Assessment of Foot Pain

Why does my foot hurt?

The foot is a complex machine which is designed to take weight and cushion the foot from impact. Pain in the front of the foot can come from many sources. It can be difficult to exactly identify each source of pain so I will assess your foot very carefully.

What is the diagnosis?

Pain in the foot can come from many sources. The pain may arise from bones or soft tissues. The bones may be poorly aligned causing abnormal pressures on the feet. The joints may have worn out. This is called arthritis. The muscles in your foot may not be working properly and this may result in your toes to bend up and rub on shoes. There may be inflammation in your foot. There may be an abnormality of the nerves in the foot. 

How is the diagnosis made?

The first step in diagnosing the problem is a thorough assessment by the clinician. This will involve a thorough history and clinical examination. An X-ray may need to be taken to assess the bones in the foot. Sometimes after this assessment special tests may be necessary.

Special tests

Magnetic Resonance Imaging (MRI) is a specialist scan using magnetism rather than X-rays to look at bone and soft tissue. The scan is painless but involves lying still in a tunnel for about 30 minutes.  The scan results will usually pin point the source of the symptoms.
Ultrasound scanning is painless investigation where a small probe is gently glided over the soft tissue over the foot and ankle. This is performed by a specialist doctor / clinician /radiologist. Sometimes the doctor / clinician / radiologist will be able to identify a problem that can be treated with an injection.  In this situation then the doctor will ask for permission to inject this area. 

Diagnostic and therapeutic injections

Injections of local anaesthetic and steroid are used to help the diagnosis of foot and ankle problems.  There are many joints and tendons around the foot. One or many of these may be a source of pain. It can be difficult to identify which of these may be causing the pain.
An X-ray doctor / radiologist can locate a specific area to inject with an ultrasound probe or using a special X-ray machine. The local anaesthetic acts to numb the affected area for a time lasting up to 24 hours. The steroid can provide some long lasting pain relief. If the pain is relieved even for a few hours then the area injected is the source of that pain. This is the diagnostic part of the injection.
The steroid injection may relieve the pain for a longer period of time. This is the therapeutic part of the injection. The pain relief may last for a few days, weeks, months or even longer. The length of pain relief is unpredictable.
If the pain relief lasts for a few hours or days then returns the injection has still been useful. If the pain has not been totally relieved then the source of the pain may be somewhere else. In this situation than further injections may be necessary to locate the source of the pain.

Treatment

At the end of the process of the clinical review and tests a diagnosis will be made and a treatment regime recommended.  

General advice

A lot of force goes through the big toe when you walk so losing weight and keeping fit may be of benefit. Finding comfortable shoes with space for the big toes may relieve some of your symptoms. 

Shoe advice

I have many patients with stiff feet and ankles who experience great pain relief from these shoes. Because the shoes have a rocker bottom the shoe moves rather than the foot.
The style of shoes recommended include Skecher Shape Ups, MBT and Dr Scholl Fitness shoe. The advice is to try lots of types of shoes and find the best suited for you.
It is really important to wear these shoes in gradually over a few weeks. The shoes will change the way you walk and will affect your feet, knees, hips and back. Your legs will ache for a few weeks afterwards but the advice is to persist with the shoes.


Skecher Shape-ups information at www.skechers.com

Skecher Shape-ups
MBT information at www.us.mbt.com

MBT Trainer

Dr Scholl's Fitness exercise trainer information at www.drschollsshoes.com


Scholl fitness shoe

Calf stretch exercises

Some patients with hallux rigidus have tight muscles in the calf. The muscle that is usually tight is the gastrocnemius muscle. This is a muscle which spans across the knee and ankle so that when your knee is bent, the muscle is relaxed. When the knee is straight the muscle is tight. If the gastrocnemius muscle is tight then it will limit the ankle movement upwards when you walk. In this situation there is a greater force taken at the front of your foot. By stretching out this muscle, you may be able to lessen the force on the front of your foot and this may relieve some of your symptoms.

leg stretch exercises

Morton’s neuroma

The nerves which supply the toes with skin sensation run between the metatarsals. These nerves branch at the level of the toe ( see diagram below ) and travel down either side of the toe. At the level where they branch the nerve can get caught between the bones and this irritates the nerve. The nerve becomes scarred and becomes thicker. This thickened nerve can get caught between the metatarsals and this can become painful.  Some patients describe walking on “a pebble”. Because the nerve is involved some patients experience altered sensation in the toe or pain “shooting “ along the toe.
A Morton’s neuroma may be identified on an ultrasound scan. If one is present then an injection of local anaesthetic and steroid may help. The role of the injection is diagnostic and therapeutic.  The diagnostic part of the injection means that if the pain is relieved by the injection then the source of the pain has been identified. The therapeutic part of the injection means that the pain may be relieved. The pain relief may last for a few days, a few weeks or possibly longer. The steroid injection may cure the condition in 30 – 50 % of cases. However the pain may return.
The pain may not be relieved completely. This may be because there is another reason for the pain in addition to the Morton’s neuroma. In this situation further assessment may be needed.

Surgery for Morton’s neuroma involves removing the nerve

This is usually done under general anaesthesia. A cut is usually made on the top of the foot at the site of the neuroma between the metatarsals. The nerve is removed along with the scar tissue. The skin edges are sutured.  

Post-operative care for Morton’s neuroma excision

You will usually have a dressing applied for 2 weeks. You can mobilise full weight bearing on the foot immediately afterwards but may need crutches if you foot is a bit sore. After 2 weeks your foot will still be swollen and sore but you should be able to wear a shoe. Your foot will settle down over a 6 week period. You should be able to drive from 2 weeks.
In my experience, the pain in the fore foot may not be completely relived by excising the Morton’s neuroma. This is because there is another reason causing the pain. However the majority of the pain will be relieved. Further treatment with specialist insoles or stretching may be required.

Risk and complications for Morton’s neuroma excision

This operation is usually successful in relieving most of the pain. In my experience, the pain in the fore foot may not be completely relived by excising the Morton’s neuroma. Further treatment with specialist insoles or stretching may be required.
There will be permanent numbness in the toe after the surgery.
There is a low risk of wound healing problems and infection.
A deep vein thrombosis is a clot in the deep veins of the leg. If this clot breaks off it can travel to the lungs. This is a pulmonary embolus. These complications can be serious.
A risk assessment will be performed preoperatively. The majority of people undergoing this surgery are at a low risk and do not require any specific treatment. If your risk is moderate or high, then specific treatment may be necessary. This may involve injections for 6 weeks.

Inter metatarsal bursitis

Between the foot bones called metatarsal bones are little bags of fluid called bursa. These can become inflamed. This can be diagnosed with an ultrasound scan and treated with an injection of steroid.  Other treatment may involve using insoles and physiotherapy.

Hammer mallet  or claw toes

This is a condition where the smaller toes become deformed. The deformed toe may rub on shoes. The deformed toe may be painful or may press against other toes.
The cause for this condition may be related to conditions such as hallux valgus or rheumatoid arthritis. However there may not be any obvious cause.

Non surgical treatment of claw / hammer toes


Wearing correctly fitting shoes with space to accommodate the toes may produce comfort for your toes. Toe splints are available commercially and may provide comfort. Special insoles may help the toes to sit in a better position. These may be provided by a podiatrist or orthotist.

Surgical treatment of claw / hammer toes


A toe which is bent may be straightened with an operation. The most common operation to achieve this is a toe fusion and may also include an operation to lengthen a shortened tendon.
The toe fusion will involve removing the bent joint. The remaining bone is joined together and stabilized with a wire. There may be a need to lengthen a short tendon. This wire will stick out of the toe for 6 weeks. After 6 weeks the bones will have healed together and the wire may be removed. The toe will remain swollen for a few months and will settle down.
It is usually possible to improve the toe shape with this procedure. The operated toe will be shorter. However it is not possible to make the toe perfect. This is an operation to improve the function but not the cosmetic appearance.

Post operative for surgical treatment of claw / hammer toes


You will be able to mobilise fully weight bearing in a special sandal immediately . You may need a set of crutches to help you walk if your foot is sore. You will need stitches to be removed at 2 weeks . Your wire will need to be removed at 6 weeks. This can be done in clinic without an anaesthetic. The wire removal is usually not painful and is usually very quick.

Risk and complications for surgical treatment of claw / hammer toes


There is a low risk of wound healing problems and infection.
A deep vein thrombosis is a clot in the deep veins of the leg. If this clot breaks off it can travel to the lungs. This is a pulmonary embolus. These complications can be serious.
A risk assessment will be performed preoperatively. The majority of people undergoing this surgery are at a low risk and do not require any specific treatment. If your risk is moderate or high, then specific treatment may be necessary. This may involve injections for 6 weeks.
There is a small risk that the bones may not heal together. This is called a non union. In this situation there may be a need for further surgery to get the bones to heal.

Metatarsalgia.

metatarsalgia x-ray


Metatarsalgia is a condition where the metatarsals bones and the overlying skin are painful. There is often a build up of hard skin on the bottom of the foot. The toes may be affected as well. The first stage in making a diagnosis is taking a good history and examining your leg.

Non- surgical treatment of metatarsalgia

Losing weight, finding suitable shoes and calf stretches as explained above will contribute to the comfort of your feet.

Orthotic ( Insole) treatment of metatarsalgia

Special insoles may be very helpful in relieving pain. A thorough assessment by a podiatrist or orthotist is essential to prescribing the correct insoles for an individual foot. It is essential that once your insoles are fitted that you wear then in gradually. This allows your feet to be accustomed to the changes that the orthotics will make to your feet .

Surgical treatment of metatarsalgia

Surgical treatment of metatarsalgia is a last resort after all conservative non-surgical treatment has been exhausted. The surgery is designed to change the shape of the metatarsals to relive the pressure . This may include one or all of the metatarsals. This is usually performed under general anaesthetic. There are up to three incisions on the top of your foot. The metatarsal bones are cut and the shape is changed. The bones are then fixed with screws or staples. The wounds are then stitched. The foot is then bandaged in a big woolly bandage. You will then mobilise in a special shoe for 6 weeks. You may need crutches for this time to help you walk.


Diagram showing that the metatarsal is pushing downwards.

matatarsal angle  diagram


Diagram showing that a wedge of bone is removed from the metatarsal.


metatarsal wedge cut


Diagram showing that removal of the wedge of bone after fixation with a screw elevated the metatarsal and hopefully will relieve pain.

metatarsal screws diagram

Post operative care for surgical treatment of metatarsalgia

You will be able to mobilise fully weight bearing in a special sandal immediately . You may need a set of crutches to help you walk if your foot is sore. You will need stitches to be removed at 2 weeks . You will have an X-ray at 6 weeks and hopefully will be able to wear shoes at this time. Your foot may be swollen and painful for up to 6 months following surgery.

Risk and complications for surgical treatment of metatarsalgia

The outcome of the operation is to improve the shape of the metatarsal bones hence to relieve pain. This is a highly skilled operation and relies on skill rather than any scientific measurement. In my experience although there is relief of pain this may not be complete. Some patients may still require orthotic provision post operatively.  
There is a low risk of wound healing problems and infection.
A deep vein thrombosis is a clot in the deep veins of the leg. If this clot breaks off it can travel to the lungs. This is a pulmonary embolus. These complications can be serious.
A risk assessment will be performed preoperatively. The majority of people undergoing this surgery are at a low risk and do not require any specific treatment. If your risk is moderate or high, then specific treatment may be necessary. This may involve injections for 6 weeks.
There is a small risk that the bones may not heal together. This is called a non union. In this situation there may be a need for further surgery to get the bones to heal.