Painful Foot
Painful Heel
Children
- Sever’s disease (calcaneal apophysitis)
- Usually male around 10 years old
- More common in overweight children
- Increased density and fragmentation of the calcaneal apophysis
- Treatment : Raise heel and avoid strenuous activities
- May require immobilisation
Adolescents
- Calcaneal knobs
- Often bilateral
- Usually female 15 – 20 years old
- Treatment : Appropriate foot-wear and occasionally excision
Young Adults
- Adventitial bursitis (bursa between skin and Achilles tendon)
- Usually related to improper footwear
- Pain worsens with certain shoes
- Retrocalcaneal bursitis
- Horse-shoe shaped structure between Achilles and calcaneus
- Aetiology
- Overuse
- Systemic arthritis
- Gout
- Constant pain, aggravated by activity and dorsiflexion
- Tenderness medial and lateral to Achilles insertion
- Treatment
- Activity modification
- Heel lift
- NSAIDs
- Cast immobilisation
- Excision
- Insertional Achilles tenditis
- Plantar fasciitis : consider enthesopathy in this age group
- Tarsal Tunnel Syndrome
- Tumor
- Osteoid osteoma
- Bone cyst
- Calcaneal stress fracture
- Commonly seen in military staff
- Bone scan / MRI is diagnostic
- Trauma
Older Adults
- Plantar Fasciitis
- Tarsal Tunnel Syndrome
- Calcaneal abcess
- Paget
Painful Tarsus
Kohler disease (osteochondritis of the navicular)
- Usually children less than 5 years old
- 20% bilateral
- Present with a painful limp
- Tender warm swelling in medial aspect of foot over the navicular
- X-Ray shows fragmentation of navicular
- Self-limited disease, but takes up to 1 year to resolve completely
- Treatment :
- Rest
- Arch support
- Casting
- Good prognosis with normal looking navicular
Brailsford’s disease
- Similar to Kohler disease, but older women are affected
The “overbone”
- Seen in adults with high arches
- Ridge of bone on dorsal surfaces of the medial cunieform and 1st metatarsal
- Treatment : Adjust shoes, bevel lump
Painful Forefoot
Plantar Fasciitis
- Extension of inflammation from plantar fascia origin to distal can occur in chronic severe cases
- Treat with NSAIDs and orthosis
- Rarely needs release of plantar fascia
Tarsal Tunnel Syndrome
Freibergdisease
- Crushing type of osteochondritis
- Affects young adults and usually females
- Head of 2nd metatarsus becomes wide, squared and thick
Stress fracture
- Usually at 2nd or 3rd metatarsal neck
- Usually associated with increased physical activity
Metatarsalgia
- Symptom, not a diagnosis
- May be primary or secondary to other conditions
- Primary metatarsalgia is caused by chronic imbalance in weight distribution between the toes and metatarsal heads, due to absent or ineffective muscle function
- Any foot condition with faulty weight distribution may cause this condition
- Secondary metatarsalgia may be due to :
- Rheumatoid Arthritis
- Gout
- Neuromuscular disorders
- Stress fracture
- Mortons neuroma
- Plantar fasciitis
- Tarsal tunnel syndrome
- Intermittent claudication
- Osteoarthritis
- Treatment:
- In primary metatarsalgia treatment should be directed toward unloading the areas subjected to increased pressure
- In secondary metatarsalgia the underlying condition must be identified and treated as well as the mechanical imbalance
Morton Neuroma (Interdigital Neuritis)
- Painful neuroma of the digital nerve, at the level of the metatarsal neck
- The most common site is 3rd web, with involvement of 3rd and 4th digital sensory nerves
- Usually affects women aged 40 – 50 years
- Sharp intermittent pain into the toes, but usually only when shoes are worn
- Clinically, tenderness is localised to the neuroma and may be associated with decreased sensation in the cleft
- A palpable click is sometimes felt when pressure is applied to the involved web space, with simultaneous compression of metatarsi
- Diagnostic Lidocaine injection is helpful
- Treatment :
- Footwear modification; avoid high heels
- NSAIDs
- Metatarsal pad proximal to pain triggering area
- Surgical resection of digital nerve and inter-metatarsal ligament