Foot and Heel Pain in Ajax: How Imaging Helps

Before going any further, try a quick exercise. Think about your sore foot and answer three questions: Where exactly is the pain? When is it worst? And did it start with a specific moment, or creep up over weeks?

Those three answers are the same ones a family doctor, podiatrist, chiropodist or physiotherapist will ask about, and they shape almost everything that follows, including whether imaging is needed at all. The foot contains 26 bones, more than 30 joints and a dense web of tendons, ligaments and nerves packed into a small space. Pain on the bottom of the heel and pain across the ball of the foot can come from completely different structures, and they are often looked at with different tests.

This article is organized as a tour of the foot, region by region. For each area, it describes the structures involved and which imaging tests health-care providers commonly use to look at them. It is written for patients in Ajax and the surrounding Durham Region communities, and it is general information only. It cannot tell you what is causing your own pain; that is a conversation for your provider.

Two tests, two kinds of question

Most outpatient foot imaging starts with one of two tests.

• X-ray shows bones and joints: fractures, alignment, arthritis-related changes and bony outgrowths. Foot X-rays are often taken while you stand, so the bones are seen under your own body weight.
• Ultrasound shows soft tissue near the surface: tendons, ligaments, the thick band on the sole called the plantar fascia, fluid and small lumps. It is also a live test, so the sonographer can watch a tendon move as you flex your ankle or toes.

A broader explanation of the differences is in our article on ultrasound versus X-ray. The rest of this guide is specific to the foot.

The bottom of the heel

Pain under the heel, often sharpest with the first steps out of bed or after sitting for a while, is one of the most common foot complaints adults bring to their providers. It is frequently linked to the plantar fascia, a tough band of tissue that runs from the heel bone to the base of the toes and supports the arch.

What ultrasound can show

Ultrasound can measure the thickness of the plantar fascia where it attaches to the heel and show whether it looks different from the other foot. It can also show fluid nearby, a tear, or small nodules along the band farther toward the arch. For this exam, you usually lie on your stomach with your feet hanging over the end of the table, and the sonographer scans the sole of the heel.

What X-ray can show

X-ray is sometimes requested to look at the heel bone itself. A provider may want to check for a stress fracture of the heel or other bony causes of pain. Heel X-rays often show a small bony projection called a heel spur. Spurs are common, and many people who have them never have heel pain, so a spur on a report does not necessarily explain your symptoms. Your provider will weigh that finding against your examination.

The back of the heel

Pain at the back of the heel can come from the Achilles tendon, the bursae that cushion it, or the bone where it attaches.

• Ultrasound can look at the Achilles tendon along its length, the point where it inserts into the heel bone, and the bursae on either side of it.
• X-ray can show bony changes at the back of the heel, including calcium within the lower tendon or a prominent bump on the heel bone.

The Achilles tendon has enough to say for itself that it has its own article: Achilles tendon injuries and ultrasound.

The arch and midfoot

The middle of the foot is a cluster of small bones held together by strong ligaments. Pain here may relate to the joints between those bones, to tendons that run along the inner and outer edges of the foot, or to the arch itself.

• Standing X-rays help a provider look at the shape of the arch, the alignment of the midfoot bones and arthritis-related changes in the joints.
• Ultrasound can follow tendons that support the arch, such as the tendon that runs behind the inner ankle bone and under the foot, and the tendons along the outer ankle.

Swelling and pain along the inner arch that gradually worsens, or an arch that seems to be flattening on one side, are worth mentioning to your provider, since tendon problems in this area can change how the foot works over time.

The ball of the foot and the toes

The forefoot takes a great deal of load with every step, especially in footwear with a raised heel or a narrow toe box.

Bones and joints

X-ray is the usual test for:

• Bunions, where the joint at the base of the big toe drifts outward; standing views show the angle of the bones
• Arthritis in the big toe joint, which can make it stiff and painful to push off
• Fractures of the long bones of the foot, called metatarsals, or of the toes

Some stress fractures in the forefoot do not show on the first X-ray, and a provider may suggest a repeat image or a different test if pain continues.

Nerves and soft tissue

Burning, tingling or a feeling of standing on a pebble between the toes, often between the third and fourth toes, can be associated with a thickened nerve in that space, sometimes called a Morton’s neuroma. Ultrasound is commonly used to look for this, and the sonographer may gently squeeze the forefoot during the scan. Ultrasound can also show inflamed bursae and fluid around the small joints at the base of the toes.

When foot pain is urgent

A community imaging clinic is for planned tests. Call 911 or go to the nearest emergency department if you have:

• An injury after which the foot or ankle looks deformed or you cannot bear any weight
• A foot that is suddenly cold, pale, blue or numb
• A sudden pop or snap at the back of the heel with difficulty walking
• Spreading redness, warmth and swelling with fever

If you live with diabetes or have reduced feeling in your feet, a new wound, colour change or swelling should be assessed promptly by a health-care provider, even if it does not hurt. Health811 offers free advice from a registered nurse in Ontario if you are unsure where to go.

Preparing for a foot scan

Foot imaging needs very little preparation, but a few small things help.

For an X-ray

Digital X-ray at Rossland Diagnostic Clinic is offered on a walk-in basis during opening hours. The department may close when daily capacity is reached, so call 905-426-3111 first for live availability and to confirm what to bring.

• Wear trousers or leggings that roll up easily past the ankle.
• Expect to remove your shoes and socks.
• If you are asked to stand for weight-bearing views, the technologist will help you get onto the platform safely.

For an ultrasound

Ultrasound is booked by appointment.

• Bring your health card and the requisition from your provider.
• Loose trousers or shorts make it easier to reach the ankle and heel.
• Remove toe rings or anklets before the scan.
• Foot ultrasound normally needs no fasting, but follow any instructions you receive when you book.

Bringing the shoes you wear most often is not required, but some patients find it helpful to have them along for their follow-up visit with their provider, who may want to see them.

Frequently asked questions

My X-ray said I have a heel spur. Is that the cause of my pain?

Not necessarily. Heel spurs are common in people with and without heel pain. Your provider will consider the spur together with your symptoms, examination and any other test results.

Why would my provider order an ultrasound if my X-ray was normal?

A normal X-ray tells your provider the bones look as expected. Many causes of foot pain involve tendons, the plantar fascia or nerves, which X-ray does not show well. An ultrasound may be the next step to look at those soft tissues.

Will I need to walk on my sore foot during the exam?

For standing X-rays, you will be asked to stand briefly. For ultrasound, you usually sit or lie down for the entire scan.

Can both feet be scanned?

Sometimes the sonographer will look at the other foot for comparison if that is part of what your provider requested. Your requisition determines which areas are examined.

Finding your footing again

Foot and heel pain can affect how far you walk, how you stand at work and how you enjoy time outdoors. Imaging does not treat the problem, but it can give your health-care provider clearer information to guide the next step.

Rossland Diagnostic Clinic is at Unit 102, 300 Rossland Road East, with free parking close to the door and ground-floor access, so there are no stairs to manage on a sore foot. Patients from Ajax, Pickering, Whitby and beyond are welcome. Call 905-426-3111 or request an appointment online when you have a requisition in hand.