55 Although the main question is the current problem – where the pain is now – it is best to try to obtain a chronological account, as summarized in Box 55.1. In order to work out the problem systematically, the questions asked should follow the order given below. • What has been the evolution since the onset? No change? Gradually worse or gradually better? Ups and downs, with complete or no recovery between attacks? Do changes depend on exertion? • What sort of treatments did you have? The present complaints should be investigated further: • Where do you feel the pain now? Posterior, middle or anterior segment? Medial, lateral or all over the joint(s)? • Is there pain at rest or during the night? Pain at night indicates a high degree of inflammation. • Is there long-standing morning stiffness? This also suggests a serious inflammatory disorder. • What brings the pain on? Is there any pain during normal walking or normal running? Can you participate in your usual sports? • Is there equal pain on walking and standing? • Can you walk on uneven surfaces? Because walking upstairs and downstairs demands normal mobility of the ankle joint, it is worth asking if the patient can do so without problems. • Is the pain provoked by particular movements? • Is the pain felt at the beginning of, during or after exertion? • Does the pain depend on the sort of shoes you wear? Sometimes an in-built wedge relieves or aggravates the pain. In Achilles tendinitis or plantar fasciitis, a raised heel with a horizontal surface relieves the stress on these affected tissues and therefore relieves the pain. Further questioning should establish whether there are ‘twinges’ or instability: • Do you have twinges, and when? A twinge in the foot is a very important symptom. It is a sudden, sharp pain, mostly occurring during walking. It should always be differentiated from ‘giving way’. In a twinge, there is only momentary pain and not a feeling of instability. By the time the patient realizes it, the pain has disappeared. A twinge is very often an indication of a momentary impaction of a loose body in the ankle or subtalar joint. If localized in the forefoot, it can be a symptom of Morton’s metatarsalgia or sesamoiditis. • Do you have a feeling of instability? If so, describe it. Real instability of the ankle or foot is only important in sports. Normal walking or even running on a flat surface hardly ever causes a feeling of giving way. In the occasional case where this does happen, it is the result of neurological weakness of the peronei muscles, rather than of a ligamentous lesion.
Clinical examination of the lower leg, ankle and foot
History
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