Foot and ankle pain in the active child or skeletally immature adolescent: Evaluation

INTRODUCTION — The diagnosis and treatment of foot and ankle injuries in the active child or young adolescent require knowledge of anatomy, gait, and biomechanics. The evaluation of foot pain in these patients is reviewed here.

Specific pediatric conditions, including fractures of the foot, are presented separately:

●(See "Forefoot and midfoot pain in the active child or skeletally immature adolescent: Overview of causes".)

●(See "Heel pain in the active child or skeletally immature adolescent: Overview of causes".)

●(See "Foot fractures (other than metatarsal or phalangeal) in children".)

●(See "Metatarsal and toe fractures in children".)

BACKGROUND — Approximately 20 percent of all musculoskeletal complaints presenting for emergency care involve the foot or ankle [1]. Among children and skeletally immature adolescents with emergent foot conditions, injuries to the bone are more common than to the ligaments. In ambulatory settings, common musculoskeletal causes of foot pain in children and adolescents include calcaneal apophysitis (Sever disease) and pes planus (flatfoot). (See "Forefoot and midfoot pain in the active child or skeletally immature adolescent: Overview of causes" and "Heel pain in the active child or skeletally immature adolescent: Overview of causes".)

Although foot injuries may occur during many types of sports or recreation, activities frequently associated with foot pain and injury include long-distance running, volleyball, dancing (especially ballet), and rock climbing [2-5].

ANATOMY

Bones — The foot has 28 bones, including 14 phalanges, 7 tarsal bones (talus, calcaneus, cuboid, navicular, and 3 cuneiforms), 5 metatarsals, and 2 sesamoids [6]. Accessory ossicles are normal variants that are commonly present (5 to 30 percent) in the foot and ankle, usually asymptomatic, and usually well-corticated bones formed by unfused secondary ossification centers [7].

The foot can be divided into three functional parts that are defined by the articulations proximally and distally as follows (figure 1) [6]:

●Hindfoot – The hindfoot consists of the talus and the calcaneus. Proximally, the ankle mortise connects the tibialis/fibula complex to the superior talus. And the distal portion of the talus and calcaneus connects to the midfoot at the midtarsal (Chopart) joint. The os trigonum is the most common accessory ossicle in the foot (25 to 30 percent) that is located at the posterior lateral process of the talus.

●Midfoot – The midfoot contains the navicular, the cuboid, and the three cuneiform bones. The bones of the midfoot connect to the proximal metatarsals at the Lisfranc joint. The os naviculare is the most common accessory ossicle on the medial aspect of the midfoot (4 to 20 percent) that is located just medial and proximal to the navicular tuberosity. The os peroneum occurs on the lateral midfoot at the level of the cuboid and is usually embedded in the fibularis (peroneus) longus tendon.

●Forefoot – The forefoot includes everything distal to the Lisfranc joint, including the metatarsals, sesamoids, and phalanges. At the proximal tip of the fifth metatarsal is the os vesalianum pedis.

Joints — The foot and ankle has five joints: the ankle (mortise), subtalar (talocalcaneal), midtarsal (Chopart), and midfoot (Lisfranc) (figure 1) as follows [6]:

●Ankle joint (mortise) – The distal tibia and fibula form the roof of the ankle joint. The dome of the talus fits snugly into the tibia and fibula (figure 2). The primary plane of movement at the ankle joint is plantarflexion/dorsiflexion.

●Subtalar joint – The subtalar joint is composed of the anterior, middle, and posterior articulations between the talus and the calcaneus. They are separated laterally by the sinus tarsi and medially by the tarsal canal. The subtalar joint is responsible for hindfoot inversion/eversion and abduction/adduction.

●Midtarsal (Chopart) joint – The talonavicular and calcaneocuboid articulations are responsible for "unlocking" the midfoot during subtalar pronation, allowing the foot to absorb more shock, and for "locking" the midfoot during subtalar supination, allowing the foot to become a rigid lever for propulsion.

●Midfoot (Lisfranc) joint – The midfoot or Lisfranc joint provides rigid stability to optimize efficiency through the medial column of the foot.

●First metatarsophalangeal (MTP) joint – The first MTP is a complex joint that includes the two sesamoids, supporting ligaments, plantar plate, and muscles (flexor halluces longus, ab- and adductor hallucis); it is essential to the propulsion phase of gait. (See 'Biomechanics' below.)

Ligaments — The foot and ankle have four main groups of ligaments (figure 3A-B) [6]:

●Lateral ligament complex – This complex is relatively weak and has three components:

•The anterior talofibular ligament (ATFL) connects the talus and distal fibula anteriorly.

•The calcaneofibular ligament (CFL) connects the calcaneus and distal fibula directly inferior to the lateral malleolus.

•The posterior talofibular ligament (PTFL) connects the talus and fibula posteriorly.

●Medial ligament complex – The deltoid ligament and spring ligament provide stability to the medial ankle. The deltoid ligament is a relatively strong group of ligaments all originating from the medial malleolus that are organized into a deep and a superficial component.

The deep component (anterior and posterior tibiotalar ligaments) stabilizes the talus against posterior and lateral translation and eversion forces. The superficial components (tibia to calcaneus, spring ligament, and navicular) provide stability to the calcaneal navicular complex and prevent external rotation of the talus.

The spring ligament (three components) originates from the sustentaculum tali of the calcaneus and insert on the navicular providing support medially and inferiorly to the neck/head of the talus.

●Tibiofibular ligament complex – The tibiofibular complex consists of the anterior and posterior tibiofibular and the interosseous membrane and ligament (figure 4 and figure 3A). This complex is responsible for maintaining the relationship between the distal tibia and fibula and preventing them from splaying apart with a cephalad force from the talus.

●Lisfranc ligament complex – The Lisfranc ligament complex is very important to midfoot stability and maintaining the transverse arch of the foot. The three components of the complex (dorsal, interosseous, and plantar) connects the lateral portion of the medial cuneiform to the medial portion of the proximal second metatarsal (figure 5).

Plantar fascia — The plantar fascia is the primary aponeurosis that originates on the plantar aspect of the calcaneus and fans out to attach to the base of each of the five metatarsal heads (figure 6). It acts to reinforce the medial arch during the propulsion phase of gait. Its impact on the medial longitudinal arch is important to the biomechanics of the foot during the toe-off phase. (See 'Biomechanics' below.)

Muscles — The muscles of the foot and ankle originate above the ankle (extrinsics) and within the foot (intrinsics) [6]. The extrinsic muscles permit the larger force-generating muscles to be located away from the foot and to avoid interference with the intrinsic structure of the foot (figure 7 and figure 8).

The extrinsic muscles are organized into four fascial compartments that are anatomically important to compartment syndromes (figure 9). Each compartment has a nerve that may cause classic neurologic symptoms in the foot if the compartment pressure is elevated. (See "Acute compartment syndrome of the extremities", section on 'Anatomic compartments and related clinical signs'.)

The anterior or extensor compartment of the leg includes the following muscles and the deep fibular (peroneal) nerve [6]:

●The tibialis anterior originates on the proximal anterior tibia and courses distally in its synovial sheath beneath the extensor retinaculum to insert on both the medial cuneiform and the medial base of the first metatarsal. It dorsiflexes and inverts the foot and is a secondary stabilizer of the arch with the posterior tibialis.

●The extensor hallucis longus (EHL) inserts on the dorsal aspect of the base of the distal phalanx of the great toe. It extends the great toe and dorsiflexes the foot.

●The extensor digitorum longus (EDL) has a distal attachment on the middle and distal phalanges of the lateral four digits and acts to extend these lateral four digits and dorsiflex the foot.

●The peroneus tertius inserts on the mid portion of the dorsal fifth metatarsal bone and acts in a minor role in dorsiflexion and eversion of the foot.

The lateral compartment of the leg contains the peroneus longus and peroneus brevis and the superficial fibular (peroneal) nerve. The peroneus longus inserts on the base of the first metatarsal bone and medial cuneiform bone and acts to evert the foot and weakly plantarflex it (picture 1). The peroneus brevis inserts on the base of the fifth metatarsal (picture 2) and has the same action as does the peroneus longus.

The superficial posterior compartment of the leg contains the sural nerve and the triceps surae (the gastrocnemius and soleus complex), which insert via the Achilles tendon into the posterior surface of the calcaneus (picture 3 and picture 4). They are the force generators that plantarflex the foot and weakly evert the heel.

The deep posterior compartment of the leg contains the tibial nerve and the tibialis posterior (TP), flexor digitorum longus (FDL), and flexor hallucis longus (FHL) muscles. The tendinous portion of these muscles are located in the tarsal tunnel (with the posterior tibial artery, vein, and nerve) as they all pass inferior to the medial malleolus.

●The TP inserts on the tuberosity of the navicular bone, along with additional insertion points on the three cuneiforms, and the base of the second, third, and fourth metatarsal bones (picture 5). It functions to plantarflex and invert the foot.

●The FDL inserts on the base of the distal phalanges of the lateral four digits and this flexes these four digits, plantarflexes the foot, and supports the longitudinal arch of the foot (picture 6).

●The FHL inserts on the base of the distal phalanx of the great toe and is responsible for flexing the great toe at all joints, plantarflexing the foot, and supporting the longitudinal arch of the foot (picture 7).

Arteries — The arteries of the foot are shown in the figure (figure 10). The dorsalis pedis artery is a continuation of the anterior tibial artery that crosses the anterior joint line of the ankle just deep to the extensor hallucis longus [6]. As the artery proceeds down the long axis of the foot to the proximal first intermetatarsal space, it divides into a deep plantar artery and an arcuate artery that sends off branches to each of the toes.

The arteries in the sole of the foot are derived from the posterior tibial artery and form the medial and lateral plantar arteries. The lateral plantar branch sends off branches through the plantar arterial arch, which anastomoses with the deep plantar artery for the dorsalis pedis.

Nerves — The common fibular (peroneal) and tibial nerves are the two major divisions of the sciatic nerve that branch just above the knee (picture 8) [6]. The common fibular (peroneal) nerve is the nerve that is injured most often in the lower limb (figure 11). Severance of this nerve causes a foot drop because of the paralysis of the dorsiflexion and eversion muscles of the foot.

The common fibular (peroneal) nerve splits into a superficial and deep branches just distal to the fibular head [6]. The superficial branch provides sensation to the lateral aspect of the dorsum of the foot and innervates the fibularis (peroneal) brevis and longus (hindfoot evertors). The deep branch provides sensation to the interdigital space between the first and second toe and is responsible for dorsiflexing the ankle and toes. The tibial nerve proceeds posterior to the medial malleolus and becomes the medial and lateral plantar nerves. The tibial and fibular (peroneal) nerves give off branches that form the sural nerve, which supplies sensation to the lateral aspect of the ankle and foot.

Veins — The major veins of the lower leg and foot consist of the great saphenous vein, medal and lateral marginal veins of the foot, and the dorsal venous arch (figure 12).

BIOMECHANICS — In addition to the structural divisions discussed above, the foot can be divided into two functional columns: medial and lateral [8]. The medial column, consisting of the calcaneus, talus, navicular, medial cuneiforms, and medial three toes, forms the medial longitudinal arch and is the main axis for weightbearing and propulsion. The lateral column, consisting of the calcaneus, cuboid, and lateral two toes, forms the lateral longitudinal arch and is the main axis for proprioception.

A review of the gait cycle is helpful in understanding the complex movements of the foot that occur during walking and running. The subtalar movement controls the locking and unlocking of the midtarsal joints and determines the actions of the forefoot. These coupled motions of the foot allow it to perform its various functions [8]. Pronation, which provides maximum shock absorption, occurs when the tibia internally rotates, the talus adducts and dorsiflexes, and the calcaneus everts. Supination, which converts the foot into a rigid lever, occurs when the tibia externally rotates, the talus abducts and plantarflexes, and the calcaneus inverts.

The gait cycle has four phases (figure 13) [8]:

●Heel-strike to foot-flat (contact)

●Foot-flat to heel-off (midstance)

●Heel-off to toe-off (propulsion)

●Toe-off to heel-strike (swing)

Detailed description of these phases is as follows [8]:

●Contact – In the contact phase, the lateral calcaneus strikes the ground. At the point of impact, the tibia internally rotates, causing the calcaneus to evert and talus to drop and adduct to unlock the midtarsal joints and provide maximum shock absorption. The foot is lowered eccentrically to the ground by the extensor digitorum longus and tibialis anterior. In runners who contact the ground with their midfoot or forefoot, they will get into midstance quicker, pronate earlier, and load the Achilles more with less impact of the lower extremity.

●Mid-stance – In the midstance phase, the cycle progresses from the flat-foot to the heel-off. As the rearfoot fully pronates, the metatarsals hit the ground to bring the foot flat on the ground. The body's center of gravity passes from behind to over the foot. During this phase, the subtalar joint resupinates (calcaneus everts and talus abducts) and locks the midtarsal joints, transforming the foot from a shock absorber to a rigid lever. The posterior tibialis is an important restraint to overpronation and is an active foot supinator. As the body passes over the mid-foot, it places the ankle in maximal dorsiflexion, putting a maximal preload on the gastrocnemius-soleus complex.

●Propulsion – In the propulsion phase, the heel-lift progresses to toe-off. As the heel rises, the body continues forward over the metatarsals and begins to pull the heel off the ground. The extension of the metatarsophalangeal (MTP) joints, especially the first MTP joint, result in the windlass effect of the plantar fascia that elevates the arch and further assists in the supination of the foot. The foot is now a rigid lever and is used to propel the body forward by maximal contraction of the gastrocnemius-soleus and hamstrings. At toe-off, the line of progression usually passes between the first and second metatarsal that are in maximal extension. This phase concludes with the body weight moving over the great toe at toe-off.

●Swing – The swing phase is the last phase of the gait cycle. The foot dorsiflexes to keep the toes from hitting the ground and supinates to position the foot for the lateral calcaneus to make contact at heel strike, and the cycle repeats itself (figure 13).

EVALUATION — A careful history and physical examination can establish a working diagnosis in most children or adolescents with foot or ankle pain or injury.

History — The problems relating to the foot and ankle can be divided into acute and chronic.

The pertinent history related to specific injuries is discussed in detail separately. (See "Forefoot and midfoot pain in the active child or skeletally immature adolescent: Overview of causes" and "Heel pain in the active child or skeletally immature adolescent: Overview of causes".)

Acute injuries — Acute injuries usually have a definitive mechanism of injury and often require immediate evaluation and therapy. Important questions to ask include:

●What type of activity led to the injury? What was the mechanism of the injury? – Answers to these questions help identify the structures that are most likely to be injured. For example, excessive inversion of the ankle during basketball is associated with a lateral ankle ligament sprain, distal fibular avulsion fracture, or a fifth metatarsal fracture.

●Can the patient bear weight? Can they ambulate? – Inability to bear weight or ambulate is associated with fractures, dislocations, or a major disruption of the ligaments.

●Was there a mechanical sensation, such as a popping or cracking, at the time of the injury? – The presence of these sensations suggests an avulsion fracture or tendon tear.

●Has there been a persistent feeling of instability in the foot or ankle since the injury occurred? – Instability of the foot or ankle suggests ligamentous laxity or tears.

●What is the location, radiation, intensity, and duration of pain? – Localization of pain helps to identify the anatomic region affected by the injury and helps to narrow the likely diagnoses.

●What aggravates the pain? – In particular, the clinician should determine if the patient's pain is worse during certain portions of the gait (eg, heel strike or toe-off) or when completing certain maneuvers (eg, cutting to the side).

●What factors alleviate the pain? – The amount and intensity of pain may be estimated based upon whether or not it responds readily to local measures (eg, cold therapy) or mild analgesics (eg, acetaminophen or ibuprofen).

●Does the patient have numbness or tingling in the foot? – These sensations suggest nerve injury.

●Does the patient have weakness that may or may not be related to the pain? – Weakness suggests disruption of the tendons or nerves to the region.

Chronic pain — Chronic foot and ankle problems require the examiner to establish an accurate chronology and to identify specific activities that cause the pain.

For chronic problems, important questions include:

●Did the patient have an acute injury prior to developing chronic pain? – Chronic injuries and pain frequently arise from acute injuries that have not properly healed or been appropriately rehabilitated.

●What activity seems to worsen the problem? –Certain activities are associated with specific chronic injuries (eg, flexor hallucis longus tendinitis in classical ballet dancers or plantar fasciitis in distance runners).

●How often and for how long does the patient engage in the activity? Has there been a recent increase in the amount or duration of activity? – Overuse conditions of the foot and ankle frequently occur with heavy activity or a sudden change in activity (eg, practices at the beginning of a sports season).

●Is pain present during or after activity, or both? – Pain present during the activity indicates that the activity is beyond the body's structural ability. Pain only after the activity may indicate an inflammatory component to the injury instead of or in addition to a structural component to the injury.

●Is pain present when the patient takes his or her first steps in the morning? – "First step in the morning pain" suggests plantar fasciitis. Early morning stiffness suggests a rheumatologic process.

●Is there a problem with activities of daily living, such as ascending or descending stairs? – Impairment of normal activities of daily living suggests a significant underlying condition that warrants limitation of sports activities.

●Is the problem only exacerbated by sports? – Problems evident only during sports activity suggest a specific stress caused by that sport on normal structures instead of a structural abnormality (eg, tarsal coalition) that predates sports participation.

Training — In addition to the above questions, if the patient is an athlete, they should be questioned about training. As an example, if the patient is a runner, the examiner should ask about weekly mileage, racing, speed workouts, and type of running surface. Runners should also be questioned about their running shoes (type, age, miles, and change in model) and the use of orthotics.

Footwear — Some shoes may be classically associated with specific foot problems as follows:

●Calcaneal apophysitis with cleats

●Morton neuroma with progress shoes that come to a point

●Posterior tibialis tendinitis with pes planus with shoes lacking medial support

●Extensor hallucis tendinitis with flip-flops

●Contusions, bursitis, or compression neuropathies with poorly fitting ice skates

Past history — Past medical history and a related review of systems also should be assessed. For chronic illnesses, ask what medications, physical therapy, home rehabilitation, or shoe or activity modifications have been tried.

Considering systemic medical illnesses or conditions that may affect the foot is also important. As an example, rheumatologic conditions may have early morning stiffness, involvement of multiple joints, back and/or hip pain and stiffness, skin rash, or positive family history.

Infectious causes, such as cellulitis or osteomyelitis, are frequently associated with fever, localized swelling, and erythema. Patients with gout may present with symptoms at the first MTP after a large, high protein meal.

Physical examination — The physical examination of the child or adolescent with foot complaints includes inspection, palpation, range of motion, and provocative and functional testing [9,10].

Inspection — Manipulation of the extremity should be minimized and neurovascular status promptly evaluated if obvious deformity is present. In patients with deformity, breaks in the skin may indicate an open fracture. Prompt orthopedic consultation is warranted. The initial management of open fractures is discussed separately. (See "General principles of fracture management: Early and late complications", section on 'Open fractures'.)

●Foot and ankle – Inspection of the foot and ankle should occur with the patient in various positions: seated, prone or kneeling on a chair, standing in various poses, and walking as follows [10]:

•With the patient seated (non-weightbearing), the examiner should examine the foot for swelling, puncture wounds, ecchymosis, erythema, deformity, and dermatologic findings (eg, rashes, warts, ulcers, calluses (picture 9), blisters, bunions (picture 10), and nail abnormalities).

•With the patient prone or kneeling on a chair and the foot in the neutral position, the orientation (eg, varus or valgus) of the forefoot should be noted.

•With the patient standing normally, varus/valgus or torsional deformities of the tibia, hallux, and rearfoot should be noted. The position of the forefoot (abduction versus adduction) should be assessed.

•The toes should be inspected for deformities (eg, claw, mallet, hammer, or splay (picture 11)). All of these may be a source of foot or toe pain. The patient should then be asked to stand with the feet three to four inches apart and to march in place for three to four steps. Once the patient has assumed the relaxed natural position, the clinician should evaluate the arch for the presence of pes planus (flat foot) (picture 12 and picture 13) or cavus (high-arched foot) (picture 14). (See "Forefoot and midfoot pain in the active child or skeletally immature adolescent: Overview of causes", section on 'Arch abnormalities'.)

•Asking the patient to stand on his or her toes permits evaluation of muscle wasting in the gastrocnemius-soleus complex, function of the posterior tibialis muscle, and dynamic function of the arch. These observations are best made while standing behind the patient. As the patient rises on his or her toes, inversion of the heel indicates normal function of the posterior tibialis. In addition, the medial longitudinal arch should increase in height. Lack of elevation of the arch indicates a static pes planus that could be caused by tarsal coalition or injury to the subtalar joint. (See "Ankle pain in the active child or skeletally immature adolescent: Overview of causes" and "Heel pain in the active child or skeletally immature adolescent: Overview of causes".)

•The patient should be asked to walk, and several gait cycles should be observed (figure 13).

●Footwear – Inspecting a runner's shoes can provide clues to some of the biomechanical problems that can result in lower extremity injuries:

•Asymmetric wear of the outsole may indicate the area of contact as well as over-striding that increase friction between the outsole and the running surface. These forces can predispose to patellofemoral syndrome.

•Rearfoot strikers will have wear on the posterior lateral portion of the shoe with a predisposition for shin splints and iliotibial band syndrome.

•Mid- and forefoot strikers may get more wear toward the front of the shoe and can have associated Achilles tendon injuries.

•Asymmetric wear of the medial midsole and heel counter may indicate more pronation on that side that may implicate inadequate hip stability in midstance. These patients are also prone to shin splints or iliotibial band syndrome.

Palpation — Palpation of the foot should include palpation of the bony landmarks, the ligaments (figure 3A-B) and tendons, and the dorsalis pedis and posterior tibialis pulses [9]. In addition, sensory examination of the nerves of the foot should be performed.

The site of maximal tenderness during examination is an important indicator for several underlying foot and ankle conditions as follows (figure 14) [10,11]:

●Plantar surface

•Calcaneal apophysitis (Sever disease) – Medial and lateral portions of the heel

•Proximal plantar fasciitis – Medial and proximal portion of the heel

•Plantar fasciitis – Medial arch

•Metatarsophalangeal joint sprain (turf toe) – Medial base of the big toe (first metatarsophalangeal joint)

•Sesamoiditis – Medial sesamoid at the base of the big toe (first metatarsophalangeal joint)

•Iselin disease – Base of the little toe (fifth metatarsal; this finding is also present in patients with avulsions or fractures)

•Morton neuroma – Forefoot between the second and third or third and fourth metatarsals

●Dorsal foot surface and ankle

•Distal fibula fracture – Lateral malleolus

•Lateral ankle sprain – Anterior talofibular ligament (medial and distal to the lateral malleolus)

•Medial ankle sprain – Over the deltoid ligament (medial and distal to the medial malleolus)

•Freiberg infraction – Head of second toe

•Köhler disease – Over the navicular bone (medial and posterior portion of the midfoot) (figure 1)

•Pes planus with tarsal coalition – Diffuse midfoot pain

•Bunion – Medial big toe (first metatarsophalangeal joint)

•Bunionette – Lateral base of the little toe (fifth metatarsophalangeal joint)

•Metatarsal stress fracture – Second metatarsal (most common location)

Although rare in children and adolescents, heel pain may be caused by deep venous thrombosis of the gastrocsoleus. Physical examination may reveal a palpable cord (reflecting a thrombosed vein), ipsilateral edema, warmth, and/or superficial venous dilation. Patients with these findings warrant additional testing to confirm or exclude the diagnosis. (See "Clinical presentation and diagnosis of the nonpregnant adult with suspected deep vein thrombosis of the lower extremity".)

Range of motion — Examination of the foot should include passive and active range of motion for the following actions: plantarflexion, dorsiflexion, inversion, and eversion of the foot; flexion and extension of the toes, particularly the great toe [10]. Testing these actions against resistance evaluates motor function and strength.

Provocative testing — Provocative testing of the foot and ankle includes various maneuvers that are performed based upon clinical suspicion:

●High ankle sprain tests – High-ankle sprain tests include the syndesmosis squeeze, and dorsiflexion/external rotation tests. All tests are performed with the patient seated, and if positive, will result in pain over the tibiofibular ligaments/syndesmosis. (See "Syndesmotic ankle injury (high ankle sprain)", section on 'Clinical presentation and examination'.)

•Squeeze test – This is the most specific physical exam test for high ankle sprains. The examiner will place their hands opposite each other around the middle third of the patient's lower leg and squeeze the tibia and fibula together. Pain will be provoked over the distal tibiofibular ligaments and syndesmosis.

•Dorsiflexion/external rotation test – Along with tenderness over the tibiofibular ligaments, these are the most sensitive tests for high ankle sprains. The examiner passively dorsiflexes the ankle and then externally rotates the ankle, which will splay the tibiofibular joint apart, provoking the pain over the tibiofibular ligaments and syndesmosis.

●Lateral ankle sprain tests – These maneuvers are performed after an inversion injury to determine laxity of the lateral stabilizing ligaments of the ankle (figure 3A). These tests have limited usefulness in the acute setting because pain, swelling, and muscle spasm may limit mobility of the joint and interfere with their reliability. They are more helpful in the evaluation of chronic ankle instability. (See "Ankle sprain in adults: Evaluation and diagnosis", section on 'Special tests'.)

•Anterior drawer test – The anterior drawer test evaluates stability of the anterior talofibular ligament (ATFL). The examiner uses one hand to cup the heel of the affected foot and the opposite hand to stabilize the anterior portion of the distal tibia and fibula. The examiner then uses the hand on the heel to pull the foot anteriorly; the amount of anterior translation of the talus on the mortise should be noted (picture 15). The test is abnormal when 3 to 5 mm more translation is present compared with the opposite side. The amount of movement should be compared with the uninjured side to determine joint laxity.

•Talar tilt test – The talar tilt test detects excessive ankle inversion. If the ligamentous tear extends posteriorly into the calcaneofibular portion of the lateral ligament, the lateral ankle is unstable and talar tilt occurs. With the ankle in the neutral position, gentle inversion force is applied to the affected ankle, and the degree of inversion is observed and compared with the uninjured side (picture 16). As with the anterior drawer test, this maneuver is of limited usefulness in the acute injury when pain, swelling, and muscle spasm are present, and it may be more important in evaluating chronic ankle instability.

•Inversion stress test for lateral ankle sprain – The inversion stress test evaluates the stability of the lateral ligament complex (the ATFL and the calcaneo-fibular ligament [CFL]) (figure 3A). The examiner uses one hand to cup the heel of the affected foot and the opposite hand to stabilize the anterior portion of the distal tibia and fibula. The ATFL is evaluated by maximally plantarflexing the ankle and then inverting the rearfoot; laxity and pain should be noted. The CFL is evaluated by maximally dorsiflexing the foot and then inverting the rearfoot. The test is considered abnormal when 10 to 15 degrees or more of inversion is present, compared with the opposite side.

●Thompson test for complete Achilles rupture – With patient lying prone and the foot hanging off the table, the gastrocnemius is squeezed. If the foot does not plantarflex, rupture of the Achilles tendon is suggested (picture 17).

●Calcaneal compression test for calcaneal apophysitis (Sever disease) – The examiner holds the affected heel in his or her palm with the fingers enveloping the upper portion of the heel and then squeezes to compress the heel in the transverse plane (picture 18). (See "Heel pain in the active child or skeletally immature adolescent: Overview of causes", section on 'Calcaneal apophysitis (Sever disease)'.)

●Test for Morton neuroma – The examiner grasps consecutive metatarsal heads and compresses them together. If a click, as well as reproduction of the patient's pain, occurs, a Morton neuroma should be suspected (figure 15). (See "Forefoot and midfoot pain in the active child or skeletally immature adolescent: Overview of causes", section on 'Morton neuroma'.)

●Test for posterior impingement – The examiner will start with the ankle in rest neutral position, and the ankle will be taken to end range of motion, which may produce the classic posterior ankle pain. Milder cases may require gentle over pressure once they are at end range of motion to provoke their ankle complaint [12].

Functional assessment — Functional testing of the foot involves asking the patient to walk with a normal gait, on his or her toes, and on his or her heels. The patient should also be asked to run a short distance and to hop five times on each foot.

Imaging — The radiologic evaluation of the child or adolescent with foot or ankle pain depends upon the location of the pain and the conditions being considered in the differential diagnosis as follows:

●Plain radiographs of the feet – Plain radiographs of the feet (anteroposterior, lateral, and oblique views) are warranted in all patients who cannot bear weight or take four steps after an acute injury and whose pain is localized to the foot. It is also appropriate in patients with focal bony tenderness, especially the base of the fifth metatarsal bone or when evaluating for accessory bones (eg, os peroneum, os vesalianum pedis, os naviculare, or os trigonum) [11,13]. The circumferential cortication of the accessory ossicles may help to differentiated them from avulsion fractures that classically have a decorticated edge and donor site.

●Plain radiographs of the ankle – Plain radiographs of the ankle (anteroposterior, lateral, and mortise views) are indicated in all patients who cannot bear weight or ambulate four steps after an acute injury, who have bony tenderness or deformity on examination, or who demonstrate findings of osteochondritis dissecans (eg, talar tenderness or joint effusion), stress fractures, sinus tarsi syndrome, and accessory ossicles.

The Low Risk Ankle Rule (figure 16) and the Ottawa Ankle Rules (figure 17) have been used in the pediatric population to identify patients who warrant imaging with some evidence that they help to reduce the need for imaging. (See "Ankle fractures in children", section on 'Imaging'.)

Plain radiographs also are often obtained to exclude bony injuries in patients in whom tendon injuries are being considered. However, direct visualization of the tendon is best accomplished with magnetic resonance imaging (MRI). (See "Ankle fractures in children".)

Radiographs are not usually necessary during the initial evaluation of the following injuries (see "Ankle pain in the active child or skeletally immature adolescent: Overview of causes" and "Heel pain in the active child or skeletally immature adolescent: Overview of causes"):

●Flexor digitorum longus tendinitis

●Tibialis anterior tendinitis

●Calcaneal apophysitis (Sever disease)

●Plantar fasciitis

Imaging with other modalities may be helpful in specific circumstances as follows:

●Computed tomography (CT) is indicated for evaluation of suspected tarsal coalition or other complex congenital abnormalities of the bones of the foot [11]. (See "Forefoot and midfoot pain in the active child or skeletally immature adolescent: Overview of causes", section on 'Arch abnormalities' and "Forefoot and midfoot pain in the active child or skeletally immature adolescent: Overview of causes", section on 'Tarsal coalition'.)

●MRI can be helpful in the evaluation of patients with negative plain radiographs when tendinous rupture or dislocation is suspected and for the evaluation for osteomyelitis [13].

●Ultrasound may be helpful for the evaluation of nonradiopaque foreign bodies in the soft tissues [13]. (See "Heel pain in the active child or skeletally immature adolescent: Overview of causes", section on 'Plantar puncture wound'.)

The clinical features and recommended radiologic evaluation of overuse conditions that cause foot and ankle pain in children and skeletally immature adolescents are discussed in greater detail separately. (See "Ankle pain in the active child or skeletally immature adolescent: Overview of causes" and "Heel pain in the active child or skeletally immature adolescent: Overview of causes" and "Forefoot and midfoot pain in the active child or skeletally immature adolescent: Overview of causes".)

SPECIFIC CONDITIONS — The location of tenderness for several important specific foot and ankle conditions is shown in the figure (figure 14).

Causes of ankle, heel, midfoot, and forefoot pain in children are discussed separately:

●(See "Ankle pain in the active child or skeletally immature adolescent: Overview of causes".)

●(See "Heel pain in the active child or skeletally immature adolescent: Overview of causes".)

●(See "Forefoot and midfoot pain in the active child or skeletally immature adolescent: Overview of causes".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Ankle sprain".)

SUMMARY

●Evaluation – A careful history and physical examination can establish a working diagnosis in most children or adolescents with foot or ankle pain or injury. (See 'Evaluation' above.)

●History – Important history questions are provided. In addition to characterizing the pain or injury, the clinician should identify the intensity of the activity or training that has resulted in pain or injury and ask about footwear. (See 'History' above.)

Some shoes may be classically associated with specific foot problems as follows (see 'Footwear' above):

•Cleats – Calcaneal apophysitis (Sever disease)

•Progress shoes that come to a point – Morton neuroma

•Shoes lacking medial support – Posterior tibialis tendinitis with pes planus

•Flip-flops – Extensor hallucis tendinitis

•Poorly fitted ice skates – Compression neuropathies, contusions, or bursitis

●Physical examination – The physical examination of the child or adolescent with foot complaints includes inspection, palpation, range of motion, and provocative and functional testing. (See 'Physical examination' above.)

Manipulation of the extremity should be minimized and neurovascular status promptly evaluated if obvious deformity is present. In patients with deformity, breaks in the skin may indicate an open fracture. (See 'Inspection' above.)

The site of maximal tenderness during examination is an important indicator for several underlying foot and ankle conditions as follows (figure 14) (see 'Palpation' above):

•Plantar surface

-Medial and lateral portions of the heel – Calcaneal apophysitis (Sever disease)

-Medial and proximal portion of the heel – Proximal plantar fasciitis

-Medial arch – Plantar fasciitis

-Medial base of the big toe (first metatarsophalangeal joint) – Metatarsophalangeal joint sprain (turf toe)

-Medial sesamoid at the base of the big toe (first metatarsophalangeal joint) – Sesamoiditis

-Base of the little toe (fifth metatarsal; this finding is also present in patients with avulsions or fractures) – Iselin disease

-Forefoot between the second and third or third and fourth metatarsals – Morton neuroma

•Dorsal foot surface and ankle

-Lateral malleolus – Distal fibula fracture

-Anterior talofibular ligament (medial and distal to the lateral malleolus) – Lateral ankle sprain

-Over the deltoid ligament (medial and distal to the medial malleolus) – Medial ankle sprain –

-Head of second toe – Freiberg infraction

-Over the navicular bone (medial and posterior portion of the midfoot) (figure 1) – Köhler disease

-Diffuse midfoot pain – Pes planus with tarsal coalition

-Bunion – Medial big toe (first metatarsophalangeal joint)

-Lateral base of the little toe (fifth metatarsophalangeal joint) – Bunionette

-Second metatarsal (most common location) – Metatarsal stress fracture

●Imaging – Plain radiographs of the feet (anteroposterior, lateral, and oblique views) are warranted in all patients who cannot bear weight or take four steps after an acute injury and whose pain is localized to the foot. It is also appropriate in patients with focal bony tenderness, especially the base of the fifth metatarsal bone or when evaluating for accessory bones (eg, os peroneum os tibiale externum [also called os naviculare], or os trigonum). (See 'Imaging' above.)

Plain radiographs of the ankle (anteroposterior, lateral, and mortise views) are indicated in all patients who cannot bear weight or ambulate four steps after an acute injury, who have bony tenderness on examination, or who demonstrate findings of osteochondritis dissecans (eg, talar tenderness or joint effusion), stress fractures, sinus tarsi syndrome, and accessory ossicles. Plain radiographs also are often obtained to exclude bony injuries in patients in whom tendon injuries are being considered. (See 'Imaging' above.)

The clinical features and recommended radiologic evaluation of specific conditions that cause foot and ankle pain in children and skeletally immature adolescents are discussed in greater detail separately. (See "Ankle pain in the active child or skeletally immature adolescent: Overview of causes" and "Heel pain in the active child or skeletally immature adolescent: Overview of causes" and "Forefoot and midfoot pain in the active child or skeletally immature adolescent: Overview of causes".)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Christopher Powers, MD, who contributed to earlier versions of this topic review.