What does a normal foot X-ray (X-ray) show?

Normal Foot X-Ray Anatomy

A normal foot X-ray demonstrates intact osseous architecture with proper alignment of the longitudinal and transverse arches, clear joint spaces, normal bone density, and absence of fractures, dislocations, or soft tissue swelling. 1

Standard Radiographic Views

The complete evaluation of normal foot anatomy requires three standard projections 1, 2:

• Anteroposterior (AP) view: Shows the alignment of metatarsals, phalanges, and midfoot bones, with clear visualization of joint spaces between adjacent bones 1
• Medial oblique view: Provides optimal visualization of the lateral column and cuboid-metatarsal articulations 1
• Lateral view: Demonstrates the longitudinal arch configuration and alignment of the talus, calcaneus, navicular, cuneiforms, and metatarsals 1

Weight-bearing radiographs are strongly preferred over non-weight-bearing films, as they reveal dynamic abnormalities including joint alignment and arch configuration that may not be apparent when non-weight-bearing 1, 2

Normal Anatomic Features on X-Ray

Bone Architecture

• Uniform bone density: Normal cortical and trabecular bone patterns without areas of lucency or sclerosis 1
• Intact cortical margins: Smooth, continuous cortical outlines without erosions or disruption 1
• Clear joint spaces: Well-defined articular surfaces with preserved joint space width throughout the foot 1

Arch Configuration

The foot functions as a segmented dome structure with specific architectural features 3:

• Medial longitudinal arch: Consists of calcaneus, talus, navicular, three cuneiforms, and first three metatarsals—this arch is more arcuated and elastic 3
• Lateral longitudinal arch: Consists of calcaneus, cuboid, and 4th-5th metatarsals—this arch is flattened and contacts the ground 3
• Transverse arches: Two arches extend from medial to lateral borders, one at the tarsometatarsal joint (lancet dome configuration) and one at the metatarsophalangeal joint (flat dome configuration) 3

Soft Tissue Appearance

• Absence of diffuse soft tissue swelling: Normal soft tissue contours without evidence of edema 1
• No joint effusions: Clear joint spaces without fluid accumulation 1
• No calcific debris or foreign bodies: Soft tissues should be free of abnormal calcifications or radio-opaque materials 1

Key Anatomic Relationships to Assess

When evaluating foot radiographs for normalcy, verify these critical alignments 1, 2:

• Tarsometatarsal (Lisfranc) alignment: The medial border of the second metatarsal should align with the medial border of the middle cuneiform on AP view 1, 2
• Metatarsal parabola: The metatarsal heads should form a smooth arc on AP view 1
• Calcaneal pitch angle: Normal range on lateral weight-bearing view indicates proper arch height 3
• No subluxation or dislocation: All joints should maintain proper articulation without displacement 1

Clinical Pitfalls

• Non-weight-bearing films may appear falsely normal: Dynamic malalignments, particularly Lisfranc injuries, may only be visible on weight-bearing views 1, 2
• Bilateral comparison is valuable: Subtle asymmetries become apparent when comparing to the contralateral foot 1, 2
• Early pathology may not be visible: Plain radiographs require approximately 2 weeks of bone loss before abnormalities become detectable 1
• Context matters: Radiographs should always be interpreted in conjunction with clinical findings, as isolated imaging without clinical correlation can lead to misdiagnosis 1