Over-Diagnosed, Under-Diagnosed, and Misdiagnosed Conditions of the Foot and Ankle

Health Professional

Look at your foot and ankle, without them you would not be able to walk to the store, dance to your favorite tune or drive a car. The foot and ankle are at times our only contact point with the earth and the things we do on earth. If something goes wrong with these important body parts, your whole world can fall apart.

Notice how complicated your foot is from heel to toes. Each foot has 28 bones and 30 joints; now that is one complicated piece of equipment Just above your foot is the ankle joint where the shinbone (tibia) rests on top of the talus (the uppermost foot bone). Because of the complicated anatomy and high degree of stress on the foot and ankle complex, this area has a frequent amount of over-diagnosed, under-diagnosed, and misdiagnosed conditions. You and your doctor need to understand that certain conditions can masquerade as others. Falling into a trap of an imposter can give you a never-ending cycle of unhappy feet.

Plantar Fasciitis is an over-diagnosed condition of the foot. Yes, the inflammation of the plantar fascia is common; however, there is a laundry list of conditions that can masquerade as plantar fasciitis. Those who wear improper shoes, those who run and dance, and those who are obese are all prone to pain in the soles of the feet. Typically, the pain of plantar fasciitis is worst in the morning with the first few steps. Sometimes a heel spur is found on x-ray, but that too represents a common pitfall leading one to believe that the spur is the cause of pain when often it is not. Sometimes foot pain is worst after prolonged standing or walking. In those cases, plantar fasciitis may not be the correct diagnosis because Tarsal Tunnel Syndrome (see below) might be the actual cause of pain at the bottom of the foot.

Other conditions of nerve sensitivity or entrapment are also possible causes of a so-called "plantar fasciitis". Sciatica is another common nerve pain that can be felt in the feet. Your nerves must be closely examined before you should be thrown into the "plantar fasciitis" wastebasket. Furthermore, the bones, especially the heel bone (calcaneous bone) must be felt for tenderness because sometimes a calcaneal stress fracture can masquerade as plantar fasciitis. The entire dance card of possibilities must be considered because misdirected treatment delays healing.

Tarsal Tunnel Syndrome was already mentioned as a painful foot condition that can masquerade as plantar fasciitis. Because of the similarities between these two different causes of foot pain, Tarsal Tunnel Syndrome is often under-diagnosed. This painful foot condition is the foot's equivalent to the hand's carpal tunnel syndrome. The foot has a tunnel on the inside portion of the arch in which a nerve (the posterior tibial nerve) passes through. When that nerve is trapped or pinched, abnormal sensations like pain, numbness, burning, itching and tingling can all be felt on the inside, sole and heel of the foot. Those with diabetes or hypothyroidism are highly susceptible to this potential cause of foot pain.  Again, if you have foot pain, especially if you have abnormal sensations, your nerves must be examined thoroughly. You may even need a nerve specialist who can catch this masquerader.

Another case of mistaken identity comes in the form of ankle sprains. A Talar Dome Fracture is commonly misdiagnosed as an ankle sprain. The typical scenario is someone who fell and twisted an ankle. "Ankle sprain" is usually the assumption, especially if a doctor has not examined the foot and ankle. But as the weeks or months go by and the pain, swelling, and stiffness do not improve, someone might clue into the fact this "ankle sprain" is an imposter. In fact, that "ankle sprain" might be a subtle fracture of the talar dome, a small fracture within the ankle joint itself.

Ankle sprains and ankle fractures might appear the same at first glance, but with further investigation and imagining these two painful conditions are very different. Even with special x-ray views (oblique and mortise views), a talar dome fracture might not be seen initially. Further follow-up with MRI or CT scans might be needed to discover this insidious monster lurking within the ankle joint. And monster it is because complications like bone death and post-traumatic arthritis can result in what was once thought to be an ankle sprain but turned out to actually be a talar dome fracture. If you have an ankle sprain, your doctor needs to follow the Ottawa Ankle Rules for imaging or refer you to a specialist who knows what the rules are. If you have an ankle sprain that is not getting better, see a specialist who can closely look for this commonly missed diagnosis. Do not let this monster masquerade as an innocent "ankle sprain" for long, or you will be left with chronic ankle pain.

Not to blame doctors, nurse practioners, or physician assistance; the foot and ankle are very complicated and sometimes requires special attention. Plantar Fasciitis, Tarsal Tunnel Syndrome, and Talar Dome Fractures represent just a few of the most common conditions that lead to an incorrect diagnosis. Your job as a patient is to give the most accurate history about the incident, the symptoms and the aggravating factors to your provider. This information is critical to correctly identifying the cause of your foot and ankle pain. Ultimately, you need to land on both feet, on the correct diagnosis and on the correct treatment plan to cure your unhappy feet. The correct diagnosis is the first step towards finding pain relief. After taking a good first step in the right direction, you might be able to get those feet comfortably planted on the ground again. Don't let imposters and masqueraders ruin your dance.