What Is Foot Pain?
The foot is a complex structure of 26 bones and 33 joints layered with an intertwining web of 126 muscles, ligaments, and nerves. The average person spends four hours on their feet and takes between 8,000 and 10,000 steps each day. The feet are very small relative to the rest of the body, and the impact of every step exerts tremendous force upon them -- about 50% greater than the person's body weight. During an average day the feet support a combined force equivalent to several hundred tons. In addition to supporting weight, the foot acts as a shock absorber and as a lever to propel the leg forward, and it serves to balance and adjusts the body to uneven surfaces. It is not surprising, then, that about 75% of Americans experience foot pain at some point in their lives. According to a recent study, chronic and severe foot pain is a serious burden for one in seven older disabled women. To compound problems, the lower back is often affected by injuries or abnormalities in the feet.
Foot pain is generally defined by one of three sites of origin: the toes; the front of the foot (forefoot); or back of the foot (hind foot). Toe problems most often occur because of the pressure imposed by ill-fitting shoes. Pain originating in the front of the foot usually involves the metatarsal bones (five long bones that extend from the front of the arch to the bones in the toe) and the sesamoid bones (two small bones imbedded at the top of the first metatarsal bone, which connects to the big toe). Pain originating in the back of the foot can affect parts of the foot extending from the heel, across the sole (known as the plantar) to the ball of the foot.
What Causes Foot Pain?
General Conditions Causing Foot Pain
The causes of most incidents of foot pain are poorly fitting shoes. High-heeled shoes are major culprits for aggravating, if not causing, problems in the toes, where the most pressure is exerted. Other conditions can also cause or exacerbate foot pain. Weather affects the feet; they contract in cold and expand in hot weather. Foot size can also increase by 5% over the day and change shape and size depending on whether a person is walking, sitting, or standing. Improper walking due to poor posture or inherited or medical conditions that cause imbalance or poor circulation can contribute to foot pain. Often one leg is shorter than the other, causing an imbalance. High impact exercising, such as jogging or strenuous aerobics, can injure the feet. Common injuries include corns, calluses, blisters, muscle cramps, acute knee and ankle injuries, plantar fasciitis, and metatarsalgia.
Medical Conditions Causing Foot Pain
Arthritic conditions, particularly osteoarthritis and gout, can cause foot pain. Although rheumatoid arthritis almost always develops in the hand, the ball of the foot can also be affected. Osteoporosis, in which bone loss occurs, can also cause foot pain. Diabetes is a particularly serious cause of foot pain, infection, and ulcers, and, without proper foot care, can result in amputation. Diabetics with foot deformities, such as claw toes, or bunions are at particular risk. Anorexia, high blood pressure, and other diseases that affect the nervous and circulatory systems can cause pain, loss of sensation, and tingling in the feet, as well as increase the susceptibility for infection and foot ulcers. A number of conditions, including pregnancy, heart failure, kidney disease, and hypothyroidism, can cause fluid build-up and swollen feet. The increased weight and imbalance of pregnancy contributes to foot stress. Diseases that affect muscle and motor control, such as Parkinson's disease, also cause foot problems. Some medications, such as calcitonin and drugs used for high blood pressure, can cause foot swelling.
Causes of Toe Pain
Corns. A corn is actually a form of a callus -- a protective layer of dead skin cells composed of a tough protein called keratin. A corn itself is cone-shaped and usually develops if a shoe rubs against the toes for a prolonged period. As the skin thickens, the corn forms a knobby core that points inward. Hard corns develop on toe joints, usually on the little toe. A shoe that squeezes the front of the foot may cause one toe to rub against another forming a corn between the toes, which is usually soft. These corns can be painful, however, if they harden and rub against each other.
Ingrown Toenails. Ingrown toenails can occur in any toe but are most common in the big toes. They usually develop when tight fitting or narrow shoes put too much pressure on the toenail and force the nail to grow down into the flesh of the toe. Incorrect toenail trimming can also contribute to the risk of developing an ingrown toenail (see How Is Foot Pain Prevented, in this report). Fungal infections, injuries, abnormalities in the structure of the foot, and repeated pressure to the toenail from high impact aerobic exercise can also produce ingrown toenails.
Bunions. A bunion is a deformity that usually occurs at the head of the first of five long bones (the metatarsal bones) that extend from the arch and connect to the toes. The first metatarsal bone is the one that attaches to the big toe. The big toe is forced in toward the rest of the toes, causing the head of the first metatarsal bone to jut out and rub against the side of the shoe; the underlying tissue becomes inflamed and a painful bump forms. As this bony growth develops, the bunion is formed as the big toe is forced to grow at an increasing angle towards the rest of the toes. A bunion may also develop in the bone that joins the little toe to the foot (the fifth metatarsal bone), in which case it is known as a bunionette or tailor's bunion. Bunions often develop from wearing narrow, high-heeled shoes with pointed toes, which puts enormous pressure on the front of the foot and causes the foot and toes to rest at unnatural angles. Injury in the joint may also cause a bunion to develop over time. Genetics play a factor in 10% to 15% of all bunion problems; one inherited deformity, hallux valgus, causes the bone and joint of the big toe to shift and grow inward, so that the second toe crosses over it. Flat feet, gout, and arthritis increase the risk for bunions.
Hammertoes. A hammertoe is a permanent deformity of the toe joint in which the toe bends up slightly and then curls downward, resting on its tip; when forced into this position long enough, the tendons of the toe contract and it stiffens into a hammer- or claw-like shape. Hammertoe is most common in the second toe but may develop in any or all of the three middle toes if they are pushed forward and do not have enough room to lie flat in the shoe. The risk is increased when the toes are already crowded by the pressure of a bunion. Lying down for long periods, diabetes, and various diseases that affect the nerves and muscles put people at risk.
Causes of Pain in the Front of the Foot
The incidence of forefoot pain and deformity increases with age. With early diagnosis, conservative therapy is often successful in treating common disorders of the forefoot.
Calluses. Calluses are composed of the same material as corns -- hardened patches of dead skin cells formed from keratin -- but calluses develop on the ball or heel of the foot. The skin on the sole of the foot is ordinarily about forty times thicker than skin anywhere else on the body, but a callus can double this normal thickness. A protective callus layer naturally develops to guard against excessive pressure and chafing as people get older and the padding of fat on the bottom of the foot thins out. If calluses get too big or too hard, however, they may pull and tear the underlying skin. Calluses can develop from wearing poorly fitting shoes and walking on hard surfaces. People with flat feet are at an increased risk of developing calluses. In people with diabetes, particularly those who have had foot ulcers, the presence of calluses is a strong predictor of subsequent ulceration.
Neuromas. Neuromas occur when the tissue surrounding a nerve becomes enlarged and inflamed causing a burning or tingling sensation and cramping. Morton's neuroma is the most common neuroma in the foot and usually develops when tight, poorly fitting shoes, often those with high-heels, cause the third and fourth metatarsal bones to pinch together compressing an underlying nerve. Injury, arthritis, or abnormal bone structures may also cause this condition.
Stress Fracture. A stress fracture in the foot, also called fatigue or march fracture, usually occurs from a break or rupture in any of the five metatarsal bones (mostly in the second or third). Fracture in the first metatarsal bone that leads to the big toe is uncommon because of the thickness of this bone. If it occurs there, it is more serious than fractures in the other metatarsal bones, because it dramatically changes the pattern of normal walking and weight bearing. (Stress fractures can also occur in the heel area.) They are caused by overuse during strenuous exercise, particularly jogging and high-impact aerobics.
Sesamoiditis. Sesamoiditis is an inflammation of the tendons around the small, round bones that are imbedded in the head of the first metatarsal bone, which leads to the big toe. Sesamoid bones bear much stress under ordinary circumstances; excessive stress can strain the surrounding tendons. Often there is no clear-cut cause, but sesamoid injuries are common among people who participate in jarring, high impact activities, such as ballet dancing, jogging, and aerobic exercise.
Metatarsalgia. When a cause cannot be determined, any pain on the bottom of the foot where the metatarsal bones connect to the four lesser toes is generally referred to as metatarsalgia.
Causes of Pain in the Heel and Back of the Foot
The heel is the largest bone in the foot. Heel pain is the most common foot problem and affects two million Americans every year. It can occur in the front, back, or bottom of the heel.
Plantar Fasciitis. Plantar fasciitis occurs from small tears and inflammation in the wide band of tendons and ligaments -- the connective tissue -- which stretches from the heel to the ball of the foot. This band, much like the tensed string in a bow, forms the arch of the foot and helps to serve as a shock absorber for the body. (The term plantar means the sole of the foot and fascia refers to any fibrous connective tissue in the body.) Plantar fasciitis is usually a result of overuse from high-impact exercise and sports and accounts for up to 9% of all running injuries. Because the condition often occurs in only one foot, however, factors other than overuse may be responsible in some cases. Other causes of this injury include poorly fitting shoes or an uneven stride that causes an abnormal and stressful impact on the foot. Pain often occurs suddenly and mainly in the heel. The condition can be temporary or may become chronic if the problem is ignored. In such cases, resting provides relief, but it is only temporary.
Bursitis of the Heel. Bursitis of the heel is an inflammation of the bursa, a small sack of fluid tissue, beneath the heel bone.
Haglund's Deformity. Haglund's deformity (also commonly called pump bump and known medically as posterior calcaneal exostosis) is a bony growth surrounded by tender tissue on the back of the heel bone. It develops when the back of the shoe, almost always one with a high heel, repeatedly rubs against the back of the heel, aggravating the tissue and the underlying bone.
Tarsal Tunnel Syndrome. Tarsal tunnel syndrome results from compression to a nerve that runs through a narrow passage behind the inner ankle bone down to the heel. It is caused by injury to the ankle, such as a sprain or fracture, or by a growth that presses against the nerve.
Achilles Tendinitis. Achilles tendinitis is an inflammation of the tendon that connects the calf muscles to the heel bone. Achilles tendinitis is caused by small tears in the tendon from overuse or injury. It is most common in people who engage in high-impact exercise, particularly jogging, racquetball, and tennis. People at highest risk for this disorder are those with a shortened Achilles tendon, which can be due to an inborn structural abnormality or can be acquired after wearing high heels regularly. Such people tend to roll their feet too far inward when walking and bounce when they walk.
Heel Spurs. Heel spurs are calcium deposits that develop over time into a sharp bony growth under the heel bone. They often result from improper foot movement during running or walking, poorly fitting shoes, and excessive body weight. As a spur develops the soft tissue in the heel becomes irritated and swells, putting pressure on the nerves and causing pain. Pain may increase with age as the fatty tissue on the bottom of the foot wears away. It should be noted, however, that plantar fascia, bursitis, stress fractures, and tarsal tunnel syndrome are more likely to be the cause of heel pain than spurs.
Excessive Pronation. Pronation is the normal motion that allows the foot to adapt to uneven walking surfaces and to absorb shock. Excessive pronation occurs when the foot has a tendency to turn inwardly and stretch and pull the fascia. It can cause not only heel pain, but hip, knee, and lower back problems.
Arch and Bottom-of-The- Foot Pain
Flat Foot. Flatfoot, or pes planus, is a defect of the foot, in which there is no arch at all. Flatfoot is usually hereditary or caused by diseases of the muscles and nerves. Arches can fall, however, under certain conditions. At particular risk are women who have habitually worn high-heels for long periods. In such cases, the Achilles tendon that runs down the back of the calf to the heel bone is not stretched, so over the years, it shortens and tightens. The ankle, then, does not bend properly, and tendons and ligaments running through the arch try to compensate. Sometimes, they then break down and the arch falls. Some studies have indicated that the earlier one starts wearing shoes, particularly for long periods of the day, the higher the risk for flat feet. One indirect outcome of flat arches may be urinary incontinence or leakage during exercise. The less flexible the arch, the more force reaches the pelvic floor, jarring the muscles that affect urinary continence.
Clawfoot and Abnormally High Arches. Clawfoot, or pes cavus, is a deformity of the foot marked by very high arches and very long toes. Clawfoot is a hereditary condition, but it can also occur when muscles in the foot contract or become unbalanced due to nerve or muscle disorders. An overly high arch (hollow foot), in general, can cause problems. Army studies have found that recruits with the highest arches have the most lower-limb injuries and that flat-footed recruits have the least. Contrary to the general impression, the hollow foot is much more common than the flat foot.
What Are Symptoms Of Foot Pain?
|Cause||Location of Symptoms||Symptoms|
|Corns and calluses||Around toes, usually little toe, bottom of feet or areas exposed to friction||Hard, dead, yellowish skin|
|Ingrown toenails||Toe nails||Nail curling into skin causes pain, swelling, and, in extreme cases, infection|
|Bunions and bunionettes (tailors bunion)||Big toe (bunions) or little toe (bunionettes)||
Toes point inward
Area next to bony bump is red, tender, occasionally filled with fluid
Toe joint may be inflamed
Note: Osteoarthritis may also occur in the big toe in older people
|Morton's neuroma||Third and fourth toes and bottom of foot near these toes||
Cramping and burning pain around the third and fourth toe
The neuroma may be detected by pressing top to bottom using one hand and with the other hand pressing on the top of the foot and moving it side to side
Aggravated by prolonged standing and relieved by the removal of the shoes and forefoot massage
|Hammertoe||Usually second toe but may develop in any or all of the three middle toes||
Toes form hammer or claw shape
No pain at first, increasing as tendon becomes tighter and toes stiffen
|Metatarsal stress fracture||Area beneath the second or third toe||Sudden pain when injury occurs|
|Sesamoiditis||Ball of foot beneath big toe||Pain and swelling|
|Plantar fasciitis||Back of the arch right in front of heel||
At onset, some people report a tearing or popping sound
Pain, most severe with first steps after getting out of bed, decreasing after stretching, returning after inactivity
|Bursitis of the heel||Center of the heel||Pain, with warmth and swelling. Increases during the day|
|Haglund's deformity (Pump bump)||Fleshy area on the back of the heel||Tender swelling aggravated by shoes with stiff backs|
|Stress fracture or, uncommonly, heel spurs||Bottom of heel||Sharp stabbing pain|
|Tarsal tunnel syndrome||Anywhere along the bottom of the foot||Numbness, tingling, or burning sensations, pain, most commonly felt at night|
|Flat feet||The arch||
Often no pain or discomfort
Sometimes people report fatigue, pain, or stiffness in the feet, legs, and lower back
|High Arches (Hollow feet)||The arch||
Lower back pain, possible tendency to lower limb injuries
|Achilles tendinitis||Achilles tendon: area along the back between calf muscles and heel||
Pain worsens during physical activities (particularly running) after which the tendon usually swells and stiffens
If it ruptures, popping sound may occur followed by acute pain similar to a blow at the back of the leg
Who Has Foot Pain?
Nearly everyone who wears shoes has foot problems at some point in their lives. Foot pain is fairly common even in children. Heel pain, for instance, is common in very active children between the ages of 8-13, when high impact exercise can irritate growth centers of the heel. Women are at higher risk than men for severe foot pain, probably because of the high incidence of wearing high-heeled shoes. In fact, severe foot pain appears to be a major cause of general disability in older women. In one study, 14% of older disabled women reported chronic, severe foot pain, which played a major role in requiring assistance in walking and in daily activities. Elderly people, in any case, tend to have problems because their feet widen and flatten and the fat padding on the sole of the foot wears down as they age. Plantar fasciitis is most common in people over 50. Anyone who is overweight puts increased stress on the feet and is also at risk for foot or ankle injuries. People who engage in high impact sports, such as tennis, jogging, or racquet ball, or whose work involves heavy lifting and walking are prone to foot injuries, especially Achilles tendinitis, stress fractures, and plantar fasciitis. Many medical conditions and inherited abnormalities predispose people to foot problems. Pregnant women not only gain weight but also often experience swelling in their feet and ankles. Pregnancy also releases hormones that cause ligaments to relax, which helps in bearing the child but can weaken feet. People with diabetes are at particular risk for foot infections and should take special precautions.
What Are The General Preventive Measures For Foot Pain?
Preventing Foot Problems in Childhood
The first year in a person's life is important for foot development. Parents should cover their baby's feet loosely, allowing plenty of opportunity for kicking and exercise. The child's position should be changed several times. Staying too long on the stomach can strain the feet. Children generally walk between 10 and 18 months; they should not be forced to start walking early. Wearing just socks or going barefoot indoors helps the foot develop normally and strongly and allows the toes to grasp. Going barefoot outside, however, increases the risk for injury and other conditions, such as plantar warts. When outdoors, shoes should be light, flexible, and made of natural materials that "breathe". (Children's feet perspire greatly.) Footwear should be changed every few months as the child's feet grow. Footwear should never be handed down. High impact sports can injure growing feet, and parents should be sure that their children's feet are protected if they engage in intensive athletics.
Toenails should be trimmed short and straight across. Filing should be straight across as well using a single movement, lifting the file before the next stroke. The file should not saw back and forth. A cuticle stick can be used to clean under the nail. Skin creams can help maintain skin softness and pliability. Taking a warm foot bath for 10 minutes two or three times a week will keep the feet relaxed and help prevent mild foot pain from fatigue. Adding 1/2 cup of Epson salts increases circulation and adds other benefits. Taking foot baths only when feet are painful is not as helpful. A pumice stone or loofah sponge can help get rid of dead skin. Hiking or strenuous walking can cause blisters. To prevent them, one study reported that treating feet with antiperspirants before setting out may be helpful. Reflexology is an Oriental massage therapy that manipulates hands and feet. A pleasant exercise using this method can be done while taking a bath. Use the thumb, index and middle finger to rotate each toe in a circular motion. Then, make a fist and rotate it slowly around the bottom of the foot. Finally, gently twist each foot as if wringing wet clothes, moving the top and bottom in opposite directions.
Foot Care for People with Diabetes. Daily foot care is extremely important for people with diabetes who are at risk for nerve damage and poor blood flow to the feet. Preventive foot care could reduce the risk of amputation in people with diabetes by 44% to 85%. Patients should make a daily inspection and watch for changes in color or texture, odor, and firm or hardened areas, which may indicate infection and potential ulcers. When washing the feet, the water should be warm (not hot) and the feet and areas between the toes should be thoroughly dried afterward. Moisturizers should be applied, but not between the toes. Corns and calluses should be gently pumiced and toenails trimmed short and the edges filed to avoid cutting adjacent toes. Patient should not use medicated pads or try to shave the corns or calluses themselves. People with diabetes should avoid high heels, sandals, thongs, and going barefoot. Shoes should be changed often (three times a day if possible). They should not wear tight stockings or any clothing that constricts the legs and feet. A new hand-held device that uses a nylon fiber brush may enable the physician to identify nerve damage that can lead to ulcers by pressing it against several points on the foot and eliciting the patient's response to the pressure.
A person with diabetes should check with a specialist in foot care for any problems. Hospitalization and intravenous antibiotics for up to 28 days may be needed for severe foot ulcers in diabetic patients. In one study, intravenous therapy using ofloxacin or penicillin for only seven days followed by an oral antibiotic was adequate treatment. A number of treatments (Dermagraft, Apligraf, Regranex) are now available that stimulate new cell growth and help heal skin ulcers or use cultures of human skin cells, although their benefits are still unproven. Granulocyte-colony stimulating factor, or G-CSF (filgrastim, Neupogen, Amgen) is showing promise as an effective alternative to antibiotics. One small study shows that treatment with human nerve growth factor (NGF) may safely prevent and reverse some of the nerve damage caused by diabetes. One study indicated that administering hyperbaric oxygen (given at high pressure) promoted healing and helped prevent amputation. There was no follow-up however, and more research is needed. According to a new study, the wearing of magnet-laden socks seems to reduce or eliminate the pain associated with diabetes induced foot disorders.
Well-fitted shoes are the best way to prevent nearly all problems with the feet. They should be purchased in the afternoon or after a long walk, when the feet have swelled. The shoe should have adequate cushioning, 1/2 inch of space should be left between the largest toe and the tip of the shoe, and the toes should be able to wiggle upward. A person should stand when being measured, and both feet should be sized, with shoes bought for the larger-sized foot. Women who are used to wearing overly pointed-toe shoes may assume that tight-fitting shoes are normal, hence increasing the risk for many foot disorders. New shoes should have padding, a flexible sole, and should always feel comfortable right away without requiring a period of breaking-in. Ideally, the shoe would have a removable insole. Elderly people wearing shoes with thick inflexible soles also may be unable to sense the position of their feet relative to the ground, significantly increasing the risk for falling. Some experts recommend that older people wear thin hard soles. More research is needed to determine if thick soles are actually responsible for foot injury in younger adults who engage in high impact exercise.
If shoes do require breaking-in, moleskin pads should be placed next to areas on the skin where friction will occur. Shoes purchased for exercise should be specifically designed for a person's preferred sport. The heel area should be strong and supportive (but not too stiff) and the front of the shoe flexible. As soon as the heels show noticeable wear, the shoes or heels should be replaced. If a person insists on wearing high-heeled shoes, the heel should be wedge-shaped. (Even in these cases, the heel height should not be extreme.) People should avoid extreme variation between exercise footwear, street, and dress shoes. Shoes should be changed during the day.
The way shoes are laced can be important for preventing specific problems. Laces should always be loosened before putting shoes on. People with narrow feet should buy shoes with eyelets farther away from the tongue than people with wider feet. This makes for a tighter fit for narrower feet and looser for wider. If, after tying the shoe, less than an inch of tongue shows, then the shoes are probably too wide. Tightness should be adjusted both at the top of the shoe and at the bottom. Where high arches cause pain, eyelets should be skipped to relieve pressure.
Although people believe that foot-binding is a problem limited to Chinese women of the past, it should be noted that fashionable high-heels are designed to constrict the foot by up to an inch. High heels are the major cause of foot problems in women and one study suggests that wearing high-heels may even lead to arthritis of the knee. Fortunately, according to a recent survey, nearly half of working women now wears flats; about one quarter wears pumps less than 2 1/4 inches in height and another quarter wears athletic shoes. Only 3% reported wearing shoes with heels higher than 2 1/4 inches. Women who insist on high-heels should at least look for shoes with wider toe room, reinforced heels that are relatively wide, and cushioned insoles. They should also reduce the amount of time they spend wearing high-heels. The American Orthopaedic Foot and Ankle Society now awards a Seal of Approval to women's shoes that they determine are healthy.
Correct Walking and Exercise
In addition to wearing proper shoes and socks, a person should also walk often and correctly to prevent foot injury and pain. The head should be erect, back straight, and the arms relaxed and swinging freely at the side. A person should step out on the heel, move forward with the weight on the outside of the foot, and complete the step by pushing off the big toe. A person should prepare for long hikes by putting moleskin pads on the heel and other parts of the foot that might be rubbing on the shoe. At the end of a hike, the foot should be checked for irritation and redness. Gentle stretching and heel lifts after warm-up and before running can help prevent Achilles tendinitis and heel pain.
Insoles and Orthotics
Insoles. Insoles are flat cushioned inserts that are placed inside the shoe; they can be obtained in athletic and drug stores. They are designed to reduce shock, provide su