Textbook of Urgent Care Medicine, Chapter 31, Ankle and Foot Pain and Injury

Original author: Robert Truax

Originally published in 2014. Substantially updated and clinically reviewed in 2026 to reflect current evidence, guidelines, and urgent care practice.

INTRODUCTION

Ankle and foot injuries are one of the most common presentations in the urgent care setting, owing to the vulnerability of the ankle and foot joint complex. Severe injuries are not limited to fractures but can also include soft tissue—skin, ligaments, tendons, and muscles. Fortunately, the severity of the injury is usually reflected in the simple but crucial act of walking. The patient’s weight-bearing status will often guide the clinician regarding injury severity.

Weight-bearing alone does not exclude fracture, syndesmotic injury, Lisfranc injury, or tendon rupture. Mechanism, local tenderness, deformity, skin integrity, and neurovascular findings must guide the evaluation.

TRIAGE PEARLS

There are 4 rapid assessment questions to answer:

• Is the person weight-bearing? Inability to bear weight raises concern for fracture, dislocation, tendon rupture, or significant instability.

• Is there gross deformity? Provisional reduction may be needed.

• Is the skin intact? Broken skin associated with a high-energy injury must raise concern for an open fracture.

• Is the skin color normal? Rapid assessment of vascular status is critical, because any compromise must be addressed immediately (possibly before an x-ray).

• Immediately assess and document distal pulses, capillary refill, sensation, motor function, severe pain or tense compartments, and any wounds. An open fracture, threatened skin, neurovascular compromise, compartment syndrome, or irreducible dislocation requires immediate ED transfer; do not delay transfer to obtain routine films.

• When major deformity threatens circulation or skin, an appropriately trained clinician may perform gentle urgent realignment consistent with local scope and protocol, followed by repeat neurovascular documentation, immobilization, and ED transfer. Do not attempt forceful or repeated reductions.

HISTORY PEARLS

Mechanism of Injury

• A low-energy, low-speed injury suggests soft-tissue damage.

• A high-energy, high-speed injury increases the risk of fracture and joint instability.

• If there is no history of trauma, consider an acute inflammatory condition (e.g., infectious, gout or pseudogout).

• Twisting and inversion commonly injure the lateral ankle. External rotation or dorsiflexion may injure the syndesmosis. Axial loading on a plantarflexed foot can injure the Lisfranc complex, and falls onto the heel may produce calcaneal fracture.

Location of Pain

• Low-energy, low-speed injuries usually produce pain at the location of injury.

• High-energy, high-speed injuries can involve several locations, not just the one that the patient reports.

• Palpate the malleoli, talus, calcaneus, navicular, base of the fifth metatarsal, midfoot, metatarsals, proximal fibula, and the entire Achilles tendon as indicated by the mechanism.

Timing of Pain

• Immediate onset of pain suggests acute tissue damage—fracture, ligament sprain, musculotendinous injury—or an acute inflammatory condition.

• Delayed onset of pain suggests a musculotendinous issue such as spasm or tendinitis.

Nature of Pain

• Weight-bearing at the time of injury is an important finding, but an ability to walk does not rule out a fracture or significant soft-tissue injury.

• The Ottawa ankle and foot rules are clinical tools developed to determine which injuries need radiographic studies; use them only in patients for whom the rules have been validated.

Table 1. Ottawa Ankle and Foot Rules: When to Order Radiographs

Ankle radiographs (malleolar zone pain)	Foot radiographs (midfoot zone pain)
If pain is present in the malleolar zone, obtain ankle radiographs when there is tenderness along the posterior edge or tip of either malleolus, OR an inability to take 4 steps immediately after the injury and at evaluation.	If pain is present in the midfoot zone, obtain foot radiographs when there is tenderness at the navicular or base of the fifth metatarsal, OR an inability to take 4 steps immediately after injury and at evaluation.

Note: The rules do not exclude injuries outside the specified zones. Do not apply them without clinical judgment in patients with altered sensation, neuropathy, major multisystem injury, or unreliable examination; routine imaging or ED evaluation may be warranted. Commonly applied in adults and children aged 5 years or older. [1–4]

Prior Medical History

Look for any medical or orthopedic issues prior to injury that put the lower extremity at risk of severe injury or metabolic disorder, such as

• Diabetes mellitus

• Stroke

• Neurologic disorders

• Ask also about neuropathy, vascular disease, steroid exposure, osteoporosis, previous fracture or surgery, anticoagulants, and current ability to use crutches or a protective boot.

PHYSICAL EXAM PEARLS

The ankle and foot complex requires numerous ligaments and tendons to maintain stability. Knowing the location of these structures is critical when assessing the acutely injured ankle and foot to ensure that instability is not overlooked.

The syndesmosis describes the anterior and posterior ligaments that hold the tibia and fibula together and keep the ankle mortise stable.

The lateral ligament complex and the very strong deltoid ligament maintain ankle stability of the lateral and medial ankle, respectively.

The peroneal muscles laterally and the tibialis posterior muscle medially provide musculotendinous stability.

General, Skin, and Palpation

Obvious deformity requires quick assessment of neurovascular status and imaging for fracture and dislocation assessment.

• A skin break near a suspected fracture raises concern for an open fracture; inability to bear weight raises concern for a significant injury.

• Swelling over the joint suggests a bone or ligament injury.

• Swelling away from joints suggests a tendon or muscle injury.

• Swelling and erythema around a joint suggest an acute inflammatory condition.

• Tenderness along a tendon, in the muscle, or in both points to tendon injury or muscle tear.

• Palpate the entire leg-ankle-foot complex because secondary injuries might be missed by focusing only on the primary presenting symptom.

• Palpate the proximal fibula because this may be the location of a secondary fracture.

• Look for plantar midfoot ecchymosis suggesting Lisfranc injury, blisters or threatened skin over displaced fractures, puncture wounds, and focal warmth or effusion suggesting septic arthritis.

Range of Motion

• Pain with passive range of motion (ROM) suggests a bony or ligament injury or an acute inflammatory condition.

• Pain with active ROM and with resistance suggests a musculotendinous inflammation injury.

• No active ROM suggests fracture, dislocation, or tendon rupture.

• Do not force ROM or stress testing across a painful, deformed, or potentially fractured joint. Marked pain with even gentle passive movement or a tense compartment requires emergency consideration of compartment syndrome.

Neurovascular Status

• Assess side-to-side palpable pulses in the injured extremity.

• Assess pinkness of toes and capillary flow.

• Assess motor function such as foot dorsiflexion, foot plantarflexion, knee flexion, and knee extension.

• Assess sensation over the dorsum, web space of the first two toes, medial and lateral foot, and plantar surface.

• Normal distal pulses do not exclude compartment syndrome. Repeat the neurovascular examination after any splinting or repositioning, and document both examinations.

TESTING PEARLS

• Apply the Ottawa rules to appropriate acute injuries; obtain ankle AP, mortise, and lateral views or foot AP, lateral, and oblique views as indicated. Weight-bearing views may better reveal ankle mortise or Lisfranc instability when safe and tolerated.

• If a Lisfranc injury is suspected despite normal or equivocal radiographs, immobilize, maintain non-weight-bearing status, and obtain urgent orthopedic evaluation for consideration of CT or MRI. A normal initial non-weight-bearing film does not exclude instability.

• With ankle fracture and proximal leg pain or syndesmotic concern, obtain full-length tibia-fibula radiographs or arrange ED-level imaging to assess for a Maisonneuve injury.

• CT is often needed to characterize talar, calcaneal, Lisfranc, and complex intra-articular fractures. MRI or ultrasound may be helpful for selected occult stress fractures or tendon injuries; these advanced studies generally occur after urgent care assessment. [3,4,9]

• When there is acute monoarthritis without trauma, testing should follow the suspected cause. Concern for septic arthritis requires urgent joint aspiration and specialist assessment, rather than treating presumed gout without excluding infection.

DIAGNOSIS PEARLS

The inability of a patient to bear weight must elicit concern for a severe ankle or foot fracture or ligament injury resulting in some type of instability. Therefore, it can be helpful to organize injuries into two distinct types: those that inhibit weight-bearing and those that cause limping.

Non-Weight-Bearing Status

Ankle Fractures and Ankle Instability

• High-energy ankle injuries can involve the distal tibia and fibula, along with the interconnecting syndesmosis, creating instability.

• Ankle fractures can be divided into the following categories: malleolar, bimalleolar, and trimalleolar.

• Syndesmotic injuries, which may or may not have an associated fracture, can be unstable.

• Always examine the foot and the proximal fibula in patients with ankle injury.

• Whether a fracture is stable depends on mortise congruity, associated ligament injury, displacement, neurovascular findings, and fracture pattern, not a single displacement measurement or the number of malleoli involved. Management and operative decisions belong to the orthopedic team.

• The Maisonneuve fracture is a proximal fibular fracture associated with distal syndesmotic disruption and ankle injury. It is easily missed when the examination is confined to the ankle.

• Squeeze and external-rotation tests may raise concern for syndesmotic injury but are not adequate to exclude instability. Do not perform them before fracture or dislocation has been assessed.

Talar Fractures

• Talar fractures include fractures of the neck, body, head, and posterior and lateral processes of the talus.

• Talar neck and body fractures are usually due to a fall from a height or a motor vehicle crash.

• Lateral process fractures are common among snowboarders.

• Persistent focal talar tenderness after injury warrants immobilization and non-weight-bearing precautions even when plain films are normal. CT is frequently necessary to define the injury; displaced fractures and dislocations require emergency orthopedic evaluation.

Calcaneal Fractures

• The mechanism of injury for calcaneal fractures is a high-impact injury, such as a fall directly onto the heel.

• Look for associated spine or other axial-load injuries and for marked heel swelling, plantar ecchymosis, threatened skin, and compartment syndrome. CT commonly defines intra-articular fracture extent after radiographs. Immobilize without weight-bearing and refer urgently.

Tarsal and Midfoot Fractures

• Tarsal fractures include navicular and cuboid injuries; these may occur with high-energy trauma and other foot fractures. Displaced or unstable fractures require orthopedic assessment.

• Navicular body fractures can follow axial loading. Focal navicular tenderness after trauma, even with normal initial radiographs, may require CT or MRI and non-weight-bearing protection.

• Cuboid fractures may be accompanied by lateral-column shortening or midfoot instability. CT helps define subtle fractures when suspicion remains high.

Lisfranc Fracture or Ligament Injury

• The Lisfranc injury is a tarsometatarsal joint complex injury involving the bone and ligament complex of the midfoot.

• The mechanism is often an axial load onto a plantarflexed foot; a twist or low-energy sports injury can also disrupt the complex. Look for midfoot pain and swelling, plantar bruising, and tenderness at the first or second tarsometatarsal joints.

• Weight-bearing bilateral foot radiographs may demonstrate diastasis if tolerated; normal films do not exclude injury. Protect the foot from weight-bearing and arrange urgent orthopedic assessment for CT or MRI when suspicion persists.

Metatarsal Fractures

Metatarsal fractures occur because of direct trauma.

• Metatarsal fractures often occur with other injuries.

• Obtain anteroposterior, lateral, and oblique x-rays; weight-bearing views should be requested only when safe and necessary for instability assessment.

• Crush injuries must be assessed for open wounds, compartment syndrome, and soft-tissue damage.

• A displaced, angulated, multiple, or intra-articular metatarsal fracture needs orthopedic review. Nondisplaced isolated fractures may be treated with a protective boot or shoe and appropriate follow-up according to fracture location.

Fifth Metatarsal Fracture

• Proximal fifth metatarsal fractures are also associated with ankle inversion sprains.

• Location determines management: zone 1 tuberosity avulsions commonly heal with a stiff-soled shoe or boot and protected weight-bearing; zone 2 (Jones) and zone 3 proximal diaphyseal fractures have greater nonunion risk and generally require initial non-weight-bearing immobilization and early orthopedic follow-up.

• Do not classify every proximal fifth metatarsal fracture as a Jones fracture, and do not rely on displacement alone to determine referral.

Stress Fractures

• Stress fractures are overuse injuries most often related to running or dancing.

• Pain can gradually worsen over weeks, or it may have a rapid onset over several days.

• Early radiographs may be normal. Persistent focal pain, especially at the navicular or proximal fifth metatarsal, requires activity restriction, protected or non-weight-bearing immobilization when indicated, and follow-up imaging or specialty evaluation.

Toe and Metatarsophalangeal Fractures

• Fractures of the lesser phalanges and interphalangeal joint can be treated with splinting or buddy-taping. Operative treatment is required for markedly displaced or open fractures.

• Great-toe and first metatarsophalangeal injuries deserve careful alignment and articular assessment because of their role in walking. Open, displaced intra-articular, unstable, or poorly aligned fractures need urgent orthopedic or podiatric referral.

Soft-Tissue Injuries

Achilles Tendon Rupture

• When the tendon ruptures, the patient may feel a “pop” behind the heel, experience difficulty pushing off the foot, and have a palpable gap in the tendon. Some plantarflexion may remain present because other muscles contribute to the movement.

• Perform the Thompson test to assess for Achilles tendon integrity: with the patient prone and the foot free, squeeze the calf; absent or reduced plantarflexion compared with the opposite side suggests rupture.

• Active plantarflexion can remain partly intact despite a complete Achilles rupture because other muscles contribute to the motion. A negative or equivocal bedside examination does not supersede strong clinical suspicion; ultrasound can help if available and performed by a trained clinician.

• Immobilize in plantarflexion, avoid dorsiflexion and weight-bearing, and arrange prompt orthopedic review to select operative or functional nonoperative treatment. Early rehabilitation belongs to a supervised specialist protocol.

High Ankle Sprain

• High ankle sprains are injuries to the tibiofibular ligaments (syndesmotic sprains).

• High ankle sprains are often due to high-energy eversion or external rotation of the ankle and present with swelling at and above the ankle joint.

• Suspected syndesmotic instability calls for immobilization, limited or no weight-bearing, and early orthopedic evaluation. Plain films may be normal despite ligament disruption.

Medial Ankle Sprain

• These sprains are injuries to the deltoid ligament.

• The physical exam will reveal tenderness along the medial ankle joint and the deltoid ligament.

• Evaluate for associated fracture or syndesmotic injury; a normal radiograph does not in itself establish stability. A stable isolated sprain may be managed with support and progressive function.

Injuries Causing Limping

Ankle Sprains

The ankle and foot complex represents the most frequently injured joint, with lateral ankle sprains making up most of these injuries.

• The anterior talofibular ligament is most commonly injured, followed by the calcaneofibular ligament; injury to the posterior talofibular ligament is less frequent.

• Anterior drawer and talar tilt examination may help classify lateral ligament injury after fracture is excluded and acute pain permits reliable testing.

• For uncomplicated lateral ankle sprains, use external support (brace or taping), symptom-directed analgesia, and progressive weight-bearing as tolerated. Begin protected ROM, strengthening, and balance training as symptoms permit; prolonged RICE alone is not a substitute for functional rehabilitation.

• For severe sprains, brief immobilization of up to approximately 10 days may be useful before progressive rehabilitation. Persistent instability, focal bony pain, or inability to progress requires reevaluation.

Foot Sprains

• The physical exam will demonstrate midfoot pain, swelling, and tenderness after sudden movement.

• A presumed foot sprain with persistent tarsometatarsal tenderness, plantar ecchymosis, or pain with weight-bearing requires reevaluation for Lisfranc injury even if the initial x-ray is normal.

Tendinitis and Tendon Dysfunction

• Tendinitis occurs with a history of sudden overload rather than a sudden event (e.g., a long hike, endurance training).

• It causes swelling and tenderness along the line of the tendon and pain with movement and with resistance to movement.

• Achilles tendinopathy can cause posterior heel pain and swelling with an intact Thompson response. Initial care includes load modification and analgesia, with exercise-based rehabilitation and follow-up; avoid corticosteroid injection into the Achilles tendon because of rupture risk.

• The tibialis posterior tendon runs along the posteromedial tibia, wraps around the medial malleolus, and inserts into the navicular bone. It is the dynamic stabilizer for the medial arch.

• Inability to perform a single-leg heel rise or progressive flatfoot deformity suggests significant posterior tibial tendon dysfunction requiring specialty evaluation.

Gastrocnemius Injury and Turf Toe

• A gastrocnemius medial head rupture (“tennis calf”) can cause a sudden pop and calf pain; assess for Achilles rupture and consider deep venous thrombosis when findings are not typical.

• Turf toe is an injury to the first metatarsophalangeal joint that can cause significant disability because of the need for a properly functioning first metatarsophalangeal joint in walking.

• Mild injury can be managed with a stiff-soled shoe or boot and restricted dorsiflexion; marked instability, fracture, sesamoid injury, or persistent inability to push off requires referral.

Inflammatory Arthritis

• Suppurative arthritis should be considered when fever, infection of the surrounding skin and soft tissue, and an immunocompromised state are present. Any suspicion for suppurative arthritis should prompt immediate referral.

• Absence of fever does not exclude septic arthritis. A hot, acutely swollen joint, pain with passive ROM, bacteremia risk, or systemic illness warrants emergency assessment and synovial-fluid evaluation before corticosteroids are given.

• The original 1977 ACR classification criteria for gout are not appropriate as a stand-alone urgent-care diagnostic rule. When infection is not suspected, a typical gout flare can be managed with an NSAID, low-dose colchicine, or a glucocorticoid selected according to comorbidities, drug interactions, and contraindications.

TREATMENT AND DISPOSITION PEARLS

Fractures and Dislocations

• Urgent reduction and splinting of the ankle or foot when there is concern for vascular compromise.

• Any open fracture, fracture-dislocation with threatened skin, progressive neurologic deficit, or compartment syndrome requires emergency transfer. Cover open wounds with sterile dressing, immobilize, address tetanus prophylaxis, and ensure prompt hospital antibiotics according to institutional protocol.

• Do not recommend routine operative versus nonoperative management using a single displacement or fibular-height threshold. For stable suspected fractures, immobilize and arrange timely orthopedic follow-up; unstable or complex patterns require same-day specialist or emergency evaluation.

• Document analgesia, ability to mobilize safely, use of a protective boot or splint, and appropriate weight-bearing restriction. Reassess and record pulses, sensation, and motor function after immobilization.

Table 2. Urgent Care Disposition by Injury

Immediate ED / EMS when unstable	Same-day or early specialty review	Appropriate outpatient care with reassessment
Open fracture, threatened skin, vascular compromise, compartment syndrome, irreducible dislocation, septic arthritis or systemic infection	Suspected Lisfranc injury, unstable ankle/syndesmotic injury, displaced fracture, talar or calcaneal fracture, high-risk navicular or fifth metatarsal injury	Uncomplicated lateral ankle sprain, stable minor foot sprain, some nondisplaced stable fractures, uncomplicated tendinopathy
Major crush injury with severe swelling or neurovascular deficit	Achilles tendon rupture; uncertain stability; persistent inability to bear weight despite negative films	Known stable toe fracture, isolated zone 1 fifth metatarsal avulsion, mild turf toe without instability

Note: Disposition must be individualized by examination, injury pattern, imaging, comorbidities, function, and local access. Immobilize and keep non-weight-bearing when instability has not been excluded.

Soft-Tissue Injuries

• Soft-tissue injuries benefit from appropriate support, analgesia, and progressive loading after serious injury has been excluded. Ice, compression, and elevation may help symptoms, but functional exercise is central to recovery in uncomplicated ankle sprains.

• Ankle sprains can usually be treated with an ankle brace and crutches.

• High ankle sprains may require a much longer recovery than low ankle sprains and should not be treated as routine lateral ligament sprains when instability is suspected.

• For pain, acetaminophen or a short NSAID course may be used when appropriate, taking account of kidney disease, ulcer or bleeding history, anticoagulants, pregnancy, and other contraindications. Avoid automatically prescribing opioids for uncomplicated soft-tissue injury.

MEDICOLEGAL PEARLS

• For patients reporting a foot injury, document the presence or absence of pain and swelling around the base of the second metatarsal. This area is an important component of the Lisfranc complex.

• Calcaneus fractures are frequently associated with a fall from a height and should prompt evaluation for associated injuries.

• Although rare, compartment syndrome of the foot should be considered in patients sustaining a crush injury to the foot.

• Record whether the Ottawa rules were applicable, the exact sites of tenderness, weight-bearing ability, neurovascular findings before and after splinting, and reasons for imaging or specialty transfer. A negative initial film does not exclude Lisfranc, talar, or stress injury.

• When a foreign body is suspected, use targeted radiography for radiopaque material and arrange ultrasound or referral when a radiolucent retained object remains possible. Do not probe deeply near neurovascular structures in urgent care.

REFERENCES

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