What is the recommended management for a patient with foot pain, normal foot exam, and a history of a popping sensation while walking, with persistent soreness but no swelling?

Management of Foot Pain with Popping Sensation and Normal Radiographs

Refer this patient to podiatry for gait analysis and consideration of custom orthotics to address the mechanical foot pain with popping sensation, as correcting foot balance and eliminating abnormal weight bearing can reduce pain while walking.

Initial Conservative Management

The patient's presentation—foot pain with a popping sensation during ambulation, persistent soreness without swelling, and normal radiographic findings—suggests a mechanical foot problem rather than structural pathology. The most appropriate next step is podiatry referral for comprehensive gait analysis and biomechanical assessment 1.

Podiatry Assessment and Gait Analysis

• Gait analysis systems should be utilized to assess the patient's walking pattern and identify areas of abnormal weight bearing that may be causing the popping sensation and pain 1.
• Correcting foot balance and eliminating areas of abnormal weight bearing has been shown to reduce pain on walking in the majority of patients 2.
• The popping sensation likely represents joint or tendon movement related to biomechanical dysfunction that can be identified through formal gait assessment 1.

Footwear and Orthotic Interventions

• Patient-specific insoles and appropriately fitting shoes should be considered as first-line interventions 1.
• Footwear should be firm and comfortably fitting, with appropriate length and width, a rounded toe, and a flexible flat sole with heel support 1.
• The American College of Radiology recommends footwear that provides adequate arch support and cushioning, with avoidance of barefoot walking or thin-soled footwear 3.
• Shock-absorbing insoles can reduce pressure and may address the mechanical source of the popping and pain 1.

Multidisciplinary Approach

• A multidisciplinary team including a podiatrist, occupational therapist, and physiotherapist should be implemented to address pain and maintain mobility 1.
• This approach has been shown to reduce pain while walking and encourage long-term mobility 2.

Pain Management During Conservative Treatment

• Ice therapy applied for 10-minute periods through a wet towel can reduce acute pain and inflammation 1.
• Topical or oral NSAIDs should be considered for pain relief, particularly during the initial treatment phase 1.
• Activity modification to reduce pain-provoking movements should be implemented while maintaining overall activity levels 4.

Follow-up and Monitoring

• Regular follow-up appointments should be scheduled every 3-6 months based on symptom severity to monitor pain levels, mobility, and response to interventions 1.
• If symptoms persist beyond three months despite conservative treatment, ultrasonography is the reasonable and cost-effective initial imaging modality to evaluate soft tissue structures not visible on radiographs 3.
• MRI should be reserved for recalcitrant cases or to rule out other pathology such as stress fracture, nerve entrapment, or occult soft tissue injury 3.

Patient Education

• Counsel the patient about healthy foot behaviors including daily foot inspection, wearing appropriate shoes and socks, and avoiding barefoot walking 2.
• Emphasize the importance of seeking medical attention if new symptoms develop, such as swelling, redness, warmth, or worsening pain 2.
• If the patient is overweight or obese, weight reduction should be strongly emphasized as obesity is a significant risk factor for mechanical foot pain and contributes to ongoing disability 3.

Common Pitfalls to Avoid

• Do not assume that normal radiographs rule out significant pathology—soft tissue injuries, tendon dysfunction, and early stress injuries may not be visible on plain films 3.
• Failure to address footwear issues can undermine the effectiveness of other interventions 1.
• Do not delay podiatry referral waiting for symptoms to worsen, as early biomechanical correction is more effective than delayed intervention 1.
• The popping sensation should not be dismissed as benign without proper gait assessment, as it may indicate joint instability or tendon subluxation requiring specific treatment 1.