Foot surgery cases rarely announce their diagnosis. A painful forefoot may reflect joint degeneration, transfer loading, nerve irritation or infection, and each possibility changes what you examine next. This guide builds clinical reasoning through four connected tasks: perform a focused examination, select tests that answer a specific question, interpret the findings and choose a defensible treatment sequence. The sixty lessons use original foot surgery cases involving deformity, trauma, wounds, vascular and neurologic disease, pediatric conditions, inflammatory disorders, tumors and postoperative problems. Work through each case by asking which finding would change management. A plan is complete only when it addresses immediate threats, explains why the proposed treatment fits the patient and identifies what must be reassessed.
Physical Examination
1. Examine the whole hallux valgus deformity
A visible bunion does not identify every source of forefoot pain. Ask the patient to point to each painful site, then examine the medial first metatarsophalangeal prominence for shoe-contact tenderness. Assess first-ray motion while stabilizing the lesser metatarsals, and compare it with the opposite foot; marked mobility may help explain transfer loading but does not establish its cause alone. Test first metatarsophalangeal dorsiflexion and pain through the arc, because a stiff or arthritic joint changes the treatment discussion. Inspect the sole for callus beneath the lesser metatarsal heads and check the lesser joints for tenderness and instability. Finally, assess whether the hallux can be reduced without forcing a painful joint. These findings turn the deformity shown in the ABFAS Foot Surgery CBPS content areas into a patient-specific problem list.
Worked example: A patient reports shoe pressure over a medial prominence and separate pain beneath the second metatarsal head. Examination reproduces pain at the prominence, shows a mobile first ray and a freely moving first metatarsophalangeal joint, and finds a tender plantar callus beneath the second head. The assessment records symptomatic hallux valgus and second-ray overload separately. Imaging may characterize alignment, but the visible bunion alone cannot explain the plantar pain.
Watch the distinction: A prominent bunion does not make every forefoot symptom bunion pain. Localize the plantar complaint and test lesser-ray loading before choosing treatment focused on the hallux.
Reference: [1]
2. Find the source of a painful lesser toe
A hammertoe describes shape; plantar plate failure describes loss of restraint at the lesser metatarsophalangeal joint. Examine the toe while standing, noting dorsal or medial drift, overlap and whether its pulp contacts the floor. Then test whether the proximal interphalangeal flexion deformity and the metatarsophalangeal deviation can be reduced separately. Palpate the plantar joint line and perform a gentle dorsal drawer while stabilizing the metatarsal head. Excess translation or a soft endpoint compared with neighboring toes supports instability, especially when plantar pain accompanies it. Check for a callus beneath the metatarsal head and for hallux crowding, both of which may contribute to abnormal loading. A flexible proximal interphalangeal joint can coexist with an unstable metatarsophalangeal joint, so correcting its appearance alone may leave the painful mechanical problem in place.
Worked example: A second toe drifts dorsomedially and no longer presses the floor when the patient stands. Plantar metatarsophalangeal palpation reproduces pain; a dorsal drawer produces greater translation than at the adjacent toe. Its proximal interphalangeal joint is still flexible. These findings favor second metatarsophalangeal instability with a developing crossover toe. Straightening only the proximal interphalangeal joint would leave the unstable joint and plantar pain untreated.
Watch the distinction: Do not label every bent lesser toe an isolated hammertoe. Toe purchase, plantar joint tenderness and drawer stability determine whether a metatarsophalangeal restraint problem also needs attention.
Reference: [1]
3. Separate hallux rigidus from sesamoid pain
Push-off loads both the first metatarsophalangeal joint and the sesamoid complex, so pain during walking does not localize the lesion. Compare active and passive dorsiflexion with the foot unloaded, then assess motion as the first ray bears weight. Joint degeneration or dorsal impingement often produces restricted dorsiflexion and pain at the dorsal joint margin, especially near the end of motion. Palpate each sesamoid through the plantar soft tissues and check whether direct pressure reproduces the familiar pain. A focal plantar response suggests sesamoid pathology, although joint disease and sesamoid disease can coexist. Record whether pain occurs only at the end of motion or throughout the arc; that distinction helps judge how much articular surface may be symptomatic. Use examination to direct targeted imaging, rather than naming the disorder from the activity alone.
Worked example: A runner reports pain at push-off. Dorsiflexion is restricted while unloaded and becomes more painful when the first ray is loaded; the familiar pain is reproduced over the dorsal joint margin. Direct palpation beneath the medial and lateral sesamoids causes no focal pain. The pattern favors symptomatic first metatarsophalangeal degeneration or impingement. Radiographs can assess joint narrowing and osteophytes before a treatment choice is made.
Watch the distinction: Push-off pain is not automatically sesamoiditis. Compare dorsal motion pain with focal plantar tenderness, and remember that absent sesamoid tenderness cannot exclude every plantar lesion.
Reference: [1]
4. Test flexible and rigid flatfoot
Flatfoot shape and flatfoot flexibility are separate findings. Observe the patient standing from behind for heel valgus and from the side for arch height; look from the front for forefoot abduction. Ask for a single-leg heel rise if safe, supporting balance when needed. Reconstitution of the arch and heel movement toward inversion show that the hindfoot can still correct under load. Palpate the medial tendon course and assess inversion strength, but avoid treating one maneuver as proof of tendon integrity. Move the subtalar joint passively and compare sides. A fixed valgus heel or restricted subtalar motion raises concern for a structural block or arthritic component and calls for different imaging and treatment planning. Document pain location and skin pressure points as well as alignment, because a flexible foot can still be symptomatic.
Worked example: An adult has medial foot pain, a low standing arch and heel valgus. With support, the patient completes a heel rise; the arch returns and the heel moves toward neutral. The deformity has a flexible hindfoot component. If the heel remained valgus and passive subtalar motion were restricted, standing images and possibly further structural assessment would become more important before considering a corrective plan.
Watch the distinction: A low arch does not establish a rigid deformity or a tendon tear. Observe correction during heel rise and test subtalar motion before assigning the deformity’s mechanism.
Reference: [1]
5. Localize cavovarus components
Cavovarus may result from a plantarflexed medial forefoot, a fixed varus hindfoot, muscle imbalance or a combination. Inspect the standing heel, arch and plantar calluses, particularly beneath the first metatarsal head and along the lateral border. Check first-ray position and passive mobility, then assess peroneal and tibial muscle function for imbalance. For the Coleman block maneuver, place the lateral foot and heel on a block while allowing the first ray to drop freely. If the heel moves toward neutral, unloading the plantarflexed first ray has removed a forefoot force driving hindfoot varus. If it stays varus, a fixed hindfoot component is more likely, although pain and guarding can limit interpretation. This distinction guides whether the first-ray driver, the hindfoot, or both must be addressed in a later treatment plan.
Worked example: A patient repeatedly develops lateral-border pain and has a plantarflexed first ray with a callus under the first metatarsal head. The standing heel is varus. On a Coleman block, with the first ray unsupported, the heel corrects toward neutral. The hindfoot is flexible and substantially forefoot driven. A plan aimed only at fixed hindfoot correction would miss the demonstrated first-ray contribution.
Watch the distinction: Do not read heel varus as proof that the heel itself is fixed. Unload the first ray and observe whether hindfoot alignment changes before locating the deforming driver.
Reference: [1]
6. Map protective sensation and motor loss
Loss of protective sensation lets repeated pressure injure tissue without a reliable pain warning. Test several plantar sites with a consistent light-pressure method, avoiding thick callus, and compare results with the patient’s reported numbness. Examine toe posture, intrinsic muscle bulk and active toe control. Weak intrinsic muscles may allow metatarsophalangeal hyperextension and interphalangeal flexion, bringing the toe tips and dorsal joints into contact with the floor or shoe. Inspect the inside of the shoes for worn areas and match those sites to redness, callus or ulceration. Also assess pulses and skin condition; neuropathy and impaired perfusion can coexist. A sensory map identifies where the patient cannot rely on discomfort to limit load, while a motor and footwear assessment identifies where that load concentrates. The broader ABFAS certification guide places this examination within foot-surgery case management.
Worked example: A patient barely detects light pressure beneath several metatarsal heads. The toes are clawed, with red dorsal proximal interphalangeal joints corresponding to tight shoe uppers and callus beneath the metatarsal heads. Sensory loss explains why sustained loading went unnoticed; the deformity and shoes explain where pressure accumulated. The immediate assessment includes skin integrity, footwear and perfusion before planning pressure relief and follow-up.
Watch the distinction: Neuropathy is more than a sensory score. A patient may have both poor warning sensation and muscle imbalance that directs pressure toward a specific ulcer site.
Reference: [1]
7. Examine perfusion in a threatened foot
No single bedside sign measures whether a threatened wound has enough blood flow to heal. Examine both feet for temperature, color, hair and skin changes, then palpate dorsalis pedis and posterior tibial pulses and compare sides. Record capillary refill in context, since cold surroundings and local tissue conditions can alter it. Locate the wound: painful toe-tip or marginal tissue loss can suggest ischemia, while a plantar pressure wound may have mixed causes. Ask about rest pain and whether dependency relieves it, then assess for infection and neuropathy because these can obscure or compound ischemia. Weak or absent pulses, a cool foot and tissue loss warrant objective vascular testing. A palpable pulse does not by itself guarantee adequate local wound perfusion, and an uncertain pulse should not be converted into a reassuring finding.
Worked example: A patient has a painful toe-tip ulcer, pain while resting, a cool forefoot and pedal pulses that are difficult to feel. These findings raise substantial concern for impaired perfusion. The wound should be protected and assessed for infection, while objective vascular studies and vascular evaluation clarify healing potential. Routine dressing changes alone cannot address inadequate arterial supply if testing confirms it.
Watch the distinction: Do not assume a small toe ulcer is minor because its surface area is small. Rest pain, cool skin and uncertain pulses can signal a limb-threatening perfusion problem.
Reference: [1]
8. Define the extent of a foot infection
A puncture opening reveals little about the path or depth of an infection. Establish when and how the injury occurred, what may have entered the foot, and how quickly pain and swelling progressed. Mark and examine erythema, warmth and tenderness, but also palpate for fluctuance, deep compartment pain and tenderness away from the skin opening. Look for drainage, necrosis, crepitus and pain with movement of nearby joints or tendons. Assess temperature, heart rate and general condition for systemic illness. Neuropathy can blunt pain, so modest tenderness does not guarantee a superficial process. A deep collection may track from a plantar entry point toward the dorsum. When examination suggests abscess or rapidly spreading infection, urgent surgical assessment and source control become central; imaging can help define anatomy when it will not delay needed care.
Worked example: A patient steps on a sharp object and presents with a tiny plantar opening, dorsal swelling and pain on deep midfoot palpation. The dorsal swelling may reflect spread through deeper tissue despite the small entry wound. If fluctuance, crepitus or systemic illness is also present, arrange urgent evaluation for drainage and broader infection management. A surface-only dressing would not address a possible deep collection.
Watch the distinction: Skin opening size does not measure infection depth. A small puncture can seed a deep space, especially when swelling or tenderness appears remote from the entry site.
Reference: [1]
9. Examine an unstable midfoot injury
The Lisfranc complex stabilizes the tarsometatarsal joints, so a twisting injury can produce meaningful instability with little initial displacement. Ask exactly where the foot was planted and how force rotated or bent it. Inspect dorsal swelling and plantar midfoot bruising; plantar ecchymosis is particularly concerning because it can reflect injury to deeper stabilizers. Palpate the first and second tarsometatarsal joints and assess pain with gentle midfoot stress without repeatedly provoking a suspected unstable injury. Record whether the patient can bear weight, but do not use walking ability alone to rule out injury. Check skin, pulses and sensation before immobilization. Persistent focal findings justify protection from loading and suitable additional imaging even if initial non-weight-bearing radiographs appear modest. The management question is joint stability, not merely whether a fracture line is visible.
Worked example: After a twisting fall, a patient has plantar midfoot bruising, swelling and focal pain over the first and second tarsometatarsal joints. Initial non-weight-bearing films show no obvious fracture. The examination still raises concern for Lisfranc instability. Protect the foot from weight bearing, document neurovascular status and obtain imaging that can assess alignment or occult injury once it is safe and feasible.
Watch the distinction: A nearly normal initial film does not settle a clinically suspicious midfoot injury. Plantar bruising and focal tarsometatarsal tenderness justify protection and further assessment.
Reference: [1]
10. Assess forefoot fracture skin and alignment
A forefoot fracture examination must identify threats to skin and circulation as well as bone alignment. Before manipulating the foot, inspect every surface for a wound, threatened skin or exposed tissue near the deformity. A small wound over a fracture may communicate with bone; assess it as a possible open injury rather than assuming it is a superficial abrasion. Document toe color, warmth, refill, sensation and available pulses, then check the position of each toe and metatarsal. Compare toe rotation by observing nail-plate orientation and the direction the toes point during gentle flexion. Shortening and sagittal displacement can shift load to adjacent rays; rotation can cause toe overlap and shoe conflict even when plain-film displacement seems small. Recheck neurovascular findings after any reduction or splinting and obtain appropriate fracture imaging.
Worked example: A heavy object crushes the forefoot. A small wound overlies a deformed metatarsal, and one toe rotates under its neighbor when the patient gently flexes it. The wound raises concern for an open fracture, so urgent open-injury evaluation is needed. The rotation is clinically important despite modest apparent displacement because it can produce persistent overlap and pressure if alignment is not restored.
Watch the distinction: Do not let a mild-looking radiograph override the skin and toe examination. An overlying wound may change urgency, and rotational malalignment may be poorly represented on a single view.
Reference: [1]
11. Recognize acute compartment danger
Foot compartment syndrome arises when pressure within a confined tissue space compromises microvascular flow. After a crush injury, follow the direction and speed of change: escalating pain, increasing tenseness, pain with passive toe motion and evolving sensory change are more informative than a single comfortable-looking moment. Examine the foot after loosening external constriction, while checking for another cause of severe pain. Palpable pedal pulses can persist because large arterial pressure may remain sufficient even as small-vessel tissue perfusion fails. Conversely, pain may be less reliable in a patient with sensory loss or heavy analgesia. Do not repeatedly delay assessment to collect every possible sign. A concerning progression requires immediate surgical evaluation; compartment pressure measurement can support assessment when the examination is uncertain, but it should not postpone action in an otherwise convincing case.
Worked example: Several hours after a forefoot crush, pain rises despite immobilization and analgesia. The foot becomes tense, passive toe movement causes marked pain and plantar sensation is changing, yet pedal pulses remain palpable. This combination is compatible with compartment syndrome because pulses do not assess tissue-level flow. Loosen external constriction and arrange immediate surgical assessment for possible decompression while continuing neurovascular monitoring.
Watch the distinction: Palpable pulses do not rule out compartment syndrome. Waiting for pulse loss risks missing the period when threatened muscle and nerve tissue may still be saved.
Reference: [1]
12. Examine a child's foot deformity by flexibility
Many children have a low arch while standing that reappears when the foot is unloaded or the child rises onto the toes. Examine whether the heel moves toward inversion and whether the arch reconstitutes; then test passive subtalar motion. Ask about pain, activity limits, repeated sprains and whether symptoms are localized to the lateral hindfoot. A painless, flexible shape with normal motion is different from a painful, rigid foot, even if both look flat when standing. Restricted subtalar motion can indicate a coalition or another structural problem, particularly when accompanied by recurrent sprains or persistent pain. Assess both sides and look for neurologic or skin findings that could change the interpretation. Foot Surgery NEW CBPS practice questions are most useful when you justify which finding changes the next diagnostic step.
Worked example: One child has low arches while standing, but the arches appear on tiptoe, the heels correct and there is no pain. Another has persistent lateral hindfoot pain, repeated sprains and little passive subtalar motion; the arch remains flat on tiptoe. The first pattern supports a flexible shape. The second warrants imaging for a structural cause such as tarsal coalition.
Watch the distinction: Do not treat all pediatric flatfeet as the same disorder. Pain and restricted hindfoot motion change the significance of a low arch far more than its appearance alone.
Reference: [1]
13. Look beyond joint redness
A red first metatarsophalangeal joint may reflect crystal inflammation, infection, trauma or another inflammatory disorder. Ask about the pace of onset, prior similar episodes, fever, recent wounds and procedures, then inspect the skin for a portal of infection. Determine whether pain is centered in the joint or in surrounding soft tissue, and assess pain with gentle passive joint movement. Examine other joints and look for spreading erythema or systemic illness. A sudden severe attack with prior similar episodes supports a crystal process, but it does not exclude septic arthritis when a wound or fever is present. Crystal disease and infection can coexist. If infection remains plausible, joint aspiration and microbiologic assessment may be needed before attributing the episode to gout or giving treatment that could obscure infection.
Worked example: A patient with previous gout flares develops overnight pain and redness at the first metatarsophalangeal joint. This time there is also fever and a skin break beside the joint. The abrupt onset fits crystal arthritis, but the wound and systemic finding raise concern for septic arthritis. Examine the extent of soft-tissue disease and seek timely joint assessment, including aspiration when appropriate.
Watch the distinction: A familiar gout history is not proof that a new hot joint is sterile. A nearby wound or systemic illness requires the infection possibility to be tested.
Reference: [1]
14. Characterize a foot mass
Describe a foot mass before deciding what to do to it. Record when it was first noticed, whether it has enlarged, and whether pain, numbness or shoe pressure has changed. Measure its location and approximate size, note its relation to skin, and assess whether it moves with skin, tendon movement or deeper tissue. Check skin color, ulceration, distal sensation and vascular findings, because a mass can compress nearby structures. A firm or fixed deep lesion, progressive growth or unclear tissue plane warrants imaging to define extent and relationships before tissue sampling. Superficial appearance cannot reliably establish pathology. If biopsy is needed, its route should be planned with the team likely to manage definitive treatment, since a poorly placed incision can complicate later removal or reconstruction.
Worked example: A plantar lump has enlarged over several months. The skin moves over it, but the lump itself appears fixed deeper in the foot; distal sensation is intact. Its growth and deep fixation leave the diagnosis unresolved. Obtain imaging that maps tissue planes and nearby structures, then arrange coordinated tissue diagnosis. Casual office excision based on a presumed benign appearance could disrupt a necessary definitive treatment route.
Watch the distinction: A normal-looking skin surface does not make a deep mass benign. Growth, fixation and location guide imaging and biopsy planning before excision is considered.
Reference: [1]
15. Examine a deteriorating postoperative foot
New severe pain and drainage after surgery require comparison with the expected course and the operative plan. Ask when symptoms changed, whether weight bearing or trauma preceded them, and whether fever or systemic symptoms appeared. Inspect the entire incision for separation, drainage character, erythema, necrosis and exposed deep tissue. Palpate carefully for a collection or prominent hardware, and reassess toe alignment and stability against the postoperative record. Document color, temperature, refill, sensation and motor function so ischemia or nerve injury is not hidden beneath the wound concern. A superficial stitch reaction, deep infection, mechanical failure and vascular compromise require different investigations and urgency. Use examination to target radiographs, infection assessment or vascular evaluation; do not assume all drainage has the same depth or cause.
Worked example: Two weeks after forefoot reconstruction, a patient reports new severe pain and drainage. The incision is separated, surrounding erythema is spreading and a deep tender area lies near a palpable implant. Toe color and sensation remain intact. The examination raises concern for deep infection or hardware-related trouble, prompting urgent operative-team assessment and targeted imaging and infection workup rather than routine dressing advice alone.
Watch the distinction: Do not call new postoperative drainage normal healing without examining depth, surrounding tissue and perfusion. Severe new pain can signal a complication beyond the incision surface.
Reference: [1]
Diagnostic procedures/labs/imaging
16. Read weight-bearing bunion views
Standing radiographs show how the first ray and hallux align under load. Review anteroposterior, lateral and suitable axial or sesamoid views where indicated, checking image quality and whether the foot truly bore weight. On the anteroposterior view, assess hallux deviation relative to the first metatarsal, first-to-second metatarsal divergence, joint congruity and the apparent relationship of the sesamoids to the metatarsal head. Examine the joint space and osteophytes because arthritis changes the clinical question. The lateral view can reveal sagittal first-ray position or another source of altered forefoot load. Measurements describe the deformity; they do not independently select an operation. Correlate them with prominence pain, reducibility, first metatarsophalangeal motion and any lesser-ray symptoms. A preserved joint space supports consideration of motion-preserving options, but does not settle treatment without the patient’s symptoms and goals.
Worked example: Standing views show lateral hallux deviation, widening between the first and second metatarsals, and lateral sesamoid displacement. The first metatarsophalangeal joint space is preserved and remains congruent enough to assess for correction. With medial shoe-pressure pain and good joint motion, the findings characterize a symptomatic deformity. No single measured angle dictates the procedure; correction must address the components confirmed clinically and radiographically.
Watch the distinction: An angle is a description, not an automatic procedure rule. Read sesamoid position, joint condition and standing alignment alongside the symptoms the patient actually wants treated.
Reference: [1]
17. Image joint degeneration and sesamoids
When first metatarsophalangeal pain has competing explanations, obtain views that show the joint under load and the sesamoid complex when plantar findings justify it. Review the joint space for narrowing, the dorsal metatarsal head and proximal phalanx for osteophytes, and the overall congruity of the joint. Dorsal spurs can mechanically block dorsiflexion and reproduce end-range impingement, while widespread narrowing and pain through motion suggest more diffuse joint disease. Assess sesamoid position and visible fracture, sclerosis or other focal abnormality, but remember that a normal plain film does not exclude every sesamoid disorder. Match each image finding to palpation and motion testing: an incidental sesamoid variant should not displace a better-supported joint diagnosis. Imaging answers where structural change lies and how advanced it appears; examination establishes whether it matches the patient’s pain.
Worked example: A runner has restricted dorsiflexion and pain over the dorsal first metatarsophalangeal joint at push-off. Standing views show dorsal osteophytes and joint-space narrowing; targeted sesamoid views show no focal abnormality matching the examination. The combined findings support symptomatic hallux rigidus. If plantar sesamoid tenderness later becomes distinct, that symptom deserves reassessment rather than being dismissed solely because the initial films were unrevealing.
Watch the distinction: Do not attribute every push-off symptom to a sesamoid finding seen on imaging. Structural abnormalities need a matching pain location and examination pattern.
Reference: [1]
18. Measure flatfoot components on standing images
Weight-bearing views describe where a collapsing foot loses alignment, while examination shows whether that alignment can still be corrected. On standing foot views, assess medial arch collapse, forefoot abduction and the degree to which the talar head is uncovered by the navicular. Review hindfoot alignment using an appropriate standing view when needed, and look for joint degeneration that could indicate a rigid component. These observations are related but distinct: talonavicular uncoverage describes transverse-plane abduction, whereas heel position describes hindfoot valgus. Compare them with arch reconstitution on heel rise and passive subtalar motion. A flexible deformity may be visibly pronounced on radiographs yet still permit joint-preserving correction; a fixed or arthritic deformity narrows those options. Avoid planning from one image measurement without identifying the symptomatic area and the components that actually need correction.
Worked example: Standing radiographs show a lowered arch, forefoot abduction and talonavicular uncoverage. The patient’s heel is valgus while standing but moves toward neutral during a supported heel rise, with preserved passive subtalar motion. The images define the deformity under load; the examination shows that its hindfoot remains flexible. Treatment planning therefore considers both the magnitude and location of collapse and the available correction.
Watch the distinction: Radiographic flatfoot severity and clinical rigidity are not interchangeable. A pronounced standing deformity may still correct, while joint degeneration or restricted motion may signal a fixed component.
Reference: [1]
19. Investigate suspected tarsal coalition
A tarsal coalition can restrict hindfoot motion and cause pain or recurrent sprains as the foot becomes less adaptable to uneven ground. Begin with standing radiographs to inspect alignment, joint shape and indirect signs of a bridge. If the examination shows marked subtalar restriction and plain views do not explain it, choose cross-sectional imaging for a specific anatomical question. CT depicts bony bridges and their extent well; MRI can show fibrous or cartilaginous coalition and associated marrow or soft-tissue change. The study should identify the involved joint and any degeneration, because anatomy and joint condition affect later treatment options. Do not label a painful rigid foot ordinary flexible flatfoot because initial films are inconclusive. Also consider other causes of restricted hindfoot motion, including arthritis or previous injury, when imaging does not confirm coalition.
Worked example: A teenager reports lateral hindfoot pain and repeated sprains. Examination finds a flat foot with little subtalar motion, but plain radiographs are inconclusive. CT is useful if a bony bridge is suspected and precise bone anatomy is needed. If CT does not explain the rigid examination, MRI can assess a nonosseous coalition and adjacent tissue. The result should be matched to pain location and joint condition.
Watch the distinction: A normal or unclear plain film does not cancel a convincing rigid-hindfoot examination. Further imaging should answer whether a structural bridge exists and what tissue forms it.
Reference: [1]
20. Image Lisfranc instability deliberately
Lisfranc instability may become evident only when the tarsometatarsal joints are loaded. Review initial films for alignment between metatarsal bases and their corresponding tarsal bones, subtle separation, small avulsion fragments and associated fractures. If pain permits safe standing, compare weight-bearing views with the other foot when useful; stress should not be forced through an acutely painful suspected injury. When standing images cannot be obtained safely, CT can define occult fractures and joint alignment, while MRI can assess ligament injury and associated marrow findings. Neither study should replace the clinical question of stability. Persistent plantar bruising and focal tarsometatarsal tenderness justify immobilization and protection from weight bearing while the injury is clarified. The ABFAS CBPS preparation guidance emphasizes selecting investigations that are pertinent to the case, then using their findings to support a diagnosis and treatment plan.
Worked example: After a twisting injury, initial non-weight-bearing radiographs appear nearly normal. The patient has plantar midfoot bruising and focal first and second tarsometatarsal tenderness but cannot stand safely for loaded views. Protect the foot from weight bearing and obtain suitable further imaging, such as CT for subtle fracture or malalignment and MRI if ligament integrity remains the key question. A reassuring initial film alone cannot establish stability.
Watch the distinction: Do not force painful weight-bearing views merely to obtain a preferred image. Protect the suspected injury and choose a study that can answer the remaining stability question safely.
21. Define a metatarsal fracture pattern
Start with foot radiographs in three planes and identify the fracture by bone, level, and relationship to nearby joints. On a fifth metatarsal, a tuberosity fragment differs from a fracture at the metaphyseal-diaphyseal junction: the latter has a different blood supply and raises greater concern about delayed healing. Describe the direction and amount of displacement, angulation, shortening, rotation, and comminution, then look for another fracture or joint malalignment. Radiographs cannot establish stability without the examination. Check skin, focal tenderness, toe alignment, and neurovascular status, and ask whether the injury was acute or followed repeated loading. Compare later films with the first study when symptoms persist. The ABFAS Foot Surgery content outline includes trauma; it does not prescribe a treatment from a fracture label alone.
Worked example: After an inversion injury, a patient has lateral foot tenderness and intact skin. Foot radiographs show a transverse fracture at the proximal fifth metatarsal's metaphyseal-diaphyseal junction, without visible displacement or adjacent joint malalignment. This is not a tuberosity-tip avulsion. Protect weight bearing and arrange follow-up because location carries a healing concern even when initial alignment looks acceptable.
Watch the distinction: Calling every proximal fifth-metatarsal fracture an avulsion hides a meaningful difference in healing risk. Locate the fracture on the images before choosing protection and follow-up.
Reference: [1]
22. Use advanced imaging for stress injury
A stress fracture develops when repeated loading exceeds the bone's ability to repair accumulated microdamage. Early radiographs may be normal because marrow edema and microscopic injury precede a visible fracture line or periosteal reaction. Localized bony tenderness, a recent increase in running or walking load, and pain that progresses from activity-only to earlier in the session strengthen suspicion. MRI can show marrow and surrounding soft-tissue changes and help distinguish a stress injury from tendon or joint disease. Interpret edema with the point of tenderness: an isolated MRI signal is less persuasive if symptoms localize elsewhere. Assess the exact bone and fracture site, since healing concerns differ across the foot. Modify loading while the diagnosis is clarified, then follow pain, function, and imaging when the particular pattern warrants it.
Worked example: A runner increased weekly mileage and now has focal tenderness along the second-metatarsal shaft. Pain began late in runs and now starts during walking. Initial foot radiographs show no fracture line. The history and examination justify MRI; marrow edema centered on the tender shaft supports a stress injury. Reduce impact loading now rather than treating the normal first radiograph as clearance to keep running.
Watch the distinction: A normal early radiograph does not exclude bone stress injury. Its absence of cortical change must be weighed against localized tenderness and a convincing loading history.
Reference: [1]
23. Investigate diabetic foot osteomyelitis
Contiguous osteomyelitis becomes plausible when an ulcer extends toward bone, especially where imaging shows new destruction directly beneath it. Record wound location, depth, exposed tissue, surrounding infection, and whether a sterile probe contacts bone. Probe-to-bone findings change probability but are not a stand-alone diagnosis. Compare current and prior plain films for cortical erosion, periosteal reaction, or other changes; radiographic findings can lag clinical infection. Inflammatory markers add context but may rise for other reasons or remain unremarkable in localized disease. MRI can define marrow involvement, abscess, and the relationship between wound and bone when plain films leave uncertainty. Recent surgery, fracture, and neuropathic change can also alter marrow signal. If diagnosis remains uncertain or organism identification will change care, properly obtained bone sampling can be more informative than a surface swab.
Worked example: A chronic plantar ulcer over a metatarsal head now reaches deep tissue. A probe contacts hard bone, and comparison radiographs show new cortical erosion directly below the wound. These concordant findings make contiguous osteomyelitis likely. MRI can map the extent if it will affect treatment. If the organism or diagnosis remains uncertain, obtain an appropriate bone specimen rather than relying on a superficial swab.
Watch the distinction: Neither a positive probe-to-bone result nor an elevated inflammatory marker proves osteomyelitis alone. Link the wound's anatomy to imaging and consider competing causes of bone change.
Reference: [1]
24. Find gas or a deep collection
A small puncture opening can conceal infection tracking along tendon sheaths or into plantar compartments. Examine the rate of spread, pain, crepitus, drainage, perfusion, and systemic condition before selecting imaging. Plain radiographs can quickly identify a radiopaque foreign body or soft-tissue gas. Gas outside an expected postoperative setting raises concern for a gas-forming or necrotizing process, although its absence does not exclude dangerous infection. Ultrasound can help locate a superficial collection or some foreign bodies; CT or MRI may define deeper anatomy when the patient is stable and the result will guide intervention. Imaging should answer a focused question about location or extent. Rapid progression, systemic instability, or necrotizing signs call for immediate resuscitation and surgical assessment while necessary treatment proceeds.
Worked example: A patient presents after stepping on a sharp object. Within hours, swelling spreads across the foot, pain intensifies, and crepitus is palpable. A prompt radiograph shows gas extending beyond the puncture track. This finding supports a dangerous deep infection. Start urgent systemic assessment and surgical evaluation; do not wait for a lengthy MRI study before addressing possible source control.
Watch the distinction: A small skin wound does not establish a superficial infection. Deep spread and systemic deterioration can advance beneath an opening that appears minor.
Reference: [1]
25. Quantify impaired foot perfusion
A wound needs sufficient arterial inflow to heal, so persistent tissue loss and a cool foot deserve objective perfusion assessment even if a pulse seems present. Examine both feet, document pulse quality and wound location, and obtain physiologic vascular testing suited to the patient. The ankle-brachial index compares ankle systolic pressure with arm systolic pressure, but incompressible, calcified leg arteries can produce falsely high ankle readings, particularly in diabetes or kidney disease. Toe pressures or a toe-brachial index may be more informative because toe vessels are often less affected. Waveforms provide another check on whether a reported pressure reflects useful flow. Interpret results alongside symptoms and tissue loss rather than treating one number as a universal healing guarantee. Concerning findings warrant vascular evaluation before elective closure or reconstruction.
Worked example: A patient with diabetes has a painful, nonhealing toe-tip wound. The foot is cool, pedal pulses are weak, and ankle pressures are reported as unusually high. Calcified arteries may have resisted cuff compression, so the ankle result could overstate perfusion. Obtain toe-based pressures and waveforms and arrange vascular evaluation before assuming the wound will heal after local care alone.
Watch the distinction: A high ankle pressure does not always mean excellent blood flow. Vessel stiffness can inflate the measurement while the toe remains ischemic.
Reference: [1]
26. Select tests for neuropathy or nerve entrapment
The distribution of symptoms helps decide whether a nerve study can answer the clinical question. Symmetric distal sensory loss in both feet suggests a length-dependent polyneuropathy; test protective sensation, vibration, strength, and reflexes, and review causes such as diabetes or other systemic disease. Burning or tingling confined to a nerve territory, especially when reproduced near the tarsal tunnel, suggests focal entrapment, but plantar pain also has musculoskeletal causes. Electrodiagnostic studies can help characterize large-fiber neuropathy or localize some focal lesions; a normal study does not reliably exclude every entrapment or small-fiber disorder. Ultrasound or MRI is more useful when a mass, scar, or other structural cause is suspected. Match the test to the question and reconcile its result with the examination. The related Foot Surgery didactic guide can support anatomy review.
Worked example: One patient reports burning across both soles with symmetric loss of vibration and protective sensation. A second has unilateral plantar tingling reproduced near the tarsal tunnel and a palpable local fullness. The first pattern calls for evaluation of diffuse neuropathy and its cause. In the second, targeted imaging can assess a space-occupying lesion, while electrodiagnostic testing may help localize nerve dysfunction.
Watch the distinction: Ordering the same nerve test for all burning feet ignores distribution. Focal symptoms and symmetric distal loss pose different localization questions.
Reference: [1]
27. Investigate acute monoarthritis
An acutely hot, swollen joint may contain crystals, infection, or both. Onset, prior flares, skin breaks, recent procedures, immunologic risk, and systemic illness change the pretest concern, but none safely settles the diagnosis when septic arthritis remains plausible. Aspirate accessible joint fluid using an appropriate sterile approach and send it for cell assessment, crystal analysis, Gram stain, and culture. Synovial white-cell counts overlap between inflammatory and infectious states, and a negative Gram stain cannot reliably rule out infection. Identifying urate or calcium pyrophosphate crystals establishes a crystal process but does not exclude concurrent septic arthritis. Blood tests and blood cultures may help in a systemically ill patient. If suspicion is substantial, coordinate prompt treatment and drainage decisions without allowing laboratory turnaround to delay care.
Worked example: A patient develops a red first metatarsophalangeal joint after a nearby skin infection. Aspiration finds urate crystals, but the fluid is cloudy and the patient has a fever. Gout is present, yet infection remains possible. Keep the synovial culture in progress, assess systemic illness, and arrange urgent management according to the combined clinical findings rather than stopping at the crystal result.
Watch the distinction: Crystals in synovial fluid do not sterilize the joint. Coexisting infection remains possible, particularly with a nearby wound or systemic illness.
Reference: [1]
28. Choose imaging before a mass biopsy
A growing deep mass should be mapped before anyone chooses an incision. Document size, rate of growth, pain, skin change, fixation, and neurologic or vascular effects. Plain radiographs can reveal bone involvement or mineralization; MRI defines whether the lesion is superficial or deep and shows its relationship to plantar fascia, tendons, joints, bone, and neurovascular structures. Imaging may narrow the differential, but appearance alone may not establish pathology. When tissue diagnosis is needed, plan the biopsy route with the team that would manage a concerning result. Its track may need removal during definitive surgery, and crossing unaffected compartments can complicate that operation. Sampling should target viable, informative tissue and preserve future options. An apparently ordinary skin surface does not make a deep enlarging lesion harmless.
Worked example: A plantar mass has enlarged over several months and feels fixed beneath normal skin. MRI shows a deep lesion abutting a neurovascular bundle and extending around a tendon. Its identity remains unresolved. Refer for coordinated tissue diagnosis, with the biopsy path planned from the imaging and potential definitive procedure. Casual office excision could leave an unfavorable track and incomplete margins.
Watch the distinction: Removing an unexplained deep mass before mapping it can make later treatment harder. Establish its extent and plan tissue sampling first.
Reference: [1]
29. Investigate a postoperative nonunion
Persistent pain after fusion can reflect incomplete union, malalignment, recurrent deformity, infection, or symptomatic hardware. First establish where the pain occurs and whether motion is detectable at the intended fusion. Compare serial weight-bearing radiographs for progressive bridging, persistent lucency, alignment, and changes around screws or plates. Hardware breakage suggests continued mechanical loading but does not, by itself, prove the exact cause. CT can assess bridging bone when radiographs and examination disagree, while recognizing that imaging appearance must still be matched to symptoms. Drainage, erythema, prior wound problems, or unexplained swelling raise concern for infection and call for a directed workup. Review factors affecting healing and the original construct before proposing revision. Correcting the wrong failure mechanism risks repeating it.
Worked example: Several months after a first-metatarsal fusion, a patient has focal pain at the fusion site. Serial films show a persistent line and a broken screw; CT demonstrates little bridging bone. These findings support symptomatic nonunion. A draining sinus adds concern for infection, so evaluate that process before planning revision. Simply replacing the screw would leave both suspected causes unaddressed.
Watch the distinction: A broken screw is evidence of mechanical stress, not a complete diagnosis. Determine whether nonunion, infection, malalignment, or another problem is generating that stress.
Reference: [1]
30. Target perioperative investigations
A perioperative investigation should resolve a decision that matters for the proposed foot procedure. A draining wound calls for examination of depth and spread, appropriate imaging for adjacent bone or a collection, and cultures when they can guide treatment. Weak pulses or poor wound behavior call for objective perfusion testing because blood flow affects healing. Fragility history, unusual bone appearance, or prior failed union may justify targeted assessment of bone health. The sequence matters: identify active infection or ischemia before scheduling elective reconstruction through compromised tissue. Broad testing unrelated to a specific concern can add noise without improving the decision. Explain what a positive and negative result would change, then choose the smallest useful set of tests. The ABFAS CBPS preparation guidance likewise emphasizes case-relevant information and clinically indicated procedures.
Worked example: An elective forefoot reconstruction candidate has a draining plantar wound near the planned incision and weak pedal pulses. Examine and map the wound, investigate possible deep infection, and obtain objective perfusion studies. Active infection or inadequate blood flow would change the timing and approach to reconstruction. Repeating unrelated routine laboratory tests cannot answer either immediate question.
Watch the distinction: A large preoperative panel does not replace a focused investigation. Test the wound and perfusion concerns that could change whether and how surgery proceeds.
Diagnosis
31. Name the symptomatic forefoot disorder
A visible hallux valgus deformity may coexist with several pain generators. Ask the patient to point to the worst pain and reproduce it with targeted examination. Medial prominence tenderness under shoe pressure supports symptomatic bunion irritation. Plantar tenderness beneath a lesser metatarsal head suggests load-related metatarsalgia, but swelling, toe drift, loss of toe purchase, and a positive dorsal drawer at the metatarsophalangeal joint identify instability that may involve the plantar plate. Assess toe flexibility, first-ray function, callus location, and weight-bearing alignment. A radiographic bunion angle describes shape; it cannot tell which structure hurts. Name each symptomatic disorder and its contribution to loading before planning treatment. That approach prevents correction of the most obvious deformity while the patient's chief pain remains.
Worked example: A patient has a marked bunion but says the main pain is beneath the second metatarsophalangeal joint. Examination finds plantar joint tenderness, dorsal drawer laxity, and a second toe that no longer purchases the floor. The chief problem is second-joint instability with plantar pain; hallux valgus is a separate deformity that may contribute to altered loading. Treat both findings in the plan.
Watch the distinction: The largest visible deformity is not necessarily the main pain source. A bunion procedure alone may leave a symptomatic unstable second joint untreated.
Reference: [1]
32. Classify first metatarsophalangeal pain
Classify first metatarsophalangeal pain by tempo, exact location, motion, and imaging. Hallux rigidus usually develops gradually, with loss of dorsiflexion, dorsal impingement, and osteophytes or joint-space change on weight-bearing views. Sesamoid disease produces more focal plantar pain under the metatarsal head, often provoked by direct sesamoid pressure or push-off; targeted views or further imaging may clarify a suspected lesion. Crystal arthritis often begins abruptly with marked inflammatory signs, while chronic inflammatory disease may involve several joints. Septic arthritis remains a concern when a wound, fever, or other infection evidence accompanies a hot joint. Loaded and unloaded motion can expose mechanical impingement, but a single finding should not override the full pattern. Identify the pain mechanism before considering a joint-directed procedure.
Worked example: A patient reports years of increasing stiffness and dorsal pain during push-off. Dorsiflexion is limited, dorsal joint pressure reproduces symptoms, and weight-bearing films show dorsal osteophytes with joint-space narrowing. There is no focal plantar sesamoid tenderness or abrupt inflammatory episode. The combined pattern supports degenerative hallux rigidus over an isolated sesamoid lesion or acute crystal flare.
Watch the distinction: Push-off pain alone does not identify the sesamoids. Dorsal impingement, restricted motion, and joint degeneration point toward the metatarsophalangeal joint itself.
Reference: [1]
33. Identify the driver of adult flatfoot
Adult arch collapse is a three-dimensional problem: the hindfoot may drift into valgus, the arch may lower, and the forefoot may abduct. Locate tenderness along the posterior tibial tendon and medial structures, assess heel-rise function, and see whether the heel and arch correct with supported maneuvers. Flexible correction suggests that joints can still be realigned; fixed deformity and restricted subtalar motion raise concern for arthritic collapse. Weight-bearing imaging helps locate joint degeneration and measure the components visible during standing. An accessory navicular can cause focal medial prominence pain, but that finding alone does not explain widespread hindfoot valgus and forefoot abduction. Diagnose the driver and the deformity's flexibility separately. These distinctions determine whether support, component-based reconstruction, or treatment of rigid joints is anatomically sensible.
Worked example: An adult has medial tendon-course tenderness, arch collapse, a valgus heel, and forefoot abduction. The heel corrects toward neutral during a supported rise, and imaging shows no advanced hindfoot joint degeneration. This supports flexible progressive collapsing foot deformity. If subtalar motion were restricted and joint surfaces degenerated, a rigid arthritic component would change treatment choices.
Watch the distinction: Medial pain near an accessory navicular does not explain every flatfoot. Check hindfoot correction, forefoot abduction, and joint condition before assigning one cause.
Reference: [1]
34. Distinguish painful pediatric flatfoot causes
Many children have a low arch that reappears on tiptoe or when the foot is unloaded. That flexible, painless shape differs from a foot with persistent pain, restricted subtalar motion, or recurrent sprains. Tarsal coalition can limit motion between hindfoot bones and create a rigid flatfoot pattern, sometimes with lateral pain. Examine heel position in stance and on tiptoe, subtalar movement, focal tenderness, and whether symptoms limit activity. Age and symptom onset provide context but do not establish a diagnosis by themselves. Weight-bearing radiographs may suggest a structural connection or another deformity. CT helps define a suspected bony coalition; MRI can help when a nonosseous bridge or competing soft-tissue condition remains plausible. The clinical question is why this child's foot hurts and fails to correct.
Worked example: A child has lateral hindfoot pain and repeated ankle sprains. The low arch stays flat on tiptoe, the heel does not correct, and subtalar motion is markedly restricted. This is a painful rigid pattern, not ordinary flexible flatfoot. Obtain appropriate imaging for coalition or another structural block, then relate the anatomy and joint condition to treatment options.
Watch the distinction: A flat-looking pediatric foot is not automatically benign. Pain, loss of hindfoot motion, and failure of arch reconstitution require a structural explanation.
Reference: [1]
35. Classify a neuropathic hot foot
Acute Charcot change results when an insensate foot sustains repeated trauma without an adequate protective pain response. Inflammation and continued loading can accelerate fragmentation and collapse. A warm, swollen foot with severe neuropathy, relatively little pain, and intact skin fits that mechanism, especially if standing alignment is changing. It is still necessary to look for a wound, spreading erythema, systemic illness, a discrete fracture mechanism, or an acutely inflamed joint. Radiographs may show fragmentation or malalignment later, while early disease can have subtle findings; MRI may help clarify bone and soft-tissue changes when the diagnosis remains uncertain. Infection and Charcot can coexist. Protect and offload the foot while the competing diagnoses are evaluated, since continued loading can turn a potentially manageable shape into a deformity that threatens skin.
Worked example: A patient with marked sensory loss develops a warm, swollen midfoot. Pain is mild, skin is intact, there is no fever, and radiographs show new midfoot fragmentation. Acute Charcot change is a leading diagnosis, so protect and offload the foot promptly. Continue examining for occult infection and fracture because neither the intact skin nor mild pain settles every alternative.
Watch the distinction: Mild pain in a severely neuropathic foot is not reassurance. Sensory loss can mask injury while repeated loading drives collapse.
Reference: [1]
36. Separate soft-tissue from bone infection
Define infection by the structure involved, not by redness alone. A shallow wound with limited surrounding inflammation may involve skin and subcutaneous tissue. Fluctuance, deep tenderness, or tracking drainage suggests a collection that may require drainage. Painful restricted joint motion near a wound raises concern for septic arthritis. A chronic ulcer or sinus that reaches bone, paired with new cortical destruction beneath it, supports contiguous osteomyelitis. Examine the entire foot because an abscess can lie away from the visible opening. Plain films establish a baseline and may show gas or bone change; MRI can map deep compartments when the patient is stable and it will change management. Bone and deep-tissue samples are more informative than superficial swabs when pathogen identification is needed. Multiple infection levels may coexist.
Worked example: A toe-tip ulcer drains through a sinus toward the distal phalanx, and comparison films show new cortical destruction there. Probable contiguous osteomyelitis is the most specific diagnosis. Separate plantar fluctuance would add concern for an abscess requiring its own assessment and source control. Do not describe the whole process as simple cellulitis merely because the surrounding skin is red.
Watch the distinction: An ulcer, abscess, septic joint, and bone infection are distinct anatomical diagnoses. Calling all drainage cellulitis can miss a collection or infected bone.
Reference: [1]
37. Identify the threatened ischemic wound
A plantar neuropathic ulcer and a painful toe-tip lesion can have different dominant causes in the same foot. Sensory loss and deformity allow repetitive loading to break down plantar skin; offloading addresses that mechanical force. A cool foot, weak pulses, rest pain, or distal tissue loss points toward inadequate arterial supply. Assess both mechanisms because reduced perfusion may prevent even a well-offloaded wound from healing. Document wound depth, infection signs, pressure points, pulses, and objective vascular measurements when indicated. Calcified arteries can make ankle pressures misleading, so toe-based tests and waveforms may better reflect distal flow. Decide whether infection needs immediate control, protect tissue from further trauma, and coordinate vascular evaluation before elective closure or deformity correction. A single label of “diabetic ulcer” is too imprecise for treatment planning.
Worked example: A patient with loss of protective sensation has a plantar metatarsal ulcer beneath a callus and a painful toe-tip lesion. The foot is cool and pulses are weak. Plantar pressure and impaired perfusion are both active problems. Offload the plantar site, assess both wounds for infection, and obtain vascular evaluation for the ischemic concern. Dressings alone address neither cause adequately.
Watch the distinction: Neuropathy does not guarantee adequate blood flow. A cool, painful toe lesion requires ischemia assessment even when another ulcer clearly has a pressure component.
Reference: [1]
38. Classify a Lisfranc injury
The Lisfranc complex stabilizes the tarsometatarsal joints, so a twisting or axial load can cause clinically important instability without a dramatic first radiograph. Plantar midfoot ecchymosis, swelling, focal tenderness, and difficulty bearing weight raise suspicion. Compare alignment of metatarsal bases with their corresponding cuneiforms and look for separation or a small avulsion fragment. Weight-bearing views may reveal displacement hidden on non-weight-bearing films, provided standing is safe and tolerable. If pain prevents those views, CT can define fractures and alignment; MRI can assess ligament injury when instability remains uncertain. A stable sprain preserves joint alignment under appropriate assessment. Widening or malalignment establishes an unstable pattern that needs protection and specialist treatment planning. Avoid allowing an initially subtle image to outweigh a strongly suggestive examination.
Worked example: After a twisting fall, a patient has plantar midfoot bruising and focal tenderness over the first and second tarsometatarsal joints. Initial non-weight-bearing films look nearly normal. Protected weight-bearing views later show separation and malalignment at the joint complex. This is an unstable Lisfranc injury, not a simple sprain; protect the foot and plan restoration of alignment.
Watch the distinction: A nearly normal non-weight-bearing film does not establish stability. Plantar bruising and focal tenderness justify further evaluation of tarsometatarsal alignment.
Reference: [1]
39. Locate a fifth-metatarsal injury precisely
The proximal fifth metatarsal has fracture patterns with different mechanisms and healing behavior. A tuberosity avulsion follows traction near the peroneus brevis insertion, often after inversion. A fracture at the metaphyseal-diaphyseal junction lies farther along the bone and raises more concern for delayed union because of local blood supply. A more distal proximal-shaft stress injury commonly reflects repeated loading and may show cortical thickening or a history of progressive pain before a complete break. Read the fracture line's exact position and orientation on multiple views; mechanism alone does not classify it. Check for displacement, skin injury, focal tenderness elsewhere, and prior symptoms. Naming the location accurately guides protection, counseling, and the intensity of healing surveillance without making treatment automatic from a label.
Worked example: A patient twists the foot inward and has immediate tenderness at the lateral proximal prominence. Radiographs show a small fragment from the fifth-metatarsal tuberosity at the peroneus brevis attachment, with no fracture line extending into the metaphyseal-diaphyseal region. This is a tuberosity avulsion pattern. It is distinct from a junctional fracture farther down the bone, whose healing concerns differ.
Watch the distinction: Mechanism alone cannot distinguish proximal fifth-metatarsal patterns. An inversion injury can draw attention to the correct bone while the radiograph determines the exact fracture level.
Reference: [1]
40. Distinguish inflammatory joint conditions
Crystal arthritis can cause abrupt severe joint pain, warmth, and redness; chronic inflammatory arthritis more often gives a longer pattern of stiffness, recurrent synovitis, and involvement of other joints. Septic arthritis may overlap both presentations and is particularly concerning with a nearby wound, fever, or systemic illness. Examine the joint and surrounding skin, then aspirate an accessible joint when infection remains plausible. Assess synovial fluid for crystals and microbiology, recognizing that crystals and infection can coexist and that a negative early test does not settle the clinical picture. Blood inflammatory markers describe systemic response but do not identify the joint's cause. Reassess as cultures and clinical course develop, and escalate promptly when infection is likely. In a Foot Surgery NEW CBPS case, each examination or test should answer a question relevant to management.
Worked example: A patient with prior gout flares has an abruptly red first metatarsophalangeal joint and an infected wound nearby. Aspirated fluid contains urate crystals, but fever and the wound maintain concern for joint infection. Keep septic arthritis in the differential, send synovial fluid for culture, and act on the clinical severity while results develop. The crystals explain one process but do not exclude another.
Watch the distinction: A known inflammatory diagnosis should not absorb every new hot joint. A nearby infected wound and acute systemic findings require a separate assessment for septic arthritis.
41. Diagnose a foot mass responsibly
A mass is a diagnosis to establish, not a name to assign from its appearance. Ask when it appeared, whether it is growing, and whether pain, numbness, or shoe pressure has changed. Examine its size, depth, mobility, skin, and effects on nearby nerves and vessels. Radiographs can reveal bone involvement or mineralization; MRI helps define its tissue plane and relationship to tendons, bone, and neurovascular structures. A superficial, stable lesion with characteristic findings may have a different pathway from a deep, enlarging, poorly defined one. If tissue diagnosis is needed, plan the biopsy route with the team that would manage the lesion definitively. The route matters because biopsy can alter tissue planes that later surgery must address. The ABFAS Foot Surgery content areas include neoplastic disorders.
Worked example: A plantar mass has enlarged over several months. It feels fixed beneath mobile skin, and MRI shows a deep lesion displacing adjacent structures without establishing its type. Normal skin does not establish benignity. Record neurovascular findings, review the full imaging extent, and arrange specialist evaluation with a planned biopsy route. Defer definitive excision until pathology and the surgical plan are aligned.
Watch the distinction: Calling a mass a fibroma because it lies in the plantar foot is premature. Growth, depth, and imaging may reveal a different lesion that needs coordinated biopsy.
Reference: [1]
42. Find the cause of failed reconstruction
Postoperative pain needs a fresh anatomical diagnosis. Locate the pain and compare current alignment, loading, wound condition, and stability with the operative goal and earlier records. Serial weight-bearing radiographs can show recurrent deformity, malunion, hardware change, or incomplete fusion; CT may clarify uncertain bone bridging. Examine plantar calluses because a corrected first ray can still shift load to a lesser metatarsal. Drainage, warmth, or a sinus raises concern for infection, including infection alongside nonunion. A solid fusion does not prove the reconstruction has restored comfortable load sharing, while a visible fusion line alone does not explain pain at a different site. Name the failure mechanism before proposing revision, then identify whether footwear, offloading, deformity correction, infection treatment, or another intervention addresses it.
Worked example: After a first-ray fusion, the medial prominence is reduced, but walking produces pain beneath the second metatarsal head. A callus marks that site, the fusion is solid on serial images, and there is no drainage. The findings favor transfer overload rather than nonunion. Assess first-ray position and second-ray mechanics, begin pressure redistribution, and consider revision only if the established cause warrants it.
Watch the distinction: A painful postoperative foot does not automatically mean failed bone healing. Pain location, callus pattern, alignment, serial imaging, and infection findings can point to different treatments.
Reference: [1]
Treatment
43. Build a hallux valgus treatment plan
Start with the symptoms the patient wants relieved: shoe pressure, joint pain, or lesser-ray overload. Examine first metatarsophalangeal motion and tenderness, first-ray mobility, lesser-toe stability, skin, and neurovascular status. Standing radiographs show the alignment, sesamoid relationship, and joint condition under load. Wider shoes and pressure modification can reduce prominence irritation without correcting the deformity. Persistent limiting symptoms may justify surgery after discussion of recovery, recurrence, stiffness, transfer pain, and patient goals. The corrective strategy must match the documented deformity and joint condition: preserving a mobile, relatively healthy joint is a different problem from treating a severely arthritic one. A procedure chosen from one angle alone can leave an unstable component or create a new loading problem. Reassess both prominence pain and lesser-ray symptoms during follow-up.
Worked example: A patient still has medial shoe-pressure pain after using wider footwear. The joint moves comfortably through its central range, standing films show hallux deviation without advanced arthritis, and examination documents first-ray alignment and mobility. Continued nonoperative care remains reasonable; correction is also discussable if symptoms justify it. Select a construct that addresses the demonstrated components, then monitor alignment and lesser-ray loading.
Watch the distinction: A large-looking bunion is not, by itself, an indication for a particular operation. Symptoms, joint condition, flexibility, loading, and the patient's priorities determine whether and how to correct it.
Reference: [1]
44. Treat hallux rigidus by pain mechanism
Pain timing during first metatarsophalangeal motion guides treatment. Dorsal pain near the end of dorsiflexion suggests osteophyte impingement; pain through the middle of motion suggests broader cartilage loss. Examine both loaded and unloaded movement, palpate the dorsal joint and sesamoids, and connect findings to radiographs showing osteophytes, joint-space preservation, or widespread narrowing. A stiff-soled shoe or rocker sole can reduce painful dorsiflexion during walking. In selected cases with preserved central cartilage and predominantly dorsal impingement, a joint-sparing procedure may address the painful block. Advanced degeneration with pain across the arc makes a motion-preserving approach less reliable, so fusion may be considered after discussing lost joint motion and expected functional tradeoffs. Treatment should follow the pain mechanism, not the osteophyte's size alone.
Worked example: Patient A has dorsal pain only at terminal dorsiflexion, an osteophyte, and preserved central joint space. Footwear modification comes first; persistent symptoms may support a joint-sparing discussion. Patient B has pain throughout motion and marked joint-space narrowing. A simple dorsal bone removal would leave painful cartilage surfaces, so fusion becomes a more coherent option if nonoperative care fails.
Watch the distinction: Removing a dorsal spur does not treat pain caused throughout an arthritic joint. Match the proposed operation to the location and timing of pain and remaining cartilage.
Reference: [1]
45. Correct lesser-toe instability
A crossover toe is often a joint-stability problem, not simply a bent toe. Plantar plate injury or attenuation permits dorsal and sideways displacement at the metatarsophalangeal joint; a hammertoe at the proximal interphalangeal joint may coexist. Examine toe purchase, the dorsal drawer response, reducibility, plantar tenderness, and calluses that reveal overload. Initial treatment can redistribute pressure with footwear changes, padding, and appropriately selected support while monitoring progression. If symptoms and instability persist, plan around the unstable metatarsophalangeal joint, the visible toe deformity, and any contributing metatarsal loading or first-ray problem. Correcting only the proximal interphalangeal shape can leave plantar pain and joint drift. Explain the risks of stiffness, recurrent deviation, floating toe, and transfer symptoms when discussing reconstruction.
Worked example: A second toe crosses toward the hallux, fails to press firmly against the floor, and translates dorsally on drawer testing. Plantar second-joint tenderness identifies the painful site. Start with shoe space and pressure relief. If surgery becomes appropriate, address metatarsophalangeal stability and load as well as toe alignment; straightening the middle toe joint alone would leave the principal instability.
Watch the distinction: A straighter toe is not necessarily a stable or painless toe. Isolated hammertoe correction can miss plantar plate failure and persistent pressure beneath the metatarsophalangeal joint.
Reference: [1]
46. Plan flexible flatfoot reconstruction
A flexible adult flatfoot can combine hindfoot valgus, forefoot abduction, arch collapse, and tendon dysfunction. Identify each component on standing examination and images, then test heel correction and forefoot flexibility. Pain along the medial tendon course differs from pain arising in an arthritic joint or an isolated accessory navicular. Supportive footwear, an orthosis or brace, activity modification, and rehabilitation may control symptoms while preserving function. Persistent disability may prompt component-specific reconstruction: the plan must restore alignment and account for deficient soft tissues rather than asking a tendon alone to resist an unchanged deforming force. A fixed, arthritic hindfoot requires a different strategy from a flexible one. For procedural distinctions involving the ankle and rearfoot, the separate RRA NEW CBPS guide covers that examination's scope.
Worked example: An adult has medial tendon-course pain, forefoot abduction, and a valgus heel that corrects on supported heel rise. Support and rehabilitation have not controlled daily pain. The flexible correction supports considering reconstruction, but the plan must address the measured hindfoot and forefoot components as well as tendon function. A tendon procedure alone would leave the same malalignment loading it.
Watch the distinction: Medial tendon pain does not prove that isolated tendon repair will correct flatfoot. Determine which bones and joints create the deformity, and whether each component remains flexible.
Reference: [1]
47. Treat cavovarus by its deforming driver
Cavovarus treatment begins by locating the driver. A plantarflexed first ray can tip the hindfoot into varus; alternatively, a fixed hindfoot deformity may remain even when the forefoot is unloaded. In the Coleman block maneuver, support the lateral foot while allowing the first ray to drop off the block. Heel correction toward neutral indicates that much of the hindfoot varus is flexible and forefoot driven. Examine muscle strength, tendon imbalance, ankle stability, calluses, and neurologic findings because repeated lateral overload may recur if the force pattern remains. Nonoperative care can redistribute load and support a flexible foot. If reconstruction is warranted, correct the plantarflexed ray and balance deforming forces; add hindfoot correction only for a persistent hindfoot component. Plan follow-up around alignment, lateral pain, and new pressure points.
Worked example: A patient has a plantarflexed first ray, lateral border calluses, and recurrent sprains. When the first ray hangs free beside the Coleman block, the heel moves toward neutral. That response identifies a flexible, forefoot-driven varus component. Start with load redistribution; if surgery is needed, target first-ray position and muscle balance before considering a hindfoot procedure unsupported by the block finding.
Watch the distinction: Every cavovarus heel does not need the same heel correction. If unloading a plantarflexed first ray corrects the heel, the forefoot is a key treatment target.
Reference: [1]
48. Manage symptomatic pediatric deformity
Symptoms and flexibility determine the next step in a child's flatfoot. An arch that reappears on tiptoe or when the foot is unloaded, with painless subtalar motion, supports a flexible pattern. Discuss comfort, activity, and shoe fit; observation or support for symptoms may be sufficient. Pain, recurrent sprains, restricted subtalar motion, or a heel that does not correct suggests a structural process such as coalition. Use imaging to define the suspected structure and assess surrounding joint health before selecting treatment. A confirmed coalition does not dictate one operation: symptom severity, coalition anatomy, remaining motion, and adjacent degeneration all matter. Nonoperative support may still be useful, while persistent painful rigidity may require a planned procedure. Keep the child's function and growth context in view during follow-up.
Worked example: A younger child has painless flatfoot, free subtalar motion, and an arch that appears on tiptoe. Explain the flexible finding and offer symptom-based observation. A teenager has lateral hindfoot pain, repeated sprains, restricted motion, and imaging confirming a coalition. Assess joint condition and anatomy, try appropriate support, and discuss a structural treatment if pain remains limiting.
Watch the distinction: A flat-looking arch alone does not justify surgery in a child. Pain, loss of motion, and failure of correction are the findings that change the investigation.
Reference: [1]
49. Offload a neuropathic plantar ulcer
A neuropathic plantar ulcer persists when repeated pressure and shear exceed the tissue's ability to recover. Loss of protective sensation removes the warning that would normally make a person shift weight; deformity or a prominent metatarsal head concentrates force at one site. Examine depth, surrounding infection, callus, footwear, gait, and perfusion before choosing wound care. Debridement may remove nonviable tissue, but a dressing cannot undo the loading that caused the wound. Select an offloading method the patient can use safely and consistently, then check both wound progress and device-related pressure elsewhere. Once the skin closes, transition to protective footwear and address the deformity or activity pattern that caused recurrence. A wound that stalls despite adequate offloading warrants reassessment for infection, ischemia, or an unrecognized mechanical source.
Worked example: A plantar second-metatarsal ulcer becomes smaller while the foot is protected, then reopens after the patient returns to ordinary shoes. The timing implicates recurrent pressure. Reassess the wound for infection and perfusion, restore effective offloading, and plan footwear that reduces second-ray load after closure. Repeated dressing changes without pressure control would reproduce the same cycle.
Watch the distinction: A clean dressing does not remove plantar force. If an ulcer repeatedly closes under protection and reopens in ordinary shoes, investigate and correct the recurring load.
Reference: [1]
50. Treat infection in stages
Treat a foot infection in a sequence that addresses both the patient and the source. First assess systemic illness, perfusion, the extent of erythema, wound depth, fluctuance, necrosis, and possible joint or bone involvement. A deep abscess needs timely drainage and removal of nonviable tissue; antimicrobial treatment alone may not reach a sealed collection effectively. Obtain useful deep specimens when feasible, then refine antimicrobial therapy as organism results and clinical response become clear. Protect and offload the foot while monitoring for progression. Closure or reconstruction belongs after infection control and an assessment that the remaining tissue has adequate blood supply and coverage potential. The ABFAS CBPS preparation guidance emphasizes case-specific examination, investigation, treatment, and follow-up decisions; in this case, each step answers a distinct management question.
Worked example: A patient with diabetes has plantar fluctuance, spreading erythema, and drainage after stepping on a sharp object. Assess systemic status and perfusion, arrange prompt drainage and debridement, and collect a meaningful deep specimen. Begin appropriate initial antimicrobial care, then adjust it to findings and response. Recheck wound depth and blood flow before deciding when and how to close it.
Watch the distinction: Antibiotics alone may leave a plantar abscess intact. Source control, specimen quality, perfusion, and repeated examination determine whether the infection is actually resolving.
51. Manage suspected bone infection
A chronic ulcer can spread directly into the bone beneath it, but treatment depends on more than the label osteomyelitis. Map the ulcer, exposed or palpable bone, surrounding soft-tissue infection, imaging changes, and perfusion. Plain films may show established cortical destruction; MRI can help define uncertain extent, while bone sampling can clarify diagnosis or guide therapy when results would change the plan. Limited bone involvement with viable soft tissue and adequate blood flow may allow a medical approach in selected circumstances. Necrotic bone, uncontrolled soft-tissue infection, poor coverage, or a deformity sustaining the wound can make resection and source control more compelling. Poor perfusion threatens either pathway, so obtain vascular assessment when indicated. Follow healing of both the infection and the overlying wound, not imaging alone.
Worked example: A distal toe ulcer overlies new cortical erosion, but pedal pulses are weak and the toe is cool. Contiguous bone infection is likely, yet the healing potential is uncertain. Define perfusion and how much bone and soft tissue are involved. Then compare targeted antimicrobial care with limited resection or a combined approach; choose only after judging source control and viable coverage.
Watch the distinction: A small focus of bone destruction does not automatically mandate amputation, and antibiotics are not automatically sufficient. Tissue viability, perfusion, extent, and source-control needs decide the path.
Reference: [1]
52. Escalate a limb-threatening infection
Rapid progression, tissue discoloration, crepitus, severe pain, and systemic instability signal an infection that may be destroying deep tissue. Bacterial toxins, vascular injury, and rising tissue pressure can accelerate necrosis while the skin initially understates the extent. Assess airway, circulation, organ dysfunction, and the limb immediately; begin resuscitation and broad initial antimicrobial coverage while arranging urgent surgical evaluation for exploration and removal of nonviable tissue. Obtain cultures and imaging when they can be acquired without delaying source control. A plain film showing gas strengthens concern, but absent gas does not rule out a dangerous deep infection. After the first operation, reassessment may reveal further tissue needing treatment, and antimicrobial care should be narrowed when reliable results permit. Delayed definitive closure until viable tissue and infection control are established.
Worked example: A patient becomes hypotensive as forefoot discoloration spreads over hours. The foot is crepitant and pain is severe. Initiate resuscitation, broad initial antimicrobial treatment, and immediate surgical assessment. Send useful specimens during source control and reassess afterward. MRI may map extent in a stable patient, but waiting for it here would delay treatment of a rapidly destructive process.
Watch the distinction: A detailed scan is not a prerequisite for acting on a rapidly worsening, unstable patient. Waiting for imaging or final cultures can allow further necrosis.
Reference: [1]
53. Coordinate care for ischemic tissue loss
Tissue loss on a cool foot cannot be managed as a local skin problem alone. Ask about rest pain, walking limitation, wound duration, and infection; examine temperature, color, pulses, wound location, and tissue viability. Objective vascular studies help establish whether blood delivery can support healing, especially when bedside pulses are uncertain or arterial calcification distorts ankle pressure readings. Protect the wound from trauma, reduce pressure, and treat any infection promptly. Coordinate vascular assessment before elective closure or deformity surgery, because a well-designed repair can still fail without sufficient perfusion. Urgent spreading infection may require source control alongside vascular planning rather than waiting for a perfect sequence. Follow pain, wound change, perfusion findings, and the response to any vascular intervention to decide when definitive foot treatment is feasible.
Worked example: A toe-tip ulcer is painful at rest, the foot is cool, and pedal pulses are weak. There is no fluctuance or spreading erythema. Protect the toe, avoid further pressure, obtain objective perfusion assessment, and involve vascular care before elective closure. Monitor closely for infection or worsening tissue loss, which would change the urgency and sequence.
Watch the distinction: Covering an ischemic ulcer does not restore its blood supply. A closure plan made before evaluating perfusion may fail even when local wound care is meticulous.
Reference: [1]
54. Treat an acute Charcot foot
Severe neuropathy allows repeated, relatively painless microtrauma. In an active Charcot process, inflammation and bone weakening can lead to fragmentation, joint subluxation, and progressive collapse while the patient continues to walk. A warm, swollen foot therefore needs prompt protection, even when pain is modest. Examine skin integrity, temperature difference, deformity, and stability; assess for fracture, infection, and vascular problems when the findings call for them. Immobilization and effective offloading interrupt further injury while serial examinations and imaging track activity and alignment. An intact skin envelope offers an opportunity to prevent a later pressure ulcer. Once the active process settles, protective footwear or bracing may maintain a usable shape; persistent unstable deformity or recurrent ulcer risk may prompt reconstructive planning. Do not choose definitive reconstruction from a single hot-foot visit.
Worked example: A patient with marked sensory loss has a warm swollen midfoot, new fragmentation on radiographs, little pain, and intact skin. Treat active Charcot change as a leading concern. Protect and offload the foot now, while checking for infection or an acute fracture. Follow temperature, swelling, alignment, and skin condition before deciding whether later bracing or reconstruction is needed.
Watch the distinction: Little pain does not mean a neuropathic swollen foot is safe to walk on. Continued loading can turn early fragmentation into deformity and skin breakdown.
Reference: [1]
55. Stabilize an unstable Lisfranc injury
The Lisfranc complex stabilizes the tarsometatarsal joints during weight bearing. Displacement means the midfoot can no longer reliably transmit load in normal alignment, and continued walking can worsen joint damage. Examine plantar bruising, focal tenderness, swelling, skin condition, and neurovascular status. Appropriate weight-bearing imaging, when safe, can show malalignment that non-weight-bearing views miss; CT may define fractures and joint relationships when standing is unsafe. Protect the foot from loading while defining the injury. A displaced, unstable injury generally requires discussion of restoring and maintaining alignment, with the exact construct chosen according to joints involved, bone injury, soft tissues, and patient factors. Follow reduction, healing, symptoms, and later arthritis because an anatomically treated injury can still produce post-traumatic pain.
Worked example: After a twisting injury, a patient has plantar midfoot bruising and focal tarsometatarsal pain. Imaging confirms displaced alignment. Keep the foot protected from weight bearing, assess skin and associated fractures, then plan reduction and stabilization appropriate to the injured joints. Early unrestricted walking would expose the displaced joints to further loading; follow-up should check alignment and later pain.
Watch the distinction: A Lisfranc injury with confirmed displacement is not a routine sprain. Pain control alone does not restore the tarsometatarsal alignment needed for stable loading.
Reference: [1]
56. Treat metatarsal fractures by pattern
Metatarsal fracture treatment follows the pattern and the soft tissues. Identify the exact bone and fracture level, displacement, rotation, shortening, comminution, and neighboring injuries on examination and radiographs. A well-aligned closed central metatarsal fracture may remain stable with protection and interval reassessment. A fracture with an open wound has a different immediate problem: contamination and tissue injury require urgent assessment, wound care, antimicrobial management, and a fixation decision based on the full injury. Proximal fifth-metatarsal fractures also differ by location because local anatomy changes healing expectations. Check toe perfusion and sensation, and look for pressure or rotational deformity that may not be obvious on a single view. During follow-up, compare pain and function with maintained alignment and evidence of healing before increasing load.
Worked example: One patient has a closed central metatarsal fracture with intact skin, preserved toe alignment, and minimal displacement; protection and repeat assessment are reasonable. Another has a small wound communicating with displaced fragments after a crush injury. Treat that as a possible open fracture requiring urgent wound and infection management plus fracture stabilization planning, rather than applying the first patient's routine pathway.
Watch the distinction: Similar fracture lines do not imply similar treatment when one is open or unstable. Skin injury, contamination, rotation, and adjacent damage can dominate the immediate decision.
Reference: [1]
57. Act on foot compartment syndrome
Within a closed foot compartment, bleeding and swelling raise pressure. As pressure approaches the small-vessel perfusion pressure, muscle and nerve blood flow falls even though larger arteries may still carry a palpable pulse. Suspect compartment syndrome after crush or high-energy injury when pain escalates, the foot becomes tense, passive toe movement worsens pain, or sensation changes. Remove external constriction, reassess promptly, and obtain immediate surgical evaluation; pressure measurement can aid an uncertain examination but should not delay action when the clinical pattern is compelling. Time matters because prolonged ischemia can leave permanent muscle and nerve damage. Analgesia or immobilization that fails to settle the pain is another warning, not reassurance. Subsequent care must address the original injury and monitor wound, neurologic, and vascular status.
Worked example: Several hours after a crush injury, pain intensifies despite loosening the splint. The foot is tense, passive toe motion sharply increases pain, and plantar sensation is changing; pedal pulses remain palpable. The pattern requires immediate surgical assessment for possible decompression. Preserved pulses show that large-vessel flow persists, not that the compartment's muscle and nerves are adequately perfused.
Watch the distinction: Palpable pulses do not exclude compartment syndrome. They assess large-artery flow, while dangerous pressure can first impair the smaller vessels supplying muscle and nerve.
Reference: [1]
58. Treat inflammatory foot disease without losing the diagnosis
Chronic inflammatory arthritis can deform the forefoot through synovitis, ligament attenuation, joint damage, and altered tendon forces. Establish which joints are persistently painful, how flexible the deformities are, and whether footwear or support addresses pressure. An acutely hot joint with a nearby wound is a separate diagnostic event: infection must be evaluated before treating the flare as established arthritis. Joint aspiration may be necessary when septic arthritis remains plausible; crystal findings do not by themselves exclude infection. Once the acute diagnosis is settled, coordinate inflammatory disease control with local measures such as pressure relief and skin care. Surgery may be considered for persistent pain, instability, or ulcer-producing deformity, with attention to tissue quality and healing capacity. Recheck both disease activity and mechanical symptoms rather than assuming one treatment solves both.
Worked example: A patient with long-standing inflammatory arthritis has painful lesser-toe deformities. One metatarsophalangeal joint becomes newly hot beneath a skin break. Examine the wound and systemic status, investigate the joint for infection, and defer elective reconstruction while the acute process is unresolved. If infection is excluded or treated, reassess chronic joint damage and pressure to choose support or a durable correction.
Watch the distinction: An established arthritis diagnosis does not explain every new red joint. An overlying wound creates a plausible route for infection that changes immediate investigation and treatment.
Reference: [1]
59. Plan management of a foot neoplasm
Neoplasm care depends on knowing what the lesion is and where it extends before cutting into it. Record growth, pain, neurologic symptoms, skin changes, and fixation, then map the lesion with imaging suited to its depth and tissue type. MRI can show relation to fascia, tendons, bone, and neurovascular structures; radiographs may reveal bone change or mineralization. Tissue diagnosis should follow a planned route coordinated with the team responsible for definitive management, because an incision through uninvolved tissue can complicate later removal. Pathology, grade where relevant, anatomical extent, and patient function then guide treatment. Options may include observation for an established benign lesion, planned excision, or broader specialist treatment for a concerning tumor. Follow-up should track local recurrence and function according to the final diagnosis.
Worked example: MRI shows an enlarging deep plantar mass abutting a neurovascular bundle and extending beneath the fascia. The image defines its position but cannot establish benignity. Arrange specialist review and a biopsy route that can be incorporated into definitive treatment. Do not excise it through an improvised plantar incision; pathology and extent must guide the eventual operation and follow-up.
Watch the distinction: A technically easy-looking lump can be difficult to manage after an unplanned excision. Its depth and relation to vital structures should shape biopsy before definitive surgery.
Reference: [1]
60. Revise a failed foot operation by cause
Revision succeeds only when it addresses the reason the first operation failed. Localize pain, assess alignment and motion, review serial images for bone bridging and hardware change, and examine for drainage or wound breakdown. A sinus near a painful fusion raises concern for infection even when imaging also shows nonunion; both processes may need treatment. Consider host factors that impair healing, the quality of remaining bone and soft tissue, and whether current loading makes a repeat construct viable. Obtain targeted infection evidence and define the defect before choosing debridement, antimicrobial care, stabilization, grafting, or an alternative functional plan. The sequence may require infection control before definitive reconstruction. Explain realistic goals and follow closely for wound healing, alignment, union, and recurrent infection rather than judging success from replacement hardware alone.
Worked example: A first-metatarsal fusion remains painful months later. CT shows scant bridging bone, a screw has broken, and a draining sinus reaches the operative region. Diagnose probable nonunion with possible infection, obtain a targeted infection assessment, and plan debridement and source control. Reconstruct only after defining viable tissue, bone loss, and healing risks; simply exchanging the screw would leave the suspected cause untreated.
Watch the distinction: Broken hardware is often evidence of an underlying mechanical or biological failure. Replacing it without assessing union, alignment, tissue health, and infection risks repeating that failure.
Reference: [1]
Official references and further reading
- Part I Board Qualification Exam Content | ABFAS
- CBPS Exam Preparation | ABFAS
- New Certification Process, Effective September 2020 | ABFAS
- NEW CBPS Overview (Board Qualified Before Fall 2020) | ABFAS