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foot pain Since the feet bear the body's entire weight, abnormalities and lesions, whether severe or minor, frequently cause pain and disability. For problems affecting the heel area, see heel pain and achilles tendon. Many forms of inflammatory arthritis such as rheumatoid arthritis, psoriatic arthritis (see psoriasis and psoriatic arthritis), reactive arthritis, sarcoidosis, and gout affect the ankle and foot, and these are discussed in the relevant sections. There is a considerable difference between adults and children as to the causes of foot pain. This section will discuss foot pain under the following headings:

Musculoskeletal foot pain in children Musculoskeletal foot pain in the adult Nerve lesions causing foot pain

Musculoskeletal foot pain in children Foot pain in children usually results from developmental problems.

• Flat feet may be congenital (the child is born like that) or acquired (it develops only after weight bearing is established at around two years of age). Congenital flat feet may be flexible or rigid. Note that infants are naturally flat-footed and only when this is severe is treatment required. Flexible flat feet are treated with exercises and insoles that hold the feet in the correct position until there is sufficient maturity and strength. in severely affected children, hinged casts that can be easily applied and removed are used intermittently to promote soft tissue maturation in an appropriate position. While casts and insoles are useful, they merely provide support. only exercise will strengthen muscles sufficiently to hold the correct position. Good exercises include walking on tiptoes and picking up marbles and moving them with the toes. The Achilles tendon may need stretching to achieve a good foot position. Acquired flat feet in children are often a manifestation of hypermobility. Treatment is similar. Rigid flat feet are more difficult to treat. Here the heel bone (calcaneus) is semifixed in a turned-out position and the talus (the bone at the heart of the ankle that acts as a universal joint) points in and down, almost reversing the normal arch along the inner border of the foot. A series of casts that progressively correct this malposition are used. in severely affected children, though, some surgical correction is often required as well. Fusing of the affected joints (arthrodesis) may be necessary later in life.

• claw foot or pes cavus is the opposite of flat feet, with an exaggerated arch and sometimes a short foot. it is usually inherited but can also occur in other conditions such as polio, Friedreich's ataxia, and spina bifida. The foot is very stiff and therefore has little shock-absorbing capacity. Athletes and people who do a lot of walking therefore frequently develop pain. Stretching the muscles that pull the toes up and wearing modified shoes helps. it is also possible to lengthen the tissues that support the arch of the foot while removing slices of bone to lower the arch toward normal surgically.

• Metatarsus varus refers to a condition in which the feet turn inward toward each other midway along the length of the foot. This can lead to an awkward gait and tripping. This should be differentiated from an intoeing gait, which may have many causes, and clubfeet. The diagnosis is best made by a foot specialist. Mild degrees of metatarsus varus can sometimes be corrected by wearing the shoes on the opposite feet. More commonly, though, progressive corrective casts are required. Good results are obtained with early treatment.

• Congenital clubfoot or talipes equinovarus occurs in about one in 1,000 births and affects both feet in half the affected infants. The foot is turned in and down and the heel is also turned in (unlike metatarsus varus above). It cannot be brought up to 90° because of a very tight Achilles tendon. Gentle stretching followed by taping or use of a cast is begun early and may correct the milder 30-40 percent. In those that cannot be adequately corrected in this way, surgery is usually performed between three and six months of age.

• Although tarsal coalition may cause a rigid flat-foot, it is usually unsuspected until it causes foot pain in adult life. In tarsal coalition, a bony bar links two of the mid- or hindfoot bones and does not allow any movement at that joint. This loss of movement causes increased stress on the other midfoot joints, which eventually give rise to pain. This commonly begins after some increased stress such as weight gain or sudden increase in the amount of walking or time spent standing. The diagnosis is evident on plain X ray and in difficult cases can be confirmed by a CT scan. The bony bar can be removed surgically, but pain may continue because of established osteoarthritis in the adjacent joints.

Musculoskeletal foot pain in the adult Most musculoskeletal foot pain that is not due to an inflammatory arthritis (see arthritis for classification) results from abnormal stresses on normal tissues, normal stresses on structurally abnormal tissues, or highly repetitive stresses on normal tissues.

• Acute foot strain may result from a sudden unaccustomed increase in walking or other activity. This could include walking on unusually rough surfaces or in poor footwear. The pain may arise from muscles, ligaments, tendons, joint capsules, or a combination of these. Treatment, if required, is with rest, ice, massage, or NSAIDs. If the activity is repeated before adequate recovery of the tissues, damage may occur and result in chronic (ongoing) foot strain. This not only takes longer for the pain to subside but may lead to permanent alterations in the tissues and, in the long term, osteoarthritis of the joints. An example of chronic foot strain is plantar fasciitis.

• Metatarsalgia refers to a condition in which pain is felt under the balls of the feet. it is often described as walking barefoot on pebbles. Normally most of the weight is borne on the ends of the first and fifth metatarsal bones (the bony enlargements just before the toes start). The ends of the second, third, and fourth metatarsals form an arch between these two at toe off and therefore do not normally take as much weight. Toe off is that point in the stride just before the foot leaves the ground when only the metatarsal heads and toes are in contact with the ground. However, if the arch flattens (splaying of the foot), they then take as much weight as the first and fifth but without as good padding as these two. As a result they become painful and develop calluses. There are many reasons for this anterior arch to flatten. The most common is loss of tone in the supporting muscles as people grow older, together with increasing weight. Along with the flattened arch the toes tend to ride up and become curved in shape (cock-up toes). Exercises to strengthen the small muscles of the foot, weight loss, and orthoses to prevent the heel bone from turning out too much and to take the pressure off the ends of the metatarsal bones are all helpful. Surgery is useful in relieving pain but will not restore normal foot biomechanics.

• In hallux valgus the first metatarsal (the longer bone on the inner border of the foot that runs down to the big toe) moves toward the other foot and away from its neighboring metatarsals. As a result the big toe deviates the other way, often pushing the second toe out of position. A bunion then develops at the base of the big toe. The cause of this abnormality has been debated for some time and there is still little agreement on it. Even if high-heeled shoes that constrict the toes are not the cause, they will undoubtedly make a mild hallux valgus worse. Most patients are older women with a broad front part of the foot and a flat arch. Many of these women will remember deviation of the big toe occurring when they were quite young, but generally, they seek treatment only when the condition becomes painful. This is usually when bursitis develops over the bunion. If hallux valgus develops before the age of 20 years, it should be treated prophylactically to prevent or delay progression. Appropriate footwear is important, especially flat heels and a broad front end. Corrective insoles for the flat foot are used, and splints that hold the foot in the desired position can be worn at night. In older patients, molding the shoe to accommodate the bunion helps relieve pain. Many surgical procedures are established for hallux valgus that work reasonably well. Two of the commonly used ones are known as Keller's and McBride's procedures. Surgical correction is reasonably successful, although it does not restore normality and many patients continue to have some pain and often some stiffness. It should be done for pain and disability, therefore, not appearances.

• Bunions may develop anywhere there is excessive pressure against a person's shoe. This is commonly on the inside of the big toe associated with splaying of the foot or hallux valgus. They are also common on the outside of the base of the little toe where there is often an underlying bursitis. This is known as a Tailor's bunion from the days when tailors used to sit cross-legged. They can also result from poorly fitting shoes. Shoe modification and bunion pads are helpful. Surgical correction of the underlying bony prominence may be indicated.

• Two small bones called sesamoids are found in the tendons beneath the end of the first metatarsal bone. Inflammation can occur here, termed sesamoiditis. Temporary rest with a shoe insert to relieve pressure is the usual treatment. occasionally in resistant cases the sesamoid is surgically removed.

• Hallux rigidus refers to stiffness of the joint at the base of the big toe such that it no longer bends enough to allow normal walking. This usually results from osteoarthritis in older individuals but can occur in younger people as a result of trauma or following recurrent attacks of gout. If mild, the wearing of a stiff-soled shoe relieves pain. corticosteroid injection may give temporary relief. If severe, surgery can be done either to fix the joint in a usable position (see arthrodesis) or to put in a joint replacement.

• Morton's syndrome describes a condition in which the first metatarsal bone is congenitally short. This is different from Morton's neuralgia (see below). Morton's syndrome causes problems around the joint at the base of the second toe because the second metatarsal bone, being longer than the abnormal first, takes an unusual amount of weight and stress during walking and running.

• A march fracture is a stress fracture of the second metatarsal bone. This occurs as a result of overuse stress, as for example new army recruits marching on the parade ground. Initial X rays may be normal and should be repeated two weeks later if the diagnosis is considered likely. Treatment is with initial immobilization and then more gradual conditioning.

Nerve Lesions Causing Foot Pain

• Lesions in the lower spinal cord that irritate or press on the L5 or S1 nerve roots can give rise to pain in the foot. In young people, this is usually due to a lumbar disc prolapse and in older people to osteoarthritic changes in the lower spine (see back pain). Especially in younger people there may be little or no back pain, and if there is no muscle weakness, the foot pain can be both puzzling and distressing.

• The common peroneal nerve is a branch of the sciatic nerve that winds around the fibula bone just below its head that can be felt as a bony prominence just below the outside of the knee. Because the nerve is close to the skin here, it can be easily damaged by trauma in this area. This can cause pain over the top of the foot and front of the ankle. However, there is usually clearcut weakness in raising the foot and turning it outward so the diagnosis is relatively easy. In addi tion, numbness is more common than pain. The nature of the trauma should also point to the diagnosis.

• The superficial peroneal nerve is a branch of the common peroneal. it can become trapped as it comes up through the fascia in front of the ankle and cause a similar unpleasant burning pain on the top of the foot. Because it supplies only relatively small muscles, the weakness is less obvious. The diagnosis can therefore be puzzling. The clue is that the web space of the big toe and the inside of the second toe are not affected since they are supplied by the deep peroneal nerve.

• The deep peroneal nerve (also called the anterior tibial nerve) enters the foot running across the front of the ankle toward the inside. Here it passes underneath a retinaculum known as the cruciate crural ligament, where it can become compressed. This is the equivalent of carpal tunnel syndrome in the hand and is known as the anterior tarsal tunnel syndrome. it causes pain in the web space of the big toe and inner surface of the second toe. Runners, skiers, dancers, and people who repeatedly sprain their ankle are at particular risk.

• The posterior tibial nerve passes down and across the inner surface of the ankle and heel bone and is covered by a ligament. it can become compressed here and cause pain in the sole of the foot.

• The small nerves supplying sensation to the toes, the interdigital nerves, can become stretched by cock-up toes or suffer direct pressure, especially in patients with rheumatoid arthritis. occasionally these nerves enlarge, and this is known as Morton's neuroma.

• REFLEX SYMPATHETIC DYSTROPHY is a complex disorder that most often affects the foot or hand.

frostbite Damage to peripheral tissues (especially toes, fingers, nose, and ears) caused by prolonged exposure to extreme cold. Frostbite affects the extremities, particularly the hands and feet. if the acute injury is severe, tissue death occurs and digits may need to be amputated. The cold injury can also damage blood vessels and cartilage in joints, resulting in osteoarthritis many years later. The problem of frostbite arthritis is a late complication. No treatment will alter the course if applied between the cold injury and the development of arthritis. other than the usual treatments for osteoarthritis, no specific treatment is available for arthritis caused by frostbite.

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