Foot Pain

Pain in the feet below the level of ankles is known as a foot pain. It is a distressing symptom that affects the gait and work productivity in routine life. It also has a psychological effect, such as depression, on the person suffering from it. Among the different causes of foot pain, heel pain caused due to an overgrowth of the bone (calcaneal spur or heel spur) is the most commonly occurring condition in the age group of 40 to 50 years. In India, 59% of the population suffers from heel pain due to calcaneal spur, out of which 60% are women. Multiple causes of foot pain range from foot deformities to a swelling in feet.

Pain in the foot occurs due to multiple reasons. The type of pain depends on the cause of foot pain.

• Physiological foot pain
  Physiological foot pain occurs as the body’s reflex to an external stimulus. This is an acute type of pain, which is experienced when there is a sudden injury to the foot, for e.g., injury from a thorn or a shoe bite. This reflex of the body in the form of pain to a harmful stimulus is known as nociception.
• Pathological foot pain
  Pathological foot pain is the one, which follows a prolonged exposure to harmful stimulus leading to an injury or pathology. Depending upon the underlying cause, pathological pain can be of three types - neuropathic (nerve-related), inflammatory (due to swelling), and chronic (pain occurring over a period of time).
  • Neuropathic pain
    Pain due to the involvement of nerves gives rise to burning or needle-like sensation in the foot. Tingling and numbness are frequently associated with nerve compression.
  • Inflammatory pain
    Dull aching or severe and unbearable pain is commonly associated with inflammation. Dull aching pain is present in the cases of chronic inflammation and pain due to prolonged standing. Heel pain due to calcaneal spur (overgrowth of bone) usually is severe and unbearable when taking the first step after prolonged sitting or lying down. Sometimes, foot pain is of a throbbing type in the case of an injury, fracture, and sprains.
  • Chronic pain
    Foot pain that has been experienced by an individual over a long inflammatory is known as a chronic foot pain. This type of pain shows characteristic features of a wide range. It usually results from chronic nerve-related diseases, dysfunction of the nerve-conducting chemicals (neurotransmitters), nerve injury, physical injury, a viral disease involving the nerves, metabolic diseases among others.
• Based on location
  Based on the area of the foot involved, foot pain can be of many types, such as:
  • Heel pain
    Pain that is experienced in the heels.
  • Achilles tendinitis
    Pain experienced in the area just above the heels where the Achilles tendon joins the heel to the leg.
  • Midfoot pain
    Midfoot pain is experienced in the area that extends between the heel and the toes.
  • Forefoot pain
    When pain is experienced in the front region of the foot involving the toes, it is known as forefoot pain.
  • Generalised foot pain
    When there is a painful sensation all over the foot and it is difficult to localise its origin, it is known as generalised foot pain.

The symptoms of foot pain depend on its types, such as:

The symptoms of foot pain include:

• Heel pain
  Plantar fasciitis is the inflammation of the thin long ligament that extends from the heel to the toes. Heel spurs (overgrowth of bone due to calcium deposition) or excessive pressure on the ligament results in strain and injury to the ligament and result in heel pain. The following symptoms might be experienced:
  • Pain in the heel or midfoot region.
  • A severe unbearable pain felt in the heel for a few initial steps on rising from a prolonged sitting or lying position (e.g. after waking up from sleep).
  • Pain decreases after walking for a while.
  • Pain worsens after exercise or long walks or other such activities.
  • Tingling or numbness may also be present with pain.
• Achilles tendinitis
  It is an inflammation in the tendon that connects the heel to the leg. The terminal end of calf muscles extends upwards to form the Achilles tendon that helps in the downward movement of the foot while walking, jumping, and running. The tendon gets inflamed due to stretching after excessive walking or running, tightness in the calf muscles, running on a hard surface, jumping and other such activities. Flat feet, heel spurs, and arthritis also result in the inflammation of Achilles tendon. The following symptoms might be experienced:
  • Pain above the heel and Achilles tendon.
  • Stiffness and pain increase with physical activities like walking or running.
  • Difficulty in standing up on the feet.
  • Soreness and swelling in the heel.
• Midfoot pain
  Metatarsalgia is a pain in the mid-foot region. Improper footwear, arthritis, and excessive sports activities result in pain in the bones of the foot that connect the ankle to the toes. Obesity, flat feet, high-arched foot, arthritis, gout, bunions (a painful swelling in the first joint of the big toe), hammertoe (a permanent downward bent in one of the toes), Morton’s neuroma (non-cancerous growth compressing the nerve), fracture, and diabetes in elder people give rise to metatarsalgia. The symptoms associated with it are:
  • Burning and aching sensation in one or both feet, especially near the toes. (Read more - Burning feet causes and treatment)
  • A sensation similar to a stone lying under the foot.
  • Pain is of shooting type and is associated with tingling and numbness.
  • Pain increases on standing or walking.
• Forefoot pain
  In-growing toenail, verrucae or warts, fungal infections of the nails and skin (athlete’s foot), corns and callosities (thickened or hardened skin), bunions, hammer toe, claw foot, and gout are some of the common conditions that affect the front portion of the foot. The symptoms that are usually experienced include:
  • Throbbing pain along with swelling and soreness in the involved area is commonly associated with in-growing toenail and gout. Gout is an inflammation in the bones, especially the great toe.
  • Pain in the foot arises as a result of a deformity in the toes such as:
    • Hammer toe
      Foot appears like a hammer due to the deformity in the toes (second, third or fourth).
    • Claw foot
      Foot looks like a claw due to deformity in the toes.
    • Bunion
      The great toe leans towards the second toe due to the formation of a hard lump on the bone.
  • Burning or aching pain in the forefoot region caused by the entrapment of the nerves due to contracted toe muscles.
  • Tingling and numbness in the foot usually accompany pain when nerves are involved.
  • Shooting pain commonly accompanies hard and thickened skin (corns or callosity) due to constant pressure on the toes and soles.
  • Pain and soreness along with the formation of boils and dry scaly skin occur in fungal infection of the skin. Nails become brittle and a change in colour is usually seen.
• Generalised foot pain
  • Pain is associated with oedema, fracture, and chilblains (swelling due to prolonged exposure to cold temperature) in the foot.
  • Sharp shooting pain in the foot occurs in the case of verrucae or warts, corn and callosity.
  • Chilblains present with severe pain and soreness in the foot. The skin becomes swollen and changes colour to dark red or blue.
  • Fracture and inflammatory diseases of the bones, such as rheumatoid arthritis, gout, osteoarthritis, psoriatic arthritis and others present with distressing pain in the foot. Pain is associated with swelling and significant restriction of the foot movements.

Causes

Various factors are responsible for causing foot pain. Some of the most common and rare causes include:

• Bunions or hallux valgus (swelling at the base of the great toe).
• Overgrowth of the bone in the heel (calcaneal spur).
• Rapid weight gain and obesity.
• Sprain and strain in the ankle and toes of the affected foot.
• Toenail growing into the surrounding skin.
• Chilblains or inflammation in the small blood vessels from exposure to excessively cold temperature.
• Swelling or oedema in the foot.
• Inflammation, injury, and strain in the ligament sheet at the base of the foot (plantar fascia) due to heel spurs.
• Overuse of foot from excessive physical activities (sports, walking, running, jumping among others).
• Uncomfortable footwear and long-standing hours.
• Development of corn and callosity (thickened skin) results.
• An injury or strain in the Achilles tendon due to excessive walking, sports, running, jogging and other intense physical activities cause pain in the heels.
• Fracture in the bones of the foot and ankle results in severe pain and restriction in the movements of the foot. 
• Deformities (hammertoe, claw foot, bunion and more) cause pain in the foot due to contraction of the toe muscles.
• Diseases that cause inflammation in the bones of the foot and ankle, such as gout, rheumatoid arthritis, osteoarthritis, and other inflammatory diseases result in pain and swelling in the foot. 
• Pressure on the nerve due to excessive contraction of the muscles and ligaments (tarsal tunnel syndrome), non-cancerous growth of the tissue around the nerve (Morton’s neuroma), and foot deformities (flat feet and high-arched foot) result in sharp shooting pain with tingling and numbness in the foot. 
• Diabetes commonly gives rise to a burning pain in the foot. 
• Warts or fungal infections of the skin and nails cause severe distressing pain in the foot.
• A deficiency of the nutrients like calcium, phosphorus, or vitamin D results in pain in the bones of the foot.

Risk factors

Common risk factors that increase the chances of experiencing a foot pain include:

• Using discomforting and ill-fitting footwear (hard sole shoes, high-heel or tight-fitting sandals) for a long time causes strain and pressure on the ligaments and bones of the foot and leads to chronic foot pain.
• Work that demands long hours of standing or walking is a high-risk factor for the development of heel spurs, plantar fasciitis, corn, and callosity e.g., surgeons, bus conductors, traffic police, construction workers, mine workers among others.
• Overweight people and those who play sports that involve excessive running, jumping, stretching, and splinting are prone to developing foot pain.
• Deformity in the foot present at birth (claw foot, flat feet, high-arched foot, and others) or which is caused due to an abnormal pressure exerted by ill-fitting shoes (hammertoe and bunions) is a significant risk factor of developing foot pain.
• Diabetes is a major risk factor for foot pain, especially in elderly people.
• Deficiency of nutrients like calcium or vitamin D results in osteoporosis of the bones and increases the risk of foot pain.

Some lifestyle modifications and self-care measures help in preventing foot pain. These are:

• Take a break at regular intervals between prolonged standing hours.
• Wear comfortable and correct sized shoes to avoid pressure on the muscles and ligaments in the feet. Shoes with soft shock-absorbing sole help in preventing foot pain to a significant extent.
• Avoid wearing high-heeled sandals or footwear with hard soles on a regular basis.
• Avoid running or walking for a long time on hard surfaces as this leads to strain in the ligaments of the foot.
• Maintain body weight appropriate to your height and age.
• Follow a healthy and nutritious diet in order to prevent a deficiency of nutrients.
• Appropriate medicines for inflammatory diseases (gout, rheumatoid arthritis, osteoarthritis) help in preventing foot pain.
• Exercise regularly and include stretching exercises for feet that help in keeping the ligaments of the foot flexible and prevent foot pain.

Clinical symptoms along with a detailed history and physical examination of the patient play a key role in the diagnosis of foot pain. Investigations that help in confirming the diagnosis include:

• X-ray of the foot
  This helps in the diagnosis of fractures, deformities, bony overgrowths, changes in the bone caused by inflammation among others.
• Foot push-up exercise test
  The test involves standing or bearing body-weight on the ball of one foot with the other foot kept off the floor. This helps in diagnosing problems related to the arch of the foot.
• Blood tests such as:
  • Complete blood count (CBC) and erythrocyte sedimentation rate (ESR) help in the diagnosis of infection (in-growing toenail) that results in foot pain.
  • C-reactive proteins and RA factor help in the diagnosis of rheumatoid arthritis and psoriatic arthritis, which result in foot pain.
  • Levels of calcium and vitamin D in the blood help in diagnosing the deficiency of these nutrients.
  • Blood sugar test helps in detecting diabetes, which is the cause of burning pain in the feet.
• Electromyography and nerve conduction velocity tests
  These tests are helpful in detecting nerve problems that cause foot pain.

The treatment of foot pain involves the use of medicines and different self-care measures.

Medicines

• Painkillers such as paracetamol help alleviate mild foot pain.
• Anti-inflammatory medicines such as ibuprofen decrease pain by reducing the inflammation.
• Corticosteroid medicines and injections at the site of pain help relieve foot pain rapidly when nothing else works.
• Gout is treated using uric-acid lowering medicines.
• Salicylic acid cream or gel helps in eradicating warts by exfoliating them.

Surgery

• Different surgical procedures are used to treat a deformity of the foot, which help in releasing the trapped nerve that usually results in tingling and numbness along with severe foot pain.
• Gastrocnemius recession involves surgical stretching of tight calf muscles that increase stress on the plantar fascia and do not respond to stretching exercises.
• Plantar fascia release involves giving a small cut to release the tension of the tightened plantar fascia.

Lifestyle management

A few lifestyle management measures may play an important role in preventing the foot pain from worsening, such as:

• Application of heat in the painful area of the foot in the case of chronic or long-standing pain helps in increasing the blood supply and subsequently reduces pain.
• Ice pack application helps in relieving the pain by reducing the inflammation and swelling in the foot. Alternately, rolling a cold-water bottle over the painful area effectively helps in reducing the pain.
• Try to put minimum possible body weight on the affected foot in order to avoid exerting excess pressure on it.
• Use comfortable shoes with soft padded sole or use heel pads to reduce pressure on the painful foot.
• Do not walk barefooted or without footwear on a hard surface.
• Stretching exercises for calf muscles, feet (plantar fascia) help in reducing the stiffness and increase the flexibility of the muscles of the foot.
• Night splints stretch the plantar fascia during sleep and help in reducing the foot pain due to plantar fasciitis.
• If overweight, reduce excess weight with moderate regular exercises.
• Keep the toenails clean and trim them regularly to avoid the extension of the nail in the surrounding skin.
• Rest is an important element in the management of foot pain. 
• Regular stretching exercises of feet and calf muscles keep the foot muscles flexible and reduce pain in the foot.
• Replace tight-fitting footwear with a hard insole and comfortable shoes with a soft insole.
• Maintain a healthy dietary lifestyle to control blood sugar and prevent a deficiency of nutrients.

Prognosis

• Self-care and non-surgical measures usually cure foot pain arising from imperfections in the lifestyle in 6 to 18 months.
• Corticosteroid injects along with self-care measure usually resolve heel pain.
• Fracture in the foot heals in 3 to 4 weeks.
• Corns and callosities respond well to footwear change and treatment with salicylic acid creams.
• Prognosis of foot pain is good when inflammatory diseases (gout, rheumatoid arthritis, osteoarthritis, and others) respond well to the appropriate treatment.
• Prognosis of foot pain after surgical treatment of tightness of the ligaments and foot deformities is also good.

Complications

Complications of untreated foot pain depend on the underlying cause. The pain might persist to become more severe and chronic or even lead to permanent nerve damage if left unattended for too long. Severe foot pain arising due to conditions like rheumatoid arthritis might progress to deformities of the foot.

Nerve damage, incomplete pain relief, and chronic dull pain are some of the complications that arise after surgery to loosen the tight ligament and entrapped nerve.