An estimated 75% of the population will experience foot pain at some stage in their life. Foot pain can result from a variety of causes, and can affect any part of the foot. An overview of the common conditions and problems associated with foot pain are listed below. The foot is made up of 26 bones and 33 joints, together with a complex network of tendons, ligaments, and muscles. The bones in the feet are grouped into three main sections. The forefoot contains the five toes and the metatarsals. The midfoot is formed by the navicular, cuboid, and cuneiform bones. The hindfoot connects the midfoot to the ankle and is made up of the talus and the calcaneus (heel bone). Many people will suffer from problems associated with one or more of these areas during their lifetime. It is said that “the foot is a mirror to the body.” It has been shown that overall health and well-being may be determined by what is happening in the feet. First signs of many systemic diseases such as diabetes, arthritis, and circulatory diseases are often presented in the feet. This is one of the many reasons why it is important to seek treatment when problems occur.
Causes of Foot Pain
The foot functions as a single functional unit, however, it is made up of 26 bones, held together by muscles, tendons, and ligaments. This complex arrangement is capable of handling a great deal of weight and stress; however, it also makes the foot prone to many more acute injuries. Consider the effect of a single stress fracture high up in the foot or an ankle inversion sprain which may cause damage to several ligaments and a subsequent dislocation of tendons. Step in a pothole and you’ll understand what I mean. These types of injuries often require periods of immobilization to ensure complete healing and to prevent further occurrence. Failure to do so can result in the injury becoming chronic and therefore far more difficult to resolve. Unfortunately, immobilization causes significant muscle wasting, loss of strength, and eventual deconditioning in the structures above and below the immobilized area. This will be explained in many overuse injuries, whereby a loss of correct foot biomechanics is the predisposing cause. A simple example is that of a tibialis posterior tendon injury, the main dynamic support for the foot arch. Damage to this tendon can cause the arch to collapse resulting in further stresses being placed on other structures. Static support is bone and joint alignment which aids in uniform distribution of weight. Any change in this alignment due to a mal-united fracture, congenital abnormality, or more commonly shoe wear, can leave certain areas of the foot prone to high local stresses and eventual pain. This is one cause of degenerative joint disease in the foot. Finally, systemic diseases such as rheumatoid arthritis can cause widespread damage to many structures and result in multiple sites of pain in the foot.
Let’s get to the core of the problem. There can be as many causes of foot pain as there are moving parts in your foot. So let’s spare us both a futile exercise in creating an exhaustive list (you and I each have better things to do with the next 3 hours). Here is a simplified way (no need to complicate things) to categorize where the pain may be coming from: An isolated incident, this can be a direct result of a twist or impact. We’ll class this as an acute occurrence. Often, pain in a joint can be caused by an acute injury, or continually recurring from an original injury. This is due to the nature of joint damage where the underlying problem may still be present. If there is no history of a specific incident, the onset of pain can be due to overuse of a particular structure over time. This is known as a chronic injury. Finally, don’t forget that pain is often referred from the lower back or other areas. Probably not as simple as you first thought! Now let’s talk more specifically. A quick lesson in some foot anatomy:
Common Foot Conditions
Structural anomalies in the foot can be generally divided into three categories: 1. Congenital, 2. Developmental, and 3. Acquired. This section will cover the most common and recognizable foot conditions. The intent is to provide a description of the condition as well as ways to differentiate between them, since many of them are very similar.
Definition: According to Mosby’s Medical, Nursing, and Allied Health Dictionary, a structural anomaly is defined as an “unusual or atypical bodily formation.” In this text, it is used as a term to describe any deviation from the foot’s normal structural makeup.
Overview: The most common cause of foot pain is due to the foot’s structure. There are 26 bones in the human foot, which are supported by an intricate array of muscles, ligaments, and tendons. The foot is divided into three sections: 1. the forefoot containing the five toes, 2. the midfoot, and 3. the hindfoot, which forms the ankle and heel. Each foot motion relies on the structural interworking of the foot, which allows it to be both flexible and stable. Because of the foot’s structural nature, there are inherent possibilities for things to go wrong. Usually, what goes wrong is an overuse of a specific muscle, ligament, or tendon, which leads to an imbalance in the foot’s flexibility and stability. When an imbalance occurs, the stability of the affected area is compromised, which can lead to further structural damage.
Common Foot Conditions Pg. 9
Importance of Early Treatment
Early treatment of foot pain has been shown to result in a decrease in overall healthcare costs for individuals as they are able to prevent further pain and disability. This is significant as it will allow people to continue participating in activities they enjoy and thus maintain a high quality of life in their later years.
Osteoarthritis is an example of a self-perpetuating chronic condition because the pain it causes results in a decreased amount of physical activity, which in turn causes an increase in weight gain and ultimately increases the severity of the condition. In this case, it is logical to conclude that reducing the symptoms of the condition would interrupt the cycle of cause and effect.
It is often thought that mild foot pain will get better on its own over time. With this attitude, many people neglect to take steps towards changing the cause of their pain (like footwear or activity levels) and the pain itself may gradually become worse or develop into a chronic condition as they continue to age. Chronic conditions are defined as those that have persisted for more than three months, and it is in the existence of these long-term conditions that the belief in proactive treatment can be beneficial is most strongly supported by the healthcare industry.
The purpose of this section is to explore the idea that early treatment is beneficial to all foot pain sufferers. At present, the belief is common in people with recently sustained injuries such as fractures. However, some long-term conditions like osteoarthritis or pain resulting from poor lower limb biomechanics or diabetes are often left untreated until they have developed into something more severe. It is the purpose of this section to highlight the potential benefits of early treatment in these cases.
Non-Surgical Treatment Options
Physical Therapy Exercises Once the condition has calmed down a bit, often physical therapy exercises will be prescribed. This can be done at home on your own, or with the assistance of a physical therapist. The goal is usually to stretch tight and shortened tissues, and to strengthen weakened muscles. A very common example of a therapy exercise for heel pain is picking up marbles with your toes. The exercise is done by placing 20 marbles on the floor and picking each marble up with your toes and placing it in a small bowl. This should be done until all 20 marbles are picked up in two sessions. This will help to stretch and strengthen the muscles of the foot.
Rest and Ice Therapy The simplest and often most effective and the first thing your doctor will have you try is “R.I.C.E.”, which stands for Rest, Ice, Compression, and Elevation. An hour or two of complete rest from weight-bearing activity is very helpful. Additional rest will not be detrimental. Application of ice packs above and below the area of pain will help to reduce inflammation. This may be done for 20 minutes at a time, 3 to 4 times a day. More frequent applications of ice packs in the first 24 to 48 hours of an acute injury will help to control inflammation. Avoid heat applications. A compression bandage will help to reduce inflammation and compress the tissue to assist in controlling swelling. Elevation of the foot is very useful. Prop your foot up so that it is higher than your heart.
Your doctor will determine what treatment is best for you. Usually, the first goal of treatment is to reduce your pain and inflammation. The next goal is to correct, support, and realign your foot and toes so that you can prevent future problems. In some cases, localized cortisone injections may work best. Often this is a very successful form of treatment. Custom orthotics provide support and correction. In the worst cases, surgery may be necessary. Traditional approaches may be only moderately effective and can cause complications.
Rest and Ice Therapy
Rest often is the key to recovery from conditions that cause pain in the foot. It can help to reduce both pain and swelling. Non-weight bearing activities like swimming or cycling are excellent alternative activities while recovering from foot pain. Icing your injury is a simple and effective way to reduce pain and swelling. Proper use of ice can be one of the cheapest, simplest and most effective self-care regimens for an injured foot. The key to using ice to control pain and swelling is in understanding how it works. Timing is important. Icing an injury immediately numbs the pain and causes blood vessels to constrict, thus reducing swelling. Icing an injury several hours after pain begins may be much less effective. When in doubt whether to use ice after an injury, do so. Icing an injured foot for 20 minutes an hour is a good regimen to follow until pain and swelling has resolved; icing for longer periods of time can cause additional tissue damage. Icing also has an analgesic effect, which helps to reduce pain. Do not use heat on an injured area during the first 72 hours, heat will increase swelling and worsen pain. A whirlpool or hot bath is also contraindicated during this period. The heat from a whirlpool increases blood flow and can cause more swelling in an injured foot.
Physical Therapy Exercises
Depending on the individual’s specific foot problem, physical therapy can be an appropriate treatment plan. Physical therapy often involves teaching a patient to correct poor foot biomechanics and to stretch and strengthen surrounding muscle groups. There are many different techniques to correct biomechanical issues, including joint mobilization, muscle energy techniques, and gait training. Physical therapists can use a wide variety of tools to help the patient do this. A common technique is to use a custom-made foot orthotic designed to correct specific biomechanical issues. Night splints are often used to correct plantar fasciitis or calf tightness. This is used to hold the foot in dorsiflexion and to lengthen the calf and plantar fascia overnight. This can be uncomfortable but has been shown to be an effective way to treat chronic plantar fasciitis. In more severe cases, surgical lengthening of the calf musculature is indicated. Physical therapists can also use kinesiology taping, which has become more popular in recent years, to relieve pain and swelling. This is a good short-term pain relief option for someone who may be training for an event and doesn’t want to stop training completely. Finally, therapeutic ultrasound and electrical stimulation can be used to treat a number of different problems and may help to speed up the recovery process for certain conditions.
Medications for Pain Relief
An alternative to the above medications is a relatively new class of drugs known as COX-2 inhibitors. These are a form of NSAID that act to only block the COX-2 enzyme. This reduces the risk of stomach irritation and ulceration known to be caused by traditional NSAIDs. This class of medications is generally more expensive than traditional NSAIDs, and due to potential heart side effects, it is recommended that you discuss the benefits and risks with a doctor.
Like NSAIDs, oral steroids are another class of medication proven to reduce pain caused by inflammation. While effective, they are usually reserved for more severe cases due to potential side effects. These medications are only available by prescription, and it is vital that the patient discuss the potential benefits and risks of taking oral steroids with a doctor. The decision to take this form of medication should be well-informed.
Inflammation is one of the body’s natural reactions to injury or disease. Inflammation is caused by a release of chemicals from the body’s white blood cells into the blood or affected tissues. This release of chemicals increases the blood flow to the area of injury or disease, causing increased warmth and redness. The chemicals and increased blood flow can cause irritation to the area, which results in pain. A class of medications called NSAIDs (non-steroidal anti-inflammatory drugs) act to reduce the above-mentioned effects of the chemicals released during inflammation. A well-known over-the-counter NSAID is aspirin. Prescription NSAIDs are also common and include medications such as diclofenac and celecoxib. These types of medications, given for a short period, are often well tolerated and effective in reducing pain from an acute soft tissue injury. It is generally not advisable to take NSAIDs for longer than 10-14 days without consulting a doctor due to potential side effects.
Non-surgical treatment options went on to suggest the use of medications for pain relief. This is an often effective part of a treatment plan. There are many types of medications available. Some are to relieve pain, while others are to reduce inflammation. A large number of studies have shown that by reducing inflammation, pain is also reduced.
Orthotic Devices and Shoe Modifications
Braces are often advised to control symptoms of foot pain. The most useful brace is a lace-up ankle support, which is often used in treating acute ankle sprains. Many patients have found that the added support provided by these braces helps to prevent recurrent injury and minimize the amount of chronic disability. More extensive and stiffer braces are available for patients suffering from posterior tibial tendon dysfunction and/or severe flatfoot. Night splints are regularly used in treating plantar fasciitis and heel pain. These splints apply a mild stretch to the Achilles tendon and plantar fascia to keep them from tightening up overnight during sleep, which can be the most detrimental time for these patients. By preventing morning pain and stiffness, it’s more conducive for patients to begin stretching out these structures in the morning.
Custom orthotic devices have been useful in many patients as a way of controlling the mechanical causes of foot pain in several areas. These devices cushion the foot from excessive pounding, support the arch, and provide the stability necessary for proper foot and ankle motion. It is estimated that the dosage achieved by regular use in athletic shoes during one year is equivalent to several weeks of the same activity off the feet. Temporary use of over-the-counter arch supports and heel cups may be useful prior to a decision to fabricate custom orthotic devices.
Surgical Treatment Options
When it comes to your health, if a diagnosis and several more conservative treatment options do not yield positive results, surgery can be recommended. This is never a first line of treatment and is only considered when your primary care doctor or foot and ankle specialist can pinpoint the problem sufficiently and feels that you could benefit. Third party endorsement from an impartial foot and ankle specialist is a good litmus test to see if foot surgery is a good choice for you. It can be considered a last resort when all other treatment types have failed to correct the problem. During surgery, a variety of anesthetic and sedation options are utilized, along with localized anesthetics, which are injected into the foot – these vary depending upon the type of procedure. Cognitive local anesthetics (nerve blocks) will prevent the foot from feeling pain during and after surgery. These are as important as the surgery itself as an anesthetic experience that is remembered by the patient to being painful will prevent future surgeries from being considered. Although these will wear off after 8-24 hours, during this time, strong painkillers can be taken to suppress pain. With any type of surgery, there are always risks, and these must be weighed against the potential benefits to make an informed decision on whether to proceed.
When Surgery is Necessary
Surgery is recommended when your foot problem has caused you severe functional limitations and/or severe pain that limits your daily activities. There are cases where surgery will improve a painful deformity, but a functional limitation still remains. An example of this would be a rigid bunion, where the pain has been successfully reduced, but the limit of the big toe joint motion prevents a normal gait pattern. In such a case, a further surgery may be recommended to improve the toe joint functions. In some cases, the surgical removal of painful callous on the sole of the foot is deemed a surgery. A callous can be painlessly removed by a podiatrist in the office, so surgical callous removal is a treatment of last resort. This would occur if the callous cannot be reduced painlessly with a shoe insert and the pressure point that caused the callous has not been resolved.
It is important to note that the majority of foot problems can be treated without surgery. There are some problems, however, that will not improve without surgery. Your physician can determine if and when surgery may be appropriate. This is done by evaluating the severity of your condition and the likelihood of improvement from various conservative treatments. This includes taking into consideration x-ray findings and the nature of the pain. Keep in mind that the final decision to undergo surgical treatment should be made by you, the patient. A good understanding of your condition, the reasons for the recommended surgery, and the potential results will help you make the best decision.
Types of Foot Surgery
There are several types of surgical procedures, ranging from incision of a simple in-grown toenail to a complex realignment of the metatarsal bones. The type of the particular procedure will depend on the nature of the problem. Foot surgery usually is recommended when a foot problem has reached a stage where conservative treatments are no longer effective or the deformity causes ongoing pain, trouble when wearing shoes, or there is an enhanced risk of further deformity or damage to the affected area. It is often the last resort in solving a foot problem. A podiatric surgeon can help in deciding the type of surgery, but it is the patient who makes the final decision. Recommended Reading: Best Foot Fungus Treatments Exploratory Surgery Sometimes foot problems are unclear and the symptoms fail to suggest a diagnosis. A minimally invasive exploratory surgery can often be helpful. Easing joint and tendon pain can make life much more comfortable and active. This procedure is usually carried out with minimally invasive surgery, avoiding an open incision.
Post-Surgery Rehabilitation
Post-surgery rehabilitation for some foot surgeries can be an extensive period of time where the patient must stay off the operated foot. This can be done with the use of crutches, a walker, wheelchair, or through various methods of immobilization. Non-weight bearing is in effect when the foot cannot touch the ground whatsoever. The second phase of rehabilitation for foot surgery usually involves some form of weight bearing restriction. In the later phases of the rehabilitation process, physical therapy is used to regain strength and motion in the foot. Your doctor may recommend physical therapy, either at home or with a therapist. Exercises are used to help improve strength and flexibility in the foot. This will help you return to normal activity. In the final phase of your rehabilitation, emphasis will be placed on your ability to return to normal or increased activity. This involves an evaluation of your gait (the way you walk) and your ability to wear different types of shoes. A functional orthotic device may be necessary to achieve this. An orthotic is a type of padded shoe insert which can be used to minimize symptoms during standing, walking, or running. It also can prevent the worsening of foot deformities which can occur over time due to the injured tendon. Functional custom-made orthotics are prescribed by a podiatrist who makes a special design for the specific foot problem. A prefabricated orthotic is one which is inserted into the shoe and is made for a general foot problem. Both custom and prefabricated orthotics can help speed up the process in returning to normal activity after foot surgery. It is important to note that certain foot surgeries do not require the use of an orthotic. Your physician will be able to determine if an orthotic is necessary for your specific foot problem.
Foot Pain Treatment in Singapore
Lead by a team of Singapore’s top foot pain specialists, Dr. Sean Leo and Dr. Radhika Kulkarni, they have been treating multiple foot and ankle conditions for many international and local patients. Some of the top services they offer include bunion treatment, diabetic wound care, and sports-related injuries to the foot and ankle. As foot surgeons, both Dr. Sean Leo and Dr. Radhika Kulkarni believe in providing comprehensive foot care to their patients by educating them about the different treatment options available. With their belief in keeping patients mobile, active, and pain-free, they always discuss with their patients to find a treatment option that is best suited for the patients’ needs. We have been providing services in the Paragon since 2005. Over the years, the medical treatment of various foot and ankle conditions has evolved. Hence, being in a medical hub, we use up-to-date medical technology to provide treatments to our patients. One example is extracorporeal shockwave therapy (ESWT). This is a treatment modality that is associated with various musculoskeletal disorders, especially in those with a chronic condition. It is less invasive and, in certain conditions, is an alternative to surgery. This is also available in Singapore General Hospital and Changi General Hospital. With the addition of this machine in our clinic, we are able to provide this treatment with a lower waiting time and at a lower cost to our patients. This is because the treatment cost can be subsidized by the patient’s Medisave account. Another more common example would be the treatment of an ingrown toenail. In the past, it would be treated as a minor surgery. Now, we are able to treat it with a method called Partial Nail Avulsion. This is a method of removing only the ingrown part of the toenail with the use of a local anesthetic.
Leading Foot Pain Specialists in Singapore
The first port of call is usually a visit to a general practitioner. For new injuries, it is important to rule out a fracture or serious soft tissue tear, and a GP can help to facilitate a referral for any required medical imaging. For more chronic, overuse type injuries, a visit to a sports physician is the best choice. While the line between what a GP and a sports physician does can often be quite blurry, a sports physician is generally more attuned to sports injuries and is able to provide a more targeted diagnosis. At this point, it may be useful to try to find a professional who specializes in podiatric medicine. This is a field which is still very much in its infancy in Singapore, and it may be difficult to find a podiatrist or sports physiotherapist with a high level of expertise in the lower limb. The terms “podiatrist” and “orthotist” are protected in the sense that only someone with a recognized qualification in these fields can be registered to practice in Singapore. A visit to a podiatrist may provide insight into relevant mechanical or training issues which have contributed to the injury at hand. However, many cases of musculoskeletal injuries of the lower limb will still require referral to a physiotherapist or an occupational therapist for conservative therapy. In complicated cases with a clear structural issue within the foot, a podiatrist may refer the patient for a surgical assessment with an orthopaedic surgeon. This is a trained medical doctor who has taken on specialist training to operate and manage various conditions of the musculoskeletal system. A referral to an orthopaedic surgeon may also be obtained by a sports physician.
When it comes to foot nerve pain treatment, whether acute or chronic, it is important to seek help from the appropriate professional. However, it can be difficult to know where to start. This is especially so in the medical industry in Singapore, where there are many different practitioners who claim to be able to treat every manner of musculoskeletal injuries. Whereas many Western countries have a well-established industry for orthopaedic and sports medicine, so far Singapore does not have a widespread system to help someone with a certain injury to know which type of doctor or allied health professional they should be seeking.
Advanced Treatment Techniques
Crucial for the success of treatment is an accurate diagnosis. Once the cause of pain has been determined, the first line of approach is to consider non-invasive treatment options. For most soft tissue and mechanical pain, temporary relief can be attained with the use of taping and padding techniques. Strapping techniques aim to reduce stress on the affected area by changing the foot’s biomechanics. Accordingly, pressure is taken off painful structures and moved to more efficient areas of the foot. Orthotic therapy involves the prescription of an orthotic device which is inserted into the shoe to support, realign or improve the function of the foot. This helps to reduce excess stress on the foot and lower limb, and is especially useful in correcting abnormal biomechanics, or in providing support to the foot in people who are overweight or in those who have to stand for long periods. An orthotic can be custom made by a podiatrist, orthotist or a specially trained health professional. A cast or mould of the foot is taken with correction of the abnormal biomechanics, followed by selection of materials and design of the orthotic. In some cases, more advanced forms of imaging (e.g. X-ray) are required to obtain the most accurate prescription. High quality, prescription orthotics are durable medical devices which can last several years if properly cared for. As the use of orthotics is to provide long-term structural or functional changes to the foot, they are usually worn for an extended period of time. Supportive shoes with a firm heel counter and insole are required to accommodate the orthotic and to optimize the treatment. Prices of orthotics can be quite variable; it is best to consult the specific orthotic provider for a quote.
Cost and Insurance Coverage
Costs for foot heel pain treatment can vary greatly. They will depend on the type of treatment, the complexity of the foot problem, the type of health insurance that you have, and if there are any subsidies that can be claimed. Considering a foot surgery can ward off future pain and is more cost-effective than continued medication or repeated modification of shoes. However, a foot surgery can be quite expensive and your insurance coverage will play a large role in determining how much you have to fork out from your own pocket. You should check with your insurance company on the extent of the foot surgery that can be covered. Insurance coverage for foot surgery is provided under MediShield and also integrated schemes by private insurers. Patients should check on the coverage and claim limits before undergoing surgery.