FOOT PAIN
The foot is a strong mechanical structure made up of 26 bones, 33 joints and more than a hundred muscles, ligaments and tendons that fit together meticulously along two crossing arches. The ankle joint connects the foot to the lower leg. The foot also has some unique areas of tissue like the plantar fascia and fat pads which provide secondary support and act as shock absorbers.
Many things can cause foot pain (or feet pain) but the most common causes are trauma, injuries and diseases.
Foot pain is often short-term or acute, lasting a few days to a few weeks and being mild in nature. It usually improves on its own with self-care and simple measures. It is called subacute foot pain if it lasts between 4 and 12 weeks.
Chronic foot pain, on the other hand, lasts for 3 months or longer, even after the initial injury or underlying cause of pain has been treated. Chronic foot pain can occur in a small group of people that get acute foot pain. This means that the pain can continue for much longer than expected and in some of those cases the chronic lower foot pain can be difficult to treat.
FOOT PAIN SYMPTOMS
Foot pain can occur suddenly or slowly, depending on the cause. Foot pain usually occurs immediately after an injury although sometimes the onset of symptoms can be delayed.
Symptoms may include a ankle pain or a stiff foot. Restrictions in certain movements might include inability to bring the foot up (heel walk) or down (walking on toes). Foot weakness may also be present. Foot pain may radiate anywhere in the region and even up into the leg. Sometimes pain may radiate down into the foot. There might be tingling, numbness, pins and needles and weakness.
Severity can be rated on a scale from 1 to 10, or from mild to severe.
Sometimes people can be very unwell if there is a more serious cause like an infection or fracture of the spine.
If there is an infection, the area could also be red, swollen and warm.
FOOT PAIN CAUSES
The foot is a highly mechanical structure and foot pain occurs when there is a disruption in the way the parts of the foot fit together and work. These include the bones and surrounding muscles, tendons and ligaments. The foot has many nerves too, so it may be that some causes of foot pain are related to nerves and nerve problems.
If one part is faulty, the whole system can be affected and malfunction.
The precise location of the foot pain and associated symptoms can provide valuable clues about the underlying cause, e.g., arch pain may signify a plantar fasciitis or a tendonitis. Back of heel pain might mean heel spurs. Forefoot pain might mean a Morton’s neuroma or metatarsagia. Big toe pain may signify a trapped lumbar L5 nerve (a nerve in the lower part of the spine). Pain in both feet in a sock-like area may signify neurological problems like diabetic neuropathy or spinal cord problems.
When foot experts make an assessment, a few things need to be considered, because the pain could be caused by a number of problems in or around the area. A few foot pain causes are:
Foot strain and sprains of surrounding muscles, ligaments, and tendons. This can cause muscle spasms and tenderness. Muscles that could be causing pain through strain or spasm include the abductor digiti or hallucis muscles, the flexor digit muscles, the extensor digiti or hallucis muscles, and the plantar aponeurosis. Achilles tendonitis is an overuse injury of the Achilles tendon, which connects the calf muscles to the heel bone, causing Achilles heel pain.
Achilles tendon rupture: sometimes if the Achilles tendon is overstretched it can tear partially or completely (rupture). This usually occurs in those playing sports but can occur in anyone.
Joints. There are 33 joints in the foot and any of them can become injured. The joints can become inflamed and swollen, which can cause stiffness and pain. Sometimes joint pain can be debilitating and long-lasting.
Bursitis occurs when small, fluid-filled sacs that cushion the foot bones, tendons and muscles become inflamed.
Myofascial pain. This is pain that occurs because of problems with the surrounding muscles, ligaments and tendons of the foot as mentioned above. The muscles may develop discrete little tight knots (taut bands) that are called myo-fascial trigger points. Trigger points are hyperirritable spots in the covering (fascia) surrounding muscle and can be very painful and quite debilitating. When a trigger point is touched or examined, it can cause exquisite pain in and around the area. Sometimes trigger points are overlooked as a cause of foot pain.
Heel pain syndrome can sometimes occur when the fat pads in the heels lose their elasticity due to aging or excess weight. This can cause inflammation and a dull, chronic ache in the heel.
Arthritis of the foot bones can occur quite commonly. Osteoarthritis can affect any of the joints. The joint at the base of the big toe is called the metatarsophalangeal (MPT) joint, is usually the joint most affected by osteoarthritis and gout. Other forms of arthritis that could affect the foot include rheumatoid arthritis, psoriatic arthritis, reactive arthritis and septic arthritis. When joints become infected it is called septic arthritis.
Morton’s neuroma is where nerves in the foot (particularly forefoot) become swollen, inflamed and painful.
Biomechanical problems. Biomechanical problems might include flat feet, bones spurs (bony projection) or bunions (bony bump usually at the base of the big toe).
Referred pain: referred pain is where pain in one part of the body can be felt in another part of the body that is nearby. This occurs when different parts of the body share the same nerves to send signals to the spine and brain. Spinal problems like facet joint arthritis or disc prolapses can both contribute to spinal nerves being compressed where they leave the spinal column (pinched nerves). This compression condition is called lumbar foraminal stenosis and can cause radiating pain anywhere down into the buttock, leg or foot. Lumbar spondylosis (osteoarthritis) is spinal arthritis, which is an age-related condition that affects the joints, discs and ligaments of the spine, which can sometimes cause foot pain. Other problems with the spine may be spondylolisthes (misalignment of spine bones occurs when one vertebra slips over the one below it).
Nerve pain: sometimes neurological problems can cause nerve pain in the foot. Neurological causes might include shingles (zoster), post herpetic neuralgia, Morton’s neuroma or even conditions like diabetic neuropathy.
When pain persists following acute pain, this can sometimes cause changes within the nerves and set up some forms of nerve pain, also called neuropathic pain. Nerve pain can sometimes be hard to diagnose and usually needs to be assessed and treated by pain specialists.
When a compression occurs into the spinal column itself, this may be called lumbar spinal stenosis and if the compression is serious it can compress the spinal cord itself, which is called myelopathy. Myelopathy is when the compression of the spinal cord starts causing symptoms, such as weakness or problems with coordination in the arms, hands, legs, or even feet.
Complex regional pain syndrome (CRPS) is a severe pain condition of an arm, hand, leg or foot, which occurs after an injury, such as a fracture. CRPS can affect other body parts, such as the face. CRPS is caused by damage to, or malfunction of parts of the nerves and nervous systems. This condition can be debilitating and should be managed early by experienced pain specialists.
Sensitisation: sometimes a problem in the nervous system called sensitisation can occur. This is when the pain, usually a nerve pain seems to be spreading up into the body and or down into the arm, or even into the other side of the body. People with sensitisation can have sensitive skin in the foot region and even light touch using a brush can be exquisitely painful.
Post-surgical pain: after an operation or surgery, pain can sometimes persist after the tissue has had sufficient time to heal. This can occur in up to 25% of all surgeries and sometimes the persistent foot pain can be intolerable and debilitating. Post-surgical pain can be caused by almost any type of operation on the foot, and can be caused by many things, including nerve injury or scarring, ongoing inflammation or infection, muscle weakness and stiffness. This is a complex pain condition and should be assessed and managed by pain specialist physicians in conjunction with the operating surgeons.
Contact us to find out what's causing your pain.
WHO GETS FOOT PAIN?
Although anyone can get foot pain some people are more likely to develop it.
Here are a few risk factors that might make the development of foot pain more likely:
Older age
Abnormal walking style (gait), such as rolling the feet inwards
Being overweight
Poor fitting shoes
Standing, running or jumping on hard surface
Lack of exercise and low fitness level
Diabetes may affect the small nerves of the legs and result in peripheral neuropathy foot pain
HOW DO I GET A FOOT PAIN DIAGNOSIS?
Foot pain is usually mild and settles by itself, but in some circumstances the pain can be complex and should be assessed by a medical professional or pain specialist who will take the time to understand the pain story and perform a physical examination before setting forward a diagnosis and treatment plan.
In some circumstances imaging tests may be required. Types of imaging tests include X-rays, CT scans, MRI scans, bone scans and ultrasounds.
Once a foot pain diagnosis is made, the medical professional or pain specialist will determine the best pain treatment options.
Book an appointment to have a Pain Specialist make a foot pain diagnosis.
WHAT FOOT PAIN TREATMENT IS AVAILABLE?
Treatment of the foot pain depends on whether the problem is acute (meaning it only occurred recently i.e. days and weeks) or chronic (meaning it has been present for more than 2-3 months).
ACUTE FOOT PAIN TREATMENT
Most acute foot pain is mild and settles with simple treatments. Treatment usually depends on the cause.
Simple treatments like hot or cold packs, physical activity, exercise and physical therapy can be effective.
Pain medications like anti-inflammatories and anti-spasm medications can provide foot pain relief.
If the cause of the pain has been treated but the pain continues, is long lasting (chronic pain), debilitating, and has not been responding to treatments an assessment should be made by a pain management specialist, who can assess and treat most types of chronic pain.
CHRONIC FOOT PAIN TREATMENT
Through years of experience, we’ve figured out that good and long-lasting chronic foot pain relief doesn’t work unless all bases are covered.
The best foot pain management combines pain-reducing treatments combined with other selected therapies like physical and psychological rehabilitation treatment.
TYPES OF TREATMENT
Medications to reduce the pain. These may be simple over the counter medications or can be medications prescribed by a pain specialist. Medications might include muscle relaxants or anti-neuropathic (nerve pain relief) medications. Sometimes analgesic compound creams are used to ease pain.
Pain interventions; injection therapies can be used to target, diagnose and manage chronic pain caused by muscle, joint and nerve pain. It includes interventional therapies like nerve blocks (saphenous nerve, sural nerve, superficial and deep peroneal nerves, tibial nerve, lumbar nerve roots, the sciatic nerve and lumbar plexus) radiofrequency ablation (RFA), pulsed radiofrequency (PRF) to the nerves previously blocked and mentioned above. Epidural and nerve root steroid injections. Sympathetic nerve blocks can also be performed.
Platelet-rich plasma can also be used in some locations around this area. Botox injections can be considered for certain types of muscular or nerve pain. For muscular pain, it can be injected into the muscle and for nerve pain it is usually injected under the skin of painful areas and can be helpful in providing pain reduction that can last many months at a time.
Nerve stimulation, also called neuromodulation or spinal cord stimulation are advanced pain reduction techniques that can work really well for severe foot pain Some forms of spinal cord stimulation are high frequency stimulation (HF10), tonic stimulation, multi-waveform stimulation, BurstDR stimulation and even dorsal root ganglion (DRG) stimulation. Spinal cord stimulation is a commonly used treatment for foot nerve pain that does not respond to other forms of treatment.
Surgery is generally recommended when tests show structural changes that need corrective surgery. These are typically performed by an orthopaedic surgeon. Types of foot surgery include repair surgery, removal (excision) surgery, remodelling (arthroplasty) surgery, stabilisation/fusion (arthrodesis) or replacement. Surgery is not a common treatment for chronic foot pain.
Rehabilitation: most types of chronic pain treatment should be managed alongside some form of specialist rehabilitation. This is when the best results occur.
HOW DO I GET FOOT PAIN RELIEF?
Severe foot pain is best assessed by a medical doctor like a general practitioner (GP). They will make an assessment and make sure there are no warning signs for something serious.
If they suspect something more serious is causing the foot pain, they may do some scans or blood tests and make a referral to the appropriate specialist for treatment. If no serious cause is diagnosed, the referral may be to a pain specialist for an assessment and therapy with the use of advanced pain management techniques.
If the pain is mild or improving, GPs may:
Reassure that there is no serious cause for concern and advise that the foot pain should improve with physical activity and simple pain medications.
If the pain persists or returns GPs may:
Use stronger pain medications
Suggest management by an expert pain physiotherapist if the foot muscles or joints are suspected to be a cause or contributor to the pain or if there is significant stiffness and weakness associated with lack of movement caused by the pain.
Refer to a pain specialist physician to provide more comprehensive pain management using options like joint and nerve blocks, sympathetic blocks and radiofrequency ablation (RFA), pulsed radiofrequency or nerve stimulation and neuromodulation using spinal cord stimulation as mentioned above.
Refer to an orthopaedic surgeon for an opinion.
Contact us to book an appointment with a pain specialist.
WARNING SIGNS OF MORE SERIOUS FOOT PROBLEMS
In some instances, pain can indicate more serious foot problems or diseases elsewhere. These problems might include cancer, fractures, infection, severe nerve compression (pinched nerve), compartment syndrome or DVT.
If there is cancer in the bones of the foot. This is not common but is possible.
Fractures of the foot can be caused by a direct hit, fall, or accident, and sometimes can occur without trauma, as spontaneous fractures.
Infections of the joints (septic arthritis) tend to occur if patients have a weakened immune system from any cause or medical condition. Sometimes infections of the spine can occur if there is an infection elsewhere in the body. People with joint infections usually feel unwell and can have sweats and a fever. Another type of infection is osteomyelitis, which is when there is an infection in the bone itself. Other types of infection include cellulitis, which is a bacterial infection of the skin and tissues beneath the skin, which can occur with poor care of the feet or in some people predisposed to foot infections, like diabetics.
Nerve compression, called myelopathy, where there is a dangerous compression of the spinal cord in the neck. Myelopathy could cause symptoms that can include weakness or problems with coordination in the legs or feet. Other types of nerve compression might occur at the knee or just below, where the common peroneal nerve can be damaged. This can cause pain in the foot and usually causes a foot drop (dropping of the forefoot due to weakness, irritation or damage to the common fibular nerve or paralysis of the muscles in the front of the lower leg).
Compartment syndrome occurs when an injury to the leg results in swelling and a dangerous build-up of pressure in the muscles of the leg, which can cut off the blood flow.
Deep vein thrombosis (DVT) is when a blood clot develops in the deep veins of the lower leg. It can occur after spending a long time sitting down, for example, on a long flight. If a DVT breaks away and travels (embolus) to the lungs it can be life threatening (pulmonary embolus).
Seek urgent and specialist medical advice if you have experienced:
Sudden, unrelenting, disabling and severe foot pain
Recent weight loss
Recent injury or fall
Large defect in the Achilles tendon and not being able to walk
Signs of infection like fever or feeling unwell, redness, heat or swelling
Burning pain, numbness or tingling
Weakness in foot e.g. a foot drop
An inability to bend the foot downward or "push off" the injured leg when walking
An inability to stand on the toes on the injured leg
Problems with bladder or bowel function
Worsening stiffness
Persistent pain after a few days or weeks
