Foot pain Problems

Mohamed Aouini nsmp physiotherapist

Your Foot_ The feet are flexible structures of bones, joints,

muscles, and soft tissues that let us stand upright and perform activities like walking, running, and jumping.

_ The foot contains 26 bones 33 joints 19 muscles 107 ligaments.

The feet are divided into three sections- Forefoot - Midfoot- Hindfoot

Forefoot

Contains the five toes (phalanges) and the five longer bones (metatarsals).

Midfoot

Pyramid-like collection of bones that form the arches of the feet.

Include the three cuneiform bones, the cuboid bone, and the navicular bone.

Rearfoot

Forms the heel and ankle.The talus bone supports the leg bones (tibia and fibula),

forming the ankle.The calcaneus (heel bone) is the largest bone in the foot.

Foot arches

Foot has three distinct arches.

Two "longitudinal" arches (one on each side)run from front to back

One "transverse arch" runs across the midfoot from inside to

outside.

Foot arches

Functions of foot arches

- The structure of an arch is the spread the load out so it can be supported with the least amount of effort and material.

- Some shock absorbency,

- Prevents blood vessels and nerves from being crushed.

Functions of the foot

Proper functioning of the foot is required for normal gait

Weight DistributionWeight of the body is supported by the foot,

and is transmitted and distributed over 6 areas

Functions of the foot

foot pain complaints

- Heel pain ( arising the rear foot ) - Midfoot pain - Forefoot pain

• Rear foot painthe most common cause of rear foot (inferior heel)pain is : - Plantar fasciitis - fat pad (Bursitis )The less common cause of rear foot is : - calcaneal stress fracture -Tarsal tunnel syndrome - lateral plantar nerve entrapment

• Anatomy of the Plantar Fascia

• Broad, dense band of longitudinally arranged collagen fibers• 3 bands: medial, central, lateral• Origin: anterior aspect of calcaneal tuberosity• Distally divides into 5 digital bands at the metatarsophalangeal joints• Each digital band pass on either side of flexor tendons and inserts dorsally at the base of the toes.

• Anatomy of the Heel Fat Pad• Within the heel pad region, particular attention is paid to the calcaneal fat pad, which is

the portion of the plantar region interposed between the calcaneus and skin that plays a fundamental role in foot mechanics (Natali et al., 2010).

• The calcaneal fat pad is mainly organized according to a honeycomb configuration (Jahsset al., 1992a-1992b; Snow and Bohne 2006).

• Fat tissue chambers are embedded and separated from each other by connective septa .

• Roles of Plantar Fascia and the heel fat pad_ Plantar Fascia:• is a ligament structure that supports on static the

longitudinal arch of the foot and dynamic shock absorbation

_ The heel fat pad:• Acting as a shock absorber, protecting the

calcaneus at heel strike

• Pathophysiology- Plantar Fasciitis :• Pain on the inner-bottom of the heel.• Decreased vascularity• Perifascial inflammation• Thickening of the proximal plantar fascia

- fat pad (Bursitis ) or (contusion)• The patient often complains of marked heel pain during weight-bearing

activities• Thick fat pad covering calcaneus bruises from sport activities• The pain is often felt laterally in the heel due to the pattern heel strike • Examination reveals tenderness often in the posterolateral heel region • There may be an area of redness

• Physical Exam _ plantar faciitis • Tenderness to palpation on the anteromedial aspect of the heel.• Ankle dorsiflexion limited by calf tightness.• Pain increased by toe extension or by standing on toes.

• Physical exam (con’t)_ The heel fat pad:• The patient often complains of marked heel pain particularly during weight bearing activities.• The pain is often felt laterally in the heel due the pattern of heel strike.• Tenderness often in the

posterolateral heel region.

Causes Plantar fasciitis :• Occupation requiring prolonged standing.• Pes planus (low arches flat feet) or pes cavus ( high arches).• Activities require maximal plantar- flexion of the ankle and

simultaneous dorsi-flexion of metatarsophalangeal joints. • in older patient Excessive walking inappropriate or non-supportive

footwear• Obesity • Reduced ankle dorsiflexion

the heel Fat pad:

• Fat pad contusion or fat pad syndrome may develop either acutely after a fall onto the heels from a height or chronically because of the excessive heel strike with poor heel cushioning or repetitive stops, starts and change direction

Treatment plantar fasciitis• Avoidance of aggravating activity • Cryotherapy after activities• Stretching of the plantar fascia, gastrocnemius and soleus• Night splints or strasbourg socks • Self massage with a frozen bottle of golf ball • Strengthening exercises for intrinsic muscles of the foot to improve

longitudinal arch support and decrease stress on the plantar fascia • Taping • Silicone gel heel pad • Soft tissue therapy both to the plantar fascia and proximal myofascial

regions including calf, hamstring and gluteals

Heel fat pad treatment • Treatment consists primarly of avoidance of aggravating activities, in

particular,excessive weight bearing • RICE • Silicone gel heel pad • Good footwear are important as a athlete • Heel lock taping will often provide symptomatic relief.

Calcaneal stress fractures • Calcaneal stress fractures are the second most common tarsal

stress fracture. They occur most commonly at two main sites:• Upper posterior margin of the os calcis • Adjacent to the medial tuberosity

Causes • Calcaneal stress fracture were first described among the

military and are related to marching; they also occur in runners, ballet dancers and jumpers.

Symptoms• Patient give history of heel pain that aggravating with weight

bearing activities especially running .• Examination reveals tenderness over the medial or lateral

aspects of the posterior calcaneus • Pain produced by squeezing the post aspect of the calcaneus

from both sides.

Investigation• X-ray may show a typical appearance on the

lateral X-ray, parallel of the posterior margin of the calcaneus

Treatment• Reduce activity • For who with marked pain a short period of non-weight

bearing may be required • Program of gradually increased weight bearing can occur • Stretching of the calf muscle and plantar fascia • Joint mobilization For long term recovery• Soft heel pads if required are recommended

Lateral plantar nerve entrapment• An entrapment of the first branch of the lateral plantar nerve occur

between the deep fascia of the abductor hallucis longus and the medial caudal margin of the qudaratus planus muscle

• Pain radiates to the medial inferior aspect of the heel and proximally into the medial ankle region

• Patient do not normally complain of the numbness in the heel or the foot

• A diagnostic injection with local anesthetic will confirm the diagnosis

Treatment • Treatment consist of rest • NSAIDs and iontophoresis• Arch support using taping or an orthosis is helpful in

athletes with excessive pronation

tarsal tunnel syndrome• impingement and inflammation of the posterior tibial nerve

within the tarsal tunnel

Causes• in approximately 50% of cases the cause of tarsal tunnel syndrome is

idiopathic, it may also occur as a result of trauma ( e.g inversion injury to the ankle) or overuse associated with excessive pronation.

• EV or PF/EV ankle injury or Forced PF • Repetitive stress associated with pes planus foot• Possible related factors :raining surface ,Distance ,Shoes

Symptoms• pain, numbness, or • parasthesia along

medial or plantar aspectof foot

• Point tendernessproximal, over, and distal to the flexorretinaculum

Examination• Pain is usually aggravated by activity and relieved by rest • Swelling , varicosities or thickening may be found on examination

around the medial ankle or heel• A ganglion or cyst may be palpable in the tendon sheaths around the

medial ankle • Tapping over the posterior tibial nerve (Tinel’s sign) may elicit the

patients pain and occasinally cause fasciculation • AROM normal EV may reproduce symptoms• PROM PF & EV may reproduce symptoms• RROM may demonstrate weakness of toe flexors

Investigation• Ultrasound or MRI may be required for the space-occupaying lesion as

a cause of the syndrom

Treatment • Conservative_Treatment with NSAID and, if required an injection of a

corticosteroid agent into the tarsal tunnel may be helpful_ if excessive pronation is present , an orthosis should be utilized

• surgical _ if there is mechanism cal pressure on the nerve a

decompression of the posterior tibial nerve and its branches should be performed

Talar stress fracture• During weight bearing activity compressive forces are placed

through the talus. When these forces are excessive, too repetitive and beyond what the bone can withstand, bony damage gradually occurs.

• This initially results in a bony stress reaction, however, with continued damage may progress to a talus stress fracture.

Causes• Stress fractures of the talus typically occur gradually over time with

excessive weight bearing activity such as running.• occur following a recent increase in activity or change in training • in athletes involved in running sports such as football and athletics. Signs and symptoms • deep ankle pain that increases with weight bearing activity. • walking may be enough to aggravate symptoms. • night ache, pain during certain movements of the foot and ankle • pain on firmly touching the talus.

Diagnosis• thorough subjective and objective examination from a physiotherapist

may be sufficient to diagnose a talus stress fracture. • Investigations such as an MRI, CT scan or bone scan are usually required

to confirm diagnosis.

Treatment

• Reduce activity • For who with marked pain a short period of non-weight bearing

may be required • Program of gradually increased weight bearing can occur • Stretching of the calf muscle and plantar fascia • Joint mobilization For long term recovery• Soft heel pads if required are recommended

Mid foot pain• the most common cause of mid foot:- Navicular stress fracture - Midtarsal joint sprain - Extensor tendinopathy - tibialis posterior tendinopathy • Less common causes - Cuneiform stress fracture - Cuboid stress fracture - stress fracture of base second Metatarsal

- Peroneal tendinopathy - Abductor hallucis strain- Cuboid syndrome

Navicular stress fracture• Patients who develop navicular stress fractures will present with a chronic

mid-foot ache. • The injury may begin after a series of repetitive loading episodes. • In sport involving sprinting,jumping,hurdling

Causes • Overuse and training errors plays • Impingement of the navicular bone occur between the proximal and distal tarsal bones when muscle exert compressing and bending forces .

Symptoms • vague arch pain with midfoot tenderness at the ‘N-SPOT’, located at the proximal dorsal portion of the navicular. • the pain radiates a long the medial aspect of the litudonginal arch or the dorsum of the foot .• the symptoms abate rapidly with rest.

investigation • X-RAY in the navicular stress fracture is poor.• CT scan or MRI is required

TreatmentThe treatment of navicular stress reaction is :• Weight bearing rest, often in an air cast until symptoms and signs have

resolved • Gradually return to activity The treatment of navicular stress fracture is :• not bear weight on their foot for at least 6 to 8 weeks with immobilzation

In a cast .• At the end of this period the cast should be removed and palpate the ‘N-

SPOT’ normally will be no tender .• Some clinician advocate surgical treatment with the insertion of a screw

where there is significant separation of the fracture.• It is essential to mobilize the stiff ankle after the cast and soft tissue

therapay and strengthening • Gradually return to activity

Extensor tendinopathy The extensor dorsiflexion of the foot comprise the :• Tibialis anterior • Extonsor onghallucis Lus and brevis • Extensor digitorum longus and brevis• Tibialis anterior is the most common tendinopathy Causes • Tibialis anterior tendon resists plantarflexion of the foot and

heel strike and Is ,therefore , sucpetible to over use injury.• Extensor muscle Weakness.• Increase training load or compression tight shoelaces.• Stifness of the first metatarsophalangeal and midfoot may

contribute.

Symptoms • patient complains of an aching dorsal aspect of the midfoot • Examination reveal tenderness with mild swelling • At the insertion of the tibialis ant tendon at the base of the first metatarsal

and cuneiform.• Resisted dorsiflexion and eccentric inversion may elicit pain .

Investigation • ultrasound and MRI may reveal swelling of the tendon at it is insertion and exclude the presence of degnerative tear .

Treatment • Rlative rest • Soft tissue therapy• Extensor muscle strengthening

Tibialis posterior tendinopathy• starts at a muscle in the calf, runs down the inside of the lower

leg and then travels around the ankle before attaching to bones navicular in the arch of the foot.

• helps point the foot down and in to stabilize and support the arch of the foot.

Causes • occur from overuse of the tendon where it is attached to the navicular

bones and helps to stabilize your arch. If your arch flattens out more than normal when you walk or run you strain more your tendon.

• With excessive, repetitive loading .• posterior tibial tendon dysfunction is more common in women and in

people older than 40 years of age. Additional risk factors include obesity, diabetes

signs and symptoms• Pain or tenderness on the inner side of the shin ankle or foot.• Pain with lifting up your foot.• Pain walking or running .• Resisted inversion will elicit pain andWeakness .

Investigation• MRI or ultrasound may confirm diagnosis• And reveal the extent of tendinosis.• In cases of suspected inflammatory tenosynovitis ,blood test for

serological martand inlammatory markers should be performed

• Treatment • Conservative treatment consisits of:- Control pain with ice- Concentric and eccentric tendon loading exercises - Soft tissue therapy to the belly muscle and tendon- Rigid orthosis to control excessive pronation

- in severe cases a period of immobilization in air cast has been prescribed to provide short-term symptom relief.

- If there is tendon rupture or failed conservative treatment surgery is recommended.

Cuboid syndrome • The cuboid is one of the small bones on the outer side of the

midfoot,due to the excessive peroneus longus the cuboid becomes subluxated

• With an inversion sprain of the ankle this is when the foot and heel bone are forced inwards while the cuboid is forced outwards.

Sings and Symptoms• Pain with weight bearing down the outside of the foot• quickly changing direction, jumping or hopping and

symptoms tend to ease with rest. • quickly changing direction, jumping or hopping and

symptoms tend to ease with rest.• There is may a visible depression over the dorsal aspect of

the cuboid.

Treatment• Treatment involves a single manipulation to reverse the

subluxation • The cuboid should be pushed upward and laterally from the

medial plantar aspect of the cuboid

Cuneiform stress fracture• The stress fracture of the cuneiform bones are rare and

described in military recruits and athletes • they are thought to occur secondary to repetitive loading of the

bone

Management • Limited weight-bearing rest for the medial cuneiform• Surgical reduction and fixation for adequate healing for the

intermediate cuneiform

Cuboid stress fracture

• Stress fracture of the cuboid are rare and occur secondary to compression of the cuboid between the calcaneus and the fourth and fifth metatarsal bones when exaggerated plantar-felxion is undertaken

Treatment • In absence of displacement is non weight-bearing for 4 to 6

weeks.• Graduated return to activity • If displacement are present surgical reduction and fixation are

required

Fore foot painHallux valgus• Hallux valgus means lateral deviation of great toe• Commonest of foot deformities• Not a single disorder; but a complex deformity of the first ray• Frequently accompanied by deformity and symptoms in lesser toes

Spectrum of hallux valgus• Varus deformity of first metatarsal• Valgus of great toe• Great toe bunion formation• Arthritis of 1st MP joint• Hammer toe• Toes corn• Calluses• Metatarsalgia• Stress fractures of lesser metatarsals

Causes of Hallux Valgus• High-heeled or ill-fitting shoes

• Inherited foot type

• Foot injuries

• Deformities present at birth (congenital)

• May be associated with various forms of arthritis and an activities that puts extra stress on the feet (eg. Bunions are common in ballet dancers.)

Bunions

Symptoms and Signs• Foot pain in the involved area when walking or wearing shoes.

That is relieved by resting.

• Bulging bump on the outside of the base of big toe

• Swelling, redness or soreness around big toe joint

• Thickening of the skin at the base of big toe

• Restricted movement of big toe

• Positioning of the big toe toward the smaller toes.

Classification of hallux valgus

• Mann and conghlin(1993) classified HV into 3 types based on Hallux valgus angle– Mild: Angle < 20 degree, intermetatarsal angle usually less

than 11 degree– Moderate: Angle 20 - 40 degree, intermetatarsal angle

between 11 and 18 degree– Severe: Angle > 40 degree, intermetatarsal angle > 16-18

degree

Treatment of hallux valgus• Management:

– Young and asymptomatic patients• Proper fitting shoes with wide deep toe boxes• Night splinting and other orthosis

– Once the deformity is established, it is difficult to check the progression of disease by conservative measures.

– In more severe cases surgery may be required to reconstruct the first metatarsophalangeal and remove the bony exostoses .

Hammertoes• A hammer toe or contracted toe is a deformity of the proximal

interphalangeal joint of the second, third, or fourth toe causing it to be permanently bent, resembling a hammer.

Hammertoes Causes Wearing poorly fitting shoes that can force the toe into a bent

position (eg. High heels)

Muscle, nerve, or joint damage resulting from conditions such as osteoarthritis, rheumatoid arthritis, stroke or diabetes

Often found in conjunction with bunions or other foot problems

Hammertoes signs and sympotms Pain with walking

Difficulty moving the toe

Corns and calluses resulting from the toe rubbing against the inside of footwear

Hammertoes Conservative treatment \• New shoes with soft, spacious toe box

• Physical therapy

• Wear shoe inserts (orthotics) or pads

to reposition the toe and relieve pressure and pain.

Surgical treatment• If the toe has become tight and inflexible

Morton's neuroma• Morton's neuroma is a painful condition that affects the ball of

your foot, most commonly the area between your third and fourth toes.

• Involves a thickening of the tissue around one of the nerves leading to your toes.

• May occur in response to irritation, injury or pressure

Morton's Neuroma Symptoms• A feeling as if you're standing on a pebble in your shoe

• A burning pain in the ball of your foot that may radiate into your toes

• Tingling or numbness in your toes

• Pain relieved with non-weight bearing

• Toe hyperextension increases symptoms

Morton's Neuroma Treatment• Ice to alleviate acute tenderness • Arch supports and foot pads fit inside your shoe help to reduce

pressure on the nerve.• An “Arch Cookie” pad can help to spread the metatarsals and

give the nerve more space• Intrinsic Muscle strengthening exercises to maintain the

transverse arch .• Injection of steroids into the painful area .• If the patient obtains no relief, surgical excision of the damaged

nerve is indicated

Athlete’s foot

• Very common skin condition that affects the sole of the foot and the skin between the toes.

• Usually a scaly, red, itchy eruption( occasionally may be weepy and oozing.)

• Athlete's foot, also called tinea pedis, is the most common type of fungal infection.

• Athlete's foot is contagious and can be spread by contact with an infected person or with contact with contaminated surfaces, such as towels, floors and shoes

Athlete’s foot Risk factors• Frequently wear damp socks or tight fitting shoes

• Share mats, rugs, bed linens, clothes or shoes with someone who has a fungal infection

• Walk barefoot in public areas where the infection can spread, such as locker rooms, saunas, swimming pools, communal baths and showers

• Have a weakened immune system

Athlete’s foot.... Causes

Caused by a fungus (group of mold-like fungi called dermatophytes ).

Can be contracted in many locations, including gyms, locker rooms, swimming pools, nail salons, airport security lines, and from contaminated socks and clothing

Athlete's foot is closely related to other fungal infections, including ringworm and jock itch- change the towel when drying off!

Athlete’s foot... Symptoms Itching, stinging and burning

Cracked and peeling skin

between your toes

on the soles of the feet

Excessive dryness of the skin on the bottoms or sides of the feet

Toenails that are thick, crumbly, ragged, discolored or pulling away from the nail bed

Athlete’s foot… Treatment

• Make the infected area less suitable for the athlete's foot fungus to grow

• Keeping the area clean and dry.• Absorbent socks like cotton that wick water away

References• Clinical Sports Medicine 4th edition Brukner & Khan Brukner & Khan McGraw-Hill

Sydney; 2009• http://orthoinfo.aaos.org/topic.cfm?topic=a00166• https://www.physioadvisor.com.au/8131291/stress-fracture-of-the-talus-ankle-pain-an

kle-s.htm• www.leedscommunityhealthcare.nhs.uk/msk• Miller CM, Winter WG, Bucknell AL, Jonassen EA. Injuries to mid-tarsal and lesser tarsal

bones. J Am Acad Orthop Surg 1998;6:249–58.• Shindle MK, Endo Y, Warren RF, et al. Stress fractures about tibia, foot and ankle. J Am

Acad Orthop Surg 2012;20:167–76.• Watson TS, Shurnas PS, Denker J. Treatment of Lisfranc joint injury: current concepts. J

Am Acad Orthop Surg 2010;18:718–28.