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Foot pain problems
The document provides information on common foot pain problems including their anatomy, causes, symptoms, physical exam findings, investigations, and treatment options. It discusses issues such as plantar fasciitis, heel fat pad syndrome, stress fractures of the calcaneus, navicular, and cuboid bones, tarsal tunnel syndrome, lateral plantar nerve entrapment, tibialis posterior tendinopathy, extensor tendinopathy, cuboid syndrome, and midfoot issues. Conservative treatments include rest, ice, stretching, orthotics, and strengthening exercises while surgical options are considered for more severe or chronic cases.
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Foot pain problems
- 1. Foot pain Problems MohamedAouini nsmp physiotherapist
- 2. Your Foot _ Thefeet 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.
- 3. The feet aredivided into three sections - Forefoot - Midfoot - Hindfoot
- 5. Forefoot Contains the fivetoes (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.
- 6. Foot arches Foot hasthree 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.
- 7.
- 8. Functions of footarches - 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.
- 9. Functions of thefoot Proper functioning of the foot is required for normal gait
- 10. Weight Distribution Weight ofthe body is supported by the foot, and is transmitted and distributed over 6 areas Functions of the foot
- 11. foot pain complaints -Heel pain ( arising the rear foot ) - Midfoot pain - Forefoot pain
- 12. • Rear footpain the 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
- 13. • Anatomy ofthe 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.
- 14. • Anatomy ofthe 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 .
- 15. • Roles ofPlantar 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
- 16. • Pathophysiology - PlantarFasciitis : • 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
- 17. • 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.
- 18. • 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.
- 19. 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
- 20. the heel Fatpad: • 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
- 21. 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
- 23. Heel fat padtreatment • 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.
- 24. 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
- 25. Causes • Calcaneal stressfracture 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.
- 26. Investigation • X-ray mayshow a typical appearance on the lateral X-ray, parallel of the posterior margin of the calcaneus
- 27. 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
- 28. Lateral plantar nerveentrapment • 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
- 29. Treatment • Treatment consistof rest • NSAIDs and iontophoresis • Arch support using taping or an orthosis is helpful in athletes with excessive pronation
- 30. tarsal tunnel syndrome •impingement and inflammation of the posterior tibial nerve within the tarsal tunnel
- 31. Causes • in approximately50% 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 aspect of foot • Point tenderness proximal, over, and distal to the flexor retinaculum
- 32. Examination • Pain isusually 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
- 34. Treatment • Conservative _Treatment withNSAID 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
- 35. 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.
- 36. Causes • Stress fracturesof 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.
- 37. 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
- 38. 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
- 39. 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 .
- 40. Symptoms • vague archpain 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
- 41. Treatment The treatment ofnavicular 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
- 42. Extensor tendinopathy The extensordorsiflexion 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.
- 43. Symptoms • patient complainsof 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
- 44. 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.
- 45. Causes • occur fromoveruse 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 and Weakness .
- 46. Investigation • MRI orultrasound 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
- 47. - in severecases 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.
- 48. Cuboid syndrome • Thecuboid 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.
- 49. 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
- 51. 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
- 52. 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
- 53. Fore foot pain Halluxvalgus • 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
- 54. Spectrum of halluxvalgus • 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
- 55. Causes of HalluxValgus • 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.)
- 56.
- 57. 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.
- 58. Classification of halluxvalgus • 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
- 59. Treatment of halluxvalgus • 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 .
- 60. Hammertoes • A hammertoe 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.
- 61. Hammertoes Causes Wearingpoorly 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
- 62. Hammertoes signs andsympotms Pain with walking Difficulty moving the toe Corns and calluses resulting from the toe rubbing against the inside of footwear
- 63. 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
- 64. Morton's neuroma • Morton'sneuroma 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
- 65. 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
- 66. 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
- 67. Athlete’s foot • Verycommon 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
- 68. Athlete’s foot Riskfactors • 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
- 70. 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!
- 71. 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
- 72. 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
- 73. References • Clinical SportsMedicine 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- ankle-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.