Foot pain

Introduction

Foot pain is a widespread complaint that can affect people of all ages, lifestyles, and health conditions. Given that the foot is a highly complex structure composed of 26 bones, 33 joints, and more than 100 muscles, tendons, and ligaments, pain can arise from multiple anatomical and pathological sources. It is often associated with overuse, trauma, musculoskeletal disorders, systemic illnesses, or neuropathic conditions. Chronic or untreated foot pain may lead to gait disturbances, reduced quality of life, and long-term disability

---

Anatomy and Function of the Foot

The foot is divided into three regions:

• Hindfoot: Comprising the talus and calcaneus, critical for weight-bearing and shock absorption.

• Midfoot: Made up of the navicular, cuboid, and three cuneiform bones, functioning as the arch stabilizer.

• Forefoot: Including metatarsals and phalanges, responsible for propulsion and balance.

Key structures influencing pain include:

• Plantar fascia (arch support and shock absorption)

• Achilles tendon (connecting calf muscles to heel)

• Nerves (tibial, peroneal, digital nerves)

• Joints (metatarsophalangeal, subtalar, ankle)

---

Common Causes of Foot Pain

1. Musculoskeletal Disorders

• Plantar fasciitis: Inflammation of the plantar fascia, causing stabbing heel pain.

• Achilles tendinopathy: Pain and stiffness along the Achilles tendon.

• Stress fractures: Microfractures in bones due to repetitive overload.

• Arthritis: Osteoarthritis and rheumatoid arthritis frequently affect midfoot and forefoot joints.

2. Neurological Causes

• Morton’s neuroma: Perineural fibrosis between the metatarsal heads.

• Peripheral neuropathy: Often secondary to diabetes, leading to burning or tingling foot pain.

• Tarsal tunnel syndrome: Tibial nerve entrapment causing medial ankle and foot pain.

3. Vascular Causes

• Peripheral arterial disease (PAD): Claudication and rest pain due to arterial insufficiency.

• Venous insufficiency: Swelling and aching due to poor venous return.

4. Infections

• Cellulitis, osteomyelitis, fungal infections (tinea pedis), and warts can all present as localized pain.

5. Trauma and Mechanical Causes

• Ankle sprains, ligament tears, dislocations, and blunt trauma.

• Improper footwear leading to bunions, corns, and calluses.

---

Diagnostic Approach

• History: Onset, location, duration, aggravating/relieving factors, systemic illness.

• Physical examination: Inspection of skin, deformities, tenderness, range of motion, neurological and vascular assessment.

• Investigations:

  • X-rays (fractures, arthritis)

  • MRI (soft tissue pathologies)

  • Ultrasound (tendon and plantar fascia evaluation)

  • Nerve conduction studies (neuropathy, entrapment syndromes)

  • Laboratory tests (inflammatory markers, uric acid, glucose, autoimmune profile)

---

Treatment of Foot Pain

1. Non-Pharmacological Management

• Rest and activity modification: Avoid overuse, use assistive devices if needed.

• Ice and heat therapy: Ice reduces inflammation, heat improves circulation in chronic pain.

• Physiotherapy: Stretching and strengthening exercises for plantar fascia and Achilles tendon.

• Footwear modification: Supportive shoes, orthotic insoles, arch supports.

• Weight management: Reduces pressure on foot structures.

---

2. Pharmacological Treatment

a) Analgesics

• Paracetamol (Acetaminophen): 500 mg to 1000 mg orally every 4–6 hours, maximum 4 g/day. Useful for mild to moderate pain.

b) Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

• Ibuprofen: 400–600 mg orally every 6–8 hours, maximum 2400 mg/day. Effective for musculoskeletal pain and inflammation.

• Naproxen: 250–500 mg orally twice daily. Longer half-life, suitable for arthritis-related pain.

• Diclofenac: 50 mg orally two to three times daily. Also available as topical gel for localized application.

• Celecoxib (COX-2 inhibitor): 200 mg once daily or 100 mg twice daily. Used for arthritis with fewer gastrointestinal side effects.

c) Corticosteroids

• Prednisone: 10–20 mg orally once daily for inflammatory conditions like rheumatoid arthritis or gout.

• Methylprednisolone acetate (intra-articular injection): 10–40 mg depending on the joint size. Used for persistent inflammatory pain such as plantar fasciitis or severe arthritis.

d) Neuropathic Pain Agents

• Gabapentin: Start at 300 mg once daily, titrate up to 1800–3600 mg/day in divided doses. Indicated for diabetic neuropathy or nerve entrapment.

• Pregabalin: 75 mg twice daily, may increase to 150 mg twice daily. Effective in neuropathic foot pain.

• Amitriptyline: 10–25 mg at night, titrate as tolerated. Tricyclic antidepressant used in neuropathic pain.

e) Disease-Specific Drugs

• Allopurinol: 100–300 mg orally daily for gout-related foot pain (urate lowering).

• Colchicine: 0.6 mg orally once or twice daily for acute gout flares.

• Methotrexate: 7.5–25 mg orally once weekly for rheumatoid arthritis.

• Biologics (e.g., Adalimumab, Etanercept): Used for inflammatory arthritis involving the foot, dosage varies depending on formulation.

---

3. Surgical Management

• Plantar fascia release: For resistant plantar fasciitis.

• Excision of neuroma: For Morton’s neuroma not responding to conservative measures.

• Arthrodesis (joint fusion): For severe arthritis.

• Fracture fixation: In cases of displaced or non-healing fractures.

---

Special Considerations

• Diabetic Foot Pain: Requires strict glycemic control, wound care, infection prevention, and neuropathic pain management with gabapentinoids.

• Elderly patients: Dose adjustments are necessary for renal and hepatic impairment.

• Pregnancy and lactation: NSAIDs should be avoided in the third trimester; paracetamol is generally safe.

---

Prevention of Foot Pain

• Wearing supportive footwear with cushioning and arch support.

• Regular foot exercises and stretching.

• Maintaining healthy body weight.

• Avoiding prolonged standing or repetitive strain without breaks.

• Monitoring blood sugar and vascular health in diabetic patients.

• Routine podiatric evaluation for high-risk individuals.