Pain in the Foot

23 Pain in the Foot


Foot pain is usually caused by inappropriate footwear, local disease, or an abnormality but occasionally results from referred pain. Therefore, examination of the foot should begin with the spine and proceed distally. Foot pain is often caused by muscular or ligamentous strain associated with trauma, unaccustomed or strenuous physical activity, and sports. Women frequently experience foot pain from new shoes or a change in shoe heel height. Other common causes are gout; rheumatoid arthritis, which usually affects the forefoot and midfoot; plantar warts; callosity; and metatarsal stress fracture (march fracture). Isolated pain in the heel can result from plantar fasciitis, subcalcaneal syndrome, arterial insufficiency, Achilles tendinitis or bursitis, and jogger’s trauma. In adolescents, pain in the heel may be caused by calcaneal apophysitis.



Nature of Patient


Foot pain in children is rare. When it does occur, it usually results from acute bone and ligament injuries or bone-tendon disorders such as traction apophysitis (Sever’s disease), which causes pain at the posterior and superior tip of the calcaneus. Overuse syndrome, especially Achilles tendinitis, often occurs in teenagers. It is caused only rarely by tumors, infections, or juvenile arthritis.


Because foot pain usually results from muscular or ligamentous strain, it is more likely to occur in people who are physically active, particularly those who are unaccustomed to physical exercise and muscular strain in their feet, such as unconditioned athletes and “weekend athletes.” The gradual development of forefoot pain in a new military recruit suggests a metatarsal stress fracture, which is most common in the second metatarsal, followed by the third and fourth metatarsals. Joggers and runners may experience Achilles tendinitis, tarsal tunnel syndrome, or plantar fasciitis. Ankle sprains and repetitive injuries are common in ballet dancers and athletes. Ankle pain can occur in rheumatoid arthritis and Lyme disease.


Gout is more common in men older than 40 years but does occur in women, especially those who are postmenopausal. The patient may present with a history of previous attacks of painful joints or urolithiasis. Often a family history of gout may be elicited.


Pain in the heel caused by plantar fasciitis and its associated soft tissue irritation is most common in obese patients older than 40 years. When adolescents complain of pain in the heel, it most likely is caused by calcaneal apophysitis. Achilles tendinitis, which also causes heel pain, is usually caused by trauma (e.g., injury from jogging), although the trauma may not be recalled by the patient. Achilles tendinitis is more common in patients with Reiter’s syndrome and ankylosing spondylitis who are positive for human leukocyte antigen (HLA) B27, even without a history of trauma. The physician should ask about recent use of fluoroquinolone antibiotics because this class of medications is known to increase risk of both Achilles tendinitis and tendon rupture. In patients with rheumatoid arthritis, foot pain is second in frequency only to knee pain, which is most common. In a diabetic patient, pain in an otherwise insensate foot may indicate Charcot’s foot, a form of neuroarthropathy. However, this condition manifests as erythema, warmth, and swelling of the foot, so osteomyelitis, arterial insufficiency, and deep vein thrombosis need to be considered.



Nature of Symptoms


As with other types of pain, a careful history of the location (forefoot, midfoot, or hindfoot) and quality of the pain (how it began, what intensifies it) is most helpful in determining its cause.


Forefoot pain, generally referred to as metatarsalgia, has many causes. They include metatarsal stress fracture, interdigital neuroma, Freiberg’s infraction, gout, sesamoiditis, synovitis or dislocation of the metatarsophalangeal (MTP) joint, plantar warts, and atrophy of the plantar fat pad. Midfoot pain is an infrequent complaint but usually results from tendinitis or acquired flatfoot. Inferior heel pain is often used to describe hindfoot pain. This common complaint is most commonly caused by plantar fasciitis. Other common causes are calcaneal apophysitis, heel pad fat atrophy, nerve entrapment, tarsal tunnel syndrome, and arterial insufficiency. Posterior heel pain is usually due to Achilles tendinitis or rupture.


Foot pain described as a dull ache is probably caused by foot strain. This is more likely to occur in older adults, overweight people, people wearing new shoes, and those who are on their feet for much of the day. It is critical that the physician establish the precise location of the ache because this fact determines which ligaments, tendons, or fascia is involved (torn or under strain). For example, pain below the ankle on the inner aspect of the heel suggests a tear or strain of the ligamentous fibers attached to the internal malleolus. Symptoms such as burning, tingling, or numbness suggest neuropathy.


Plantar warts and callosity can cause severe pain, particularly with weight bearing. These conditions are typically located on the plantar surface of the foot in the metatarsal region. Pain from a calcaneal spur or plantar fasciitis is usually continuous, although it may worsen with weight bearing. The spur is usually located in the center of the undersurface of the heel, about 2.25 cm from the back of the foot; however, the pain may be more toward the back of the heel. The condition called jogger’s foot or tarsal tunnel syndrome may produce the complaint of a burning pain in the heel, aching in the arch, or diminished sensation in the sole behind the large toe.


Patients with entrapment of the tibial nerve (tarsal tunnel syndrome) may report poorly localized burning pain around the medial malleolus that radiates to the plantar surface of the foot and toes.


The pain of Achilles tendinitis is usually over the Achilles tendon and may be associated with tenderness on palpation and swelling.


With gout the pain is usually acute, frequently recurrent, and often agonizing, although atypical cases of gout may cause less severe symptoms. The attacks usually have a sudden onset and characteristically start during the early hours of the day, while the patient is still in bed. Before gout is diagnosed, the patient may attribute the bouts of pain to minor trauma such as “stubbing the toe” or “spraining” the involved joint. Once the diagnosis of gout has been established, the patient usually recognizes subsequent attacks. Although the MTP joint of the big toe is classically affected, one or more other joints, including the ankle, may also be affected.


In general, systemic causes of foot pain, such as gout, rheumatoid arthritis, and diabetes occur at rest, whereas biomechanical causes of foot pain, such as sprains and calcaneal spurs, occur with ambulation and decrease with rest.

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Mar 21, 2018 | Posted by in BIOCHEMISTRY | Comments Off on Pain in the Foot

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