Foot Pain

Differential Diagnosis

Common Diagnoses

Occasional Diagnoses

Rare Diagnoses

  • March Fracture
  • Sever’s Disease (Apophysitis of the Calcaneus), Usually a Problem of Adolescence
  • Osteochondritis: Navicular = Köhler’s Disease; Head of Second or Third Metatarsal = Freiberg’s Disease
  • Osteomyelitis and Septic Arthritis
  • Erythromelalgia and Painful Polyneuropathy
  • Ischaemia

Ready Reckoner

Key distinguishing features of the most common diagnoses

GoutVerrucaBunionIGTNPlantar Fasciitis
Forefoot PainYesPossibleYesYesNo
Very Tender Joint(s) YesNoPossibleNoNo
Pain at RestYesNoNoPossibleNo
Tender HeelNoPossibleNoNoYes
Sudden OnsetYesNoNoPossiblePossible

Possible Investigations


Possible:Urinalysis, FBC, ESR/CRP, rheumatoid factor/anti-CCP antibodies, uric acid, X-ray.

Small Print:Bone scan, angiography.

  • Urinalysis may reveal glycosuria in previously undiagnosed diabetic with neuropathy (suspicion of neuropathy may in itself require further investigations).
  • FBC/ESR/CRP: Raised WCC and ESR/CRP in infection and severe inflammation.
  • Rheumatoid factor: Of prognostic help if foot pain is part of clinical diagnosis of rheumatoid arthritis (consider anti-CCP antibodies if negative).
  • Uric acid: If gout suspected, especially with recurrent attacks and if considering prophylaxis.
  • X-ray useful if suspect possible arthritis, osteomyelitis, march fracture, osteochondritis, radio-opaque foreign body. If clinical suspicion high and X-ray unhelpful, bone scan may be more useful.
  • Angiography: If ischaemic foot with rest pain.

Top Tips

  • The vast majority of causes are obvious from the history or from a cursory examination. The harder you have to think, the more likely that there may be an obscure cause requiring investigation.
  • It can be difficult to distinguish gout from a severely inflamed bunion. With gout, the patient may have had previous episodes, the onset tends to be sudden, the joint is extremely tender and joint movements are very limited.
  • Important pointers can be picked up in the history, especially for some of the less common causes. Thus, Morton’s neuroma causes a sharp pain often radiating to the third and fourth toes, relieved by removing the shoe; plantar fasciitis is described as ‘walking on a pebble’, especially after resting; and a march fracture results in a pain which initially comes on predictably with exercise and which then becomes continuous, with local bony tenderness and possibly a lump.

Red Flags

  • If a known arteriopath complains of pain in the ball of the foot disturbing sleep then the diagnosis is probably critical ischaemia. Refer urgently.
  • Fever and systemic illness with localised extreme bone pain and signs of local infection is acute osteomyelitis or septic arthritis until proved otherwise. Admit.
  • Pain with no obvious signs – particularly tenderness – in the foot suggests ischaemia, neuropathy or an L5/S1 nerve root lesion.
  • If no cause is evident but the patient has very localised sole tenderness away from the heel, consider a foreign body.
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