Foot pain is common with a spectrum of causes – check the soles of the feet (foreign body, verrucae), nails (ingrown toenails) and signs of ill-fitting footwear.

Trauma is common but can be a ‘red herring’. If an apparent injury is not resolving, look for other pathology.

Check for red flags to suggest infection, rheumatic fever or malignancy. Osteomyelitis of the foot or ankle may follow injury.

Inflammatory arthritis of the ankle is common in Juvenile Idiopathic Arthritis - the ankle may be the only joint involved and swelling is most easily observed from behind the child.

Muscle bulk assessment is important – wasting suggests a chronic problem (disuse atrophy, for example is observed in JIA with ankle involvement) and bulky muscles suggests a muscle dystrophy.

Observe for flat feet and the presence of a normal arch on tiptoe. Mobile flat feet are normal in young children. Flat feet persistent into childhood are often associated with hypermobility. A non-mobile flat foot, especially if painful, suggests pathology and can be due to tarsal coalition or inflammatory arthritis. Flat feet are not always painful so be careful not to miss pathology.

Pain in the forefoot can be due to mechanical causes or inflammatory arthritis.

Low trauma fractures suggest osteopenia.

Infected ingrown toenails are more common in children taking immunosuppression and the infection can be indolent.

Heel pain is common in physically active children and especially during growth spurts. Enthesitis, tendonitis and Sever’s disease can all cause heel pain but clinical assessment can differentiate.