What is the best course of treatment for a patient with bilateral foot pain?

Bilateral Foot Pain: Treatment Approach

Start with plain radiographs of both feet (three-view: anteroposterior, oblique, lateral) as your initial diagnostic step, followed by a structured conservative treatment protocol that includes daily stretching exercises, NSAIDs, proper footwear modification, and activity modification for 6-8 weeks before considering advanced interventions. 1, 2

Initial Diagnostic Workup

Obtain standard three-view radiographs of both feet first - this is the most cost-effective approach with 80-100% sensitivity for common structural causes like tarsal coalitions and toe fractures, though sensitivity drops to only 12-56% for stress fractures. 1, 2

Critical Physical Examination Elements

• Palpate systematically: Achilles insertion, lateral malleolus, posterior superior calcaneus, lateral calcaneal wall, calcaneofibular ligament, and plantar fascia insertion. 2
• Perform calcaneal squeeze test (medial-to-lateral compression) to assess for stress fractures. 2
• Assess bilateral pedal pulses to screen for peripheral arterial disease, especially in patients ≥65 years or those 50-64 years with atherosclerotic risk factors. 1
• Examine feet with shoes and socks removed - inspect for deformities, skin changes, nail abnormalities, asymmetric hair growth, elevation pallor, or dependent rubor. 1

Special Population Considerations

For diabetic patients: Perform comprehensive foot examination at every visit (not just annually) if they have insensate feet or deformities. 1 Screen for loss of protective sensation, assess for signs of infection (erythema, warmth, tenderness, purulent discharge), and maintain high suspicion for osteomyelitis. 1, 2

First-Line Conservative Treatment (Weeks 0-6)

Implement all of these interventions simultaneously - do not wait to see if one works before adding others. 2, 3

Stretching Protocol (Most Critical Component)

• Calf muscle and plantar fascia stretching 3-5 times daily - this is the most consistently effective intervention. 3, 4
• Add eccentric strengthening exercises if Achilles tendinopathy is suspected (pain 2-6 cm proximal to heel insertion). 4

Footwear and Orthotics

• Proper footwear with adequate arch support, cushioning, and appropriate width. 3
• Over-the-counter heel cushions and arch supports initially. 3
• Consider custom orthotics if no improvement after 6 weeks. 3
• For posterior heel pain, recommend open-backed shoes to reduce pressure. 3

Pharmacologic Management

• NSAIDs (oral or topical) for pain relief and inflammation reduction. 3
• Avoid corticosteroid injections near the Achilles tendon due to rupture risk. 1, 3

Activity Modification

• Reduce activities that worsen pain but avoid complete immobilization to prevent muscular atrophy and deconditioning. 3
• Ice therapy through wet towel for 10-minute periods. 3
• Weight loss if indicated to reduce pressure on feet. 3

Second-Line Treatment (Weeks 6-12)

If no improvement after 6 weeks of appropriate conservative treatment:

• Continue all conservative measures. 3
• Add padding and strapping of the foot. 3
• Consider customized orthotic devices if not already implemented. 3
• Order MRI foot without IV contrast if stress fracture, plantar fascia tear, or nerve entrapment (Baxter's neuropathy) is suspected. 2
• Consider extracorporeal shockwave therapy for persistent plantar fasciitis. 3, 4
• Evaluate for cast immobilization or fixed-ankle walker-type device. 3

Referral Indications (After 6-8 Weeks)

Refer to podiatric foot and ankle surgeon if:

• No improvement after 6-8 weeks of appropriate conservative treatment. 3
• Displaced fractures or open fractures identified. 5
• Suspicion of systemic disease causing bilateral foot pain. 5
• Need for surgical evaluation (plantar fasciotomy) after 2-3 months of failed conservative treatment. 3

For diabetic patients with additional risk factors, refer to foot care specialist for ongoing preventive care if they smoke, have loss of protective sensation, structural abnormalities, or history of prior ulcers/amputation. 1

Critical Pitfalls to Avoid

• Do not reexamine too early - always reexamine 3-5 days post-injury, as excessive swelling and pain limit initial examination within 48 hours. 2
• Do not miss stress fractures - patients often report increased walking activity before symptom onset, and initial radiographs may be negative. 2
• Do not overlook small avulsion fractures on radiographs - requires systematic review. 2, 5
• Do not fail to obtain weight-bearing views when indicated, as this can miss subtle deformities. 2, 5
• Do not underestimate proper footwear impact on symptom management. 2, 5

Red Flags Requiring Immediate Evaluation

• Pain becomes constant at rest. 3
• Numbness or increasing swelling/redness suggesting infection. 3
• Signs of foot infection in diabetic patients (≥2 signs of inflammation or purulent secretions). 2
• Positive ankle-brachial index or significant claudication suggesting peripheral arterial disease. 1