Struggling with foot pain? Top 5 most common causes of foot problems
As you head-off for your favourite winter activity, make sure your feet are in good shape. Your big toe, heel and ball of your foot are the spots most likely to cause pain.
Due to the complexity of the foot, diagnosis and management of problems may appear difficult but only a few conditions account for the vast majority of symptoms. Identifying the exact site of the pain often leads directly to the correct diagnosis.
Foot problems are ideally assessed by a medically trained, specialist orthopaedic foot and ankle surgeon, who is uniquely placed to consider the foot in the context of the rest of the body and understands all the treatment options, whether they are conservative or surgical.
Foot and ankle surgery has advanced hugely within the last 10 years and outcomes have greatly improved in the hands of the specialist.
Symptoms in the feet can almost always be alleviated. Causes of foot pain are usually based on specific factors. Arthritis is the most common cause of foot pain however injury, overuse or conditions causing inflammation in the bones, ligaments or tendons can also cause pain.
The 5 most common conditions are discussed here, from the bunion to the onset of flat foot.
The commonest condition is the bunion which is a deformity of the big toe, due to the angulation of the first metatarsal inwards and causing the corresponding toe to deviate towards the second toe. This leads to prominence of the first metatarsal head. Once a deformity has appeared it usually progresses, but the rate of progression is highly variable. As the deformity worsens, the pressure is exerted on the smaller toes, especially the second, which can lead to a deformity.
The cause of a bunion is not completely understood, but there is often a family history. The diagnosis is obvious on examination and can be quantified by radiographs through x-rays.
The best advice is to find comfortable shoes with enough room. Some patients find benefit in wearing pressure-relieving plasters or inserts between their toes. These can help to relieve symptoms, but no form of taping or insole will affect the progression on the bunions.
If simple measures fail to provide acceptable relief, surgery may be considered. The principle of surgical treatment is to return the first metatarsal head to its normal position. This is done by dividing the first metatarsal (osteotomy) and shifting the head inwards towards the second metatarsal. The commonest osteotomy is known as a scarf, which is z-shaped cut of the bone. This is secured with two permanent screws, which are embedded in the bone. The soft tissues are also re-balanced.
Bunion surgery is now relatively pain-free due to stable fixation and local anaesthetic techniques. Most patients are up and walking within hours of surgery without significant discomfort.
The indications for surgery are persistent pain and disability often with difficulty with shoe wear. Surgery should not be performed purely for cosmetic reasons or to prevent deformity occurring in later life.
Postoperatively, the foot is placed in a wool and crepe bandage for 2 weeks, then normally a removable fabric splint for a further 4 weeks. During this time the patient walks in a stiff-soled, postoperative shoe, taking weight on the foot as they are able. At 6 weeks the splint is discarded and a comfortable shoe can be worn. Whilst the majority of the swelling will have resolved by 3 months, it can take up to a year for all symptoms to settle.
Hallus rigidus is osteoarthritis of the first toe-bone joint and is characterised by pain, stiffness and bony lumps. Pain is worse on walking and more noticeable when going downstairs or wearing high-heeled shoes. Movement in the top of the foot is often maintained but causes pain due to sustained stretching. Movement of the foot upwards is reduced and painful and there may be grinding or crunching. The diagnosis and severity is confirmed by foot x-rays.
Usually, there is no particular cause, but it may follow injury or other joint diseases. Men are more commonly affected and having osteoarthritis in the first toe-bone joint does not mean that other joints will be affected as it may occur in complete isolation.
Conservative measures include avoiding exacerbating activities, painkillers and wearing comfortable shoes that do not rub. Usually, stiffer-soled shoes are better as they limit movement.
Treatment depends on the severity. Initially, a steroid injection under x-ray guidance can be used. If the arthritis is more advanced but only affects part of the joint, removal of the osteophyte, with a treatment known as Cheilectomy, can reduce pain and increase movement.
Following surgery, the foot is placed in a wool and crepe bandage for two weeks, after which patients can return to comfortable footwear and start to increase activity, but in 25% arthritis progresses.
If the whole joint is affected, the most common operation performed is a fusion. Following surgery, the foot is immobilised in a plaster shoe for 6 weeks. The toe is still but pain-free, and patients function very well.
Replacement of the joint is a newer technique, although long-term studies have demonstrated poor outcomes. Very careful consideration needs to be given before recommending a replacement and the patient needs to be aware of the risks of failure, requiring a more challenging fusion.
When the forefoot is generally swollen, warm or red, the two commonest causes are:
- New onset inflammatory arthropathy
- Metatarsal stress fracture
New-onset inflammatory arthropathy usually affects middle-aged women and no other symptoms may be evident.
A stress fracture may present after significant physical activity, but often there is no history of increased activity. Often there is tenderness.
Treatment is symptomatic and may require a plaster shoe. If there is no swelling, warmth or redness, diagnoses may conclude, Morton’s neuroma, Osteoarthritis or Metatarsalgia.
Morton’s neuroma is a benign swelling of the common nerve in the ball of the foot. It most commonly affects the nerve between the third and fourth toes. The cause is repeated compression underneath the ligament that connects the two metatarsals.
Pain is felt in the ball of the foot, which may radiate into the toes. It is worse when wearing shoes, particularly those with a high heel. There may be the sensation of walking on a pebble and clicking.
Examination reveals tenderness between two toes and specific tests may reproduce the pain. Diagnosis is usually confirmed by further imaging.
Initial treatment is show modification. A steroid injection can be curative in the early stages.
If symptoms fail the settle, the neuroma can be cut out during surgery. The procedure has a 90 – 95% success rate. Following surgery, the foot is placed in a wool and crepe bandage for 2 weeks.
Osteoarthritis usually affects the second toe-bone joint and is more common in men. Pain is felt in the forefoot when walking. Examination shows tenderness in the joint, lumps and crunching or grinding.
Initial treatment includes avoiding exacerbating factors, anti-inflammatories and comfortable shoes. A steroid injection may provide relief. Surgery is possible to correct the joint and shorten the metatarsal.
Metatarsalgia is a pain in the ball of the foot due to the increased pressure under the metatarsal heads. Common causes include high-heeled shoes; high-arched foot; a long metatarsal bone; claw or hammer toes; tight Achilles or hallux valgus.
Treatment includes advice about shoe wear, weight loss, resting after activity and painkillers. Only rarely is surgery offered.
Heel pain typically results from an inflammation of the band of tissue that extends from your heel to the ball of your foot. People with this condition compare the pain to someone jabbing a knife in their heel.
Plantar fasciitis is believed to be due to degenerative changes but is occasionally post-traumatic.
Examination picks up specific tenderness at the site where the plantar facia inserts into the heel bone, but there may be more tenderness around the heel.
Plantar fasciitis can be a very painful condition, but 95% of patients settle with conservative measures although this can take up to two years. Surgery is very rarely required and involves release of a portion of the plantar fascia and a nerve.
Most people’s feet have a space on the inner side of the foot where the bottom of the foot is off the ground (the arch of the foot). The height of the arch varies a lot from one person to another. People who have no arch or a low arch are said to have flat feet. If you have had a normal arched foot that becomes flat in middle age it is termed adult flat foot.
There are several causes of adult-onset flat foot, but the commonest is tibialis posterior tendon dysfunction. The tibialis posterior is a large muscle that runs from the calf onto the foot behind the medial malleolus (inner side of the ankle). This muscle’s function is to invert the foot, support the arch and help initiate tip-toe standing.
Initially, pain and swelling will be felt below the medial malleolus (inner side of the ankle). While the foot is inflamed it will keep it its normal shape.
If the condition is not treated the tendon will degenerate and lose function. The arch will fall and heal will move outwards. Pain will then be felt on the outer side of the ankle and the tissues will be damaged between the heel bone and the fibula. The patient will experience weakness when inverting their foot or standing on tip-toe. Eventually, the tendon will rupture and, if the condition remains untreated, the subtalar joint will develop arthritis.
The condition most commonly affects middle-aged women with pain on the inside of the ankle.
Management for early disease includes anti-inflammatories, orthotics and physiotherapy. Often an ultrasound-guided injection into the membrane around the tendon is tried. If symptoms are not controlled and the arch collapses then surgery is usually required. Surgery involves replacing the function of the damaged tibialis posterior with another tendon that runs in the area and also moving the heel inwards. If the subtalar joint has become arthritic then the treatment is subtalar fusion.