe extension

›Toe flexion

Key maneuvers

›Plantar fascia maneuvers

›Windlass test pain reproduction

›Heel squeeze tenderness

›Tendon and ligament maneuvers

›Thompson test

›Pain with resisted plantarflexion

›Forefoot maneuvers

›Mulder click

›Metatarsal squeeze pain

›Midfoot maneuvers

›Forefoot abduction stress pain

›Midfoot instability

11Lab Studies/labs21

Targeted labs by syndrome

›Infection concern labs

›CBC

›CRP

›ESR

›Blood cultures with fever

›Metabolic and diabetic assessment

›Glucose

›Creatinine

›Ketones with systemic illness

›Severe illness physiology

›Lactate with sepsis concern

›Venous blood gas with shock concern

Interpretation pearls and pitfalls

›Inflammatory markers

›ESR and CRP elevation supports infection or inflammation

›Normal ESR and CRP does not exclude early infection

›Uric acid

›Normal uric acid during acute gout flare possible

›Hyperuricemia not diagnostic of gout

›Leukocytosis

›Absence does not exclude diabetic foot infection

›Steroids may blunt response

12Imaging/img39

Scoring Systems

›Ottawa Ankle Rules and Ottawa Foot Rules

›Foot radiograph criteria

›Midfoot pain

›Bone tenderness at navicular

›Bone tenderness at base of 5th metatarsal

›Inability to bear weight

›Necrotizing infection risk tools

›LRINEC score

›Not for ruling out necrotizing infection

MRI

›Indications

›Stress fracture with negative radiographs

›Osteomyelitis evaluation

›Deep soft tissue infection extent

›Contraindications and limitations

›Non MRI compatible implants

›Motion artifact risk

›Interpretation pearls

›Bone marrow edema patterns for stress injury

›Sinus tract and marrow changes for osteomyelitis

›Indications

›Complex fracture characterization

›Suspected Lisfranc injury with equivocal radiographs

›Preoperative planning

›Contrast considerations

›Iodinated contrast allergy history

›Kidney disease risk

›Interpretation pearls

›Subtle midfoot fractures

›Joint congruity assessment

Ultrasound

›POCUS targets

›Abscess versus cellulitis

›Tendon rupture screening

›Joint effusion screening

›Limitations

›Deep space infection may be missed

›Operator dependence

›Interpretation pearls

›Compressibility and cobblestoning for cellulitis pattern

›Fluid collections with posterior enhancement for abscess

13Special Tests/spec16

Bedside maneuvers and procedural diagnostics

›Diabetic foot bedside tests

›Probe to bone test

›Monofilament sensation screening

›Vascular bedside tests

›Ankle brachial index

›Doppler signal assessment

›Arthrocentesis when joint infection concern

›Synovial WBC and differential

›Gram stain and culture

›Crystal analysis

Pitfalls and limitations

›Probe to bone

›Best for ulcers over bony prominences

›Negative test does not exclude osteomyelitis

›Arthrocentesis

›Crystals can coexist with infection

›Prior antibiotics reduce culture yield

14ECG/ecg6

When relevant in foot pain presentations

›Indications uncommon

›Sepsis physiology

›Chest pain or dyspnea with thromboembolism concern

›High risk findings to act on

›New ischemic changes

›Unstable arrhythmia

15Assessment/ax27

Problem representation and risk stratification

›Foot pain syndrome classification

›Traumatic with suspected fracture

›Atraumatic mechanical

›Inflammatory monoarthritis

›Infection suspected

›Neurovascular compromise suspected

›Severity stratification

›Non weight bearing

›Severe rest pain

›Rapid progression

›Complications to rule out

›Compartment syndrome

›Acute limb ischemia

›Septic arthritis

›Necrotizing infection

Working diagnosis examples with codes

›Plantar fasciitis (M72.2)

›Heel pain first steps pattern

›Plantar fascia insertion tenderness

›Stress fracture (M84.37)

›Overuse history

›Focal bony tenderness

›Gout (M10)

›Sudden monoarthritis pattern

›Podagra pattern

›Diabetic foot infection (E11.621)

›Ulcer plus erythema

›Purulent drainage

16Plan/plan49

Approach to the critical patient first 5 minutes

›Immediate stabilization priorities

›Airway and breathing concerns if toxic

›Cardiac monitoring with sepsis physiology

›IV access criteria

›Two large bore IV with shock concern

›Analgesia early

›Acetaminophen PO 1000 mg once

›Ibuprofen PO 400 mg once

›Avoid NSAID with kidney disease concern

›Limb threat pathway

›If pulseless or mottled foot immediate vascular surgery

›If compartment syndrome concern immediate orthopedics

Diagnostic sequencing

›Trauma pathway

›Radiographs foot 3 view

›Weight bearing radiographs with Lisfranc concern

›CT with complex fracture concern

›Infection pathway

›CBC

›CRP

›ESR

›Blood cultures with fever

›MRI with osteomyelitis concern

›Inflammatory arthritis pathway

›Arthrocentesis with effusion and severe pain

›Crystal analysis

›Culture regardless of crystals if infection concern

Therapeutics

›Immobilization and protection

›Walking boot for suspected fracture pending imaging

›Non weight bearing with Lisfranc concern

›Antibiotics for suspected severe infection

›Local protocol dependent empiric coverage

›MRSA risk based coverage decision

›Gout flare treatment options

›Naproxen PO 500 mg once

›Then naproxen PO 250 mg twice daily

›Colchicine PO 1.2 mg once

›Then colchicine PO 0.6 mg once 1 hour later

›Avoid colchicine with severe kidney disease

›Plantar fasciitis symptom control

›Relative rest

›Ice after activity

›Supportive footwear

Reassessment loop

›Time based reassessment

›Recheck pain and neurovascular status within 30 to 60 minutes after interventions

›Repeat compartment exam if worsening pain

›Escalation triggers

›Increasing pain despite analgesia

›New numbness

›Worsening perfusion signs

17Disposition/dispo25

Level of care and consultation criteria

›ICU considerations

›Septic shock physiology

›Rapidly progressive necrotizing infection concern

›Admission indications

›Septic arthritis suspected

›Osteomyelitis with systemic signs

›Acute Charcot with inability to offload safely

›Urgent consult indications

›Vascular surgery for acute limb ischemia concern

›Orthopedics for open fracture

›Orthopedics for Lisfranc instability

›Discharge criteria

›Stable vitals

›Pain controlled with oral medications

›Neurovascularly intact

›Safe ambulation plan

›Follow up plan reliable

Follow up timing

›Fracture or suspected fracture

›Orthopedics within 3 to 7 days

›Earlier if worsening pain or swelling

›Diabetic foot ulcer or infection

›Wound care or podiatry within 48 to 72 hours

›Earlier with spreading erythema

›Plantar fasciitis

›Primary care or sports medicine within 2 to 6 weeks

18Discharge Instructions/di26

Copy discharge instructions

›Summary

›Foot pain evaluation today with no immediate life threatening cause identified

›Imaging and tests reviewed based on your symptoms

›Activity

›Limit weight bearing as discussed

›Use the boot or splint as directed

›Elevate the foot when resting

›Pain control

›Acetaminophen as directed on label

›Ibuprofen as directed on label unless told to avoid

›Do not combine multiple NSAID products

›Wound and skin care if applicable

›Keep wound clean and dry

›Check skin daily if diabetes or neuropathy

›Follow up

›Follow up with primary care or specialist in the recommended time frame

›Return for reassessment if unable to arrange follow up

›Return to emergency care now for

›Fever

›Rapidly worsening redness

›New drainage

›Increasing swelling

›New numbness

›Blue or cold foot

›Inability to bear weight that is worsening

›Severe pain not controlled with medications

19References/r12

Guidelines and decision tools

›Project instructions source

›Evidence based clinical reference generator instructions

›Formatting and structure requirements

›IWGDF and IDSA guideline on diabetic foot infections 2023

›Diagnosis and treatment guidance for diabetes related foot infection

›Local protocol dependent antibiotic selection

›ACR Appropriateness Criteria Chronic Foot Pain 2020

›Imaging selection framework by clinical variant

›Reviewed annually by ACR process

›Ottawa Ankle Rules and Ottawa Foot Rules derivation 1992

›Radiography decision tool for ankle and midfoot injuries

›Validation and implementation studies followed

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.