Since the onset of the COVID-19 pandemic, podiatrists and musculoskeletal specialists have observed a new patient population: individuals with persistent foot and ankle symptoms following SARS-CoV-2 infection. Long COVID — defined as symptoms persisting beyond 4 weeks after acute infection — has numerous musculoskeletal manifestations, and the foot and ankle are among the affected structures. Understanding these presentations helps patients seek appropriate evaluation and treatment rather than attributing symptoms to unrelated causes.

Mechanisms of Post-COVID Musculoskeletal Symptoms

Several pathophysiological mechanisms have been implicated in long COVID musculoskeletal symptoms:

• Post-infectious inflammation: Persistent low-grade systemic inflammation (elevated CRP, IL-6, and other inflammatory markers) can perpetuate joint and soft tissue pain beyond the acute infection.
• Small fiber neuropathy: SARS-CoV-2 has documented neurotropic effects. Post-COVID small fiber neuropathy produces burning pain, numbness, and tingling — particularly in the feet — that closely resembles diabetic peripheral neuropathy. Skin punch biopsy showing reduced intraepidermal nerve fiber density confirms the diagnosis.
• Microvascular injury: COVID-19 causes endothelial damage and microvascular thrombosis. In the feet, this can manifest as “COVID toes” (pernio-like chilblain lesions), persistent Raynaud’s-like vasospasm, and chronic ischemic-type foot pain.
• Deconditioning: Extended periods of reduced activity — particularly during hospitalization or severe illness — lead to significant lower extremity muscle atrophy, tendon deconditioning, and biomechanical dysfunction. Plantar fasciitis, Achilles tendinopathy, and tibialis posterior dysfunction can all develop or worsen in this context.
• Post-inflammatory arthropathy: Reactive arthritis following viral infections is an established phenomenon. Post-COVID arthropathy affecting the ankle, subtalar, and smaller foot joints has been reported, typically presenting within weeks to months of acute infection.

Common Foot and Ankle Presentations in Long COVID

Podiatrists have observed several recurring presentations in post-COVID patients:

• Burning, tingling, or numbness in the feet: The most commonly reported post-COVID neurological foot symptom. May affect the soles, toes, or diffusely. Night symptoms and allodynia (pain from light touch) suggest small fiber neuropathy involvement.
• Diffuse foot pain with activity intolerance: Patients report feet hurting significantly more than expected with relatively minimal activity — often attributed to post-COVID fatigue syndrome and deconditioning effects on lower extremity structures.
• New-onset plantar fasciitis or Achilles tendinopathy: Deconditioning-related, frequently presenting in previously asymptomatic patients several months after acute infection as they attempt to resume normal activity.
• COVID toes: Pernio-like erythematous or violaceous lesions on the toes and feet, now understood as a post-COVID inflammatory microvascular response. Typically self-limited but may recur with cold exposure.
• Ankle and midfoot joint pain: Diffuse joint aching consistent with post-viral arthropathy, often with mild synovitis on MRI.

Evaluation and Management

A thorough evaluation including nerve conduction studies (NCS) and electromyography (EMG), skin punch biopsy for small fiber neuropathy, inflammatory markers, and imaging guides treatment. Management is symptom-specific:

• Small fiber neuropathy: pregabalin, duloxetine, or low-dose naltrexone; referral to neurology
• Post-COVID arthropathy: NSAIDs, short-course prednisone, hydroxychloroquine for persistent cases
• Deconditioning-related tendinopathy and fasciitis: structured graduated physical therapy, custom orthotics, and paced return to activity
• COVID toes: topical steroids, amlodipine for vasospastic symptoms, cold avoidance

Rehabilitation must respect post-COVID fatigue syndrome — the graded exercise approaches effective for standard deconditioning can worsen post-exertional malaise (PEM) in post-COVID patients. A paced, symptom-guided approach is essential.