The Nature of Your Foot Pain Can Clue You As To the Cause

painful heel

Foot pain can have many different causes, and sometimes the actual cause is not immediately clear if the pain feels like it is spread over a wide area. Fortunately, the nature of the pain itself can sometimes provide a clue as to the actual origin. It is not uncommon in cases where pain is felt in several areas of the foot at once that the doctor must rely on the type and timing of the pain to assist in making a proper diagnosis. Today I will discuss different types of foot pain and what they may reveal about its cause. Keep in mind, this is a general discussion about the cause of foot, and may not accurately reflect each individual case. Your actual symptoms need to be addressed by a podiatrist, as a foot exam is vital to making a proper diagnosis.

Throbbing or aching: This type of pain typically indicates inflammation from some type of injury. This can include sprains, strains, chronic injuries, bruises, or bone stress. It is probably the least specific type of pain.

Sharp or stabbing pain: These symptoms usually indicate a more significant injury, and a more focused area of injury. Conditions with sharp pain include tissue tears from more significant sprains, bone injuries (including fractures), nerve injuries, penetrating foreign objects, wounds and skin tears/lacerations, and more focused bruises or blunt injuries (like a crushing injury).

Ripping or tearing pain: The searing nature of this pain often means there is a ligament, tendon, or other similar tissue that is still in the process of tearing, pulling apart, or is otherwise unstable and needs to be immobilized.

Pain felt in the heel more in the morning or after getting out of a chair: This pain is usually associated with plantar fasciitis, a condition involving chronic injury to a ligament in the arch and heel.

Numbness, burning, electrical, or tingling when walking, but not when at rest: These symptoms may suggest a pinching or irritation of a nerve within the foot itself. When the pain is felt in the ball of the foot, it could suggest a neuroma, which is a thickened nerve near one of the toe bases that may also be accompanied by a sensation of a pebble or hot marble in the foot. When the pain is felt on the inner side of the ankle, heel, or in a general manner to the bottom of the foot or the toes, the issue could be with nerve pinching in an area called the tarsal tunnel. This condition is similar in nature to carpal tunnel syndrome in the wrist.

Numbness, burning, electrical, or tingling when sitting in a chair for awhile or lying down: These symptoms suggest that the back may be responsible for the foot pain. Lower back arthritis or a slipped disk can cause irritation to the branches of the spinal nerve that give sensation and muscle control to the legs and feet. When one is sitting or lying down, bending or strain on the back can cause these symptoms to appear. Additionally, many diseases that cause nerve dysfunction, such as diabetes, can create the above symptoms, particularly at night.

Constant, never ending foot pain worsened when the foot is elevated: This type of pain indicates poor circulation, and often is accompanied by leg pain when walking a short distance, cold and discolored feet, and thin skin.

Remember, always see your podiatrist when you develop foot pain that does not go away after a couple days. Foot pain is NOT normal at any age or activity level, and only indicates that something has been injured or is damaged. The above descriptions can serve as a general guide as to the basic nature of the problem, but only a physician’s foot exam can lead to the proper diagnosis. Your podiatrist is the best place to start, as your primary care/family doctor will only be versed in a few basic foot diseases/injuries and may not be able to recognize or quickly treat more complicated conditions.

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Pain on the outside of your foot? It could be due to peroneal tendonitis.

pain on the outside of the foot

A common foot injury often misdiagnosed as a complex ankle sprain is called peroneal tendonitis.  The peroneal tendons are two in number, and run together under the outside of the ankle joint, where they stay together for a couple inches until they reach the middle part of the side of the foot.  It is here that one stays on the side of the foot, attaching to the bone prominent on the outside of the foot.  The other longer tendon runs underneath the foot to attach near the other side.  These tendons are known as everters, because they help the foot to roll to the outside, or evert.  This motion is very important during the normal walking cycle, and helps to balance the more powerful muscles on the other side of the foot that draw it inward.

The peroneal tendons can become injured during simple ankle sprains, as the twisting force that tears ankle ligaments can stretch and injure the peroneal tendons running near the ligaments.  However, the peroneal tendons can also become injured without having a specific sprain.  Walking on uneven surfaces, simple excessive climbing, using unstable shoes, and even compensating for arch pain can lead to peroneal tendonitis.  Because the symptoms, which may include pain around and under the outside of the ankle, are similar to the pain of an ankle sprain, it is often misdiagnosed as an ankle sprain. The typical pattern of pain also includes sharp or achy pain to the side of the foot, where the majority of the time the pain is at it’s strongest.  Bearing weight on the injured foot, twisting it inward, and moving on uneven ground like lawns or gravel can aggravate the pain.  There is rarely ever swelling or bruising visible on the side of the foot, and there is never a cracking or popping sensation (unless the tendons are moving over the ankle bone or a fracture has occurred on the side of the foot- both of which are different conditions).

Fortunately, the treatment of peroneal tendonitis is not too different from that of an ankle sprain, so if there is a misdiagnosis at least the recovery process is similar.  In general, peroneal tendonitis needs rest, ice, anti-inflammatory medications, and ankle brace support.  Cases that don’t respond to these measures need physical therapy to help with healing and strengthen the tissue.  The difference in treatment from an ankle sprain lies in that if physical therapy is needed to improve the recovery, a misdiagnosis could lead to imprecise therapy and a poor result.  In addition to the above treatment, severe cases of peroneal tendonitis may require immobilization of the leg or surgery to repair the tissue damage.  It is not uncommon for partial tears of the tendon to accompany the tendonitis, and often these need to be surgically repaired if the pain is not resolving with non-surgical treatment.

Is a neuroma really a pinched nerve?

neuroma

A neuroma is a common foot malady that does indeed involve a nerve in the foot, and is often described by health care professionals, general medical doctors or orthopedists, and even podiatric specialists as being a pinched nerve. This is often done to simplify the medical language for a patient, but I think when my colleagues do this they do a disservice to their patients as that description is in actuality not very accurate. I try to avoid the term pinched because it conveys a different sense of what is going on in the foot as opposed to a ‘pinched’ nerve in the back. Nerves in the feet can get pinched in narrow tunnels, primarily at the ankle level. However, the neuroma is a different condition that has more of a mechanical irritation externally causing the nerve damage rather than a constricting band around the nerve itself causing pinching.

In a traditional neuroma, the nerve at the center of the pain is one of five found on the bottom of the foot, between one of the long bones (metatarsals). As this nerve reaches the toe bases, it splits into two branches, each supplying sensation to two adjacent toes. It is at this spot, near the head of the metatarsal, that the nerve becomes inflamed. There is a ligament that sits on top of this nerve that, when bowed down as the foot flexes and flattens a little, can irritate the outer covering of the nerve. Over time, this irritation causes the outer layer to swell and become fibrotic, or scarred. The process is similar, but slightly different, in a high arched foot where there is more direct pressure on the nerve from the prominent and inflexible position of the ball of the foot on the ground. Regardless of the cause, as the nerve covering thickness increases, external pressure on the foot from standing and walking can cause pain to develop. If the scarring is thick enough, the pressure from the adjacent metatarsals can also cause pain if a shoe is tight enough to constrict the foot.

The distinction between this and ‘pinching’ may seem trivial, but in regards to treatment the correct understanding of the underlying cause of a neuroma is very important. Because it is mechanical irritation, and not nerve constriction (pinching), treatment does not necessarily have to involve surgery. In mild to many moderate cases, the simple use of shoe inserts designed to reduce pressure to the ball of the foot can help prevent the nerve from becoming irritated again one the inflammation is reduced with medication. This can in many cases preempt surgery, and still result in long and lasting relief. Although I have performed many surgeries for this condition, I have just as much, if not more, success treating it without surgery.

Did you know you can get bursitis in your heel?

heel bursitis pain

While most cases of pain on the bottom of the heel are caused by plantar fasciitis, some are not.  A common alternate cause of heel pain is a condition called bursitis, and it can lead to severe pain directly on the bottom of the heel.

Bursitis is inflammation of a bursal sac, which is a pad of tissue that can be found throughout the body, protecting bony prominences as well as other sensitive tissue.  In the bottom of the heel, the bursa is not necessarily a naturally occurring object.  In general, unlike many other bursas, this bursa is more reactive, meaning that it forms as a result of abnormal pressure and irritation under the heel.  The bursa becomes irritated when the heel bone of a person with a flat foot rotates excessively as it will naturally do during walking, generally exposing the bottom of the heel tissue to a more irritating part of the heel bone that is not usually prominent on the bottom of the heel.  Eventually, a bursal sac will form to protect the irritated soft tissue under the heel bone, and in turn this will become irritated itself.  Other causes for bursitis include walking for extended periods on rocky or bumpy surfaces, high arched feet with poor shock absorption capabilities, as well as poor heel fat pad in older people with a prominent heel bone resulting.  I have even often seen this condition in people who have a more angular shape to the bottom of the heel bone as opposed to a more normal rounded shape.

Bursitis can often be present at the same time as plantar fasciitis.

Treatment of bursitis under the heel is relatively simple.  Steroid injections often take care of the inflammation in and around the bursa, usually more effectively than anti-inflammatory medication taken orally.  Ice helps, as well as increased shock absorption via gel heel inserts or orthotics with soft heel padding.  Surgery is typically not an option, as the attempt to find and remove the bursa can lead to more damage to sensitive tissue such as nerve bundles within the heel, making things worse.