Foot overuse injuries are caused by repetitive stress over time. They have a gradual onset and progressive nature. Signs of inflammation (eg, swelling, redness, pain) can occur in the acute phase. The etiology may be intrinsic, extrinsic, or a combination of the two. Intrinsic factors can include patient age, sex, genetic predisposition, body weight, and blood supply. Extrinsic factors can include training errors, environmental conditions, equipment malfunction, and shoes. Common causes of foot pain and overuse injury include Achilles tendinopathy, Morton neuroma, and plantar fasciitis. The history should include onset, duration, and progression of symptoms; new physical activity or increased intensity of activity; and aggravating and relieving factors. The physical examination should include assessment of range of motion, adjacent structures, and provocative maneuvers. Laboratory testing and imaging are not required, but imaging can be used to rule out other conditions or when surgical intervention is being considered. Conservative management, including analgesia, nonsteroidal anti-inflammatory drugs, rest, activity modification, and physical therapy, is the mainstay of treatment. Referral to podiatry, sports medicine, or orthopedics can be considered in difficult cases. Surgical intervention may be necessary if conservative management does not bring relief.

Case 4. AZ is a 46-year-old patient with obesity and gastroesophageal reflux disease. He comes to your office with a 3-month history of posterior heel pain, especially when walking. The physical examination reveals no erythema, but there is tenderness at the insertion of the Achilles tendon. AZ says he works as a courier 5 days/week and cannot afford to take time off. He asks you for advice about how to manage his foot pain, and wonders if his work boots may be contributing to the problem.