FOOT PAIN: AN OVERVIEW
Foot pain is very common—most people experience some type of foot pain during their lifetime. Pain can occur anywhere in the foot, including the toes, the ball of the foot, the arch, the instep, the sole, the heel, and the ankle. The incidence of foot pain increases with age.
The three main parts of the foot are the forefoot, the midfoot, and the hindfoot. The forefoot consists of the toes and the connecting long bones (the metatarsals). The midfoot, or arch, consists of five irregularly shaped tarsal bones, which are connected to the forefoot and hindfoot by muscles and the plantar fascia (arch ligament). The hindfoot, which is comprised of three joints, links the midfoot to the ankle (talus) and includes the heel bone (calcaneus). The heel is the largest bone in the foot and it joins the talus to form the subtalar joint. The bottom of the heel bone is cushioned by a layer of fat.
The components of the feet work together to provide support, balance, and mobility. A structural abnormality or malfunction in any part of the foot can cause pain and also can result in problems elsewhere in the body (e.g., back, hips, knees).
Toe pain is one of the most common types of foot pain. Wearing ill-fitting or narrow shoes regularly is a frequent cause for toe pain. Shoes with narrow toe boxes can cause blisters, calluses, corns, and ingrown toenails, and can worsen other conditions, including bunions, hammertoes, claw toes, and Morton’s neuroma.
The five toes (phalanges) and their connecting long bones (metatarsals) comprise the forefoot. Each toe (phalanx) is made up of several small bones. The big toe (hallux) has two phalanges, two joints (interphalangeal joints), and two tiny, round sesamoid bones. The other four toes each have three bones and two joints. The phalanges are connected to the metatarsals by five metatarsal phalangeal joints at the ball of the foot.
In addition to ill-fitting and narrow shoes, other common causes for toe pain include skin conditions, such as dry, cracked skin, eczema, and psoriasis; fungal infections, such as athlete’s foot; bacterial infections; frostbite (i.e., damage to the skin and sometimes the underlying tissue caused by extreme cold); and fractures and bruises.
Gout is a disease caused by the buildup of uric acid in the joints that can cause severe toe pain. Gout usually affects the first metatarsal phalangeal joint of the big toe (hallux), the ankle joint, or the heel.
In addition to severe pain, gout may cause swelling, inflammation, redness (erythema), warmth, and stiffness. According to the National Institutes of Health (NIH), gout affects approximately 2.1 million people in the United States.
Risk Factors and Causes
Risk factors for foot pain include the following:
- Age (children and the elderly are at increased risk)
- Heredity (many structural foot problems are inherited)
- Prolonged periods of standing (especially on hard surfaces)
- Repetitive jumping and running (especially on hard surfaces)
- Wearing ill-fitting, high-heeled, or narrow shoes regularly
Certain medical conditions also increase the risk for developing foot pain. These conditions include diabetes, arthritis, and inflammatory conditions (e.g., ankylosing spondylitis, tendonitis, bursitis).
Causes for foot pain include the following:
- Forefoot, including toe pain and ball of foot pain
- Bone bruise
- Bruised, sprained, or broken toe
- Frostbite (damage to the skin and/or underlying tissue caused by extreme cold)
- Hammertoes/claw toes
- Ingrown toenail
- Morton’s neuroma
- Midfoot, including foot arch pain, bottom of foot pain, top of foot pain
- Abnormalities in foot structure, such as flatfeet (excessive pronation) or high arches (supination)
- Gait abnormalities (unusual and uncontrollable walking patterns)
- Plantar fasciitis (inflammation of the fibrous connective tissue on the sole of the foot)
- Plantar warts
- Soft-tissue sarcoma of the foot (cancer that originates in fat, muscle, nerve, fibrous tissue, blood vessels, or deep skin tissue of the foot; rare)
- Tarsal tunnel syndrome (nerve entrapment that may cause pain on the sole of the foot)
- Hindfoot, including heel pain and ankle pain
- Achilles tendonitis
- Ankle injuries (e.g., sprain, fracture)
- Haglund’s deformity (bony growth at the back of the heel that usually occurs when shoes repeatedly aggravate tissue and underlying bone)
- Heel spurs (bony growths)
- Plantar fasciitis
- Sever’s disease (relatively common condition in active growing children and adolescents)
- Stress fractures (crack in the outer shell of the bone)
Signs and Symptoms
Foot pain can occur in the toes, the ball of the foot, the heel, the arch, the instep, the sole (bottom of the foot), the top of the foot, or the ankle. The onset of pain may be sudden, or may develop slowly over time. Foot pain can vary from a mild ache, to a severe stabbing, throbbing, and burning pain.
Depending on the cause, symptoms that may accompany foot pain include the following:
Complications that can occur include infection (e.g., fever, redness, severe pain, warmth, swelling), an inability to bear weight, and deformities (e.g., hammertoes/claw toes, bunions). Patients who have diabetes are at increased risk for foot complications, such as sores (ulcers), Charcot foot, and diabetic neuropathy.
A personal and family medical history, physical examination, and diagnostic tests (e.g., imaging tests, blood tests) may be used to help diagnose foot pain. A family history includes information about structural foot problems and other medical conditions, such as diabetes, gout, and arthritis in the patient’s family.
A medical history includes information about the following:
- Additional symptoms (e.g., swelling, redness, numbness, warmth)
- Circumstances surrounding the pain’s onset (e.g., sudden or gradual, whether an injury occurred)
- Exact location of the pain
- Severity of the pain
- Whether pain worsens or improves with rest or with activity
During a physical examination, the physician assesses the feet, legs, and back. The position of the body as a whole (posture), the position of the body while standing (stance), and the manner of walking (gait) are also evaluated.
X-rays can be used to rule out fractures and other conditions (e.g., arthritis) and to determine bone density. Blood tests may be performed to detect conditions such as rheumatoid arthritis).
Foot Pain Relief
Treatment for foot pain varies, depending on the cause. Mild foot pain often can be relieved by wearing shoes with wide toe boxes, by using shoe inserts or pads (available over the counter), and by keeping off the affected foot as much as possible until the pain subsides.
RICE therapy—rest, ice, compression, and elevation—can be used to treat some types of foot pain. Rest involves reducing activity as much as possible until the pain subsides. In some cases, crutches, and/or a splint, air cast, or hard cast is necessary. Ice can be applied to the painful area to reduce pain and swelling. Ice should not be applied directly to the skin. Compression involves supporting the foot with a firmly (not tightly) wrapped elastic bandage, compression stocking, or gel wrap. Keeping the foot elevated about 6 inches above the heart with a slightly bent knee can help to minimize bruising and swelling.
Over-the-counter pain medication (e.g., ibuprofen, acetaminophen) also can be used to relieve mild foot pain. Plantar warts and corns sometimes can be treated using over-the-counter removers, but this should be done only on the advice of a qualified health care provider. Patients who have diabetes or other conditions that can compromise skin quality (e.g., lupus, scleroderma) must be extremely cautious when using over-the-counter preparations.
Foot pain that does not respond to conservative therapy may be treated using the following:
- Corticosteroid (cortisone) injections (e.g., to treat tendonitis, bursitis, plantar fasciitis, and Morton’s neuroma)
- Custom-prescribed orthotics (e.g., to treat structural foot problems, such as flat feet)
- Physical therapy (e.g., to treat plantar fasciitis, Achilles tendonitis)
- Surgery (e.g., to treat hammertoes/claw toes, bunions, and heel spurs)
To help prevent foot pain, shoes should fit properly and should have adequate cushioning, arch support, and room at the ball of the foot and the toes. In addition, shoes should be in good repair, should always be worn with socks, and should be appropriate for specific activities (e.g., sneakers for exercise, running shoes for running).
The feet should be washed regularly and dried thoroughly. Toenails should be trimmed carefully, straight across and to a comfortable length. It is also important to use sunscreen whenever the feet are exposed to the sun (e.g., when wearing sandals) to avoid sunburn.
Maintaining a healthy weight also can help prevent some types of foot pain. During exercise, warming up properly, stretching adequately, and cooling down afterward may help reduce the risk for developing foot pain.