Despite the fact that there are 26 bones in each foot and over 20 joints, the vast majority of foot pain stems from soft tissue inflammation and injury – caused mostly by overuse. When people have swelling, pain and disability in their feet they often think an x-ray should be taken. In fact, an x-ray is rarely useful. The most common foot pain that is x-rayed is heel pain. Even when an x-ray shows a “heel spur” it is a misleading diagnosis, since heel pain is almost always caused by soft tissue inflammation of the soft tissue structure known as the plantar fascia, where it inserts into the heel. The x-ray finding is usually irrelevant. My favourite soft tissue disorders are listed below.
Defined as pain in the ball of the foot. There are an infinite number of causes. Generally speaking, pain in the ball of the foot is caused by soft tissue inflammation. It usually affects the 2nd or 3rd ball of the foot joints (MPJ’s) or can be felt on the outside of the foot. People mistakenly think the pain is caused by a dropped metatarsal head. This is almost never true. Metatarsal heads cannot “drop” because they are all connected via ligaments and joint capsule – the 2nd, 3rd and 4th MPJ’s work together as a unit. Unless you have systemic arthritis, metatarsal heads do not and cannot “drop”. This is why the use of metatarsal pads (which are designed to “lift” a dropped metatarsal head) is generally unsuccessful and often counterproductive. Occasionally, pain in the metatarsal head area can be a stress fracture. This condition can be diagnosed easily because of the characteristic swelling and warmth it causes in a localized and specific area of the foot. An x-ray can confirm the diagnosis 10 days after the crack in the surface of the bone occurs.
Back to the usual cause of metatarsalgia – soft tissue strain. The most common causes are over-exertion, poor footwear, high arched feet, high impact activities, excess pronation. The classic scenario involves someone who has just returned from a walking holiday in Europe where they wore thin soled flimsy shoes for miles and miles of walking on cobblestone streets.
Treatment usually includes rest, massage, improved footwear, some type of insole or orthotic and time.
This condition is extremely painful and difficult to treat. Under the big toe joint there are 2 small bones called sesamoids. They act for the foot in a similar way that the patella acts for the knee. They guide tendons to the big toe joint and are responsible for maintaining stability of the joint. If they become inflamed they result in considerable pain with walking and standing. They burn, ache and make one’s life downright miserable. This condition is common in dancers.
The treatment involves unweighting the sesamoids (using padding techniques to lift weightbearing pressure off the bones). Sometimes this can be done with simple padding and other times it has to be done in conjunction with a custom orthotic.
There are a number of tendons that can become inflamed – the 3 most common are the peroneal tendon (on the outside of the leg and foot), the posterior tibial tendon (on the inside of the leg and foot) and the achilles tendon. All of these tendons are responsible for control of foot motion. They become inflamed when faulty biomechanics of the foot or lower extremity changes the function of these tendons. Generally speaking, people with overly pronated feet are more likely to have problems with the posterior tibial tendon or the achilles tendon, while people with overly supinated feet tend to develop problems with the peroneal tendon. Peroneal tendonitis is also commonly associated with chronic foot pain. The tendons can be tender, warm, swollen or may simply ache and interfere with regular activities and walking.
Achilles tendonitis is quite common, especially in runners and athletes. Eliminating or modifying one’s running activities is the most effective but least desirable treatment option. There may be underlying factors that predispose someone to developing achilles tendonitis. These would include a tight achilles tendon, excess pronation, improper footwear and improper training techniques. Many a sports medicine specialist sees achilles tendonitis en masse. Physiotherapy is a good place to start. The podiatric approach focuses on proper pronation control and dealing with the faulty biomechanics.
Suffered by most of us on an ongoing basis because we simply are on our feet too much. The odd ache and pain in the foot is usually a ligamentous strain. It hurts intensely in a localized area – usually for less than a week. Often the problem is related to a specific incident – dancing barefoot for an evening. twisting the foot while walking on a railroad track, wearing heels higher than one is used to – there are many scenarios. Rest and ice and good shoes are the standard treatment suggestions.