Foot Pain

Medical Author : Jayson Goo, ATC, MA, CKTI

Medical Editor : William C. Shiel Jr., MD, FACP, FACR

 

Top and side view illustrations of the foot bone structure.

How is the foot designed?

The foot is an intricate structure of 26 bones that form two crossing arches of the foot. The longitudinal arch runs the length of the foot, and the transverse arch runs the width. The ankle joint is formed by the interaction of the foot and the lower leg, and the toes are on the far side of the foot. The bones of the foot are primarily held together by their fit with each other and connected by a fibrous tissue known as ligaments. The muscles of the foot, along with a tough, sinewy tissue known as the plantar fascia, provide secondary support to the foot. The foot has internal muscles that originate and insert in the foot and external muscles that begin in the lower leg and attach in various places on the bones of the foot. There are also fat pads in the foot to help with weight-bearing and absorbing impact.

Picture of the metatarsal (foot) and calcaneus (heel) bones, the plantar fascia ligament, and the Achilles tendon of the lower leg and foot
Picture of the metatarsal (foot) and calcaneus (heel) bones, the plantar fascia ligament, and the Achilles tendon of the lower leg and foot

The foot is the foundation of movement of the lower extremity. Pain in the foot indicates that there is something wrong with either the interaction of internal structures of the foot or with the how the foot is interacting with external influences. How and when the pain occurs and the locations of the pain are the primary clues to what may be causing the pain. When there is pain, the body reacts by changing the way it moves or functions in an effort to reduce the pain. Biomechanical changes or disease may prevent the normal movement and cause further injury.

 

A female runner in pain holds her injured foot.

What causes foot pain?

Foot pain may be caused by many different diseases, biomechanical conditions, or injuries. Acute or repeated trauma, disease, or combinations of the problems are the most common causes of foot pain and are commonly seen in sports and workplace environments that require physical activity Trauma is a result of forces outside of the body either directly impacting the body or forcing the body into a position where a single or combination of forces result in damage to the structures of the body. Poor biomechanical alignment may lead to foot pain. Wearing shoes that are too tight or high heels can cause pain around the balls of the feet and the bones in that area. Shoes that are tied too tightly may cause pain and bruising on the top of the foot.

Injuries such as ligament sprains, muscle strains, bruises, and fractures typically occur suddenly (acutely). Sprains, strains, bruises, and fractures may be the result of a single or combination of stresses to the foot. A sprain of the foot or ankle occurs when ligaments that hold the bones together are overstretched and their fibers tear or stretch too far. The looseness of ligaments in the joints of the foot may lead to foot pain.

The muscle's bursa and fascia of the foot can be strained by overstretching, overuse, overloading, bruising, or a cut (such as by stepping on a sharp object). Achilles tendonitis is a common injury of the tendon that attaches at the back of the heel.

Injury to the bones and joints of the foot can be caused by a single blow or twist to the foot, or also by repetitive trauma that can result in a stress fracture. A blunt-force injury such as someone stepping on your foot may result not only in a bruise (contusion) injury but also damage to the muscles and ligaments of the foot. Direct blows to the foot can cause bruising, breaking of the skin, or even fracturing of bones. Metarsalgia is the irritation of the joints of the ball of the foot. The term "stone bruise" is commonly referred to as a specific localized pain and tenderness of the bottom of the foot. "Turf toe" is a common athletic injury in which the tendon under the joint at the base of the big toe is strained. Trauma to the toenail can cause pooling of blood under the nail and the temporary or permanent loss of a toenail. Repetitive trauma to the bones, muscles, and ligaments can result in extra bone growth known as spurs or exostoses.

Sprains, injuries to the ligaments of the foot, occur when ligaments are overstretched. The ligaments that attach the foot to the ankle are also commonly sprained.

 

Bruises, bunions, corns and blisters are common causes of foot pain as shown here.

What causes foot pain? (Continued)

Injuries to both the skin covering and the internal structures may also be caused by multiple small repetitive traumas. Microtrauma injuries can be caused by running on uneven surfaces or surfaces that are too hard or too soft, or by wearing shoes that have poor force-absorption qualities or fit incorrectly. Thickenings of tissue of the outer foot and toes are commonly known as bunions, corns, and calluses. These are often caused by poor-fitting shoes. Morton's neuroma caused by thickening of tissue around a nerve between the toes can cause toe numbness and pain and may also be aggravated by poor-fitting shoes. Footwear can be a contributor to foot pain. Poor-fitting shoes in the short term can cause blisters, bruising, and be a source of athlete's foot. The long-term effects may be bunions, corns, irritation of nerves and joints, misalignment of the toes, and the source of microtrauma injuries to the foot.

Repeated overstressing of the same structure of the foot may cause stress fractures, tendonitis, plantar fasciitis, and acute and chronic osteoarthritis. Stress fractures commonly occur in the metatarsal bones, the long bones of the foot.

The arches of the feet absorb and return force to and from the body to the outside world when we are standing on our feet. Injury to the plantar fascia is a common cause of arch pain. The plantar fascia is a tough fibrous sheath that extends the length of the bottom of the foot and lends support to the arch. When the plantar fascia is damaged, the resulting inflammatory response may become a source of arch pain. High and low arches (flat feet) may cause pain because of strain to the feet.

Disease, viruses, fungi, and bacteria may also be the sources of foot pain. Diabetes, Hansen's disease, arthritis, and gout are common diseases that affect the foot. Disorders of the nerves to the feet may cause numbness and burning sensation in the feet known as peripheral neuropathy.

Plantar warts on the bottom of the foot are caused by a virus and can cause irritation. Athlete's foot, which is caused by a fungus, also can lead to foot irritation. A common cause of foot pain is the ingrown toenail. Ingrown toenails occur when the edges of the nail grow through or into the skin, resulting in irritation and sometimes leading to infection.

 

A football player gets help walking off the field after injuring his foot.

What other symptoms and signs may accompany foot pain?

Pain and point tenderness are the immediate indicators that something is wrong in a specific area. The onset of pain, whether suddenly or over time, is an important indicator of the cause of the problem. The following questions are also important.

  • Is there pain with movement of the affected area?
  • Is it affected by weight-bearing?
  • Does it change your walking motion?

Bones of the foot are joined together by ligaments. A sprain occurs when the ligaments that hold the bones together are overstretched and the fibers tear. Point tenderness and looseness of a joint can be indicators of a sprain.

Injury to the bones of the foot can be caused by a single blow or twist to the arch or also by repetitive trauma that can result in a stress fracture. Fractures are indicated by a focal point of pain that may be exquisitely tender on the bone. There may be a distinguishable lump or gap at the site of the fracture. A rotated toe or forefoot may also be a sign of a fracture or dislocation.

Muscle and tendons move the body tissues around the joints. A strain occurs when a muscle or group of muscles are stressed to the point where there is tearing of the muscle fibers. The muscles and tendons of the foot may be strained by overstretching, overuse, overloading, bruising, or even being lacerated. Weakness in contraction of a joint, difficulty in stabilizing body parts, and pain working against resistance are signs of muscle problems. Swelling, tenderness, loss of function, and discoloration over and around the injury of can be symptoms and signs of a strain.

Bruises (contusions) are most commonly the result of a direct impact injury to the body. A bruise can occur to the foot by a variety of causes, such as having your foot stepped on or by stepping on a rock. Blows to the foot that result in pain, discoloration, swelling, and changes in how you walk may indicate more serious damage such as fractured bone.

Pain and tenderness associated with planter fascia strains are usually felt on the bottom of the foot between the heel and the base of the toes. Plantar fascia pain may be increased or decreased by stretching of the arch. In mild cases of plantar fasciitis, the pain will decrease as the soft tissues of the foot "warm up," however, pain may increase as use of the foot increases. In more severe cases of plantar fasciitis, pain may increase when the arch is stressed. Often the sufferer of plantar fasciitis will feel pain in the morning until the plantar fascia warms up. Foot pain at night may be a sign of plantar fasciitis as well as other possible problems.

A sensation of rubbing or burning on the surface of the foot is usually the first signs of a blister. Itching and burning sensations between the toes or around the foot indicate a skin infection or athlete's foot. Pain and redness at the edge of a toenail are usually the result of an ingrown toenail.

 

A man with a foot injury seeks medical attention at a hospital.

When should I seek medical treatment for foot pain?

When the pain begins to interfere with your activities of daily living or if you cannot perform your desired activities without pain, you should consider seeking medical attention. Indicators that you should seek medical care are if the area looks deformed, you have loss of function, change of sensation, a large amount of swelling with pain, prolonged change of skin or toenail color, the affected area becomes warmer than the surrounding areas, becomes exquisitely tender to the touch, or is causing you to move differently.

A doctor examines the foot injury of a patient.

How is foot pain diagnosed?

Proper evaluation and diagnosis of foot pain is essential in planning a treatment. A good general guideline is to compare the injured side to the uninjured side. Injury may present itself as distinguishable lump or gap felt at that location or a "crunchy" feeling on that spot caused by inflammation. The types, causes, and severity (sharp pain versus a dull ache) also are good indicators of the seriousness of the injury.

Four grades of pain:

  • During activity
  • Before and after, and not affecting performance
  • Before, during, and after athletic activity, affecting performance
  • Pain so severe that performance is impossible

The doctor will ask you several questions to determine how the problem began. It can be helpful to tell the physician about how and when it started, how it affects you, when it bothers you, what you may or may not have done to make the pain better or worse. If necessary, a thorough physical exam may be conducted to evaluate for any other injuries.

  • Feet will be physically and visually examined at rest, with weight- and non-weight-bearing movement by the medical professional.
  • The foot and arch will be touched and manipulated and inspected to identify obvious deformities, tender spots, or any differences in the bones of the foot and arch.
  • The medical professional will examine how the muscles of your foot function. These tests may involve holding or moving your foot and ankle against resistance, you may also asked to stand, walk, or even run.
  • The nerves in the foot will be tested to make sure no injury has occurred there.
  • An X-ray, MRI, or bone scan of the foot and arch may be taken to determine if there are abnormalities of the bone and/or soft tissues.
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    An athlete with a sprained foot applies RICE (rest/ice/compression/elevation) to the injured area.

    What is the treatment for foot pain?

    Treatments are optimally directed toward the specific cause of the pain.

    When you first begin to notice discomfort or pain in the area, you can treat yourself with rest, ice, compression, and elevation (RICE). Over-the-counter medications may also be used to reduce discomfort and pain.

    Rest will allow the tissues to heal by preventing any further stress to the affected area. Crutches should be used if you have difficulty putting weight on the foot. Appropriate use of commercially available ankle and foot supports may provide rest, comfort, and support to the affected area.

    Ice should be applied no longer than 20 minutes. The ice may be put in a plastic bag or wrapped in a towel. Commercial ice packs are not recommended because they are usually too cold. If extreme discomfort occurs, icing should discontinue immediately.

    Compression and elevation will help prevent any swelling of the affected tissues.

    There are two types of over-the-counter medications that may help with the pain and swelling of foot pain. Acetaminophen (Tylenol) will help reduce the pain, while a nonsteroidal anti-inflammatory such as aspirin, ibuprofen (Motrin), or naproxen (Naprosyn) can help lessen the pain and as well as reduce the inflammatory response. Caution should be taken when using these drugs as dosage should not exceed the labeled directions.

    A popular home remedy for relief of plantar fasciitis is rolling a golf ball on the ground with the bottom of the foot.

    Blisters occur as a result of chafing. These "hot spots" should be attended to immediately with padding or friction reducers. If these spots progress to a blister and are unbroken, the doctor can drain them by puncturing from the side with a clean needle, and drained, the skin will act as a natural bandage and should not be trimmed away. If the skin over the blister is broken, the loose skin should be peeled back and the area should be treated as an open wound. Blisters should be covered and padded before returning to activity; in simple cases, a Band-Aid may solve the problem. If the blister is bigger, donut pads, gel pads, or commercially available blister pads may be more appropriate. To avoid blistering in the future, a generous application of petroleum jelly to the affected area can be helpful.

  • A technician performs ultrasound on the foot of a patient.

    What is the treatment for foot pain? (Continued)

    Medical treatment

    Once the severity and cause of foot pain is determined, a course of corrective and rehabilitative actions can be started.

    • Qualified medical personnel may use electrical medical devices such as ultrasound, various forms of electrical stimulation, LED light therapy (laser), and/or manual therapies to reduce pain and increase circulation to the area to promote healing.
    • Maintenance of fitness levels via modification of activity may be prescribed.
      • Substitute activities that aggravate the pain and soreness. Running causes the body to have repetitive impact with the ground. The use of bicycling, elliptical trainers, step machines, swimming, or ski machines minimize impact and allow you to maintain and improve your fitness.
    • Corrective prophylactic measures
      • New shoes or the replacement of current shoe insoles
      • Proper footwear fitting, including lacing and sock combinations to eliminate compression and friction issues
      • Additional supports added to the shoes such as heel pads or cushions, arch supports, and various wedges to help maintain the foot in a proper position
      • Athletic shoes lose the elastic properties of the soles through usage and age. A good rule of thumb is to replace your shoes every six months or more often if there is heavier usage. The use of replacement insoles can increase energy absorption and add support to the foot.
      • Corrective and over-the-counter orthotics may also improve the biomechanics of the foot.
    • Muscle strengthening and flexibility
      • You may be given exercises to increase the strength and stability of the affected area and to correct muscles that may not be balanced.
      • Exercises to increase flexibility will maintain or improve the length of a muscle. Flexibility helps to make a stronger muscle and less likely to be injured.
    • Appropriate medication to control inflammation or disease-related symptoms
    • In some cases, surgery may be necessary.
    • Biomechanical evaluation
      • Your body will create various changes in movement when you have an injury. A therapist can evaluate these changes and help you make the appropriate corrections. Prolonged, uncorrected biomechanical changes may lead to secondary mechanical changes that are painful and difficult to correct and may lead to a poor prognosis and possibly a slow or incomplete recovery from the symptoms.
      • Techniques such as chi and barefoot running or using minimalist running shoes have been helpful and may help correct biomechanical problems in runners when properly implemented.
    • Follow up with your doctor until you are better.
    • A woman consulting with her podiatrist about proper shoes.

      What follow-up care is needed after foot pain is treated?

      There may be follow-up tests, scans, or X-rays. A plan for a gradual return to play should be started once the pain is reduced and muscle strength and flexibility are restored.

      How can foot pain be prevented?

      To prevent injuries and pain, the following issues should be addressed before starting an exercise routine. Are you in good health? A general physical exam by a physician will help to evaluate your cardiovascular function, the possibility of disease or any other general medical problems that you may have. Before beginning activities, diseases such as gout, diabetes, certain types of arthritis, and neuropathies should be treated.

      Physicians with sports medicine, physical medicine, or orthopedic backgrounds may also help you choose an appropriate activity. After choosing the sport or activity that you wish to participate in, proper preparation will help minimize the initial aches and pains of that activity. Proper technique in any activity will help you to properly and safely perform your chosen activity and avoid injury. Good coaching can help you develop good biomechanics that can prevent foot pain.

      Shoes and socks appropriate to your activity will also be a deterrent to foot pain. Properly fitting shoes and proper foot hygiene can prevent blisters, ingrown toenails, corns, calluses, bunions, stress fractures, metatarsalgia, Morton's neuroma, mallet toes, and plantar fasciitis. Poorly fitting footwear can make poor biomechanics worse, and properly fitting footwear can help to minimize the effect of bad biomechanics.

      A plan for a gradual return to play should be started once the pain is reduced and muscle strength and flexibility are restored. Returning to participation and prevention of foot pain are governed by the same factors as preparing for participation. Foot pain can be caused by doing too much of a particular activity too fast. Ignoring pain can also lead to further problems with the foot. Different types of foot pain can be seen at different times of the season. Typically, blisters, shin splints, and arch injuries are seen at the beginning of the season. Again, to avoid blistering in the future, a generous application of petroleum jelly to the affected area can be helpful.

      Stress-related problems are related to the workloads. If the body is not prepared for an increase of workload that is typical early in the season and with "weekend warriors," acute shin splints and tendonitis are very common, in addition to increased muscle soreness.

      After one has foot pain, an optimal workout program begins with a physical exam by a physician, followed by a gradual, consistent workout plan. A good example of this type of program is a running program that starts with a good warm-up, such as walking five to 10 minutes, then alternating sets of jogging and walking. An example of such a program would be 20 sets of jogging for two minutes, then walking one minute, with jogging time increased until you can run continuously for 40 minutes. Good surfaces and proper equipment used in your workout will lower the risk of foot pain.

      Components of a good exercise program should include core strengthening, muscle strengthening, and flexibility specific to the goals of the workout program or the sport.

      If pain is encountered when working out, try decreasing the intensity of the workout. If the pain persists, then you should immediately stop and seek medical advice to discover the source of the pain. Pushing through pain often results in injury.
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      A doctor holding a model of a foot.

      Foot Pain At A Glance

      • The foot is a complex anatomical structure that may be affected by disease within the body or the foot itself.
      • The arches of foot are the primary structures that control the amount of ground force transmitted into the body.
      • When pain due to foot pain interferes with your normal activities, you should seek medical advice.
      • Treatment of foot pain will depend on the cause of the pain and may involve medication, strengthening, stretching, and possibly the use of and physical therapy.

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