What are the evaluation and management steps for an adult patient with no significant past medical history experiencing pain over dorsiflexion of the foot?

Evaluation and Management of Pain with Dorsiflexion of the Foot

Begin with plain radiographs of the foot and ankle as your initial imaging study, then perform a focused physical examination to localize the pain anatomically—anterior ankle pain with dorsiflexion suggests anterior ankle impingement syndrome, while posterior or lateral pain points to Achilles tendinopathy, Haglund's deformity, or lateral ligament pathology. 1, 2

Initial Clinical Assessment

Key History Elements to Obtain

• Pain location during dorsiflexion: Anterior ankle pain suggests anterior impingement syndrome, posterior heel pain indicates Achilles tendinopathy or bursitis, and lateral pain suggests lateral ligament injury or Haglund's deformity 2, 3
• Trauma history: Recent inversion injury raises concern for lateral ligament sprain (calcaneofibular ligament) or lateral process talus fracture ("snowboarder's fracture") 2
• Activity changes: Progressive worsening after increased walking or change to harder surfaces suggests calcaneal stress fracture 2
• Footwear patterns: Pain relieved barefoot but worsened by shoes indicates Haglund's deformity or retrocalcaneal bursitis 2, 3
• Neurologic symptoms: Burning, tingling, or numbness suggests nerve entrapment rather than mechanical causes 3

Critical Physical Examination Findings

• Palpation sites: Examine the anterior ankle joint line (anterior impingement), medial plantar calcaneus (plantar fasciitis), lateral to Achilles tendon (Haglund's deformity), lateral calcaneal wall (stress fracture), and over the calcaneofibular ligament course 2
• Calcaneal squeeze test: Compress the calcaneus medially to laterally—pain suggests calcaneal stress fracture 2, 3
• Ankle stability testing: Assess for medial or lateral ligamentous laxity, particularly if the patient reports ankle "giving way" 4
• Swelling pattern: Rapid onset swelling suggests acute ligamentous injury or fracture; lateral gutter swelling indicates lateral ligament involvement 2

Imaging Algorithm

Initial Imaging

Order plain radiographs (foot and ankle views) as the first-line imaging study for all patients with pain on dorsiflexion. 1 Radiographs have 80-100% sensitivity for calcaneonavicular coalitions and can identify osteophytes causing anterior impingement, though they have limited sensitivity (12-56%) for stress fractures 1

• Include lateral and oblique views to evaluate for tarsal coalitions and anterior ankle osteophytes 1
• Apply Ottawa Ankle Rules: Order radiographs if unable to bear weight immediately after injury, point tenderness over malleoli/talus/calcaneus, or inability to ambulate 4 steps 2

Advanced Imaging (If Radiographs Negative)

• For persistent pain >1 week: MRI without contrast or CT without contrast are equivalent alternatives 2
• For suspected stress fracture with negative radiographs: Technetium bone scanning is recommended, as symptoms often precede radiographic findings 2, 3
• For anterior impingement evaluation: MRI is superior to radiographs for detecting soft tissue overgrowths and early osteophytes 5

Common Pitfall in Examination Timing

Always reexamine patients 3-5 days post-injury if initial examination is limited by swelling and pain within the first 48 hours. 2 Excessive early swelling can obscure critical examination findings and lead to missed diagnoses.

Diagnosis-Specific Management

Anterior Ankle Impingement Syndrome

• Clinical presentation: Anterior ankle pain specifically on hyperdorsiflexion 5
• Conservative treatment: Activity modification, NSAIDs, cryotherapy (10-minute periods through wet towel), and stretching exercises 6, 3
• Surgical option: Arthroscopic excision of soft tissue overgrowths and osteophytes is effective for patients without joint space narrowing 5

Lateral Ligament Injury (Calcaneofibular Ligament Sprain)

• Clinical presentation: Lateral heel pain with inversion trauma, pain with dorsiflexion, point tenderness over calcaneofibular ligament 2
• Treatment: Rest, NSAIDs, activity modification, and appropriate footwear with arch supports 6, 3

Haglund's Deformity with Retrocalcaneal Bursitis

• Clinical presentation: Posterior and lateral heel pain, prominent posterior superior calcaneus visible on radiographs 2
• Treatment: Open-backed shoes, accommodative padding, NSAIDs, corticosteroid injections into the bursa (avoiding the Achilles tendon), and physical therapy 3

Calcaneal Stress Fracture

• Clinical presentation: Progressively worsening pain after increased activity, positive calcaneal squeeze test, tenderness at lateral calcaneal wall 2
• Treatment: Protect and immobilize the foot; consider cast or fixed-ankle walker-type device 6
• Imaging: Technetium bone scanning if radiographs negative 2, 3

Conservative Treatment Protocol

First-Line Interventions (Implement Simultaneously)

• Stretching exercises: Calf muscle and plantar fascia stretches 3-5 times daily 6, 3
• Footwear modifications: Proper fit, width, and cushioning; open-backed shoes for posterior pathology 6, 3
• Orthotic devices: Heel lifts, cushions, or over-the-counter arch supports 6, 3
• NSAIDs: Oral or topical for pain relief and inflammation reduction 6, 3
• Cryotherapy: Ice application for 10-minute periods through wet towel 6, 3
• Activity modification: Reduce aggravating activities but avoid complete rest to prevent muscle atrophy 6, 3
• Weight loss: If indicated, to reduce pressure on the foot 6, 3

Second-Line Interventions (If No Improvement After 6 Weeks)

• Customized orthotic devices 3
• Night splinting 3
• Corticosteroid injections (with critical caveat below) 3

Critical Warning About Corticosteroid Injections

Never inject corticosteroids near the Achilles tendon due to significant risk of tendon rupture. 6, 3 Corticosteroid injections should be used judiciously and only in appropriate anatomic locations (e.g., into the retrocalcaneal bursa, avoiding the tendon itself) 3

Referral Indications

Refer to a podiatric foot and ankle surgeon if:

• No improvement after 6-8 weeks of appropriate conservative treatment 3
• Need for advanced imaging or diagnostic testing beyond plain radiographs 3
• Consideration of surgical intervention required 3
• Neurologic heel pain requiring subspecialist evaluation with electromyography, nerve conduction studies, and MRI 3

Red Flags Requiring Immediate Evaluation

• Pain becomes constant at rest 6
• Numbness or increasing swelling/redness (concern for infection or nerve compression) 6
• Complete sensory loss or motor paralysis (suggests acute limb ischemia) 1