By Dr. Shane Drakes
Foot pain is a very common complaint, especially in older persons. It is a significant cause of limited mobility, making it difficult to perform activities of daily living and hindering sports participation.
The foot is a complex region which is important for bearing the weight of the body and for locomotion. Multiple bones (tarsals, metatarsals and phalanges) and joints give the foot its shape and multiple ligaments help to maintain the stability of the foot. The muscles and tendons in the foot are crucial for movement. The tendons also assist the ligaments with maintenance of the arches of the foot. The foot is divided into three distinct regions- rear foot, midfoot and forefoot.
There are multiple causes of foot pain and we will consider some of the common ones according to the anatomical region involved:
- Rear foot- plantar fasciitis
- Midfoot- midfoot joint impingement/arthritis
- Forefoot- disorders of the region of the hallux (big toe)
The plantar fascia originates on the calcaneus (heel bone) and attaches to the toes and is a very important structure. It provides support for the arch of the foot and plays a role in shock absorption while walking and running. Overuse can initiate a degenerative process at the attachment of the plantar fascia to the calcaneus. This causes gradual onset of pain in the heel, initially worst in the morning and getting better with activity. As the condition worsens, pain may be more constant and worsen with activity. Risk factors for this condition include:
- Flat feet or high arches
- Repetitive sporting activities
- Abnormal lower limb biomechanics
- Excessive walking
- Inappropriate footwear
The midfoot forms the top of the arch of the foot and is susceptible to problems, if the arch sags or collapses. If the arch collapses, the normal relationship of the bones is lost and there is abnormal contact between them (impingement). If this happens repeatedly over a period of years, joint damage occurs and leads to arthritis in that region. Symptoms would include pain with walking, running, or other weight-bearing activities which generally grows worse throughout the day. The pain can be felt on the outside or inside of the midfoot initially and later may be present across the entire region. Swelling may also be present in the affected area. Risk factors for these problems include:
- Tight calf muscles
- History of tendinopathy contributing to a collapsed arch
- Poor footwear
Many of the causes of forefoot pain affect the region of the hallux, especially the area of the first metatarsophalangeal (MTP) joint. These are mostly caused by overuse except for first MTP joint sprain (“turf toe”) which is caused by forced hyperextension at the joint. This leads to pain, swelling and tenderness and painful or restricted range of motion at the joint. Other causes of pain in this area include hallux limitus and hallux valgus (bunion). In hallux limitus, there is restriction of dorsiflexion (bending upward) at the first MTP joint due to development of osteoarthritis. This leads to gait abnormality and the condition may progress to “hallux rigidus” where there is complete restriction of movement. Hallux valgus refers to deviation of the big toe towards the other toes. Osteoarthritic changes occur over time and may become severe enough to restrict joint range of motion. There is also pain over the 1st MTP joint with pressure from shoes. Risk factors for these two conditions include:
- Biomechanical abnormalities
- Tight shoes (hallux valgus)
The rehabilitation/sports medicine physician plays a vital role in the management of foot pain. This begins with a comprehensive evaluation to diagnose the cause of the pain. In some cases, imaging such as x-rays, ultrasound or MRI may be needed to confirm the diagnosis. Once the condition is diagnosed, patient education can begin and the individualized treatment plan can be created. This will usually include an exercise program which may be led by a physical therapist or by the patient. Pain control is essential and this is achieved by avoiding aggravating activities and use of oral or injected medications as necessary. The use of heel lifts, heel cups, orthotics or change of footwear may be required. In cases where indicated, a referral for surgery is made.
Foot pain which is not improving after a short period of relative rest and pain medications or which is worsening should be evaluated. This will help accelerate the process of returning to optimal physical function.
(Dr. Shane Drakes is a Specialist in Physical Medicine & Rehabilitation and Sports Medicine. He can be contacted at firstname.lastname@example.org)