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Lviv clinical bulletin 2014, 4(8): 54-60

https://doi.org/10.25040/lkv2014.04.054

Pain in the Foot: Pathogenesis, Diagnosis and Treatment

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A. Yatskevych

Danylo Halytsky Lviv National Medical University

Deformation and foot pain are significant causes of the patient’s medical care. The pain in the foot combined with the violation of its structure is the basic indicators for the surgical treatment in about 30.0 % of patients in orthopedic hospitals [4, 8, 10, 11]. The effectiveness of its treatment is insufficient, there is a tendency to chronization of the processes often followed by relapses [8, 9, 21].

For the effective choice of the treatment metod it is important to determine the cause, the origin of the pain impulses, and its “substrate” [1, 3, 9, 11, 24, 27, 29]. There are four groups of lesions of patients following the predominant localization of pain in the foot [3, 12]: with pain in the anterior part of the foot; with pain in the medial part of the foot; with pain in the lateral part of the foot; with pain in the back of the foot. The respective etiological and pathogenetic situations are characteristic for each of these groups [6, 13, 14, 15, 48].

Pain in the anterior foot can be caused by the following pathological conditions: impingement of the ankle joint, toes deformity, pathological changes of the sesamoid bones, stress – fractures metatarsal bones, arthrosis of the anterior foot, Morton’s Neuroma [1–3, 12].

The most common cases of the pain of medial dorsal foot caused by the dysfunction of the posterior tibial muscle & Tarsal tunnel syndrome [3, 12].

Pain in the lateral department of the foot usually caused by sprain of the small peroneal muscles, their compression, tendinopathy, also injuries of the lateral ligament complex. The main cause of the pain in the rear of the foot: Achilles tendinopathy, Achilles bursitis, Plantar fasciitis [41, 44, 46, 47].

There are many controversial reasons described in the medical literature regarding causes of the foot pain.

Morton’s Neuroma (MN) – caused by pathological changes of the anastomosis of the branches of Medial & Lateral plantar(?)  nerves, located at the lll & lV Metatarsal bones.

Clinical presentation – usually severe pain in the 3rd intermetatarsal space with radiation to the toes & middle of the foot – plantar surface.

There are different theories described in the literature regarding causes of MN: intermetatarsal bursitis, chronic injuries, nerve ischemia [12].

For the diagnostic purposes following  tests are used: bilateral squeezing of the foot (reproduces pain), XR, US, MRI evaluation. MRI is the most informative method & also aids in the treatment approach.

MN is treated by conservative & surgical approaches depending on the duration of the condition (starting with more conservative approach first).

Conservative approach includes: picking up proper orthopedic shoes, supinators, manual therapy. Medical treatment includes anti inflammatory medications & local injections [25, 30]. When conservative approach fails then surgical treatment is recommended. There are different surgical methods: Open decompression of the intermetatarsal space, Endoscopic decompression or resection of the neuroma.

Toe deformity, especially Halux Valgus, Rigid 1st toe, Hammer toes & Hook toes deformity of the 2-5 toes are easily diagnosed. Important to establish the causes of such deformities, treatment of which can require different surgical approach. In most studies, authors agreeing with the necessity for the surgical treatment [5–7].

Stress fractures of the metatarsal bones can cause anterior foot pain. Usually they are caused by the increased pressure (overload with weight bearing) on the foot, foot deformity, especially in Rheumatoid arthritis patients.

Most common symptoms of the Stress fractures:

  • pain that is increasing with the increase in activity;
  • pain with normal activity that is increasing;
  • ache & bruising on the dorsum of the foot;
  • swellings on the top of the foot.

Treatment is conservative. Very important is early diagnosis (3). Diagnostic methods include: XR, US , CT, MRI. Sesamoiditis – usually involves inflammation of the sesamoid bones & first metatarso-phalangeal joint, that usually is the cause of the foot pain & often is overlooked.

Pain caused by sesamoiditis affects gait, usually pain increases with physical exertion, wearing high heel shoes. Usually there is swelling in the front of the foot. Sesamoiditis  can be caused by arthrosis , bone spurs of the sesamoid bones, fractures & sprains [3, 12].

Conservative treatment includes: rest, limited exertion, orthotics, anti inflammatory medications, steroid  injections. Currently described surgical approach is not widely described, only in a few articles [33, 48, 50]: surgical excisions of the bones, exostoses, bone transplant. Also, due to Valgus & other deformities , surgical correction is used [5–7].

Tarsal tunnel syndrome – can cause pain in the medial foot. Carpal tunnel syndrome is the bio mechanical analog of this condition. TTS – caused by the compression of the tibial nerve, that can also lead to less known posterior tibial muscle dysfunction. Causes include neuropathy of the nerve, varicosities, bone spurs, flat feet, synoviitis of the tendon sheaths [20, 50].

Clinical presentation – pain in the medial surface of the foot with occasional radiation to the front.

Compression test (compression of the nerve in the Tarsal canal during overextension & internal rotation which causes pain) is highly sensitive (80%). MRI is used for more accurate diagnosis [38].

Conservative treatment includes [30]: decreased pressure from foot wear, decreasing physical activity, orthotics with supination, stretching & improving muscle tone in the calf, systemic & local anti inflammatory treatment. Surgical treatment is used in more complicated cases. Surgical treatment – Tarsal tunnel release [18]. There is not enough information in the current literature regarding the choice of treatment.

Pain in the medial foot can be caused by dysfunction of the tendon of the posterior tibial muscle (PTMTD). This pain is exacerbated by physical activity, also one can observe decrease in the arch of the affected foot. Diagnosis is supported by US & MRI studies. Conservative treatment [20, 27, 30] includes: modifications in the physical activity, orthotics, fixation, cryotherapy, systemic NSAIDs (nonsteroid anti inflammatory drugs) Treatment. There is limited & controversial  information in the medical literature regarding local steroid drugs use [45]. Also there is no consensus on surgical approaches in PTMTD treatment. Proposed approaches on the tendon include: synovioectomy, plastic surgery, transposition. Since PT muscle actively participates in the formation of the foot arch – surgical approach is directed towards optimization of the arch- osteotomy & arthrodesis of the foot [10].

Pain of the dorsum & lateral foot usually is caused by the injury of the peroneal muscles tendons, their insertion sites & sprains. Especially important part in the pathogenesis: partial tendon injury, their stenosis/compression due to synoviitis , bone spurs, hypermobility, sprains & strains of the tendons. Diagnosis & differential diagnosis is complicated & in addition to standard XRs, we use US & MRI imaging [3, 12].

Conservative treatment is based on the absence of obvious anatomical injuries & includes: decrease in physical exertion, rest, proper foot wear (to decrease pressure on the foot), orthotics, physical therapy exercise directed on stretching & strengthening of the peroneal  muscles, NSAIDs, local anti inflammatory treatment [27, 31, 39, 40].

In case of structural injuries, especially in case of sprain of the peroneal muscles , surgery is recommended [42, 44, 49, 51]: plastic surgery with grafting, improving – deepening of the canal for the tendons in the peroneal bone, use of the autologous transplants (using fasciae, tendons, including Achilles’ tendon).

Pain in the back of the foot, heel pain, retrocalcaneal pain in most cases is associated with Heel spur, in case of personal injury history – deforming arthrosis of the ankle joint & foot joints pathogenesis of this pain is way more complex [50, 52]. Heel pain can also be caused by the pathologic changes in the distal part of the Achilles’ tendon , which often is overlooked by orthopedic surgeons. Symptoms of Achilles bursitis, Haglund syndrome – intense pain in the point of the Achilles’ tendon insertion into calcaneal bone, which is exacerbated by walking, running.

On exam there are swelling & deformity in the calcaneal tuberosity, and in the location of the calcaneal burses. Their inflammation causes synovitis, fibrosis & calcification. This process can be reoccurring [52].

Due to low efficacy of the conservative treatment [limiting physical activity, NSAIDs, local steroid injections, homeopathic and biologycal treatment, proper foot  ware [33, 35, 37], surgical treatment is used. There are different surgical approaches and techniques used : bursa excision , Achilles’ tendon enthesis debridement, calcaneal spurs excision with reinsertion of the tendons & prologue rehabilitation [23, 38].

Achilles tendonitis (AT) is very common in runners. According to some studies , important role in the pathogenesis of the AT are partial injuries of the tendon with spinning induration & relative stenosis , tendonitis [16, 32, 33]. Conservative treatment includes NSAIDs, & exclude over exertion of the Achilles’ tendon & calf muscles [33]. Local injections include biological agents [37, 42], steroids, which can be delivered directly into tendon insertion and not into the tendon thickness.

Conservative treatment usually is ineffective. Surgical approaches include: longwise excision of the degenerative changes involving tendon, which preserves it as a whole, if there is no insertion stenosis or thickening involved; endoscopic debridement [15, 18, 19, 20, 22, 26].

Plantar fasciitis (PF) – presents with significant pain in the sole of the foot, especially in the morning, after night rest, with applying pressure. Pain radiates inside the foot & into the shin, lessens during physical exertion. Pain is reproducible upon applying pressure in the area of plantar aponeurosis insertion into calcaneal bone. On the XR – studies heel spur can be seen, but its absence does not exclude the diagnosis of Plantar Fasciitis. Pain that radiates into the calf, caused by the tunnel neuropathy of the великогомілкового nerve. In this situation differential diagnosis must exclude vertebrogenic causes [12, 43, 48, 50].

According to current studies conservative treatment of the PF is effective in 90.0 % of cases. Treatment includes stretching if the plantar fascia & crural muscles twice a day (morning & night); decreasing pressure on the plantar fascia with the use of orthopedic shoes , inserts, orthotics use. Also nighttime orthotics used prophylactically to avoid shortening of  the aponeurosis & muscles. NSAIDs & steroid shots are used as well [40, 42]. In the current literature regarding PF treatment [43, 48], especially high efficacy (60.0-88.0 %) given to high technology treatment: shock-wave therapy, injections with platelets enriched plasma, high frequency transdermal nerve ablation, low energy laser therapy.

Surgical treatment effective in 70.0-80.0 % of cases and includes partial dissection (up to 50.0 %) of the aponeurosis & removing compression of the Lateral plantar nerve. According to American Podiatrist Association, surgical treatment is advised only after failed conservative treatment of 6 months duration [43]. Surgical approaches & techniques should be thoroughly planned since the effectiveness of the surgical treatment not always successful, with high complication rate. Complications include: hematoma formation, wound infection, slow healing with chronic pain & swelling, toes contracture, failures for the osteotomy site healing.

Conservative treatment not always effective, often pain reoccurs with increase in foot deformity.

Case1. Patient P., 63 years old women, was treated in November, 2013 (Trauma & Orthopedic surgery division of the Lviv City Community Hospital #8). Patient has been suffering with pain & deformity in the Left foot for approximately 17 years. During her youth she vas diagnosed with Flat foot & Valgus deformity. According to the Patient, at that time she was not in pain, deformity was moderate, so no specific treatment was done. Over the years deformity got worse. I’m 2011 Patient started to have spontaneous pain in the front of her foot, that was increasing during walking & would become unbearable towards the evening & after physical exertion. Dorsal surface of her foot started to swell up , especially after prolonged standing, walking. XRs & US studies showed flat Valgus deformity & stress fractures of the 2nd & 3rd metatarsal bones (Fig. 1).

Fig. 1.

Conservative treatment with cast fixation for 3 weeks, use of individuality fit orthopedic shoe improved pain in the foot & patients gait. Following year Patient came back again with the complaints of pain in her toes & sole & anterior foot, inability to use shoes due to significant toes & anterior foot deformity, periodic foot infections, hyperkeratosis. Pts had gait difficulty & started to limp. Based on clinical (Fig. 2) & XRay (Fig. 3) information diagnosis of Flat Valgus foot deformity, Hammertoe deformity 2-5 toes.

Fig. 2.

Fig. 3.

Surgical treatment performed, directed to optimize cross arch of the foot, fixing toe deformity, proximal corrective osteotomy of the 1st metatarsal by metalosynthesis using metal plate & screws, resection & arthroplasty of the 2-5 metatarso-phalangeal joints. Stable osteosynthesis added into early ambulation. Pt was able to walk bearing weight on her heal on the 2nd day, wounds healed in 14 days, pins removed 4 weeks after the procedure. Patient started walking with normal weight bearing. By the 6 weeks post-op , Patient has no pain with normal function. One year after the surgery Patient started to experience morning pains in the back of her foot, in the sole (“like stepping on the nail“), usually with applying pressure upon getting out of bed. Patient contributed her pain due to her stopping to use supinators. After clinical evaluation & MRI – Plantar fasciitis was diagnosed (Fig. 4).

Fig. 4.

Pt was treated with shock wave therapy & steroid injection. Patient became pain free, resumed normal function.

Studies show that pathogenesis & causes of foot pain are various & there is need in further studies & investigation in this area. More knowledge & understanding of the causes, circumstances, triggers of the foot & ankle pain will help in more narrow diagnosis & will improve treatment options & surgical approaches & techniques.

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