There are several causes of pain in the arch of the foot and heel region. The type of pain and its location help the doctor in determining the cause of the pain and helps to direct them in the best treatment for the patient

The most common pain in the bottom of the foot is heel pain. This pain tends to be worse first thing in the morning or after rest. It is associated with a tight ligament in the bottom of the foot called the plantar fascia. X-rays will often reveal a spur on the bottom of the heel. (See plantar fascists and heel spurs)

Pain in the back of the heel can be due to bony enlargements (Hagland's deformity), spurring in the Achilles tendon or Achilles tendonitis.

Burning pain in the bottom of the foot may be caused by a condition called tarsal tunnel syndrome or it may be due to peripheral neuropathy. People with diabetes frequently experience burning in the bottom of the feet.

Pain in the middle of the arch of the foot that is also associated with small, hard knots may be due to plantar fibromatosis.

The spontaneous development of pain in children generally indicates some form of injury to the growth plate of a growing bone. This can occur without a specific memorable event. When pain occurs in the ball of a child's foot the most likely cause is injury to the growth plate of one of the long bones behind the toes called metatarsals. The most common bone involved is the metatarsal behind the second toe. When numbering the toes the big toe is the first toe.

This condition is called Freiberg's disease. This disorder is most frequently seen in the adolescent between the ages of 13 - 15 years of age. It is three times as likely to occur in females as compared to males. The pain is a result of a loss of blood flow to the growth plate in the bone.

Diagnosis

The diagnosis of Friebergs disease is made by x-ray evaluation. X-rays will reveal a flattening of the head of the metatarsal bone. Early changes may be very subtle or not apparent. On physical exam there may be swelling in the area that is tender to touch. A useful tool for diagnosing growth plate injuries and stress fracture is to strike a tuning fork and placing the vibrating tuning fork on the area of the suspected site of injury. Pain with vibration may indicate bone or growth plate injury.

Treatment

Treatment consists of reducing pressure under the affected bone. This may consist of anything from using crutches to a custom insole for the shoe called an orthotic. Left untreated the affected bone may not develop properly and permeate damage to the joint behind the affect toe may result in painful arthritis. Once the joint becomes arthritic surgery to place an artificial joint may be required.

There are several causes of pain in the ball of the foot. The type of pain and its location help the doctor in determining the cause of the pain and helps to direct them in the best treatment for the patient.

Calluses on the bottom of the foot can be painful. These calluses are caused by an abnormal alignment of the bones behind the toes called metatarsal bones. When there is an abnormal alignment of one or more of these bones, they will experience excessive weight and pressure. The skin thickens in response to this pressure forming the callus. Treatment consists of periodic trimming or shaving the callus, padding the shoes to remove the pressure, functional shoe orthotics, or surgery. Surgery should not be contemplated until the use of orthotics has been determined to have failed. The surgery consists of fracturing the involved metatarsal bone to realign it (See metatarsal surgery). Following the surgery, the patient should wear an orthotic to prevent the occurrence of new areas of callus. People with diabetes should not trim or shave these areas or use over the counter corn removers.

Pain in the ball of the foot not associated with calluses can be a result of inflammation of a tendon into the toe, inflammation of the joint, or due to a pinched nerve called a Neuroma. A neuroma will also often cause a burning pain into one or more toes. Another cause of pain in the ball of the foot is arthritis. Arthritis will usually affect multiple joints in the ball of the foot. Common types of arthritis are rheumatoid arthritis, osteoarthritis and degenerative arthritis. Degenerative arthritis most commonly affects the big toe joint. The big toe joint is often stiff causing jamming (Hallux Limitus). Over time the jamming of the joint will cause an enlargement on the top of the joint.

The most common cause of pain in the ball of the foot, in the area of the big toe joint, is sesamoiditis. Sesamoiditis is an inflammation of two small bones under the big toe joint. On occasion, a stress fracture can occur in one of these bones. Severe pain with sudden onset about the big toe joint may be gout.

The common cause of a painful bump on the back of the heel is called Hagland's deformity. This is due to an enlarged bony prominence on the back of the heel. It can involve the entire back of the heel or just a portion of the back of the heel, usually on the outside portion of the heel. Also called the Pump Bump, it is most common in women and is frequently a result of pressure from the back of the shoe. As the shoe rubs on the back of the heel bone it begins to swell and enlarge. Quite often a bursa will form. A bursa is a sack that is created over any bony prominence when excessive pressure or friction to the areas occurs. Bursae can be filled with a thick watery like fluid.

Treatment

Treatment consists of removing the pressure and avoiding shoes that rub on the back of the heel. Orthotics, custom molded shoe inserts, can be useful because they reduce the rocking motion side-to-side of the heel while walking which aggravates the painful area. Cortisone injections can temporarily reduce the pain or eliminate the pain. Surgery can be the treatment of choice if other means to reduce the pressure are unsuccessful.

Spurring in the Achilles tendon

Closely related to Hagland's deformity is an enlargement that can occur on the back of the heel that is a result of the formation of a large spur where the Achilles tendon attaches. Treatment is the same as with the Hagland's deformity except that the surgical procedure to remove the spurring is more complex and has a longer recovery period.

Achilles Tendonitis

Swelling and lumps can also occur in the Achilles tendon just above its attachment into the heel bone. Termed Achilles tendonitis, this occurs when there is a tear in the tendon. If this goes untreated the tendon is at risk of rupturing. Treatment consists of immobilization with a cast, possibly crutches to take weight off the foot, oral anti-inflammatory drugs and if severe surgery may be necessary. Once the area is healed aggressive physical therapy and calf muscle stretching exercises may be needed. There is another small tendon that attaches in the back of the heel that can become injured. It is called the Plantaris tendon. This tendon can tear or rupture during exercise. It is associated with a sudden onset of pain during exercise and mimics Achilles tendonitis.

An Uncommon Cause - Xanthomas

An uncommon cause of small lumps in the Achilles tendon is an excessively high cholesterol level in the blood stream. This is a hereditary disorder that results in the deposition of cholesterol in the Achilles tendon. This is a serious condition and requires aggressive treatment by a physician to lower the cholesterol levels. Left untreated the high cholesterol levels can lead to premature heart attack and death.

There are several causes of pain in the arch of the foot and heel region. The type of pain and its location help the doctor in determining the cause of the pain and helps to direct them in the best treatment for the patient.

The most common pain in the bottom of the foot is heel pain. This pain tends to be worse first thing in the morning or after rest. It is associated with a tight ligament in the bottom of the foot called the plantar fascia. X-rays will often reveal a spur on the bottom of the heel. (See plantar fasciitis and heel spurs) Pain in the back of the heel can be due to bony enlargements (Hagland's deformity), spurring in the Achilles tendon or Achilles tendonitis. Burning pain in the bottom of the foot may be caused by a condition called tarsal tunnel syndrome or it may be due to peripheral neuropathy. People with diabetes frequently experience burning in the bottom of the feet. Pain in the middle of the arch of the foot that is also associated with small, hard knots may be due to plantar fibromatosis.

The common cause of a painful bump on the back of the heel is called Hagland's deformity. This is due to an enlarged bony prominence on the back of the heel. It can involve the entire back of the heel or just a portion of the back of the heel, usually on the outside portion of the heel. Also called the Pump Bump, it is most common in women and is frequently a result of pressure from the back of the shoe. As the shoe rubs on the back of the heel bone it begins to swell and enlarge. Quite often a bursa will form. A bursa is sack that is created over any bony promance when excessive pressure or friction to the areas occurs. Bursa can be filled with a thick watery like fluid.

Treatment of Hagland's Deformity and Pump Bumps

Treatment consists of removing the pressure and avoiding shoes, which rub on the back of the heel. Orthotics, custom molded shoe inserts, can be useful because they reduce the rocking motion side-to-side of the heel while walking which aggravates the painful area. Cortisone injections can temporarily reduce the pain or eliminate the pain. Surgery can be the treatment of choice if other means to reduce the pressure are unsuccessful.

Spurring in the Achilles tendon

Closely related to Hagland's deformity is an enlargement that can occur on the back of the heel that is a result of the formation of a large spur where the Achilles tendon attaches. Treatment is the same as with the Hagland's deformity except that the surgical procedure to remove the spurring is more complex and has a longer recovery period.

Achilles Tendonitis

Swelling and lumps can also occur in the Achilles tendon just above its attachment into the heel bone. Termed Achilles tendonitis, this occurs when there is a tear in the tendon. If this goes untreated the tendon is at risk of rupturing. Treatment consists of immobilization with a cast, possibly crutches to take weight off the foot, oral anti-inflammatory drugs and if severe of surgery. Once the area is healed aggressive physical therapy and calf muscle stretching exercises. There is another small tendon that attaches in the back of the heel that can become injured. It is called the Plantaris tendon. This tendon can tear or rupture during exercise. It is associated with a sudden onset of pain during exercise and mimics Achilles tendonitis.

An Uncommon Cause - Xanthomas

An uncommon cause of small lumps in the Achilles tendon, called Xanthomas, are due to an excessively high cholesterol level in the blood stream. This is a hereditary disorder that results in the deposition of cholesterol in the Achilles tendon. This is a serious condition and requires aggressive treatment by a physician to lower the cholesterol levels. Left untreated the high cholesterol levels can lead to premature heart attach and death.

Deformities of the toes are common in the pediatric population. Generally they are congenital in nature with both or one of the parents having the same or similar condition. Many of these deformities are present at birth and can become worse with time. Rarely do children outgrow these deformities although rare instances of spontaneous resolution of some deformities have been reported.

Malformation of the toes in infancy and early childhood are rarely symptomatic. The complaints of parents are more cosmetic in nature. However, as the child matures these deformities progress from a flexible deformity to a rigid deformity and become progressively symptomatic. Many of these deformities are unresponsive to conservative treatment. Common digital deformities are underlapping toes, overlapping toes, flexed or contracted toes and mallet toes. Quite often a prolonged course of digital splitting and exercises may be recommended but generally with minimal gain. As the deformity becomes more rigid surgery will most likely be required if correction of the deformity is the goal.

Underlapping Toes

Description

Underlapping toes are commonly seen in the adult and pediatric population. The toes most often involved are the fourth and fifth toes. A special form of underlaping toes is calledclinodactyly or congenital curly toes. Clinodactyly is fairly common and follows a familial pattern. One or more toes may be involved with toes three, four, and five of both feet being most commonly affected.

The exact cause of the deformity is unclear. A possible etiology is an imbalance in muscle strength of the small muscles of the foot. This is aggravated by a subtle abnormality in the orientation on the joints in the foot just below the ankle joint called the subtalar joint. This results in an abnormal pull of the ligaments in the toes causing them to curl. With weight bearing the deformity is increased and a folding or curling of the toes results in the formation of callus on the outside margin of the end of the toe. Tight fitting shoes can aggravate the condition.

Treatment

The age of the patient, degree of the deformity and symptoms determine treatment. If symptoms are minimal, a wait and see approach is often the best bet. When treatment is indicated the degree of deformity determines the level of correction. When the deformity is flexible in nature a simple release of the tendon in the bottom of the toe will allow for straightening of the toe. If the deformity is rigid in nature then removal of a small portion of the bone in the toe may be necessary. Both of these procedures are common in the adult patient for the correction of hammertoe deformity. If skin contracture is present a derotational skin plasy may be required.

 

Overlapping Toes - Overlapping Fifth Toe

Description

This deformity is characterized by one toe lying on top of an adjacent toe. The most common toe involved is the fifth toe. When one of the central toes is involved the second toe is most commonly affected. The etiology of the condition is not well understood. It is though that it may be caused by the position of the fetus in the womb during development. The condition my run in families so there may be a hereditary component to the deformity.

Treatment

Effective conservative treatment depends upon how early the diagnosis is made. In infancy, passive stretching and adhesive tapping is most commonly used. This may require 6 to 12 weeks to accomplish and reoccurrence is not uncommon. Rarely will the deformity correct itself. As the individual matures the deformity becomes fixed. When surgical correction is warranted a skin plasty is required to release the contracture of the skin associated with the deformity. Additionally a tendon release and a release of the soft tissues about the joint at the base of the fifth toe may be required. In severe cases the toe may require the placement of a pin to hold the toe in a straightened position. The pin, which exits the tip of the toe, may be left in place for up to three weeks. During this period of time the patient must curtail their activities significantly and wear either a post-operative type shoe or a removable cast. Excessive movement at the surgical site can result in a less than desirable result. The pin can be easily removed in the doctor's office with minimal discomfort. Following removal of the pin splinting of the toe may be required for an additional two to three weeks.

 

Hammertoes and Mallet Toes

Description

Another common digital deformity is contracture of the toes in the formation of hammertoes and mallet toes. Hammertoes are described in depth in another article. Mallet toes are a result of contracture of the last joint in the toe. In the pediatric population it is often flexible and not painful. Over time the deformity becomes rigid and a callus may form on the skin overlying the joint at the end of the toe. Additionally the toenail may become thickened and deformed form the repetitive jamming of the toe while walking. The deformity usually involves one or two toes, with the second toe most commonly affected. Mallet toes have several etiologies. Longer toes that are forced against a short toe box in the shoe will, over time, develop a contracture of the last joint in the toe causing a mallet toe.

Treatment

Conservative treatment consists of padding and strapping the toes into a corrected position. This treatment may alleviate the symptoms but will not correct the deformity. Diabetic patients often develop ulcerations on the ends of their toes secondary to mallet toe deformity and the pressure that results from the toe jamming into the shoe. When standing, the toe will demonstrate a contracture, with the tip of the toe facing downward into the floor. If the deformity is flexible a simple release of the tendon in the bottom of the toe will allow straightening of the toe. Following the procedure the patient must avoid shoes that cause jamming of the toe or the deformity can reoccur. When the deformity is rigid surgical correction requires the removal of a small section of bone in the last joint of the toe. On occasion fusion of the last two bones in the toe may be necessary. This requires removing the cartilage from the last joint in the toe and pinning the bones together. When the bone heals it forms a single bone and the toe remains in a straightened position. Healing time is dependent upon the procedure selected. If a tendon release is performed the patient my return to a roomy shoe within a week. If the toe is straightened by removing a section of the bone in the toe it make ten days to three weeks for a patient to return to normal shoes. If a fusion is performed to straighten the toe, the patient may not return to normal shoes for 6 to 8 weeks. Time off from work will depend upon the type of shoe gear that must be worn and the level of activity necessary to perform the job. A minimum of three to four days off from work is generally recommended and longer if the job responsibilities can not be modified to accommodate the normal healing time for the surgery.

Infection can be caused by a number of different agents. Athlete's foot is an infection of the skin caused by a fungus. Warts are caused by a viral infection of the skin. When most people think about infections they are thinking about infection caused by bacteria. There are numerous types of bacterial infection. Infection generally requires a break in the skin from a cut, abrasion, puncture wound or ulceration. The most common infection is caused two bacteria, Staphylococcus and Streptococcus. Both of these infections cause progressive tissue damage of varying degrees. People with diabetes can develop infections by several bacteria at the same time.

Infection that occurs in the skin is called cellulitis. Deep infections that develop puss pockets are called abscesses. The most common bacterium that causes cellulitis is Streptococcus. These infections can become very serious and even life threatening. Cellulitis is characterized by spreading redness in the area with an increase in the temperature of the skin, often accompanied by fever and chills. People who suffer from venous stasis, chronic swelling in the legs, are prone to these infections. Cellulitis is also commonly seen in associated with athlete foot conditions. The athlete's foot causes small breaks in the skin, which can become infected, by the Streptococcus bacteria. Soft corns, particularly between the fourth and fifth toes can also become infected and cause cellulitis and or an abscess. Puncture wounds are very likely to become infected. This can result in a very dangerous deep abscess that can also infect the bone. A doctor should evaluate all deep puncture wounds as soon as possible. Simply cleaning the outside of the puncture wound is not enough to prevent infection. Oral antibiotics should be prescribed and the wound watched carefully. If there is any sign of infection, surgical cleaning of the wound should be preformed.

People with diabetes are at particular risk of infection. In fact, people with diabetes spend more time in the hospital for foot infections than for any other reason. Corns and calluses on the feet of people with diabetes can break down and allow bacterial invasion of the tissue. In people with long standing open ulceration the underlying bone can become infected. Bone infections, called osteomyelitis, generally require surgery to remove the infected bone. These infections are very difficult to cure with oral or intra-venous antibiotics without also removing the infected bone. The presence of bone infection can be diagnosed with special tests such as bone scans and MRI. These test are not 100% accurate however and the experience of the treating doctor becomes very important in making the correct determination as to the presence of bone infection.

Gout, which is caused by an elevated blood uric acid level, can be confused with infection. This condition can cause sudden onset of pain, redness, and swelling of a joint or in the soft tissues. It is important to rule out an infection, particularly if it is in a joint. Rare instances of infection can occur without evidence of a break in the skin. The infection is carried to the site by the blood stream. Close examination of the patient may reveal an abscessed tooth that likely is the source of the infection. In other instances no source of the infection can be found.

People who have joint replacements, heart valve replacements or who have a pacemaker must be very cautious regarding infections. They are at risk of an infection spreading from another site to the area of their joint replacement, heart valve replacement or pacemaker. Also, people who have mitral valve prolapsed must be cautious if they have infections because the infection can spread to the heart.

A subungual exostosis is a bony prominence that can occur under the toenail. They generally are a result of some form of trauma to the toe that results in the formation of bony irregularity or prominence. When they are symptomatic, removal of the spur is the treatment of choice. Additionally other small tumors called osteochondromas and enchondroma can also form in the bone beneath the toenail as well as in other bones in the body.

An osteochondroma is a benign bone tumor that accounts for 50% of all benign bone tumors. They have a predilection for the long tubular bones of adolescents and young adults. Its peak incidence is in the second decade of life with a male to female ratio of approximately 2:1. They are generally painless or minimally painful unless they cause irritation to the surrounding tissue. When they are in the bone beneath the toenail they can deform the toenail and cause an ingrown toenail. The treatment of symptomatic osteochondromas is surgical excision. The final diagnosis is made after the bone tumor is removed and examined by a pathologist. Recurrence of the tumor is possible following their removal. Hereditary multiple exostosis (osteochondromatosis) have a prominent hereditary incidence which affects males more often then females. The disease is characterized by the presence of multiple exostosis, which are frequently bilateral and somewhat symmetrical and usually make their appearance during childhood or adolescence.

Enchondroma is a fairly common benign cartilaginous tumor, which is the most common bone tumor of the hands and feet. They affect patients in a wide age range with no sex predilection. When they occur within the small tubular bones the tumor can involve large portions of these bones, causing thinning of the cortex of the bone. This can weaken the bone and cause it to break spontaneously. When they occur in the small bone in the end of the toe they can cause pain that may mimic the pain of ingrown toenails. Ollier,s disease, also known as enchondromatosis, shows a strong predilection for the small bones in the hands and toes (phalanges) and the long bones behind the phalanges called metatarsals. It is often shows an asymmetric involvement, tending to affect one side of the body more than the other and has a propensity to transform into a malignant sarcoma. Maffucci's syndrome is a very rare form of enchondromatosis associated with multiple soft tissue hemangiomas. This tumor has a greater predilection for the hands and feet, and has a greater toward malignant transformation than Ollier,s disease.

Knee pain in children may be caused by a variety of conditions. Some of these conditions may be rare but can be quite serious in nature. Knee pain in children should be evaluated by your doctor.

Osgood-Schlatter's Disease

A common cause of knee pain in a growing child is injury to a growth plate in the front of the knee. This may be accompanied by swelling in the area. This condition is called Osgood-Schlatter's disease. It occurs most commonly in children between the ages of 10 -14. It is often associated with playing sports and aggressive bicycle riding. It is felt that the condition is primarily caused by an abnormal pull of the tendon that attaches into the painful area from the kneecap. This tendon is called the patellar tendon.

Treatment of Osgood-Schlatter's Disease

Treatment consists of avoiding activities that aggravate the condition such as kneeling or excessive flexion of the knee. Icing the area and anti-inflammatory medications such as Tylenol or Advil may provide temporary relief. Often the abnormal knee function is due to the way the foot functions. In this instance the foot causes the lower leg to rotate slightly inward. This causes the patellar tendon to pull in an abnormal direction where it attaches in front of the knee causing damage to the growth plate in this area. If this is the cause of the problem then treatment might consist of a custom fitted shoe insert called an orthotic. The orthotic corrects the underlying foot condition that is affecting the lower leg and knee. A podiatrist trained in the use of functional orthotics should be able to evaluate the cause of the problem and if it is caused by abnormal foot function adequately treat the condition.