Foot Pain

• The foot is a complex anatomical structure that may be affected by disease within the body or the foot itself.
• The arches of the foot are the primary structures that control the amount of ground force transmitted into the body.
• When pain due to foot pain interferes with your normal activities, you should seek medical advice.
• The foot contains bone and joint, ligament, muscle/tendon, nerve, blood vessels, skin, and soft tissue structures.  The disease of any of these structures in the foot can cause foot pain.
• Treatment of foot pain will depend on the cause of the pain and may involve medication, strengthening, stretching, physical therapy, immobilization, and surgery.

The foot is an intricate structure of 26 bones, 33 joints, multiple muscles, tendons, ligaments, blood vessels, nerves, and lymphatics. The bones form two crossing arches of the foot. The longitudinal arch runs the length of the foot, and the transverse arch runs the width. The ankle joint is formed by the interaction of the foot and the lower leg, and the toes are on the far side of the foot. The bones of the foot are primarily held together by their fit with each other forming joints surrounded by joint capsules and connected by fibrous tissues known as ligaments. The muscles of the foot, along with a tough, sinewy tissue known as the plantar fascia, provide secondary support to the foot and the longitudinal arch. The foot has internal muscles that originate and insert in the foot and external muscles that begin in the lower leg and attach in various places on the bones of the foot. There are also fat pads in the foot to help with weight-bearing and absorbing impact.  Various tendons in the foot act together to provide synchronized pull on a bone or joint structure. This allows the foot to remain in optimal alignment. The foot is also covered by dense soft tissue structures that include capsules, subcutaneous fat, dermal, and epidermal layers. These soft tissue structures work as a unit to function as a primary defense mechanism from external hazards such as infection and trauma. The soft tissue can allow fluid to accumulate, which can cause swelling in the foot.

The foot is the foundation of movement of the lower extremity.  It is an intricate and complex system that provides efficient shock absorption and propulsion in order for us to walk and run.  Pain in the foot indicates that there is something wrong with either the interaction of internal structures of the foot or with how the foot is interacting with external influences. How and when the pain occurs and the locations of the pain are the primary clues to what may be causing the pain. When there is pain, the body reacts by changing the way it moves or functions in an effort to reduce the pain. These compensations or biomechanical changes may prevent normal movement and cause further injury in the foot and/or other parts of the body.

Foot pain may be caused by many different diseases, deformities, biomechanical conditions, improper footwear, or injuries.

• Infectious diseases, viruses, fungi, and bacteria can cause foot pain. Plantar warts on the bottom of the foot are caused by a virus and can cause irritation and pain. Athlete's foot, which is caused by a fungus, can lead to foot irritation and pain. A common cause of foot pain is an ingrown toenail. Ingrown toenails occur when the edges of the nail grow through or into the skin, resulting in pain and often leading to infection. Patients with diabetes are more prone to infection since their immune system is compromised.
• Many systemic diseases such as diabetes, lupus, gout, and rheumatoid arthritis can cause foot pain. Rheumatoid arthritis can cause painful inflammation in the joints of the foot, accompanied by alignment changes that lead to foot deformities.
• Deformities, such as tarsal coalitions, calcaneal varus, calcaneal valgus, bunions, claw toes, mallet toes, hammertoes, and bone spurs, are common causes of foot pain.
• Biomechanical abnormalities from muscle and tendon tightness or laxity, flat feet, or high arched feet often lead to muscle imbalances, deformities, and foot pain.
• Trauma from an acute injury or from accumulative repetitive injury is a very common cause of foot pain, as well.  An example of such an injury is Achilles tendonitis or rupture.  The tendon can rupture from an acute, sudden injury or it can become inflamed (tendinitis) from repetitive insult to the structure.  Injuries to the skin and internal structures may also be caused by small repetitive traumas or pressures. Micro-trauma injuries can be caused by running on uneven surfaces or surfaces that are too hard or too soft, or by wearing shoes that have poor force-absorption qualities, are not activity-specific, or fit incorrectly.
• Wearing shoes that are too tight or high heels can cause pain in the forefoot. Shoes that are tied too tightly can cause pain and bruise on the top of the foot. Improper, non-sport-specific shoes for running or cycling can lead to foot pain with activities. Poorly fitting shoes in the short term can cause blisters, bruising, and be a source of an athlete's foot. The long-term effects of poorly fitting shoes may be bunions, corns, calluses, irritation of nerves and joints, and misalignment of the toes. Morton's neuroma caused by the thickening of tissue around a nerve between the toes can cause toe numbness and pain and may also be aggravated by ill-fitting shoes as can many foot deformities such as hammertoes, mallet toes, and bunions.

• Injuries such as ligament sprains, muscle strains, bruises, and fractures typically occur suddenly (acutely). Sprains, strains, bruises, and fractures may be the result of a single or combination of stresses to the foot. A sprain of the foot or ankle occurs when ligaments that hold the bones together are overstretched and their fibers tear or stretch too far. The looseness of ligaments in the joints of the foot may lead to chronic foot pain, joint instability, and deformity. Repeated overstressing of the same structure of the foot may cause stress fractures, tendonitis, plantar fasciitis, and acute and chronic osteoarthritis. Stress fractures commonly occur in the metatarsal bones, the long bones of the foot, and can occur in the tarsal or rear foot bones, as well. These fractures are often called march fractures because it is often caused by non-distinct and minor stress of excessive walking (marching) rather than a large traumatic event. 
• The muscles and fascia of the foot can be strained by overstretching, overuse, or overloading. Achilles tendonitis is a common injury of the tendon that attaches at the back of the heel. Plantar fasciitis (the most common cause of heel pain) is a result of micro-trauma strain to the large ligament called the plantar fascia. Tendon pain and swelling from repetitive abnormal strain lead to tendinitis, which can eventually lead to tears in the tendons.
• Injury to the bones and joints of the foot can be caused by a single blow or twist to the foot or also by repetitive trauma that can result in a stress fracture. A blunt-force injury such as someone stepping on your foot may result not only in a bruise (contusion) injury but also damage to the muscles and ligaments of the foot. Direct blows to the foot can cause bruising, breaking of the skin, or even fracturing of bones. Metatarsalgia is from the repetitive irritation of the joints of the ball of the foot. The term "stone bruise" is commonly referred to as a specific localized pain and tenderness of the ball of the foot. "Turf toe" is a common athletic injury in which the tendon and capsule under the joint at the base of the big toe is strained. Trauma to the toenail can cause the pooling of blood under the nail and the temporary or permanent loss of a toenail. Repetitive trauma to the bones, muscles, and ligaments can result in extra bone growth known as spurs or exostoses.
• Delayed treatment of many foot pain can lead to complications, chronic long-term pain, disability, and arthritis of the affected foot.

Pain and point tenderness is the immediate indicators that something is wrong in a specific area. Swelling, redness (erythema), bruising (ecchymosis), numbness/tingling, and shooting pains may also present localized to the injured area. The onset of pain, whether suddenly or over time, is an important indicator of the cause of the problem. The following questions are also important.

• Is there pain with the movement of the affected area?
• Is it affected by weight-bearing?
• Does it change your walking motion?

The bones of the foot are joined together by ligaments. A sprain occurs when the ligaments that hold the bones together are overstretched and the fibers tear. Point tenderness and looseness of a joint can be indicators of a sprain.  Ligament injury is often accompanied by a sense of instability when walking or exercising.

Injury to the bones of the foot can be caused by a single blow or twist to the arch or also by repetitive trauma that can result in a stress fracture. There may be a distinguishable lump or gap at the site of a fracture. The fracture can be accompanied by dislocation of involved joints.  In such circumstances, the joint alignments are disrupted in addition to a break in the bone. Fracture and dislocation are common causes of post-traumatic arthritis. This is due to additional injury to joint cartilage.

Muscles and tendons allow movement of the foot in various directions. A strain occurs when a muscle or group of muscles are stressed to the point where there is tearing of the muscle fibers. The muscles and tendons of the foot may be strained by overstretching, overuse, overloading, bruising, or even being lacerated. Weakness in the contraction of a joint, difficulty in stabilizing body parts, and pain working against resistance are signs of muscle problems. Swelling, tenderness, loss of function, and discoloration over and around the injury can be symptoms and signs of a strain.

Bruises (contusions) are most commonly the result of a direct impact injury to the body. A bruise can occur to the foot by a variety of causes, such as having your foot stepped on or by stepping on a rock. Blows to the foot that result in pain, discoloration, swelling, and changes in how you walk may indicate more serious damage such as fractured bone.

Pain and tenderness associated with plantar fascia strains are usually felt on the bottom of the foot between the heel and the base of the toes. Plantar fascia pain may be increased or decreased by stretching of the arch. In mild cases of plantar fasciitis, the pain will decrease as the soft tissues of the foot "warm-up," however, pain may increase as the use of the foot increases. In more severe cases of plantar fasciitis, pain may increase when the arch is stressed. Often the sufferer of plantar fasciitis will feel pain in the morning until the plantar fascia warms up. Foot pain at night may be a sign of plantar fasciitis, as well as other possible problems. Plantar fasciitis can cause a shift in the weight-bearing surface in order to avoid pain, which may cause compensation pain in the other areas of the heel.

A sensation of rubbing or burning on the surface of the foot is usually the first sign of a blister. Itching and burning sensations between the toes or around the foot indicate a skin infection or athlete's foot. Pain and redness at the edge of a toenail are usually the results of an ingrown toenail.

When the pain begins to interfere with your activities of daily living or if you cannot perform your desired activities without pain, you should consider seeking medical attention. Indicators that you should seek medical care are if the area looks deformed, you have a loss of function, change of sensation, a large amount of swelling with pain, prolonged change of skin or toenail color, the affected area becomes warmer than the surrounding areas, becomes exquisitely tender to the touch, or is causing you to move differently. Experiencing little to no improvement with a few days or rest, ice, and temporary pain reliever suggests that the injury will not likely heal on its own.  It is not recommended to “push through” the pain since this can worsen the injury.

Proper evaluation and diagnosis of foot pain are essential in planning treatment. A good general guideline is to compare the injured side to the uninjured side. Injury may present itself as a distinguishable lump or gap felt at that location or a "crunchy" feeling on that spot caused by inflammation. The types, causes, and severity (sharp pain versus a dull ache) also are good indicators of the seriousness of the injury. Comparing functional ability to the unaffected side also provides insight into the nature and severity of the injury.

There are four grades of pain:

• During activity
• Before and after, and not affecting performance
• Before, during, and after athletic activity, affecting performance
• Pain so severe that performance is impossible

The doctor will ask you several questions to determine how the problem began. It can be helpful to tell the physician about how and when it started, how it affects you, when it bothers you, what you may or may not have done to make the pain better or worse. If necessary, a thorough physical exam may be conducted to evaluate for any other injuries.

• Feet will be physically and visually examined at rest, with weight- and non-weight-bearing movement by the medical professional.
• The foot and arch will be touched and manipulated and inspected to identify obvious deformities, swelling, tender spots, or any differences in the bones of the foot and arch.
• The medical professional will examine how the muscles of your foot function. These tests may involve holding or moving your foot and ankle against resistance; you may also be asked to stand, walk, or even run.
• The skin will be inspected for any signs of bruising, break in skin, or infection.
• The nerves in the foot will be tested to make sure no injury has occurred there.
•  An X-ray, MRI, or bone scan of the foot and arch may be taken to determine if there are abnormalities of the bone and/or soft tissues.
• A blood test may be ordered to rule out systemic diseases such as rheumatoid arthritis, gout, or diabetes.

Treatments are optimally directed toward the specific cause of the pain.

• When you first begin to notice discomfort or pain in the area, you can treat yourself with rest, ice, compression, and elevation (RICE).
  • Over-the-counter medications may also be used to reduce discomfort and pain.
• Rest will allow the tissues to heal by preventing any further stress to the affected area.
  • Crutches should be used if you have difficulty putting weight on the foot.
  • Appropriate use of commercially available ankle and foot supports may provide rest, comfort, and support to the affected area.
• Ice should be applied no longer than 20 minutes. The ice may be put in a plastic bag or wrapped in a towel. Commercial ice packs are not recommended because they are usually too cold. If extreme discomfort occurs, the icing should discontinue immediately.
  • Alternatively, one can soak the affected limb in cool water mixed with Epsom salt.
• Compression and elevation will help prevent any swelling of the affected tissues.  Excessive swelling can cause stretching of the nerve fibers in the affected area, which can cause more pain.  Therefore, decreasing swelling often provides some degree of pain relief.  
• There are two types of over-the-counter medications that may help with the pain and swelling of foot pain.
  • Acetaminophen (Tylenol) will help reduce the pain, while a nonsteroidal anti-inflammatory.
  • (NSAID) such as aspirin, ibuprofen (Motrin), or naproxen (Naprosyn) can help lessen the pain and as well as reduce the inflammatory response.
  • Caution should be taken when using these anti-inflammatory medications as the dosage should not exceed the labeled directions. In addition, individuals with a history of acid reflux or stomach ulcer and kidney problems should consult a medical doctor prior to using them. 
• A popular home remedy for the relief of plantar fasciitis is rolling a frozen water bottle on the ground with the bottom of the foot. 
  • Various stretching exercises are known to be beneficial. 
  • Proper shoe gear with a supportive insert is also beneficial, as well as avoiding going barefoot. 
  • A corticosteroid injection can be helpful.
• Blisters occur as a result of chafing. These "hot spots" should be attended to immediately with padding or friction reducers. If these spots progress to a blister and are unbroken, the doctor can drain them by puncturing them from the side with a clean needle, and once drained, the skin will act as a natural bandage and should not be trimmed away. If the skin over the blister is broken, the loose skin should be peeled back and the area should be treated as an open wound.
  • Blisters should be covered and padded before returning to activity; in simple cases, a Band-Aid may solve the problem.
  • If the blister is bigger, donut pads, gel pads, or commercially available blister pads may be more appropriate.
  • To avoid blistering in the future, a generous application of petroleum jelly or anti-chafing topical cream to the affected area can be helpful.
  • Shoe sizing should be assessed as well as sock construct and material.
  • Synthetic cotton combinations can provide a wicking effect to reduce moisture and friction. 
  • It is also possible to sustain blisters from contact-related allergies. In such cases, it is important to identify the causative agent and to avoid contact with the agent in the future.  The topical or oral steroids may be necessary to relieve pain and itching caused by these allergic blisters.

Medical treatment

Once the severity and cause of foot pain are determined, a course of corrective and rehabilitative actions can be started.

• Qualified medical personnel may use electrical medical devices such as ultrasound, various forms of electrical stimulation, LED light therapy (laser), and/or manual therapies to reduce pain and increase circulation to the area to promote healing.
• Cast or boot immobilization can provide adequate rest.  Prolonged periods of immobilization can cause muscle weakness and joint stiffness.  This is managed by various forms of physical therapy.
• Maintenance of fitness levels via modification of activity may be prescribed.
  • Substitute activities that aggravate the pain and soreness. Running causes the body to have repetitive high-impact with the ground. Bicycling and/or using elliptical trainers, step machines, swimming, or ski machines minimizes impact and allows you to maintain and improve your fitness.
• Corrective prophylactic measures
  • New shoes or the replacement of current shoe insoles
  • Proper footwear fitting, including lacing and sock combinations to eliminate compression and friction issues
  • Additional supports added to the shoes such as heel pads or cushions, arch supports, and various wedges to help maintain the foot in a proper position and reduce impact at the site of pain/injury.
  • Athletic shoes lose the elastic properties of the soles through usage and age. A good rule of thumb is to replace your shoes every six months or approximately 200 miles. The use of replacement insoles can increase energy absorption and add support to the foot.
  • Corrective and over-the-counter orthotics may also improve the biomechanics of the foot.
• Muscle strengthening and flexibility
  • You may be given exercises to increase the strength and stability of the affected area and to correct muscles that may not be balanced.
  • Exercises to increase flexibility will maintain or improve the length of a muscle. Flexibility helps to make a stronger muscle and less likely to be injured.
• Appropriate medication to control inflammation or disease-related symptoms
• In some cases, surgery may be necessary.
• Biomechanical evaluation
  • Your body will create various changes in movement when you have an injury. A podiatrist can evaluate these changes and help you make the appropriate corrections. Prolonged, uncorrected biomechanical changes may lead to secondary mechanical changes that are painful and difficult to correct and may lead to a poor prognosis and possibly a slow or incomplete recovery from the symptoms.
  • Custom functional orthotics can be used for abnormal compensatory foot mechanics and improve function as well as prevent injury.
• Follow up with your doctor until you are better.

There may be follow-up tests, scans, or X-rays. A plan for a gradual return to play should be started once the pain is reduced and muscle strength and flexibility are restored. Temporary bracing and use of the custom orthotic devices may become necessary to gradually return to pre-injury activity level.

To prevent injuries and pain, the following issues should be addressed before starting an exercise routine. Are you in good health? A general physical exam by a physician will help to evaluate your cardiovascular function, the possibility of disease, or any other general medical problems that you may have. Before beginning activities, diseases such as gout, diabetes, certain types of arthritis, and neuropathies should be treated.

Physicians with sports medicine, physical medicine, podiatric, or orthopedic backgrounds may also help you choose an appropriate activity. After choosing the sport or activity that you wish to participate in, proper preparation will help minimize the initial aches and pains of that activity. Proper technique in any activity will help you to properly and safely perform your chosen activity and avoid injury. Good coaching can help you develop good biomechanics that can prevent foot pain.

Shoes and socks appropriate to your activity will also be a deterrent to foot pain. Properly fitting shoes and proper foot hygiene can prevent blisters, ingrown toenails, corns, calluses, bunions, stress fractures, metatarsalgia, Morton's neuroma, mallet toes, and plantar fasciitis. Poorly fitting footwear can make poor biomechanics worse, and properly fitting footwear can help to minimize the effect of bad biomechanics.

A plan for a gradual return to play should be started once the pain is reduced and muscle strength and flexibility are restored. Returning to participation and prevention of foot pain are governed by the same factors as preparing for participation. Foot pain can be caused by doing too much of a particular activity too fast. Ignoring pain can also lead to further foot problems. Different types of foot pain can be seen at different times of the season. Typically, blisters, shin splints, Charley horse (muscle spasms/cramps), and arch injuries occur at the beginning of the sports season.

Stress-related foot problems are related to the workloads. If the body is not prepared for an increase of workload that is typical early in the season and with "weekend warriors," acute shin splints and tendonitis are very common, in addition to increased muscle soreness.  A stress fracture can result from a sudden increase in workload. 

After foot pain has been successfully treated, an optimal workout program begins with a physical exam by a physician, followed by a gradual, consistent workout plan. A good example of this type of program is a running program that starts with a good warm-up, such as walking five to 10 minutes, then alternating sets of jogging and walking. An example of such a program would be 20 sets of jogging for two minutes, then walking one minute, with jogging time increased until you can run continuously for 40 minutes. Good surfaces and proper equipment used in your workout will lower the risk of foot pain.

Components of a good exercise program should include core strengthening, muscle strengthening, and stretching specific to the goals of the workout program or the sport.

If pain is encountered when working out, try decreasing the intensity or duration of the workout. If the pain persists, then you should immediately stop and seek medical advice to discover the source of the pain. Pushing through the pain often results in injury.