Best Initial X-ray for Foot Pain
For a patient presenting with foot pain, order a standard three-view radiographic series of the foot (anteroposterior, oblique, and lateral views), with weight-bearing views when the patient can tolerate them. 1
Standard Three-View Foot Series
The three-view foot radiograph series is the mainstay of initial imaging for acute foot trauma and chronic foot pain, consisting of anteroposterior (AP), oblique, and lateral projections. 1
This combination achieves 99% sensitivity for detecting foot fractures when Ottawa rules are positive, making it the gold standard first-line study. 1
The oblique view is essential and not optional—it uniquely reveals abnormalities in 4.8% of cases and increases diagnostic confidence by reducing equivocal findings from 13.9% to 8.4%. 2
The oblique view is equally valuable across all foot regions including the ankle, midfoot, forefoot, and toes. 2
Weight-Bearing Views: Critical When Feasible
Always obtain weight-bearing radiographs when the patient can tolerate standing, as non-weight-bearing films may miss subtle malalignment and joint instability. 1, 3, 4
Weight-bearing views are particularly crucial for suspected Lisfranc injuries, where they increase detection of abnormal alignment at the Lisfranc joint that would otherwise be missed. 1
For plantar heel pain, weight-bearing radiographs combined with assessment of plantar fascia thickness and fat pad abnormalities achieve 85% sensitivity and 95% specificity for plantar fasciitis. 1
Percentage weight-bearing only matters clinically if the patient bears less than 25% body weight—graduated weight-bearing between 25-100% does not significantly alter radiographic measurements. 5
Special Circumstances Requiring Additional Views
Suspected Calcaneal Fracture
- Add an axial calcaneal view to the standard three views, as this increases specificity for diagnosing calcaneal fractures and sensitivity for distinguishing intra-articular involvement. 1
Suspected Lisfranc Injury
Add an AP view with 20° craniocaudal angulation to the standard three views when clinical suspicion is high. 1
Include bilateral foot AP radiographs to compare subtle malalignment with the uninjured side. 1
Hallux MTP Joint Injury
- Order weight-bearing AP, lateral, and sesamoid axial views with comparison radiographs of the contralateral foot to evaluate for plantar plate disruption and sesamoid migration. 1
Critical Pitfalls to Avoid
Never order ankle radiographs when evaluating midfoot or tarso-navicular pain—the tarso-navicular joint will not be properly visualized; foot radiographs are required. 3, 4, 6
Do not rely solely on initial radiographs to exclude stress fractures, which have only 12-56% sensitivity on plain films. 1, 3, 4, 6
Do not skip radiographs even with known hyperuricemia or obvious clinical diagnosis—other pathology must be excluded first. 6
For patients with diabetic neuropathy or peripheral neuropathy, obtain radiographs even if Ottawa rules are negative, as pain perception is diminished and fractures may be present despite ability to ambulate. 1
When Standard Radiographs Are Insufficient
Radiographs detect only 80-100% of calcaneonavicular coalitions and may miss talocalcaneal coalitions due to overlapping structures. 1, 4
In polytrauma patients, approximately 25% of midfoot fractures identified on CT are overlooked on radiographs, making CT the primary imaging technique in high-energy trauma. 1
For persistent pain after negative radiographs with suspected stress fracture, MRI without contrast is the next appropriate study, as it detects occult fractures, bone marrow edema, and stress reactions invisible on radiographs. 3, 6
Three-phase bone scan has 100% sensitivity and negative predictive value for ruling out stress fractures when radiographs are negative. 3