Foot and Ankle Pain: Causes, Diagnosis and Treatment

By the myphysiohelp.it team

Summary

Introduction: Anatomy and Biomechanics of the Foot and Ankle
Plantar Fasciitis
Achilles Tendinopathy
Hallux ValgusMorton’s NeuromaPosterior Tibial Tendinopathy
Ankle Sprain

Retrocalcaneal Bursitis
When to Consult a physical therapist
Frequently Asked Questions (FAQ)

Introduction: Anatomy and Biomechanics of the Foot and Ankle
Foot and ankle pain: The foot and ankle form the body’s base of support and represent a masterpiece of biomechanical engineering. Foot health influences the entire musculoskeletal system: a foot problem can generate a cascade of compensations that manifest as knee, hip, or back pain.
The foot is composed of 26 bones, 33 joints, and over 100 muscles, tendons, and ligaments, organized into a structure that must fulfill two seemingly contradictory functions: to be flexible enough to adapt to uneven terrain and absorb impacts, and rigid enough to transmit propulsive force during walking and running. This duality is ensured by the “windlass” mechanism of the plantar aponeurosis and the transformation of the foot from a mobile structure (initial contact phase) to a rigid lever (push-off phase).
The ankle (tibiotalar joint) allows dorsiflexion and plantarflexion movements, while the subtalar and midtarsal joints allow pronation and supination movements. The lateral and medial (deltoid) ligament complex ensures joint stability. In this guide, we will analyze the most common pathologies of the foot and ankle, with practical indications on diagnosis, treatment, and prevention of recurrence.

Plantar Fasciitis
Plantar fasciitis is the most common cause of heel pain, affecting approximately 10% of the population during their lifetime. The plantar aponeurosis (or plantar fascia) is a robust fibrous band that extends from the calcaneus to the metatarsal heads, supporting the medial longitudinal arch of the foot. Its inflammation and degeneration cause characteristic heel pain, which has become one of the most frequent reasons for clinical consultation.
The classic symptom is pain with the first steps in the morning: intense and sharp, localized to the medial margin of the calcaneus, which subsides after a few minutes of walking, only to reappear after prolonged periods of standing or walking. Risk factors include overweight, flat or high-arched foot, Achilles tendon stiffness, inadequate footwear, and a sudden increase in training load in runners.
Physiotherapy treatment is based on specific stretching exercises for the plantar fascia and triceps surae, strengthening of the intrinsic foot muscles, manual therapy of the foot joints, the use of taping, and, when indicated, custom orthopedic insoles. Extracorporeal shockwave therapy has good scientific evidence in resistant cases. Clinical experience shows that plantar fasciitis requires patience in treatment — recovery times vary from 6 weeks to 6 months — but complete resolution is the rule.
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Achilles Tendinopathy
The Achilles tendon is the largest and strongest tendon in the human body, capable of withstanding forces up to 12 times body weight during running. Its tendinopathy is a frequent condition, especially among runners and athletes, but it also affects the sedentary population, particularly in the 40-60 age group.
Two main forms are distinguished: insertional tendinopathy (at the tendon’s insertion on the calcaneus) and mid-portion tendinopathy (2-6 cm above the insertion). The distinction is important because the two forms have partially different etiologies and respond to different therapeutic protocols. The patient complains of tendon pain, morning stiffness, tendon thickening on palpation, and pain that worsens with physical activity.
The treatment of Achilles tendinopathies is based on the principle of progressive loading: the tendon needs calibrated mechanical stimuli to activate remodeling and healing processes. Alfredson’s eccentric exercise protocol, while no longer considered the sole effective approach, remains a cornerstone of treatment. Heavy isometric exercises for pain management, Heavy Slow Resistance exercises, and, in clinical practice, the gradual reintroduction to sport through a structured loading program complete the therapeutic arsenal.
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Posterior Tibial Tendinopathy
The posterior tibialis muscle is the main dynamic stabilizer of the medial longitudinal arch of the foot. Its tendinopathy, often underestimated and misdiagnosed, is a frequent cause of pain in the medial ankle and foot region, and can lead, if untreated, to progressive collapse of the plantar arch with the development of adult-acquired flatfoot.
The pain is localized behind and below the medial malleolus, along the course of the tendon, and worsens during walking, running, and prolonged standing. The patient may notice a progressive flattening of the plantar arch and increasing difficulty in performing a single-leg heel raise — a simple but very specific clinical test for this condition.
Early treatment is crucial to prevent progression to structured flatfoot. The physiotherapy pathway includes specific strengthening of the posterior tibialis through progressive exercises (starting with isometric contractions and progressing to eccentric and concentric exercises under load), the use of foot orthoses for medial arch support, manual therapy of the hindfoot joints, and gait pattern re-education. In advanced cases with posterior tibialis insufficiency and structured deformity, orthopedic consultation is necessary.
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Ankle Sprain
Ankle sprain is the most frequent musculoskeletal trauma overall: it is estimated that approximately 10,000 ankle sprains occur daily in Europe. In 85% of cases, the mechanism is inversion (the foot “turns” inward), involving the lateral ligament complex — primarily the anterior talofibular ligament.
The severity of the sprain is classified into three grades: grade I (ligamentous stretch without rupture), grade II (partial rupture), and grade III (complete rupture). The most common error in clinical practice is underestimating the “minor” sprain: 30-40% of patients with ankle sprains develop chronic instability if rehabilitation is inadequate.
Treatment follows the PEACE & LOVE protocol (which has replaced the old RICE): Protection, Elevation, Avoid anti-inflammatories in the first few days, Compression, Education in the acute phase; and Load (early loading), Optimism, Vascularisation (light aerobic activity), Exercise in the subacute phase. The rehabilitation pathway must mandatorily include a proprioceptive re-education program — the true key to preventing recurrence — and strengthening of the peroneal muscles and posterior tibialis.
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Hallux Valgus
Hallux valgus is one of the most common foot deformities, characterized by the lateral deviation of the first toe and the medial prominence of the first metatarsal head (the so-called “bunion”). It predominantly affects women (10:1 ratio compared to men) and has a strong genetic component, although tight and high-heeled footwear can accelerate the progression of the deformity.
The pain of hallux valgus is not always correlated with the severity of the deformity: some patients with significant deviations are asymptomatic, while others with minor deviations experience significant pain. Pain can be localized at the medial prominence (due to conflict with footwear), in the metatarsal region (transfer metatarsalgia), or in the metatarsophalangeal joint itself (due to secondary osteoarthritis).
Conservative physiotherapy treatment is indicated in the initial stages and when surgery is not desired or indicated. It includes the choice of appropriate footwear (wide toe box, low heel), the use of toe spacers and night splints, manual therapy for maintaining joint mobility, strengthening of the intrinsic foot muscles (particularly the abductor hallucis), and custom orthotics for biomechanical correction. Surgery is indicated when pain is persistent and does not respond to conservative treatment.
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Morton’s Neuroma
Morton’s neuroma is a thickening of the plantar digital nerve, most frequently in the third intermetatarsal space (between the third and fourth toes), caused by chronic compression of the nerve between the metatarsal heads. It is not a true neuroma (nerve tumor), but a reactive perineural fibrosis.
The patient reports burning or electric pain in the forefoot, radiating towards the involved toes, accompanied by paresthesias (tingling, numbness) and the sensation of having a “pebble in the shoe.” Symptoms worsen with tight footwear and prolonged standing, and are relieved by removing the shoe and massaging the forefoot. Mulder’s sign (lateral-to-lateral compression of the forefoot with direct pressure on the intermetatarsal space) is the most reliable diagnostic clinical test.
Conservative treatment includes footwear modification (wide toe box, rigid sole), the use of orthotics with a metatarsal bar to spread the metatarsal heads, manual therapy of the forefoot, neurodynamic techniques, and, in resistant cases, ultrasound-guided injections. Clinical experience confirms that conservative treatment is effective in 60-70% of cases. When it fails, surgical neurectomy offers reliable results.
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Retrocalcaneal Bursitis
Retrocalcaneal bursitis is the inflammation of the bursa located between the Achilles tendon and the posterior surface of the calcaneus. This bursa functions to reduce friction between the tendon and the bone during ankle movements, and its inflammation causes pain in the posterior heel region, often confused with insertional Achilles tendinopathy.
The main causes include mechanical overload (sudden increase in sports activity), footwear with a rigid heel counter that irritates the region, bony deformities such as Haglund’s deformity (a bony prominence on the upper part of the calcaneus), and biomechanical alterations of the hindfoot. The pain is localized on the sides of the Achilles tendon, just above the calcaneal insertion, and worsens with ankle dorsiflexion and direct pressure.
Physiotherapy treatment includes footwear modification (elimination of rigid heel counter), the use of heel lifts to reduce compression on the bursa, local cryotherapy, manual therapy of the hindfoot joints, controlled eccentric strengthening of the triceps surae, and, when indicated, shockwave therapy. In cases with associated Haglund’s deformity and failure of prolonged conservative treatment, orthopedic surgical consultation is appropriate.
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Foot and Ankle Exercises: Strengthening and Proprioception Program
The following exercises represent a basic program for strengthening, mobility, and stabilization of the foot and ankle. Before starting, it is advisable to consult your doctor or physical therapist to ensure that the exercises are appropriate for your condition. In case of acute pain during execution, stop immediately.
Phase 1 — Mobility and Stretching

Exercise 1: Wall Calf Stretch (Gastrocnemius)
Difficulty: Easy | Equipment: Wall | Duration: 4 minutes

Starting position:
Stand facing a wall, about an arm’s length away. Your hands are placed on the wall at shoulder height. One foot is forward with the knee slightly bent. The other foot is back about 60-80 centimeters, with the heel firmly pressed to the ground and the foot pointing forward.
Step-by-step execution:

Step 1: Keeping the heel of the back leg firmly pressed to the ground and the back knee fully extended, shift your body weight forward by bending the front knee.
Step 2: Lean forward until you feel a stretch in the calf of the back leg (in the upper part, in the gastrocnemius area). Hold the position for 30 seconds.
Step 3: Slowly release and repeat with the other leg. To increase the stretch, move the back foot slightly further back.

Sets and repetitions: 3 sets x 30 seconds per side — 15-second rest between sets
Common mistakes to avoid:

Lifting the heel of the back leg off the floor during the stretch
Rotating the back foot outward: it should remain pointing forward
Arching the lower back: the body should form a straight line from the head to the back heel

How to know you’re doing it correctly:
You feel a distinct stretch in the upper part of the calf of the back leg. The heel remains firmly in contact with the floor. You do not feel pain in the Achilles tendon, but a sensation of progressive muscle tension.

Exercise 2: Wall Soleus Stretch
Difficulty: Easy | Equipment: Wall | Duration: 4 minutes

Starting position:
Stand facing a wall in the same position as the previous exercise, but with your feet closer together. Your hands are resting on the wall. The back foot is about 30-40 centimeters back.
Step-by-step execution:

Step 1: Slightly bend the knee of the back leg (about 20-30 degrees), keeping the heel firmly pressed to the ground.
Step 2: Shift your weight forward until you feel the stretch in the lower part of the calf, near the Achilles tendon (in the soleus muscle area). Hold for 30 seconds.
Step 3: Slowly release and repeat with the other leg.

Sets and repetitions: 3 sets x 30 seconds per side — 15-second rest between sets
Common mistakes to avoid:

Fully extending the back knee: it should remain slightly bent to isolate the soleus
Lifting the heel off the floor
Feeling sharp pain in the Achilles tendon area: in this case, stop and consult your doctor or physical therapist

How to know you’re doing it correctly:
You feel the stretch in the lower and deeper part of the calf, near the ankle, unlike the previous exercise where the stretch is higher up. The sensation is one of moderate, non-painful tension.

Phase 2 — Muscle Strengthening

Exercise 3: Heel Raise (Bilateral and Single-Leg)
Difficulty: Intermediate | Equipment: Step or stair, railing or wall for support | Duration: 5 minutes

Starting position:
Stand with the balls of your feet on the edge of a step, heels hanging off. Your hands rest on a railing or wall for balance (not to assist with the lift). Your feet are hip-width apart.
Step-by-step execution:

Step 1: Slowly lower your heels below the level of the step over 3 seconds, until you feel a moderate stretch in your calf. This is the starting position for each repetition.
Step 2: Rise onto the balls of your feet over 2 seconds, going as high as possible and actively contracting your calves at the top position. Hold for 2 seconds.
Step 3: Slowly lower your heels below the level of the step over 3 seconds (slow and controlled eccentric phase). This phase is the most important part of the exercise.

Sets and repetitions: 3 sets x 15 repetitions (bilateral) or 3 sets x 10 repetitions per side (single-leg, advanced level) — 60-second rest between sets
Common mistakes to avoid:

Performing jerky movements, bouncing in the low position: the movement should be fluid and controlled
Over-assisting with your hands by pulling yourself up with the railing
Rotating your feet outward or inward during the lift: your feet should remain parallel

How to know you’re doing it correctly:
You feel intense muscle work in your calves, both during the upward phase and, especially, during the controlled downward phase. The movement is symmetrical on both feet. In the last repetitions, you feel a sensation of muscle fatigue in the calf.

Exercise 4: Intrinsic Foot Muscle Strengthening (Short Foot / Towel Curl)
Difficulty: Intermediate | Equipment: Towel, chair | Duration: 5 minutes

Starting position:
Sit on a chair with bare feet on the floor. A towel is spread on the floor under the foot to be trained. The heel is positioned at the edge of the towel closest to the chair.
Step-by-step execution:

Step 1: Keeping your heel firmly on the ground, grasp the towel with your toes and pull it towards your heel, shortening the sole of your foot. The plantar arch visibly lifts.
Step 2: Hold the grip for 3 seconds, then release your toes and extend the towel with a toe extension movement.
Step 3: Repeat the gripping and releasing movement for the indicated number of repetitions. Advanced alternative (Short Foot): without a towel, try to shorten the foot by bringing the base of the toes closer to the heel, lifting the plantar arch without bending the toes.

Sets and repetitions: 3 sets x 15 repetitions per foot — 30-second rest between sets
Common mistakes to avoid:

Curling the toes “like claws” without activating the arch muscles: the movement should involve the entire sole of the foot
Lifting the heel during execution
Compensating with leg muscles: the work should be isolated to the foot muscles

How to know you’re doing it correctly:
You feel muscle work in the sole of your foot and the arch muscles visibly contract. The plantar arch lifts during contraction. In the last repetitions, you feel fatigue in the sole of your foot.

Phase 3 — Proprioception and Stability

Exercise 5: Single-Leg Balance on an Unstable Surface
Difficulty: Advanced | Equipment: Proprioceptive cushion or folded towel, chair for safety | Duration: 5 minutes

Starting position:
Stand next to a chair for safety. A proprioceptive cushion (or a towel folded several times) is placed on the floor. Step with one foot onto the center of the unstable surface. Gaze fixed on a point in front of you.
Step-by-step execution:

Step 1: Gradually transfer all your weight onto the leg placed on the unstable surface, lifting the other foot off the ground. The knee of the supporting leg is slightly bent.
Step 2: Maintain balance for 30 seconds, trying to stabilize the ankle and reduce oscillations. Your arms can be open laterally to aid balance.
Step 3: When the exercise becomes manageable, increase the difficulty: close your eyes, rotate your head from side to side, or throw and catch a small ball with your hands while balancing on one leg.

Sets and repetitions: 3 sets x 30 seconds per side — 30-second rest between sets
Common mistakes to avoid:

Locking the knee in hyperextension: always maintain a slight bend
Stiffening the entire body: arms and torso should be relaxed, stabilization occurs at the ankle
Getting discouraged by initial wobbles: it’s normal and a sign that the proprioceptive system is working

How to know you’re doing it correctly:
You feel continuous muscle adjustments in the ankle and foot. With daily practice, oscillations significantly reduce. You feel muscle work in the peroneal muscles (outer part of the ankle) and the posterior tibialis (inner part).

Exercise 6: Toe and Heel Walking
Difficulty: Easy | Equipment: None | Duration: 4 minutes

Starting position:
Stand barefoot on a flat, safe surface. Your arms are by your sides. Your torso is erect and your gaze is directed forward.
Step-by-step execution:

Step 1: Rise onto the balls of your feet and walk forward for 10-15 meters (or about 20 steps), maintaining an upright posture and keeping your heels as high as possible. Steps are short and controlled.
Step 2: Return to normal position, rest for 10 seconds, then lift your toes and walk on your heels for the same distance, keeping your toes lifted as high as possible towards the ceiling.
Step 3: Alternate between the two walking modes for the indicated number of sets. To increase difficulty, try walking on the outer and then the inner parts of your feet.

Sets and repetitions: 3 complete sets (toes + heels) — 30-second rest between sets
Common mistakes to avoid:

Leaning your torso forward during toe walking
Bending your knees: your legs remain straight during both modes
Walking too fast: the pace should be slow and controlled

How to know you’re doing it correctly:
You feel muscle work in your calves during toe walking and in the front of your leg (tibialis anterior) during heel walking. Steps are

Sources and Scientific References

1. Gogate N et al. (2021). The effectiveness of mobilization with movement on pain, balance and function following acute and sub acute inversion ankle sprain – A randomized, placebo controlled trial. Phys Ther Sport. 48:91-100. DOI | PubMed
2. Alghadir AH et al. (2020). Effect of Chronic Ankle Sprain on Pain, Range of Motion, Proprioception, and Balance among Athletes. Int J Environ Res Public Health. 17. DOI | PubMed
3. Nazim B Tengku Yusof T et al. (2022). Extracorporeal Shockwave Therapy for Foot and Ankle Disorders: A Systematic Review and Meta-Analysis. J Am Podiatr Med Assoc. 112. DOI | PubMed
4. Negahban H et al. (2023). Comparing the effects of ankle integral and conventional physiotherapy on pain, range of motion, balance, disability, and treatment effectiveness in patients with chronic ankle instability: Randomized controlled trial. Clin Rehabil. 37:362-372. DOI | PubMed
5. Zirngibl B et al. (2017). [Hallux valgus : Etiology, diagnosis, and therapeutic principles]. Orthopade. 46:283-296. DOI | PubMed

Frequently Asked Questions

Can foot problems affect other parts of my body?

Yes, foot health significantly impacts your entire body. Issues in your feet can create a cascade of compensations, leading to pain in your knees, hips, or back.

What are the main symptoms of plantar fasciitis?

Plantar fasciitis typically causes sharp, intense heel pain with your first steps in the morning. This pain often eases after a few minutes of walking but can return after prolonged standing or activity.

What are the common risk factors for plantar fasciitis?

Key risk factors include being overweight, having flat or high-arched feet, and wearing inadequate footwear. Achilles tendon stiffness and sudden increases in training load for runners can also contribute.

How long does it take to recover from plantar fasciitis with physiotherapy?

Consistent physiotherapy, including stretching and strengthening, is crucial for resolving plantar fasciitis. While recovery times vary from 6 weeks to 6 months, complete resolution is generally the rule with proper treatment.

Why is the foot’s structure so important for movement?

The foot is a complex structure of 26 bones, 33 joints, and over 100 soft tissues, forming the body’s base of support. It must be flexible to absorb impacts and adapt to terrain, yet rigid enough to transmit propulsive force during walking and running.