Fractures: Stress vs. Acute

Foot and ankle fractures are classified as either acute (caused by a single traumatic event) or stress fractures (caused by repetitive loading over time). Both require prompt evaluation, but they present differently and are managed differently.

Acute fractures typically result from a fall, direct impact, or sudden twisting injury. Swelling, bruising, and an inability to bear weight are common signs. X-ray confirms the break and guides treatment, which may range from immobilization in a boot or cast to surgical fixation depending on displacement and bone involved.

Stress fractures develop gradually when muscles fatigue and can no longer absorb repetitive shock, transferring that load directly to bone. The second and third metatarsals are the most commonly affected. Symptoms include a dull ache that worsens with activity and improves with rest, point tenderness over a specific bone, and mild swelling. Stress fractures may not appear on initial X-rays — an MRI or bone scan is sometimes needed for diagnosis.

  • Risk factors: sudden increase in training intensity, hard surfaces, poor footwear, vitamin D or calcium deficiency
  • Treatment: rest, offloading boot, activity modification — rarely surgery unless the fracture is high-risk (navicular, fifth metatarsal base)
  • Returning to activity too soon is the most common cause of re-fracture

Osteoporosis and the Feet

Osteoporosis reduces bone density throughout the body, including the small bones of the feet. Patients with osteoporosis are at significantly elevated risk for stress fractures and fragility fractures with minimal trauma. Certain foot deformities can also accelerate from bone-weakening conditions.

If you have been diagnosed with osteoporosis or are postmenopausal, mention this during your podiatric evaluation. We may modify activity recommendations and footwear guidance accordingly, and coordinate with your primary care provider on calcium, vitamin D, and medication management.

Arthritis of the Foot and Ankle

Arthritis — inflammation of the joints — is extremely common in the foot and ankle. The two main types encountered in podiatric care are:

Osteoarthritis (OA) is the most prevalent form, caused by gradual wear and breakdown of joint cartilage. It often affects the big toe joint (hallux rigidus), the midfoot, and the ankle joint — particularly after prior injury. Symptoms include joint stiffness (worse in the morning), deep aching pain with activity, bony enlargement at the joint, and reduced range of motion.

Rheumatoid arthritis (RA) is an autoimmune condition that attacks the joint lining (synovium). RA commonly affects the forefoot first — causing pain, swelling, and deformity at multiple joints simultaneously. Patients with RA often develop bunions, hammertoes, and metatarsalgia as deformities progress. Coordination with a rheumatologist is important for disease management.

  • Conservative management: custom orthotics, supportive footwear, anti-inflammatory medication, joint injections, physical therapy
  • Surgical options: joint fusion (arthrodesis) or joint replacement when severe deformity or intractable pain is present
  • Early intervention slows progression and preserves function

Tendonitis: Achilles and Posterior Tibial

Tendonitis is inflammation of a tendon, most often caused by overuse, sudden increases in activity, or poor biomechanics. The two tendons most commonly affected in the foot and ankle are:

Achilles tendonitis presents as pain and stiffness along the back of the heel and lower calf, particularly after inactivity or at the start of exercise. The Achilles is the largest tendon in the body and connects the calf muscles to the heel bone. Two forms are recognized: insertional (at the heel bone attachment) and non-insertional (2–6 cm above the insertion, more common in younger active patients). Risk factors include tight calf muscles, flat feet, hill running, and rapid training escalation.

Posterior tibial tendon dysfunction (PTTD) occurs along the inside of the ankle and arch. This tendon supports the arch; when it weakens or tears, the arch progressively collapses — causing adult-acquired flatfoot. Early stages present as inner ankle pain and mild swelling; later stages involve significant deformity and difficulty standing on the toes of one foot.

  • Rest, ice, and anti-inflammatories provide short-term relief
  • Eccentric calf exercises are strongly evidence-supported for Achilles tendonitis
  • Custom orthotics or a brace offload the tendon and allow healing
  • Physical therapy addresses underlying biomechanical contributors
  • PRP (platelet-rich plasma) injections may be considered for chronic cases
Do not ignore a sudden "pop" in the heel area. A sudden sharp pain at the back of the ankle during activity — sometimes described as being kicked or shot — may indicate an Achilles tendon rupture. Seek care immediately. Ruptures treated promptly have far better outcomes than those evaluated weeks later.

Tendon Tears and Ruptures

Partial and complete tendon tears are more serious than tendonitis and often require more aggressive treatment. In addition to the Achilles, the peroneal tendons (on the outer ankle) are a common site of tearing, often following an ankle sprain or in patients with a high-arched foot.

Diagnosis typically requires MRI to determine tear extent. Treatment depends on the tendon involved, the degree of tear, patient age and activity level, and how long the injury has been present. Options range from immobilization and physical therapy for partial tears to surgical repair or reconstruction for complete ruptures or failed conservative care.

Ankle Sprains

Ankle sprains are among the most common musculoskeletal injuries, accounting for roughly 2 million emergency department visits per year in the United States. A sprain stretches or tears the ligaments that stabilize the ankle joint — most commonly the anterior talofibular ligament (ATFL) on the outer ankle.

Sprains are graded I (stretch without significant tearing), II (partial tear), or III (complete tear). While mild sprains often heal with rest, ice, compression, and elevation (RICE), moderate and severe sprains require formal evaluation to rule out fracture (Ottawa Rules), guide rehabilitation, and prevent chronic instability.

  • Chronic instability — a giving-way sensation with everyday activity — develops in up to 40% of patients who do not fully rehabilitate a significant sprain
  • Balance and proprioception training is essential to full recovery
  • Recurrent instability may require surgical ligament reconstruction (Brostrom procedure)

When to Seek Care

Not every ache requires an immediate visit, but these signs warrant prompt podiatric evaluation:

  • Pain that does not improve after 1–2 weeks of rest and home care
  • Swelling, bruising, or an inability to bear weight after an injury
  • A sudden "pop" or snapping sensation in the ankle or heel area
  • Visible deformity or change in the shape of the foot or ankle
  • Pain that wakes you at night or is present at complete rest
  • Any bone or joint symptoms in a patient with diabetes, osteoporosis, or immunosuppression

Early diagnosis almost always expands your treatment options and reduces recovery time. What begins as tendonitis left untreated can progress to a tear; an undiagnosed stress fracture can displace and require surgery that a short course of rest would have prevented.