CONDITIONS AND TREATMENTS

FOOT PAIN IN THE ACTIVE AND ATHLETIC INDIVIDUAL

Plantar Heel and Arch Pain
Heel and arch pain is caused by many different conditions. The most common heel pain is caused by plantar fasciitis. The pain is located on the medial tuberosity of the heel and is present upon first arising in the morning or after arising from a seated position. Plantar fasciitis is seen in those with both hyperpronated feet and high arches. Hyperpronation causes chronic stretching and tearing to the fascia's calcaneal origin. High arches cause abnormal shock to be transmitted to this area with every step. Direct trauma, though less common, can also cause inflammation to the plantar fascia. Though possibly self-healing over a long period of time, this condition can last for many years when no treatment is given, and can make exercise nearly impossible. For treatment, a combination therapy of inflammation reduction with NSAIDs, corticosteroid injections, icing and stretching is necessary. It should also be combined with arch support through prescription orthotics to support hyperpronation or provide shock absorption to a high arched foot. Only rarely is surgery actually required. It should also be noted that the plantar calcaneal spur often present with this condition is rarely a source of pain and is usually of no consequence.

 

Posterior Heel Pain
Pain in the posterior heel can be caused by Achilles tendonitis, retrocalcaneal exostosis or Haglund's deformity of the posterior superior calcaneus. When Achilles tendonopathy is combined with an exostosis or Haglund's deformity, even simple shoe use can be painful. Treatment centers around stretching of the Achilles tendon, icing, NSAIDS, ankle bracing, and physical therapy. Untreated Achilles tendonitis can lead to tendon degeneration and even rupture. When the bone spur or enlargement is causing most of the pain, surgery is needed to remove it. Out of all the conditions described here, this is the one that requires the most surgical recovery time and needs 3-4 months rehabilitation prior to returning to exercise activities.

 

Pain On The Lateral Foot
The most common cause of pain in the lateral foot is inflammation of one or both of the of the peroneal tendons. Often slowly injured when walking or running on uneven surfaces, this tendon group can also be chronically irritated during athletic activity. The tendonitis can progress to a more significant longitudinal intrasubstance tearing injury if left untreated. Treatment involves the use of gauntlet bracing brace to temporarily stabilize the ankle, NSAIDS, icing, and rest. Physical therapy is used later on if not improving, and severe cases may need surgery for repair and augmentation. Usually a speedy recovery back to activity is seen in most cases.
Occasionally osseous problems can cause pain to the lateral foot. A stress fracture can develop from repetitive lateral stress or foot inversion, and cortical fractures of the fifth metatarsal shaft, styloid process, or Jones type injury can develop from a twisting injury or weight dropped on the lateral foot. Some of these fractures can be notorious for nonunion due to the region's anatomic hypermobility, and require complete rest from activity and immobilization for the quickest return to activity. Surgery is generally recommended for athletes when a full fracture is present in order to return to activity sooner.
When the pain is felt near the fifth metatarsal-phalangeal joint, a Tailor's bunion is usually at fault. This is a lateral prominence of the fifth metatarsal head, and can cause pain with shoe use. Treatment simply involves wearing a wider shoe or using padding to keep the shoe from rubbing on the prominence. If this doesn't help, then a simple exostectomy or medial shifting osteotomy works well.

 

Pain On The Medial Foot
Similar to lateral pain, medial foot pain is often caused by tendonopathy, primarily the posterior tibial tendon. Usually seen with hyperpronation, this tendon slowly degenerates over time due to the medial strain caused by the hyperpronation. Athletic activities worsen it. This condition requires orthotics to stabilize hyperpronation in the long term, as well as rest, icing, NSAIDS, and possibly physical therapy. Gauntlet bracing is also very helpful, or immobilization. If allowed to progress, this tendonopathy can become very severe and may require reconstructive surgery. If treated early, healing is successful and can allow a quick return to activity. The orthotics will generally prevent it from returning.
Other causes of medial pain includes entrapment of the posterior tibial nerve. The resultant tarsal tunnel syndrome, similar to carpal tunnel syndrome, can cause pain to radiate into the heel and into the plantar foot, and it may even cause numbness, burning, and tingling neuralgia to the foot. Initially treated similarly to the tendonitis discussed above, this condition may also heal with corticosteroid injections. If the inflammation does not resolve, surgery may be needed to free up the nerve. Release of the tarsal tunnel is often, but not always required as conservative treatment can have efficacy in some cases.
When the pain is along the medial side of the first metatarsal phalangeal joint, it could be due to bunion deformity. Bunions (hallux abductovalgus) are a complex foot deformity due to osseous and soft tissue adaptation of biomechanical pathology, usually hyperpronation. Over time, muscular and ligament changes needed to adapt to walking with flat feet will contract the great toe towards the second toe, and make prominent the 1st metatarsal head medially. This can create pain over the medial joint when rubbed against tight shoes. Arthropathy and motion pain can eventually develop due to the abnormal joint subluxation. The great toe can also deviate laterally into the lesser toes, causing saggital plane deformities. Treatment can include measures that attempt to pad the joint or separate the great toe from the second toe. Wider shoes may also help relieve medial pain. However, in most all cases surgical correction with osteotomy and soft tissue contracture release is necessary to permanently treat this condition.

 

Nail Pain
Most nail pain is caused by ingrown nails. Ingrown nails may be inherited, and may also be seen later in life due to gradual damage to the nail matrix. Repetitive injuries to the toe, such as heavy objects falling, pressure from poorly fitting shoes, nail mycosis, or toe bruising (common in athletes) may cause irreversible changes to the nail matrix. In time, the nail may abnormally grow inward due to these changes. Regardless of its cause, an ingrown nail will cause pain and inflammation (paronychia) to the nail fold skin, and eventually infection will develop. If untreated for a very extended period, cellulitis and lymphangitis can possibly develop, and osteomyelitis is possible at the distal phalanx.
Temporary treatment may consist of regular soaking in warm, soapy water, application of antibiotic ointment, and the use of oral antibiotics to control the infection. The offending nail border must be removed to resolve the condition, and due to significant reoccurrence potential the nail border must not be allowed to re-grow. This is accomplished through a short office procedure during which a relatively noninvasive phenol matrixectomy is performed. Recovery is quick and usually uneventful. Home based "bathroom surgery" is not recommended for anyone as this may significantly worsen the condition. This is especially true in diabetics or those with PAD or neuropathy.
Other causes of nail pain can include nail mycosis, which may cause the nails to become thickened, loosened, discolored, and crumbly. The nail hypertrophy causes pain when it strikes the shoe during activity. Treatment requires either oral terbinafine to eliminate the infection(topical ciclopirox if oral contraindicated), nail avulsion/matrixectomy with nail removal permanently, or simply aggressive debridement of the nail to provide palliative comfort.
Another common nail problem seen in runners and treadmill users is bruising and loosening of the toenails. When shoes are a little too long, the foot will piston in and out of the shoe, resulting in low level injury to the distal toes. This can also occur in shoes that are too tight. The nails will subsequently bruise and loosen. This can be prevented by wearing properly sized shoes.

 

Pain In The Ball Of The Foot
Pain in the forefoot can be caused by many conditions. The most common pathology seen in active people is a neuroma. This is an irritation inflammation of the neural sheath of one of the intermetatarsal nerve. Symptoms can include the sensation of a hard or hot pebble in the ball of the foot, as well as burning, tingling, and numbness in the toes immediately beyond the area of pain in the ball of the foot. Rubbing often relieves some of the symptoms. The pain generally worsens with activity. Usually one's foot structure combined with poorly fitting shoes is the underlying cause, but other factors including injury can be present. Treatment can consist of corticosteroid injections to shrink the nerve tissue swelling, as well as NSAIDS and icing. Custom orthotics help to relieve the submetatarsal head pressure, and wider shoes reduce compressive forces at the forefoot. Sometimes surgical excision, or at least intermetarsal ligament release, is necessary to relieve the painful nerve segment.
Other causes of forefoot pain can include too much pressure to the metatarsal heads, as seen in the mechanics of hyperpronation, or derived from excessive metatarsal declination in high arches (pes cavus). This pressure eventually overwhelms the body's natural fat pad, and inflammation develops. Anterior fat pad migration is seen in older patients. The metatarsal phalangeal joints feel more prominent on the ground, and any hammertoe deformity present can aggravate this by causing increased retrograde buckling to the metatarsal heads. Treated with well padded custom orthotics and supportive shoes, the pain usually can be controlled without surgery and a quick return to activity is possible. Sometimes the digital deformities need to be corrected and metatarsals dorsiflexed through osteotomy when the pain is more severe, or if a plantar plate rupture has occurred.
If the pain is under the great toe joint, the cause may be due to inflammation of the sesamoids. These egg shaped bones are found in every foot, and can be injured if repetitive stress is applied to them, such as in running or other impact activities. This condition needs a brief period of rest and de-weighting of the great toe joint, along with icing and anti-inflammatory medications. Reoccurrent cases need modified orthotics to reduce pressure and stress to the sesamoids directly. Surgical excision may be necessary in recalcitrant cases, but careful surgical planning is needed to avoid possible toe destabilization.
Many times, pain in the forefoot is simply from a painful callus. Hyperkeratosis are formed when the skin is compressed by the ground or a shoe into a prominent bone underneath. Treatment involves regular debridement and orthotics to decrease any pressure from flexible foot deformities modifiable by subtalar joint control. Certain deformities allowing increased bone prominence can be corrected surgically with good long term success and hyperkeratosis reduction.

 

Ankle Pain
Most pain felt around the ankle can be attributed to the tendonitis conditions described above. However, ankles can become osteoarthritic over time, with gradual pain and motion loss. When symptoms begin at an earlier age, this can be due to traumatic arthropathy from a previous injury or fracture. NSAIDS can help, along with physical therapy. Surgical arthroplasty is sometimes needed to restore motion, and severe cases may need fusion.
Ankle ligament sprains are common. Even the most mild of sprains can take 3-4 weeks to heal. All active people should have their sprains evaluated, as sometimes other occult injuries occur which need more specialized treatment, such as sural neuritis, Jones fractures, and peroneal tendon injuries. Generally ankle sprains respond well to icing, rest, and ankle bracing. More involved sprains or sprains in competitive athletes may need physical therapy in order to return to activity. Very severe sprains with ligament tears and instability may need surgical repair and augmentation, although there is debate as to whether primary repair is ill advised due to scar fibrosis, further reducing function. Repeated sprains increase instability, and disability may result after awhile. Secondary repair and augmentation is needed in those cases. Consistent ankle brace use during activity are recommended for those with numerous ankle injuries for protection otherwise.