Common Foot and Ankle Conditions in Primary Care: Insights from ACP 2025
In this Q&A, Matthew B. Carroll, MD, MACP, FACR, discusses his session, "Foot and Ankle Pain for the Internal Medicine Physician", which he presented at the American College of Physicians Internal Medicine Meeting in New Orleans, LA. In his talk, Dr Carroll details the four foot and ankle conditions frequently seen in primary care. He also shares clinical considerations for initial management, potential knowledge gaps, when referral may be appropriate, and more.
Additional Resource: https://annualmeeting.acponline.org/educational-program/scientific-program/scientific-sessions.
Consultant360: What are the key themes of your presentation entitled, “Foot and Ankle Pain for the Internal Medicine Physician” at the ACP Internal Medicine Meeting in New Orleans, LA?
Matthew B. Carroll, MD, MACP, FACR: In my presentation, I talk about common foot problems, which are not unusual for us to treat as internists. Although I am a board-certified rheumatologist, I still pride myself as being an internist. And I do know that even when I was an internist many years ago, that I saw plenty of foot and ankle problems that patients would come in and expect us to triage right away. So, the presentation that I gave really focused on four common issues that we would see as internists affecting the foot and ankle. And while it’s easy for us to simply refer these patients to podiatry, I think there's certainly foot and ankle problems that we should be able to diagnose and Initially manage. That's why I wanted to talk about these different issues. The four common issues I discussed were Morton's neuroma, metatarsophalangeal (MTP) joint osteoarthritis, so basically osteoarthritis of the big toe joint, Achilles tendonitis, and plantar fasciitis.
And I'm in my early to mid 50s, and unfortunately all these problems seem to hit us in that age range. These foot problems typically range between 40 to 60 years of age and are generally related to degenerative issues. Although there's a differential diagnosis for each of those different disorders, as a rheumatologist, I might be inclined to focus on inflammatory disorders. So, if I see somebody with planar fasciitis, my first thought might be spondylarthritis. The reality is that the conditions I spoke about are common and often not related to inflammatory disorders. We always need to be thinking about broad differentials, so putting my internist hat back on, I should consider spondylarthritis, but maybe not at 60. Maybe it's an overuse issue or something else that's going on.
C360: Why is this presentation topic relevant right now? I assume it would relevant to patients in that age range, correct?
Dr Carroll: While foot and ankle problems affect everyone across the age spectrum, these issues increase across our 40, 50, and 60-year-old patients. And some of them are probably going to be healthier or present to us for a different reason like a cholesterol check. For example, a patient’s cholesterol and blood pressure looks good, but maybe they mention during the appointment that they are having some foot pain or ankle pain and it's making it harder for them to stay engaged in a healthier lifestyle. Maybe a patient who's not as active, but nonetheless, they have severe foot pain at night. If we find that they have plantar fasciitis, for example, those first couple of steps will make it difficult for them to walk. And I think, again, there's a lot that we can do there from counseling to potentially medications that might be prescribed or even to injections or basic recommendations on footwear or splints that might be beneficial to our patients. Perhaps we can treat these types of patients without referring them to podiatrists or orthopods. I appreciate what our podiatry and orthopaedic colleagues bring to the table, but I also know that in our health care system, there's an additional burden of time and money that comes into play when we're referring out to different specialists. So again, if these types of foot and ankle problems fall in our scope of practice, and it's something we feel comfortable treating, then it's really great to take care of that patient.
C360: What are they key takeaways from your presentation?
Dr Carroll: The focus of my lecture was to point out that while medicine is a team sport, and that it is always good to get professionals from other specialties involved early in the process, there still Is an opportunity for internists to manage these patients before a referral. Again, if we need to refer a patient, then that’s what we need to do, but I think there is quite a bit that we can do at our level before we have to point a patient to a podiatry or orthopedic specialist, and the presentation reviews those four common issues and potential management approaches.
C360: Are there any gaps in our knowledge that you discuss in your presentation?
Dr Carroll: Yes, there are many. For example, what is really happening at a biomechanical level. I think we certainly have a decent understanding, but there seems to be some knowledge gaps there about why these foot and ankle problems are happening to certain people and maybe not to others. That's an area that's evolving for first MTP joint osteoarthritis and Morton's neuroma. Can we potentially get out ahead of it? Are we able to identify risk factors beforehand to maybe encourage our patients when they're being active to anticipate those problems? Another knowledge gap Is how do we treat these issues. There's some information about how injections might help with this part, but how frequently should we be doing injections? Should we use steroids or platelet rich plasma or maybe other novel modalities? Are splints better than injections? That's just two, to name a few. Additional gaps exist that range from pathophysiologic changes to different treatment options, prevalence, and ultimately, the best way moving forward.
C360: Is there anything that you would want clinicians interested in the ACP conference to know about your presentation?
Dr Carroll: I would point out that this Is a very focused, 40-to-45-minute presentation. And while my presentation was just a small microcosm of what's happening with the foot and ankle problems, my hope was that for those who attended, what they've learned will give them a good step forward, pun intended, to where they can learn about other esoteric foot conditions, and again, feel comfortable diagnosing and treating these common maladies.