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Foot pain and management.

Foot and/or ankle pain is a common presenting problem affecting people all ages. Overuse, misuse and trauma of tendons and muscles afflict the young and athletic and the aged are affected by degeneration and disease. (1) The end result is a painful foot, or ankle, which can affect balance, walking and exercise and force the patient to the podiatrist and A&E departments for treatment. 7% of all adults report tenderness under the heel and planter fasciitis can count for 8% of all running -related injuries. (2) The majority of sufferers are treated conservatively with foot-rest and supports and pain diminishes within a few months. (3) Bruising and sprains of small tendons of foot and ankle are common and self-limiting.

Heel pain is not usually caused by a single injury, e.g. sprain, or fall, but from repetitive stress and pounding of the heel on the ground. It can radiate in to the foot.

Heel bumps are common in teenagers when the heel bone is not yet fully developed and, if rubbed excessively, can form too much bone. Associated with flat-foot they can be precipitated if young women start to wear high heels before the bone is fully mature.

Heel bursitis--Inflammation of the back of the heel from pressure can result in formation of a protective bursa (a fibrous sac full of fluid). It can be caused by repetitive heavy landing on the heels, or by pressure from footwear. Pain is typically felt either deep inside the heel or at the back of the heel. It usually gets worse over the course of the day. (4)

Plantar Fasciitis (PF) When the plantar fascia is over-stretched, soft tissue fibres can degenerate, usually where attaching to the heel bone. The history may reveal recurrent overstretching of the small tendons over a short period of time. (5,6)

Case History. A patient presented sorely crippled after an adventurous walk over the sands of Morecambe Bay. The seven mile traverse wearing sandals had been across rippled sand and had severely stretched midfoot tendons. He was unable to walk the next day, but a few days of foot rest brought pain relief and return of normal walking.

PF is a complex mechanical, traumatic or pathological degenerative condition with absence of an inflammatory process. It can include myxoid degeneration, fragmentation of plantar fascia, degeneration of the plantar fascia and bone marrow vascular ectasia. (7) PF is mainly a clinical diagnosis principally made on history and examination alone. It is usually a self-limiting condition which mostly resolves with non-operative management, but can take up to 12 to 18 months before settling.

Pain occurs under the front of heel or just behind. It can come on gradually with no obvious injury to the affected area, or be triggered by wear of flat shoes e.g. sandals, or to repetitive small tendon stress. The discomfort is felt at the tender spot located postero-medially at the insertion of the plantar fascia with deep pressure. Post-static dyskinesia (pain after rest) is often present--symptoms tend to be worse just after getting out of bed in the morning, and after a period of rest during the day. In plantar fascia tear pain is acute and very severe. The patient may have noted a "pop" at the time of injury and may have pain at all times with ambulation.

Histologically PF is a degenerative fasciosis without inflammation, but aetiology is complex, (8-10) In management, some use injection therapies (11-14) as Glucose and Lidocaine Prolotherapy (15) Platelet Rich Plasma (16,17) and Botulinum Toxin (18).

Corticosteroids injections are often advocated, but are a potential cause of dense connective tissue rupture. Effective in first line short-term relief in refractory cases, treatments with serial corticosteroid injections into the plantar area are the primary cause of rupture. (19)

Achilles tendonosis/tendonitis (degenerative tendinopathy) can be crippling. The condition is associated with progressive degeneration of the Achilles tendon. If the Achilles tendon receives more tension than it can cope with, microscopic tears develop; the tendon thickens, and becomes painful and disabling. Achilles tendon rupture occurs with acute trauma to the ankle. Chronic Achilles tendon lesions (CATLs) ensue from a neglected acute rupture or a degenerated tendon. A patient presented with a history of a weekend of ski touring which resulted in crippling pain just above the calcaneum. He admitted to wearing too tight ski boots. He had correctly been applying ice pads but had torn Achilles tendon fibres. He was treated with a few days bed rest, limited walking for ten days, a heel raise support, antinflammatory ointment but remained severely disabled in normal walking for 6 months before return to normal function. The healing process can be prolonged with tendon tears especially in older patients. (20)

Tarsal tunnel syndrome occurs when the nerve running down the back of the foot becomes pinched, or trapped. This compression can result in neuropathy in foot or ankle. This condition has multiple aetiologies. (21)

Stress fracture is caused by repetitive stress, by strenuous exercise, sports or heavy manual work. Runners are particularly prone to stress fracture in the metatarsal bones of the foot.

Severs disease (calcaneal apophysitis)--is a common cause of heel pain in child/teenage athletes, due to overuse and repetitive microtrauma of the growth plates of the calcaneus Children aged from 7-15 are most commonly affected and it predominates in males. Prospective, well-designed studies are required to allow any confidence in describing this condition and its treatment. (22)

Gout--a systemic disease where there excess uric acid in the blood (hyperuricaemia), causing urate crystals to build up around the joints. This can cause inflammation and severe toe and foot pain. (23)

Morton's neuroma--a benign (non-cancerous) growth of nerve tissue causing metatarsalgia often between the third and fourth toes. Symptoms usually occur unexpectedly and tend to worsen over time. There is pain on weight bearing. A shooting pain affecting the touching sides of two toes, may be felt after only a short time of walking. Paresthesia and "pins-and-needles." sensation may occur in the ball of the foot and often radiate to toes. More common in females than males, symptoms may last for days, and even weeks. The neuroma develops as a result of irritation, pressure, or injury to one of the nerves that leads to the toes; causing thickened nerve tissue. It can be caused by :-wear of high-heeled shoes--especially over 5 centimeters, or with a pointed or tight toe box, high-arched feet or flat foot or bunion, hammer toe.

Can also result from high-impact sporting activities --including running, and court sports and injuries to the foot. (24)

Peripheral neuropathy--from systemic disease eg diabetes, rheumatoid arthritis, psoriatic arthritis) (25)

Patient History--Appropriate questions can help define cause and diagnosis of foot pain.

* How long has the patient had the problem?

* How often does the pain occur?

* How long does it last?

* What improves the problem or makes it worse?

* Was there any associated trauma?

* What treatment has been used?

* Is there a systemic or arthritic condition?

* Does pain reduce with rest?

When pain is acute, common causes are often traumatic, e.g. stress fracture, gout, plantar fascia tear or nerve irritation. In cases of fracture, soft tissue masses, calcaneal cyst, nerve entrapment, tendon tear or fascia tear, the pain gets worse with increased activity. In short-lasting pain improving with ambulation--consider plantar fasciitis, systemic arthritic heel pain and mild cases of nerve entrapment. In cases of fasciitis and systemic causes of heel pain, a short period of ambulation often improves the condition. When pain is long lasting pain, or is chronic with ambulation, consider nerve entrapment, fracture, cyst or plantar calcaneal tendon tear.

Examination

Look for lumps, swelling, cysts, inflammation. Palpate for irregularities and swelling Localise pain and tenderness To diagnose Mortons neuroma palpate the area to elicit pain, squeezing the toes from the side. Try to feel the neuroma by pressing a thumb into the third interspace. Elicit Mulder's sign, by palpating the affected interspace with one hand and squeezing the entire foot at the same time with the other hand. In many cases of Morton's neuroma, this causes an audible click. (24)

Referral may be required for x-ray to rule out foot injuries such as a stress fracture and ultrasound examination, a good diagnostic tool to identify Morton's neuroma

Treatment. This involves bed resting the limb, anti-inflammatory ointments. Massage, orthotic supports, heel raises, non-traumatic foot wear. Foot-wear Stretching exercises and insoles will not improve a calcaneal cyst, fracture or tendon tear but can help symptoms of nerve pain, fasciitis or systemic sources of pain. Anti-inflammatory treatments can improve almost all of the above conditions but can mask pain which would direct towards a diagnostic source. (25)

Neuroma treatment

Self-help measures

* Rest foot

* Massage foot and affected area

* Use ice pack

* Change footwear to wide-toed shoes, or flat (non, high-heeled) shoes.

* Wear arch supports--metatarsal pads or bars placed over the neuroma..

* Avoid activities which put repetitive pressure on the neuroma

* Practice strength exercises for intrinsic foot muscles

References

(1) Helfand A) Foot Problems in Older Patients. Journal of the American Podiatric Medical Association: 2004, 94, 3, 293-304.

(2) L Greenberg H Davis Isomoto S1, Tanaka Y Mortons disease Brain Nerve. 2014 Dec; 66(12):1453-7.

(3) Foot problems in the US. The 1990 National Health Interview Survey Journal of the American Podiatric Medical Association Aug 1993, Vol. 83, No. 8 (August 1993) pp. 475-483

(4) GA Gorecki (1978) Shoe related foot problems and public health. Journal of the American Podiatric Medical Association: April 1978, Vol. 68, No. 4, pp. 245-247.

(5) Lemont H, Krista M. Ammirati, and Nsima Usen (2003) Plantar Fasciitis. Journal of the American Podiatric Medical Association: 2003, 93 3, 234-237.

(6) Jariwala,A Bruce DA guide to the recognition and treatment of plantar fasciitis Primary Health Care, 2011, 21(7):22-24

(7) Lemont H, Ammirati KM, Usen NJ. Plantar fasciitis: a degenerative process (fasciosis) without inflammation. J Am Podiatr Med Assoc. 2003; 93(1):234-7

(8) Hafner S, Han N, Pressman M, Wallace C. Proximal plantar fibroma as an aetiology of recalcitrant plantar heel pain. J Foot Ankle Surg. 2011; 50(2):153-7

(9) Riddle DL, Pulsic M, Pidcoe P, Johnson RE. Risk factors for plantar fasciitis: a matched case-control study. J Bone Joint Surg. 2003; 85(5):872-7.

(10) Patel A, DiGiovanni B. Association between plantar fasciitis and isolated contracture of the gastrocnemius. Foot Ankle Int. 2011; 32(1)5-8.

(11) Riberio AP, Trombini-Souza F, Tessutti V, et al. Rearfoot alignment and medial longitudinal arch configurations of runners with symptoms and histories of plantar fasciitis. Clinics. 2011; 66(6):1027-33.

(12) Davis PF, Severud E, Baxter DE. Painful heel syndrome: results of nonoperative treatment. Foot Ankle Int. 1994; 15(10):531-5.

(13) Davidson J, Javarman S. Guided interventions in musculoskeletal ultrasound: what's the evidence? Clinical Radiology. 2011; 66(2):140-52.

(14) Demir et al, Prolotherapy Versus Corticosteroid Injections and Phonophoresis for the Treatment of Plantar Fasciitis: A Randomized Controlled Trial., 2015 ACR/ARHP Annual Meeting 2015

(15) Kiter E, Celikbase E, Akkava S, et al. Comparison of injection modalities in the treatment of plantar heel pain: a randomized controlled trial. J Am Podiatr Med Assoc. 2006; 96(4):293-6

(16) Scioli MW. Platelet-rich plasma injection for proximal plantar fasciitis. Tech Foot Ankle Surg. 2011; 10(1):27-31.

(17) Martinelli N, Marinozza A, Carni S, et al. Platelet-rich plasma injections for chronic plantar fasciitis. Int Orthop. 2013; 37(5):839-42.

(18) Diaz-Llopis IV, Rodrfguez-Rufz CM, Mulet-Perry S, et al. Randomized controlled study of the efficacy of the injection of botulinum toxin type A versus corticosteroids in chronic plantar fasciitis: results at one and six months. Clin Rehabil. 2012;26:594-606

(19) Kim C, Cashdollar MR, Mendicino RW, Catanzariti AR, Fuge L. Incidence of plantar fascia ruptures following corticosteroid injection. Foot Ankle Spec. 2010;3:335-7

(20) Buda R Castagnini F,Pagliazzi,G2017) Treatment Algorithm for Chronic Achilles Tendon Lesions. Journal of the American Podiatric Medical Association: 2017, 107, 2. 144-149.

(21) NA Grumbine, PA Radovic, R Parsons, and GS Scheinin (1990) Tarsal tunnel syndrome. Comprehensive review of 87 cases. Journal of the American Podiatric Medical Association: September 1990, Vol. 80, No. 9, pp.

(22) Rolf W. Scharfbillig, Sara Jones, and Sheila D. Scutter (2008) Sever's Disease: What Does the Literature Really Tell Us?. Journal of the American Podiatric Medical Association: May 2008, Vol. 98, No. 3, pp. 212-223.

(23) McIntosh I The aged foot. Podiatry Review2003 28.35 18-20

(24) Jigna Jani (2013) Histologic Evaluation of Intermetatarsal Mortons Neuroma. Journal of the American Podiatric Medical Association: May 2013, Vol. 103, No. 3, pp. 218-222.

(24) Mcintosh I Tendon and tissue problems in the foot Podiatry Review 70,4,6-7

(25) McIntosh I Orthotics--valuable or useless devices in Podiatric care 2015 Podiatry review 72. 2 .4-5

Written by Iain McIntosh BA (Hons) MBChB.DGMRCP
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Author:McIntosh, Iain
Publication:Podiatry Review
Geographic Code:4EUUK
Date:Jul 1, 2017
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