Foot pain is one of the common symptoms observed in all age groups. Foot pain is either acute lasting less than 3 months or chronic lasting for more than 3 to 6 months. About 75% of the people in the United States have foot pain. Foot carries body weight during standing, running, and walking. Bones and joint of foot forms a normal arch known as arch of the foot. The normal arch of the foot is important for weight distribution. Deformities of curvature of arch such as flat foot, and injuries of bone or ligament are the most common cause of the foot pain. Understanding of the brief anatomy of the foot is essential to grasp the cause of the pain.
Anatomical Distribution Of Foot Pain
Bursae: Cause of Foot Pain-
Bursa is a lubricating viscous fluid sac, which lies between tendon and bone or ligament and bone.
Tendon: Cause of Foot Pain-
- Thick bundle of tough fibrous tissue lies between bone and muscles.
- Muscle end in to tendon and tendon is attached to bone.
- Contraction of muscles pulls the tendon and bone resulting in various joint movements.
Ligaments: Cause Of Foot Pain-
Ligament is a bundle of tough fibrous tissue. Ligament is attached to 2 or 3 adjacent bone to form a joint. Ligament prevents separation or dislocation of joint.
Muscles: Cause Of Foot Pain-
Muscles continue as a tendon at both the ends. Tendon is attached to bone or joint of foot. Muscle contraction pulls tendon and bone causing flexion, extension and rotation movement of the joints in foot.
Bones: Cause Of Foot Pain-
Foot has 26 bones. Injuries such as fracture or inflammation secondary to osteomyelitis (bone infection) causes severe pain.
Foot has 33 joints. Joint subluxation, dislocation and inflammation causes acute or chronic pain.
Causes of Foot Pain
- Foot Inflammation
- Foot Infection
- Foot Injury
- Abnormal Bone Growth
- Abnormal Arch of the Foot
- Foot Neuroma
1. Foot Inflammation Causing Foot Pain
- Soft Tissue Inflammation
- Joint Inflammation
A. Soft Tissue Inflammations
Following Are The List Of Soft Tissue Inflammations Causing Foot Pain:
- Bursitis is an inflammation of bursa. Bursa is a fluid sac filled with viscous fluid and functions as a lubricant.
- Bursa lies between bone and tendon or ligament and bone.
- Trauma, friction and repeated injury of bursa causes inflammation of the membrane lining the internal surface of the bursa.
- Inflammation of bursa is extremely painful and prevents any kind of joint movements and activities.
- Retro-calcaneal bursitis is often misdiagnosed as inflammatory disease of tendon tendo-achillis.1
- Skin infection such as carbuncle or furuncle causes severe pain.
b. Plantar Fasciitis:
- Fascia is a thin fibrous tissue that separates soft tissue in to compartments within the foot.
- Plantar fascia is a thick band of tough fibrous tissue spread between heel and toes.
- The inflammation of plantar fascia is known as plantar fasciitis.
- Plantar fasciitis is one of the most common causes of foot pain.
- Pain is severe in the morning and continues for several hours.
- Pain is increased with activities.
c. Tarsal Tunnel Syndrome:
- Tarsal tunnel lies behind medial malleolus (inner side ankle bump).
- Tunnel is a passage covered by a thick fibrous fascia known as flexor retinaculum.
- Tibial nerve passes through the tunnel with several tendons.
- Narrowing of the tunnel compresses or irritates the tibial nerve and causes severe pain in foot.
- Tarsal Tunnel syndrome is also caused by Schwannoma of posterior tibial nerve.2 Schwannoma is an inflammatory condition of posterior tibial nerve.
- Inflammation of tendon is known as tendonitis.
- There are several tendons in the foot.
- Tendons are spread over dorsal and plantar surface of the foot.
- Dorsal surface is the top of the foot and plantar surface is at the bottom of the foot.
- Pain becomes severe when muscle attached to inflamed tendon contracts. Joint movement and muscle contraction induces severe pain lasting for prolonged period.
- Injury is common among runners.3
e. Ligament Inflammation:
- Inflammation of the ligament is rare and very painful.
- Ligament links the proximal and distal bones to form a joint.
- Inflammation of the ligament causes severe pain with minimum joint movement. Joint inflammation is observed in patients suffering with rheumatoid arthritis or osteoarthritis.
- Inflammation of ligament is also observed in septic arthritis and following severe trauma.
f. Myalgia or Myopathy:
- Myalgia is an inflammation of muscles seen following injury.
- Muscle inflammation or myalgia is also seen following viral or bacterial infection.
- Generalized myalgia following autoimmune disease often causes severe muscle pain in foot.
g. Skin and Subcutaneous Tissue Inflammation
- Inflammation of the skin and subcutaneous tissue follows infection or cellulitis.
- Non-infected inflammation is rare and seen after allergic reaction like dermatitis.
- Inflammation of subcutaneous tissue or pad of fat underneath the heel or toes is observed following prolonged walking or jogging.
- Callus is a thick and hard bump over skin, which may be painful or painless.
- Callus spreads through epidermis and part of the dermis.
- Rubbing, friction and irritation causes inflammation of callus and results in pain. If not treated may result in infection and ulcer formation.
- Corn is smaller in size than callus.
- Bump is a painful thick skin and mostly spread over epidermis or outer layer of the skin.
- Corn is often seen over toes and sole of the foot.
B. Joint Inflammation (Inflammatory Joint Disease): Cause of Foot Pain
- Seen in older patients.
- Characterized by articulating cartilages degeneration and adjacent bone osteophyte or spur formation.
- Osteophytes or sharp protrusion of the bone adjacent to joint causes severe pain with movements of foot.
- Joint space is narrowed resulting in bone rubbing against each other causing foot pain.
- During advanced stage, atrophy of tendons and muscles are observed.
- Ligaments become lax resulting in joint subluxation or dislocation.
- Osteoarthritis is considered as hereditary disease seen in identical twins.
b. Rheumatoid Arthritis
- Rheumatoid arthritis is an autoimmune disease that causes pain in small joint of foot and ankle joint.
- Rheumatoid arthritis is an inflammatory arthritis. Inflammation of synovial membrane and capsule causes severe pain with joint movements.
- Joint is swollen secondary to excessive secretion of synovial fluid.
- Articulating cartilages are inflamed and painful during initial stages. Later stages cartilages are degenerated and become very thin.
- Inter-Phalangeal or Metatarsal joint subluxation is often seen in advanced stage of the disease
- Rheumatoid arthritis is most common in shoulder and knee joint
- Small joint in foot are warm, stiff, swollen and painful.
c. Psoriatic Arthritis
- Psoriatic arthritis of foot is very rare disease.
- Psoriatic arthritis is genetic disease. Blood test is positive for HLA_B27 factors.
- Affects more than one joint in foot.
- Inter-phalangeal joint swelling caused by psoriatic arthritis is often associated with sausage like swelling of toes.
- Associated with nail bed changes like pitting nail and separation of nail bed
- Inter-Phalangeal joint and Metatarsal joint is red and warm to touch
- Gout is a rare inflammatory joint disease and can cause severe foot pain.
- Gout is caused by uric acid deposit in the joint causes joint inflammations.
- Gout is often seen in big toe. Toe is red-hot and swollen.
- Pseudogout is rare arthritic disease that mostly affects large joint.
- Pseudogout is an inflammatory disease that results in sudden acute painful joint.
- The acute inflammation is on and often and lasts for 3 to 7 days. Inflammatory episode causes swelling and pain in the foot lasting for days or weeks.
- Joint inflammation is caused by calcium pyrophosphate crystals deposit within joint.
f. Osteochondritis Dissecans
- Osteochondritis dissecans is an inflammatory disease of articulating cartilage of the joint.
- Inflammation of the cartilage causes degeneration or cracks on the surface of cartilage resulting in severe foot pain with joint movement.
- Osteochondritis dissecans is an avascular necrosis of cartilage caused by lack of blood supply. Lack of blood supply causes fragmentation of cartilage.
- Fragmented cartilage often is reabsorbed if treated in earlier stage. If treatment is delayed or not effective then fragmented cartilage eventually breaks down resulting cartilage loose fragment in the joint.
- Mostly observed in young patients and treated by endoscopic surgery.4
2. Foot Infection Causing Foot Pain
Following Are The 3 Types Of Foot Infection Which Can Cause Foot Pain
- Soft Tissue Infection
- Joint Infection
- Bone Infection
A. Soft Tissue Infection Causing Foot Pain:
Different Types of Soft Tissue Infection That Can Cause Foot Pain Are:
a. Skin and Subcutaneous Tissue Infection:
- Impetigo- Bacterial infection is caused by Staphylococcus aureus and staphylococcus pyrogenes. Extremely painful skin disease results in patient being unable to walk or stand on diseased foot.
- Erysipelas- Skin infection caused by streptococcus and spreads through lymphatics.
- Cellulitis- Skin infection spreads into deeper tissue such as subcutaneous tissue.
b. Infected Bursitis
Bursitis rarely follows infection. Injuries of the bursa with compound fracture or penetrating wound often result in infected bursitis causing foot pain.
c. Cellulitis Infection
Cellulitis is an infection of the skin and subcutaneous tissue that spreads through the connective tissue. Cellulitis may be associated with pus or abscess.
B. Joint Infection Causing Foot Pain
- Septic arthritis is rare disease, but infection of foot joint is common among infection of all other joint.
- Septic arthritis is seen in Inter-Phalangeal joint and Metatarsal joint.
- Septic arthritis of joints in the foot is observed in immune suppressed patients.
- Immune suppressions are caused by cortisone, chemotherapy and autoimmune diseases.
C. Bone Infection Causing Foot Pain
- Osteomyelitis is an infection of the bone.
- Infection spreads into bone from blood known as bacteremia.
- Primary infection may be in lung as pneumonia or urinary tract and spread into bone through blood stream.
- Osteomyelitis is often observed following penetrating would or compound fracture.
3. Foot Injuries Causing Foot Pain
Following Are The Different Types Of Foot Injuries That Can Cause Foot Pain:
- Soft Tissue Injury
- Joint Injury
- Bone Injury
A. Soft Tissue Injuries Causing Foot Pain
a. Skin and Subcutaneous Tissue Injury
- Laceration- Skin cut and scratch causes severe foot pain. Pain is more severe under the toes than heel. Laceration often gets infected in foot if not treated immediately.
- Skin Blisters- Continuous long walking or tight fitting shoes often causes blisters and severe foot pain.
- Incision or wound caused by invasive procedure like surgery, needle placement for medication may be followed by infection and severe pain.
b. Tendon Injury
Foot Pain Due To Tendon Laceration
- Tendon laceration causing foot pain is seen following fall or accident.
- Skin bruises and cut following domestic fall, auto accident or sports injury often is associated with tendon laceration.
- Tendon laceration is superficial injury of tendon. Tendon laceration causes mild to moderate foot pain at rest.
Foot Pain Caused By Partial Tear of Tendon
- Direct impact following work accident or auto injury causes partial or complete tear of tendon.
- Patient is able to move the bone or joint when muscle attached to injured tendon contracts. The muscle contraction causes severe pain.
Foot Pain Caused By Complete Tear of Tendon
- Complete tear is extremely painful at rest and with activities.
- Patient is unable to move the bone or joint when muscles attached to tendon contracts.
Foot Pain Caused By Dislocation of Tendon
- Tendon is attached to bone on one side and muscle on other side.
- Direct impact or twist of foot and toes can cause separation of tendon from bone.
- The separation of tendon from bone is known as dislocation or separation of tendon.
c. Ligament Injury
Foot Pain Caused By Ligament Laceration
- Ligament is deeply situated against the bone.
- Ligament laceration is seen following surgery and violent twisting of the foot.
- Laceration of ligament is painful and patient needs limited restriction of foot activities and joint movements.
Foot Pain Caused By Partial Tear of Ligament
- Tear of ligament is common injury following twist and turn of the foot and toes.
- Partial tear is less painful at rest than with joint movement.
- Ligament holds the two bones of the joint. Any joint movement causes severe pain.
Foot Pain Caused By Complete Tear of Ligament
- Direct impact, twist of foot, twist of toes and hyperextension or flexion of the joint causes complete tear of the ligament.
- Foot Pain is severe at rest and following activities. Joint is often swollen and stiff because of bleeding and hematoma (blood clot).
Foot Pain Caused By Detachment of Ligament
- Ligament is attached to two bones so as to prevent separation of the bone or joint dislocation.
- Multiple ligaments link each joint. Single ligament tear does not cause joint dislocation. Detachment of ligament causes same symptoms as complete tear of the ligament.
d. Muscle Injuries
Foot Pain Caused By Muscle Laceration
- Muscle laceration is more common than ligament laceration or tear. Muscle laceration is associated with bleeding.
- Severe foot pain is often caused by laceration of muscle and hematoma causing pressure on lacerated or torn muscles.
Foot Pain Caused By Muscle Tear
- Muscle is a bundle of several groups of muscle fibers.
- Symptoms of partial or complete tear depend on number of group of muscles injured.
- Muscle injury is accompanied by mild to severe bleeding and collection of blood between muscle and surrounding tissue.
- Blood clot causes severe pressure on injured muscle and surrounding normal tissue.
- Massive blood clot may cause pressure or irritation of nerve resulting in symptoms like tingling, numbness and muscle weakness.
e. Skin Injuries
Foot Pain Caused By Skin Laceration
- Trauma or injury of the skin is caused by blunt or sharp trauma.
- Blunt trauma causes bruises or bleeding underneath the skin. Sharp trauma is caused by penetrating injury.
- Laceration causes superficial or deep scratch of the epidermis and dermis.
- The wound does not penetrate beyond dermis.
Foot Pain Caused By Skin Incision
- Incision causes penetrating injury, which cuts through the skin and dermis.
- The depth of penetration often is till subcutaneous tissue and deeper.
- Incisional injury causes bleeding in subcutaneous tissue and may be associated with injury of muscles and tendon.
B. Joint Injuries Causing Foot Pain
a. Foot Joint Subluxation
- Subluxation is partial separation of the bones, which are linked as a joint.
- Subluxation is often seen following fall or push in patients suffering with advanced arthritis such as osteoarthritis or rheumatoid arthritis.
- Subluxation of toe is often seen following twist or pull of toe in patients suffering with rheumatoid arthritis.
b. Foot Joint Dislocation
Listed below are the 3 types of foot dislocation that can cause severe foot pain:
Foot Pain Caused By Anterior Dislocation
- Dislocation of foot and toes are separation of proximal and distal bone.
- The position of distal bone following dislocation is anterior, posterior or lateral to the proximal bone.
- Anterior dislocation is seen following forceful hyper flexion of the toe and foot.
Foot Pain Caused By Posterior Dislocation
- Posterior dislocation results in posterior or ventral displacement or displacement of distal bone of the joint.
- Hyperextension often causes posterior dislocation or sliding of the distal bone towards the direction of ground.
Foot Pain Caused By Lateral Dislocation
Direct impact by heavy object or accelerated twist of the foot often causes lateral displacement of the either proximal or distal bone of the joint.
c. Foot Joint Hematoma
- Joint hematoma is seen following auto or work accident.
- Joint hematoma causes joint swelling and pain.
- Severe hematoma may result in ligament tear or separation resulting in partial or complete dislocation.
- Hematoma if not treated may result in infection and formation of abscess.
d. Foot Joint Abscess
- Joint abscess is observed following penetrating wound or joint hematoma.
- Joint is extremely painful and signs of infections are observed during examination.
- Patient may complaint of fever, pain, joint swelling, increased skin temperature over joint and red discoloration of the joint.
C. Bone Injuries Causing Foot Pain
Injuries to the Foot Bone often lead to fracture of the foot bone. Listed below are the different types of foot bone fracture that can cause foot pain.
a. Hairline Fracture Of Phalanges And Bones In Foot
- Hairline fracture often occurs after twist and pull of the phalanges, metatarsal and other foot bones. Fracture is also known as "Stress Fracture".
- Hairline fracture does not cross entire thickness of the bone.
b. Non-Displaced Fracture of Phalanges, Metatarsal Joint And Bones Around Heels
- Fracture causes full thickness crack in the bone.
- The ends of proximal and distal fragment of the fractured bone are in contact and maintain anatomical positions.
- Adjacent bones are stable and conservative treatment succeeds in healing fracture when joint is immobilized for 4 to 8 weeks.
c. Displaced Fracture of Phalanges, Metatarsal Joint and Bones Around Heels
- The proximal and distal fragments of the fractured bones are separated.
- Two fragments of fractured bone often lies side-by-side or overlap on its surface.
- Blood supply to adjacent fractured bone is interrupted and may result in avascular necrosis if not treated within 6 to 8 hours following injury.
d. Comminuted Fracture of Phalanges, Metatarsal Joint and Bones Around Heels
- Comminuted fracture is often associated with multiple fragments of bones.
- Comminuted fracture is often seen following direct impact or forceful twist of foot and toes.
- Fragments of the bone are shattered in multiple pieces.
- Blood supply to adjacent fractured bones are interrupted resulting in avascular necrosis.
e. Compound Fracture of Phalanges, Metatarsal Joint and Bones Around Heels
- Compound fracture is a complete displaced fracture with open wound seen with metatarsal fracture as well as fracture of phalanges.
- The fragment of the bone is exposed to atmosphere through an open skin wound.
- Infection and avascular necrosis is common complication.
f. Extra-Articular and Intra-Articular Fracture
- Fracture is either extra articular or intra-articular.
- Extra-articular fracture is outside the joint mostly located over the shaft of the bone.
- Intra-articular fracture is within the joint or extra-articular fracture extends in joint.
- Intra-articular fracture involves head (epiphysis) of the metacarpal bone or phalanges.
4. Abnormal Bone Growth Causing Foot Pain
Heel Spurs and Bunions are the abnormal bone growths that can cause foot pain.
A. Heel Spurs Causing Foot pain
- Heel bone is calcaneal bone.
- Occasionally in few patients, abnormal growth of the bone is observed over calcaneal bone at the bottom of the heel.
- Abnormal bone growth is also known as bony spurs.5
- Walking or jogging becomes extremely painful as any pressure on spurs results in severe pain.
B. Bunions Causing Foot Pain
- Bunions are bony swelling mostly seen on inner side of base of big toe and known as "Hallux Valgus".
- Skin over bony swelling often gets inflamed and becomes painful and red.
- Smaller bony swelling are also observed over little toe or outer side of little toe.
- Bunions are often seen in individual wearing tight shoes.6
5. Abnormal Arch Of The Foot: Cause of Foot Pain
Abnormal arch of foot are described as flat foot or high arch foot.
- Flat Foot
- High Arch Foot
A. Flat Foot Causing Foot Pain
- Flat foot is also known as "Pes Planus" or fallen arches.
- In normal arch, middle of the sole does not touch the standing ground.
- In Flat foot, the middle of the sole and entire foot is rested on standing surface of the ground.
- The cause is often congenital, as arch is never developed in 20 to 30% of population.
- Biomechanics of weight transmission through foot during standing, walking or jogging depends on normal arch of the foot.
- The stress on joint, ligaments, tendon and irritation of nerve causes pain spread over bottom of the foot as well as top of the foot.
- Foot Pain often responds to conservative treatment.7
B. High Arch Foot Causing Foot Pain
- Also known as "Pes Cavus" or cavoid foot.
- Sole of the foot is curved and creates a hollow between heel and toes.
- High arch foot is often observed in Charcoat -Marie-Tooth disease and Friedreich's ataxia.
- High arch foot is less common than flat foot.
- Weight transmission and distribution is through ankle joint to heel in the back and toes in front.
- Unequal weight distribution either through ankle or toes causes severe pain during walking or jogging.
6. Foot Neuroma: Cause of Foot Pain
- Morton Neuroma or Plantar Neuroma
- Hammer Toe
- Claw Toe
A. Morton Neuroma or Plantar Neuroma Causing Foot Pain
The fibrous tissue surrounding nerves are hypertrophied or thickened resulting in pressure or irritation of the nerve. The neuroma is extremely painful condition. Pain is triggered during walk or jogging when nerve is pressed or irritated by surrounding tissue.
B. Hammer Toe Causing Foot Pain9
- Also known as contracted toe.
- Toe appears like hammer because of deformity caused by permanent bend at proximal inter-phalangeal joint of 2nd, 3rd and 4th toe.
- Caused by high heels and poorly fitting shoes.
C. Claw Toe Causing Foot Pain
- Observed in all toes but most often seen on outer side of the foot.
- The metacarpal-phalangeal joint is flexed like a claw.
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