Umów wizytę

Tomasz Poboży

Kategoria: Foot and Ankle (EN)

English-language patient articles about foot and ankle pain, fractures, sprains, tendons, nerves, diagnosis and treatment.

  • Starting Pain — Why Do the First Steps After Rest Matter?

    Pain that is strongest during the first steps after getting out of bed or after sitting for a while is sometimes described as “starting pain”. It is a useful symptom pattern because it shows how symptoms respond to rest and renewed loading. It does not, however, point automatically to a single diagnosis.

    How does an orthopaedic surgeon interpret “first-step pain”?

    The pattern matters. Some people notice that the first several steps after sleep or a longer period of sitting are the most painful, that symptoms then ease partly with movement, and that pain may increase again after prolonged walking or exercise. Constant pain that worsens with every step is a different pattern, as is sudden pain after an injury.

    These differences can help organise the diagnostic process, but they do not replace an examination. The exact location of pain, duration of stiffness, swelling, strength, range of motion and response to increasing load all matter.

    When the pain is under the heel

    Pain with the first steps after rest is a typical feature of plantar heel pain associated with plantar fasciitis. It is usually felt on the plantar-medial side of the heel. The 2023 clinical practice guideline includes first-step pain after rest among the characteristic clinical features, while also stressing that other causes of heel pain need to be considered.

    Not every episode of morning heel pain has the same cause. Recent trauma, burning or numbness, more diffuse pain in the heel bone, or symptoms associated with inflammatory disease require a different assessment. See also: Foot and Ankle Conditions.

    When the Achilles tendon feels stiff

    Morning stiffness and pain after inactivity can also occur with midportion Achilles tendinopathy. Symptoms may change during walking or training, so the beginning of activity is only part of the picture; the response during loading and afterwards is important as well.

    A sudden snap, a marked loss of push-off strength or difficulty rising onto the toes does not fit the usual gradual pattern of tendinopathy and should prompt earlier assessment for a possible tendon rupture.

    Why the symptom name is not enough

    Pain that “warms up” with movement is not necessarily trivial, and pain after rest does not automatically mean there is damage that needs a procedure. Similar descriptions can come from different tissues and conditions. Imaging does not settle every case either: ultrasound, X-ray or MRI findings need to be interpreted alongside the site of pain and functional examination.

    Before a consultation, it can be useful to note how long a period of rest triggers the pain, how many steps or minutes it takes to ease, whether symptoms return after longer walking or exercise, where the most painful point is, whether there is swelling, warmth, numbness or weakness, and how the area feels the next day after greater loading.

    When is earlier assessment important?

    “Starting pain” should not be used to explain away a sudden loss of function after injury, inability to bear weight, visible deformity, rapidly increasing swelling, a hot red joint with fever, or new loss of sensation or strength. Persistent pain at rest or at night also deserves earlier assessment when it is worsening or does not follow the usual relationship with movement.

    The whole symptom pattern matters

    When pain appears is only one part of the history. Combined with its location, response to load and examination findings, it can help distinguish several possible sources and decide whether imaging is needed. First-step pain alone should not be used to self-diagnose a condition or choose insoles, an injection or a procedure.

    References

    1. Koc TA Jr, Bise CG, Neville C, Carreira D, Martin RL, McDonough CM. Heel Pain — Plantar Fasciitis: Revision 2023. J Orthop Sports Phys Ther. 2023;53(12):CPG1–CPG39. DOI: 10.2519/jospt.2023.0303.
    2. Chimenti RL, Neville C, Houck J, Cuddeford T, Carreira D, Martin RL. Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision — 2024. J Orthop Sports Phys Ther. 2024;54(12):CPG1–CPG32. DOI: 10.2519/jospt.2024.0302.

    ← Back to Patient Blog

    Polish version: Ból startowy — dlaczego pierwsze kroki po odpoczynku są ważne?

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Worn Shoes Under the Microscope — A Clue, Not a Diagnosis

    Wear on a shoe sole can draw attention to asymmetry, the way the heel meets the ground or a difference between the right and left side. It can be a useful clue during a musculoskeletal examination, but it is not a diagnosis. The same wear pattern may result from several factors, including the design of the shoe, walking style, the surface used, mileage and repeated movement habits.

    What does an orthopaedic surgeon actually look at?

    The worn area of the outsole is only one part of the picture. It is useful to compare both shoes, see whether the upper leans or deforms, note where material is stretched and look for obvious pressure marks on the insole. The shoe itself also matters: sole height and stiffness, cushioning and fit can all influence how the limb is loaded.

    In a study that analysed 252 people, centro-lateral or lateral heel wear was far more common than medial wear. The investigators found associations between some gait features, knee alignment and shoe-wear patterns, but also identified effects of sex and body dimensions and limitations of visual assessment. These findings describe relationships within the study group; the appearance of a sole alone cannot diagnose valgus, varus or the cause of pain.

    Why can the same wear pattern have different causes?

    A shoe records the effect of thousands of steps, but it does not record the whole context. Running shoes used mainly on asphalt wear differently from work footwear or a pair worn mostly while driving. Sole materials also differ. Body weight, walking speed, surface, previous injuries and how long the shoes have been used can all contribute.

    Marked asymmetry is therefore the start of a question, not the answer. It should be considered together with symptoms, examination of the feet, knees and hips, limb alignment and gait observation. Sometimes pressure measurement, strength testing or movement recording adds useful information; sometimes the clinical examination is enough. Insoles or attempts to alter gait should not be prescribed from a photograph of the outsole alone.

    When is it worth bringing your shoes to an appointment?

    • when pain mainly appears during walking, running or work in particular footwear;
    • when one sole wears noticeably faster than the other;
    • when you use insoles, heel lifts or other shoe modifications;
    • when symptoms keep returning despite changing shoes;
    • when symptoms involve the foot, ankle, knee, hip or lower back.

    Bring the pair you use most often and, if symptoms are related to sport or work, the footwear used for that activity as well. An older pair may reveal more than a new one, but it helps to know how long it was worn and in what conditions. Bring any insoles you regularly use too.

    Shoes do not replace examination

    Outsole wear can help direct attention to a particular aspect of movement, but it cannot by itself explain the source of symptoms. A similar pattern may be present in someone without pain and in someone with a problem that requires treatment. The useful interpretation comes from combining the history, physical examination and observation of function, particularly when pain is worsening, limiting weight bearing or followed an injury.

    Explore patient information · Polish version

    References

    1. Soon J, Lee DW, Choi GR, Kim KJ, Bahn S. Identification of Gait and Personal Factors Associated with Shoe Abrasion Patterns. Int J Environ Res Public Health. 2022;19(19):12558. DOI: 10.3390/ijerph191912558.
    2. Finestone AS, Petrov K, Agar G, Honig A, Tamir E, Milgrom C. Pattern of outsole shoe heel wear in infantry recruits. J Foot Ankle Res. 2012;5:27. DOI: 10.1186/1757-1146-5-27.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Osteochondral Lesion of the Talus — Symptoms, Diagnosis and Treatment

    Polish version

    An osteochondral lesion of the talus is damage involving the articular cartilage and the bone immediately beneath it. It often becomes apparent after an ankle sprain as deep joint pain that does not settle within the expected time. Recurrent swelling, catching or locking may also occur. Standard X-rays can be normal, so persistent symptoms may require more detailed imaging—most often MRI and, in selected situations, CT.

    Not every osteochondral lesion requires surgery. Management depends on the size and depth of the defect, the condition of the subchondral bone, fragment stability, duration of symptoms, age and activity level, and whether ankle instability is also present.

    What does “osteochondral lesion” mean?

    The surface of the talus is covered by cartilage that forms a smooth part of the ankle joint. An injury can damage cartilage alone, cartilage together with the underlying bone, or create an osteochondral fragment. In some cases, a cyst develops in the bone beneath the lesion.

    These injuries are commonly abbreviated as OLT, for osteochondral lesion of the talus. Finding an OLT on imaging is not, by itself, enough to determine treatment. The key question is whether the lesion actually explains the patient’s symptoms.

    When should cartilage injury be suspected after an ankle sprain?

    A typical ankle sprain should gradually improve. If deep pain inside the joint persists despite appropriate treatment—particularly with weight bearing, running, descending stairs or twisting movements—it is worth considering causes other than ligament injury alone.

    Symptoms that may accompany an osteochondral lesion include:

    • persistent or recurrent ankle pain after injury,
    • pain felt deep within the joint rather than only around the lateral or medial malleolus,
    • swelling after greater activity,
    • catching, clicking or intermittent locking,
    • restricted motion,
    • difficulty returning to running or sport despite improvement in ligament stability.

    If the problem began with a recent sprain, the initial assessment still needs to address the ankle injury as a whole. See: Ankle Injuries.

    How is an osteochondral lesion of the talus diagnosed?

    Clinical examination

    The examination considers the location of pain, range of motion, swelling, ligament stability, foot and ankle alignment, and any mechanical symptoms. This matters because similar complaints can result from chronic instability after a sprain, syndesmotic injury, impingement, tendon disorders or degenerative joint disease.

    X-ray

    Radiographs are often the first imaging test, especially after injury. They may show a larger bony defect, a loose fragment, evidence of previous trauma or degenerative change. A normal X-ray does not exclude an osteochondral lesion, particularly when the defect is small or predominantly cartilaginous.

    MRI

    MRI provides useful information about cartilage, bone-marrow oedema, joint fluid, ligaments and other intra-articular structures. It is particularly helpful when pain persists despite normal radiographs or when associated injuries need to be assessed.

    CT

    CT depicts the bony architecture in detail, including the size of the osseous defect, cysts and fragment morphology. It may be useful before surgery or when the principal diagnostic question concerns the bony component of the lesion.

    Is ultrasound enough?

    Ultrasound is not the primary test for a complete assessment of cartilage over the talar dome because much of the articular surface lies deep within the joint and is obscured by bone. It can, however, help assess associated effusion, ligaments, tendons and other superficial structures. A normal ultrasound therefore does not exclude an OLT.

    Does every lesion need surgery?

    No. For a stable lesion without a loose fragment or another urgent indication, non-operative treatment is often a reasonable first step. This may include modifying activity and loading, temporary unloading or stabilisation in selected cases, and a progressive exercise programme to restore movement, strength and ankle control. Coexisting chronic instability should be addressed as part of the treatment plan.

    In a prospective study of 40 patients involving 42 ankles, clinically meaningful improvement in pain while walking was achieved by 38% of patients after one year of non-operative treatment. The mean improvement for the group as a whole remained below the threshold considered clinically important, but lesion size on imaging did not increase during the one-year follow-up. This illustrates two points: conservative management can be a sensible first option for appropriately selected patients, but it will not provide sufficient improvement for everyone.

    When does an orthopaedic surgeon consider surgery?

    Surgery is considered mainly when symptoms persist despite appropriately conducted non-operative treatment, when significant mechanical symptoms are present, when a fragment is unstable, or when the characteristics of the lesion favour repair from the outset.

    There is no single operation that suits every osteochondral lesion. Depending on the situation, options may include:

    • arthroscopic debridement with stimulation of subchondral healing for selected small lesions,
    • fixation of a preserved osteochondral fragment when its quality and morphology allow stable repair,
    • osteochondral grafting or other restorative techniques for larger, deeper or previously unsuccessfully treated lesions,
    • bone grafting when there is a substantial cyst or osseous defect.

    The latest international consensus on moderate-to-large lesions emphasises that the choice between reparative and restorative procedures still relies partly on expert judgement because high-quality head-to-head trials of many techniques are lacking. Lesion size matters, but it should not be the only criterion used to choose an operation.

    Can an osteochondral fragment be fixed rather than removed?

    In selected cases, yes. If there is a sufficiently large and viable osteochondral fragment, fixation may be considered to preserve the native joint surface. A systematic review of 10 studies involving 241 ankles reported high rates of union and clinical improvement after fixation, but most of the evidence came from non-comparative studies. These results therefore do not prove that fixation is superior to all other treatment options.

    What influences treatment selection?

    • lesion size and depth,
    • the presence of a subchondral cyst,
    • stability and quality of an osteochondral fragment,
    • lesion location,
    • time since injury and previous treatment,
    • age, activity level and patient expectations,
    • ankle instability, limb alignment and other associated pathology.

    For that reason, two patients with very similar MRI reports may require quite different management.

    When is urgent assessment needed?

    • the ankle is locked and cannot move freely after an injury,
    • the limb cannot be loaded after a recent injury or there is obvious deformity,
    • the foot becomes cold, pale or blue, or increasing numbness develops,
    • the joint becomes hot, markedly swollen and red, particularly with fever,
    • pain is rapidly worsening rather than gradually settling.

    Common questions

    Does an osteochondral lesion always occur after a sprain?

    No, although ankle trauma is common in the clinical history. The lesion may become apparent immediately, or only later when deep weight-bearing pain persists after an apparently healed sprain.

    Does a normal X-ray exclude cartilage damage?

    No. Small osteochondral lesions may not be visible on standard radiographs. If symptoms persist, MRI or CT may be requested depending on the specific diagnostic question.

    Is an MRI finding alone an indication for surgery?

    No. The decision should integrate symptoms, clinical examination and imaging characteristics. An asymptomatic or incidental lesion is not the same clinical problem as an unstable fragment causing pain and mechanical locking.

    Back to: Foot and Ankle Conditions

    References

    • Buck TMF, Steman JAH, Dahmen J, et al. Nonoperative Treatment for Osteochondral Lesions of the Talus Provides Clinical Improvement in the Minority of the Patients at Short-term Follow-up. Foot Ankle Int. 2025;46(7):699-706. DOI: 10.1177/10711007251330881.
    • van Bergen CJA, Baur OL, Murawski CD, et al. Diagnosis: History, Physical Examination, Imaging, and Arthroscopy: Proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle. Foot Ankle Int. 2018;39(1 Suppl):3S-8S. DOI: 10.1177/1071100718779393.
    • Rubin J, et al. Surgical Intervention for Moderate-To-Large Lesions (1-2.9 cm²): Proceedings of the International Consensus Meetings on Cartilage Repair of the Ankle. Foot Ankle Spec. 2026. DOI: 10.1177/19386400261456897.
    • Rikken QGH, Dahmen J, Stufkens SAS, Nakasa T, Kerkhoffs GMMJ. Fixation for osteochondral lesions of the talus leads to successful clinical outcomes in 9 out of 10 patients: A systematic review. J ISAKOS. 2025;11:100389. DOI: 10.1016/j.jisako.2025.100389.

    This material is educational. Investigation and treatment should be selected from the clinical examination and the individual characteristics of the lesion.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Tarsal Tunnel Syndrome — What Causes Numbness in the Sole?

    Polish version

    Burning, tingling or numbness in the sole can result from compression of the tibial nerve or its branches within the tarsal tunnel, the space on the inner side of the ankle. These symptoms do not automatically mean tarsal tunnel syndrome, however. Similar complaints can arise from the lumbar spine, other peripheral nerves or structures within the foot. Diagnosis therefore depends on the history, clinical examination and appropriately selected tests rather than on any single investigation.

    The tarsal tunnel lies behind and below the medial malleolus. Tendons, blood vessels and the tibial nerve pass through it; the nerve then divides into branches supplying much of the sole. Symptoms can develop when the available space becomes restricted or when the nerve is compressed locally by another structure.

    Which symptoms fit tarsal tunnel syndrome?

    The most typical complaints are felt around the medial ankle and on the sole. Patients may describe burning, tingling, numbness, electric-shock sensations or shooting pain. Symptoms can radiate into the heel, arch or toes.

    • numbness or tingling mainly affects the sole rather than the top of the foot,
    • symptoms may worsen with prolonged standing, walking or running,
    • pressure or percussion behind the medial malleolus may reproduce tingling into the foot,
    • pain may feel burning or electrical rather than purely mechanical,
    • more advanced cases can produce sensory loss and, much less often, weakness of the small muscles of the foot.

    The symptom pattern alone is not enough for diagnosis. Tarsal tunnel syndrome can be confused with plantar fasciopathy, S1 radiculopathy and other neuropathies of the foot. Pain that is most prominent with the first steps in the morning and is centred at the medial heel may point instead toward plantar fascia overload.

    What can compress the tibial nerve?

    The cause is not always obvious. Reduced space within the tunnel may follow injury and scarring, bony changes, tendon-sheath inflammation, a ganglion or another space-occupying lesion. Varicose veins and other vascular abnormalities, accessory muscles and foot deformity that alters local mechanics have also been described.

    For that reason, the aim of assessment is not simply to label the problem as “nerve compression”, but—when possible—to identify what is causing the compression. This can directly influence treatment: a ganglion, post-traumatic scarring and a syndrome without a clear structural lesion are not managed in exactly the same way.

    How is the diagnosis made?

    The first step is to define the exact sensory distribution and how the symptoms are provoked. Examination includes sensation, strength, sites of tenderness, foot alignment and whether pressure or percussion over the tibial nerve behind the medial malleolus reproduces typical paraesthesia. At the same time, the clinician should look for evidence of another explanation such as lumbosacral radiculopathy or a generalised polyneuropathy.

    A review in EFORT Open Reviews emphasised that there is no single test that can diagnose tarsal tunnel syndrome with complete certainty. Clinical findings should be integrated with imaging and, where appropriate, nerve-conduction studies or electromyography.

    What can nerve ultrasound show?

    Ultrasound can trace the tibial nerve around the ankle and through the tarsal tunnel, assess its calibre and internal appearance, and look for a local cause of compression. It can also reveal neighbouring abnormalities such as a ganglion, tendon-sheath inflammation, selected vascular abnormalities, accessory muscles or post-traumatic change. A further advantage is dynamic assessment while the ankle moves or symptoms are provoked locally.

    Ultrasound is not a rule-out test. In a 2026 study of 26 feet with tarsal tunnel syndrome confirmed clinically and electrophysiologically, nerve ultrasound detected abnormalities with a sensitivity of about 65% when the commonly used nerve cross-sectional-area threshold of 11.8 mm² was applied. In other words, a normal ultrasound does not exclude tarsal tunnel syndrome.

    The same study noted that, when ultrasound was abnormal, nerve swelling was often seen within the tunnel itself rather than only just proximal to the presumed compression. This supports scanning the nerve over a sufficiently long segment and comparing its appearance within the tunnel with more proximal portions.

    Is EMG necessary?

    Nerve-conduction studies and electromyography can provide objective information about the function of the tibial nerve and its branches, and can help distinguish local compression from radiculopathy or polyneuropathy. Their sensitivity is also limited, however. A normal result should not automatically end the diagnostic process when the history and examination continue to strongly suggest an entrapment neuropathy.

    When are MRI or CT useful?

    MRI is particularly helpful when deeper tissues need more detailed assessment, a space-occupying lesion is suspected, or the clinical examination and ultrasound do not provide a clear answer. In a small surgical series, MRI identified the site of compression in 23 of 28 feet, but it did not always identify the specific cause, including some varices or small vascular branches compressing the nerve.

    CT has less value for assessing the nerve itself, but it can be useful when a bony cause is suspected—for example deformity, an osteophyte, a consequence of fracture or another osseous abnormality whose anatomy matters for treatment planning.

    What else should be considered?

    Burning or numbness in the foot does not always originate in the tarsal tunnel. Depending on the distribution and character of symptoms, the differential diagnosis includes S1 radiculopathy, polyneuropathy, plantar fasciopathy, stress fracture and more distal focal neuropathies of the foot. Forefoot pain and tingling that radiate into adjacent toes, especially in tight footwear, may suggest Morton’s neuroma instead.

    How is tarsal tunnel syndrome treated?

    Treatment depends mainly on the cause and on the degree of nerve dysfunction. When there is no progressive neurological deficit and no clear lesion that requires removal, management usually starts non-operatively: reducing the loading that reproduces symptoms, modifying footwear or using an orthotic when appropriate, treating pain, and addressing relevant mechanical factors of the foot.

    An injection around the tarsal tunnel may be considered in selected patients, particularly when a local inflammatory component or swelling is suspected. Because the nerve and vessels lie close together, ultrasound guidance allows direct control of needle position. This is not, however, a universal treatment for every tibial neuropathy.

    When does an orthopaedic surgeon consider surgery?

    Surgical decompression is considered mainly when clinically important symptoms persist despite appropriate non-operative treatment and there is credible evidence that the nerve is actually being compressed within the tarsal tunnel. The indication is stronger when a specific cause can be identified, such as a ganglion, post-traumatic scar or another space-occupying lesion.

    Reported rates of good surgical outcomes vary widely. The result cannot be promised on the basis of one positive provocative test or one ultrasound image. Better outcomes have been reported when symptoms have been present for a shorter time, the cause of compression is clear and the clinical findings are concordant. Long-standing neuropathy with established nerve damage may not fully recover even after the compression has been removed.

    Which symptoms need faster assessment?

    • progressive weakness of the toes or foot muscles, especially with a new gait disturbance,
    • rapidly worsening or extensive sensory loss after a recent ankle injury,
    • marked swelling after injury accompanied by increasing pain and numbness,
    • a cold, pale or blue foot or other signs of impaired blood flow,
    • fever, redness, warmth and increasing swelling suggesting infection,
    • numbness affecting both feet or multiple limb regions, which may indicate a generalised problem rather than compression of one local nerve.

    What is the practical takeaway?

    Tarsal tunnel syndrome is worth considering when burning, tingling and numbness mainly affect the sole and relate to the region behind the medial malleolus. The key is to establish whether the symptoms truly fit tibial nerve compression and, where possible, identify the cause. Ultrasound can be very useful, but a normal scan does not exclude neuropathy. Likewise, an isolated abnormal EMG or MRI finding should not be interpreted without clinical correlation.

    Back to: Foot and Ankle Conditions

    See also: Peripheral Nerves

    References

    • Holtz B-O, Ceanga M, Behnert A, Marquardt R, Geis C, Axer H. Nerve Ultrasound for the Diagnosis of Tarsal Tunnel Syndrome: Findings in 26 Clinically and Electrophysiologically Confirmed Feet. J Clin Med. 2026;15(5):1699. DOI: 10.3390/jcm15051699.
    • Rodríguez-Merchán EC, Moracia-Ochagavía I. Tarsal tunnel syndrome: current rationale, indications and results. EFORT Open Rev. 2021;6(12):1140–1147. DOI: 10.1302/2058-5241.6.210031.
    • de Souza Reis Soares O, Duarte ML, Brasseur J-L. Tarsal Tunnel Syndrome: An Ultrasound Pictorial Review. J Ultrasound Med. 2022;41(5):1247–1272. DOI: 10.1002/jum.15793.
    • Kim K, Kokubo R, Isu T, Nariai M, Morimoto D, Kawauchi M, Morita A. Magnetic Resonance Imaging Findings in Patients with Tarsal Tunnel Syndrome. Neurol Med Chir (Tokyo). 2022;62(12):552–558. DOI: 10.2176/jns-nmc.2022-0118.

    This information is educational and does not replace an individual medical consultation.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Lateral Ankle Pain — Could It Be the Peroneal Tendons?

    Polish version

    Pain on the outer side of the ankle, particularly behind or just below the lateral malleolus, may come from the peroneal tendons. It often becomes more noticeable when walking on uneven ground, running, rising onto the toes or after an ankle sprain. Similar symptoms can also arise from ligaments, joint cartilage, bone or the sural nerve, so pain location alone is not a diagnosis.

    What are the peroneal tendons?

    The peroneus longus and peroneus brevis tendons run together behind the lateral malleolus. They help stabilise the foot and ankle, especially during weight bearing on uneven surfaces, and are held within their groove by the retinaculum. Problems can include tendinopathy, longitudinal splitting or tearing, tenosynovitis, or instability in which the tendons snap or move out of their normal position.

    Which symptoms are typical?

    • pain and tenderness behind the lateral malleolus or along the outer border of the foot,
    • pain that increases on uneven ground, during running or with resisted eversion of the foot,
    • swelling along the course of the tendons,
    • a snapping sensation or audible click behind the ankle,
    • recurrent feelings of instability after previous ankle sprains.

    A sudden snap after injury can indicate retinacular damage with tendon subluxation. By contrast, persistent lateral ankle pain without one clear injury is more often associated with overload, foot alignment, recurrent sprains or chronic tendon damage.

    What else can cause pain in the same area?

    The differential diagnosis includes lateral ligament injury after a sprain, fracture of the ankle or the base of the fifth metatarsal, an osteochondral lesion of the talus, ankle impingement, sural nerve irritation and pain arising from more distal joints of the foot. After an acute injury, this is why an X-ray is often the first imaging test rather than ultrasound.

    See also: Ankle Injuries.

    How is the problem assessed?

    Clinical examination

    The exact site of tenderness, muscle strength, ankle stability, foot alignment and reproduction of pain with resisted movement all matter. When tendon snapping is suspected, the tendons should also be assessed while the ankle is moving.

    X-ray

    After a recent injury, radiographs help exclude a fracture. They may also show bony anatomy that contributes to impingement or chronic overload, but they do not usually assess the tendons themselves adequately.

    Ultrasound

    Ultrasound can show tendon continuity and structure, fluid within the tendon sheath and tendon behaviour during movement. Dynamic assessment is especially useful when snapping or subluxation behind the lateral malleolus is suspected. A normal ultrasound, however, does not exclude every subtle abnormality.

    MRI

    MRI can help define the extent of tendon injury while also assessing cartilage, ligaments, bone marrow and other deeper structures. The choice between ultrasound and MRI depends on the clinical question; the two tests can be complementary.

    How are peroneal tendon problems treated?

    Overuse-related symptoms and stable partial injuries are usually treated non-operatively first. Management may include temporarily reducing activities that provoke pain, progressive strengthening and ankle-control exercises, footwear modification and, in selected cases, an orthotic or a short period of immobilisation. Return to running should depend on strength, stability and the tendon’s response to loading rather than simply on the number of days that have passed.

    Analgesic or anti-inflammatory medication may be appropriate for selected patients, but it does not repair a damaged tendon. Tendon-sheath injections are considered selectively; image guidance is advisable, and steroid should not be injected into the tendon itself. Evidence for injections in this region remains limited.

    More about image-guided procedures: Injection Treatments.

    When does an orthopaedic surgeon consider surgery?

    Surgery is considered mainly for complete or extensive tendon tears, recurrent subluxation, persistent weakness or pain that continues despite appropriate non-operative treatment. The procedure depends on whether the main problem lies in the tendon itself, the retinaculum, the groove behind the lateral malleolus or associated ankle instability.

    Warning signs

    Earlier assessment is needed after an injury if the foot cannot be loaded, there is an obvious deformity, swelling is increasing rapidly, sensation or circulation is impaired, there is an open wound, fever develops with marked local redness, or a sudden snap is followed by clear weakness of the foot. The ability to take a few steps does not by itself rule out a significant injury.

    Back to: Foot and Ankle Conditions

    More about: Tendons and Enthesopathies

    References

    • van Dijk PAD, Miller D, Calder J, et al. The ESSKA-AFAS international consensus statement on peroneal tendon pathologies. Knee Surg Sports Traumatol Arthrosc. 2018;26(10):3096–3107. DOI: 10.1007/s00167-018-4971-x.
    • Ghandour S, Mercer RW, Strahan JA, et al. Diagnostic accuracy of MRI and US for peroneal tendon tears: a systematic review and meta-analysis. Eur Radiol. 2025. DOI: 10.1007/s00330-025-11472-w. PubMed.
    • Dombek MF, Lamm BM, Saltrick K, Mendicino RW, Catanzariti AR. Peroneal tendon tears: a retrospective review. J Foot Ankle Surg. 2003;42(5):250–258.

    This material is educational and does not replace an individual medical consultation.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

  • Fifth Metatarsal Base Fracture — Avulsion or Jones Fracture?

    Not every fracture at the base of the fifth metatarsal is a Jones fracture. An avulsion fracture lies closer to the tip of the bone and usually heals more readily. A Jones fracture is slightly more distal, in an area with less favourable blood supply, so it more often requires prolonged protection from loading, closer follow-up and, in selected patients, surgery.

    Polish version · For Patients

    Where is the fifth metatarsal?

    The fifth metatarsal runs along the outer side of the foot and connects with the little toe. Its proximal end forms the bony prominence that can be felt along the lateral border of the foot. Several different injuries can occur in this small region, with different prognoses, so the phrase “fracture of the fifth metatarsal base” is not always specific enough to plan treatment.

    Avulsion, Jones and stress fractures — what is the difference?

    Zone 1: avulsion fracture

    A fragment is pulled away from the tuberosity at the base of the bone. This injury often accompanies an inversion-type ankle or foot injury and may initially resemble a simple ankle sprain. Most small, stable fractures in this zone are treated without surgery.

    Zone 2: Jones fracture

    The fracture line lies at the metaphyseal-diaphyseal junction, typically near the articulation between the fourth and fifth metatarsals. Blood supply is less favourable here, increasing the risk of delayed union or nonunion. The term “Jones fracture” should not be used for every fracture along the lateral border of the foot.

    Zone 3: stress fracture

    This occurs farther distally toward the shaft, often after repetitive loading. Pain may build gradually without a single clear injury. It has to be distinguished from other metatarsal stress fractures.

    Which symptoms are important?

    • pain along the outer border of the foot, worse with walking;
    • focal tenderness over the base or proximal fifth metatarsal;
    • swelling and bruising along the lateral foot;
    • difficulty bearing weight;
    • pain that increases with running or jumping even without a single acute injury.

    Similar symptoms can come from an ankle sprain, injury around the cubometatarsal joint or peroneal tendon pathology. The point of maximal tenderness and the injury mechanism are therefore more useful than the general label “sprained foot”.

    How does an orthopaedic surgeon establish the diagnosis?

    After an acute injury, standard foot radiographs in appropriate views are the first-line investigation. They help define the fracture zone, displacement and any articular involvement. In a stress-type presentation, early X-rays can still be normal; further imaging should then be selected according to the clinical examination.

    CT can be useful when union is difficult to assess, the fracture pattern is complex or surgery is being planned. MRI is particularly useful for a suspected early stress fracture when radiographs remain normal. Ultrasound may show some cortical abnormalities or associated soft-tissue injuries, but it does not replace standard imaging of the entire fracture.

    Is surgery always required?

    No. Stable avulsion fractures are most often treated functionally in a walking boot or stiff-soled shoe, with weight bearing adjusted to pain and the treatment plan. Follow-up is used to confirm satisfactory healing.

    For an acute Jones fracture, non-operative treatment usually requires more careful protection and a period of restricted weight bearing. Surgery is considered more often when there is displacement, failure of healing to progress, a stress fracture, refracture, or in athletes for whom a predictable return to high loads is particularly important. Activity level alone does not replace assessment of the fracture pattern and a discussion of surgical risk.

    Why does follow-up of union matter?

    Pain can improve before the bone has regained full strength. Returning too early to running, jumping or cutting sports increases the risk of refracture. Progression of loading should be based on symptoms, examination, fracture type and evidence of healing rather than simply the number of weeks since injury.

    When is urgent assessment needed?

    • the foot is visibly deformed or a wound exposes bone;
    • the toes become cold, pale or blue;
    • numbness is increasing or the toes cannot be moved normally;
    • pain and swelling increase rapidly despite elevation;
    • it is impossible to take a few steps after the injury;
    • persistent lateral foot pain remains after an earlier diagnosis of a “sprain”.

    Sources

    1. Chloros GD, Kakos CD, Tastsidis IK, Giannoudis VP, Panteli M, Giannoudis PV. Fifth metatarsal fractures: an update on management, complications, and outcomes. EFORT Open Reviews. 2022;7(1):13–25. DOI: 10.1530/EOR-21-0025.
    2. Attia AK, Taha T, Kong G, Alhammoud A, Mahmoud K, Myerson M. Return to Play and Fracture Union After the Surgical Management of Jones Fractures in Athletes: A Systematic Review and Meta-analysis. American Journal of Sports Medicine. 2021;49(12):3422–3436. DOI: 10.1177/0363546521990020.

    Content prepared by: Tomasz Poboży - orthopaedic surgeon.

    Related postoperative rehabilitation protocol

    Fifth metatarsal fracture — postoperative rehabilitation. The rehabilitation pathway depends on the procedure performed.