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Management of foot pain

Case history

Julie is a 34-year-old waitress in a busy restaurant. She is 5'5" tall and weighs 12 stone. She has been trying to lose weight by exercising for several months. She jogs twice a week and has lost about 4lb in the last month. Over the past few weeks she has developed pain in her left forefoot which worsens towards the end of the day and often leaves her limping. She is also finding it difficult to jog. Ibuprofen does not seem to help very much. Dr Tanvir Jamil discusses.

This seems fairly straightforward

Foot problems are very common in general practice and satisfying to treat as the cause is often obvious. However, the harder you have to think about the diagnosis, the more likely there is to be an obscure cause requiring investigation.

Foot pain, shoes and women ­ a definite connection?

I'm sure there is! Shoes can play a major role in the aetiology of foot pain especially if they are combined with obesity and a job that involves standing for long periods of time. Some of the commonest problems related to ill-fitting footwear include:

Bunions Usually hereditary, they can become inflamed and painful. Contrary to popular belief, they are not a direct result of bad footwear although narrow-toed shoes can make them worse.

Calluses and corns The former occur on the balls of the feet or heels and the latter appear on the toes. Both can become very painful.

Hammer toes Certain shoes often make a neuroma more painful. High heels cause more weight to be transferred to the front of the foot and tight toes create lateral compression. Metatarsalgia can also be affected by problem footwear.

What are the other causes of foot pain?

Some of the commonest are gout, verrucae, infected ingrowing toenail, Morton's neuroma, metatarsalgia, arthritis (osteo and rheumatoid), march (stress) fracture, Frieberg's disease (osteochondritis of head of second or third metatarsal) and plantar fasciitis.

The rare but important ones not to miss include osteomyelitis, diabetic neuropathy, ischaemia and referred pain from a nerve root lesion.

If a patient's foot looks normal ­ what are the key questions to ask?

·Where is the pain?

·Metatarsalgia ­ over the second to fifth metatarsal heads.

·Morton's neuroma ­ usually around the fourth metatarsal head.

·Stress fractures ­ over the shaft of the metatarsal bone on the dorsal aspect of the foot.

·Polyneuropathy ­ all over the foot, usually symmetrical.

Occupation/any injury/new activity?

Think contact sports or pounding activities (for example jogging and aerobics). A penetrating injury could cause osteomyelitis.

What makes the pain worse/better?

Gradual increase in pain with exercise might suggest march (stress) fracture or generalised metatarsalgia. Extremely severe pain on walking on uneven ground might suggest Morton's neuroma.

Taking off shoes often alleviates pain from Morton's neuroma and bunions.

Radiation of pain?

Morton's neuroma often radiates to the third and fourth toes. Stress fractures can result in a dull ache behind the toes.

History of flat feet?

This can result in the interdigital nerve being pulled more medially than normal, causing irritation of the nerve leading to neuroma formation.

Any systemic symptoms?

Osteomyelitis can cause temperatures, rheumatoid arthritis can cause general tiredness and early-morning stiffness.

Thirst, polyuria and tiredness may point to diabetes causing polyneuropathy.

Any specific golden nuggets?

Pain produced on squeezing the forefoot is indicative of metatarsalgia, Morton's, march fracture or Frieberg's so it's not very specific.

Oedema of the dorsum of the forefoot and tenderness over the affected metatarsal head can occur in Frieberg's.

With time, the metatarso-phalangeal joint stiffens, the pain and tenderness becomes less, but a bony lump (the thickened metatarsal head) can be palpated.

There will be local tenderness dorsally over the metatarsal shaft in a march fracture and possibly a bony lump.

How do I avoid missing serious causes?

Remember a few rules:

·If a known arteriopath complains of pain in the ball of the foot disturbing sleep then he probably has critical ischaemia and needs urgent referral.

·Fever and systemic illness with localised extreme bone pain and signs of local infection is acute osteomyelitis or septic arthritis unless proved otherwise.

·Pain in the foot, especially tenderness, with no obvious signs, suggests ischaemia, neuropathy or an L5/S1 nerve root lesion.

Tanvir Jamil is a GP in Burnham, Buckinghamshire

Apart from NSAIDs and

cortisone injections, is

there anything else we

can tell our patients?

·Self-help is often the mainstay of treatment and it is worth having a printed leaflet to hand out to patients.

·Wear comfortable, properly-fitting shoes with good arch support and cushioning.

·Wear shoes with adequate room

around the ball of the foot and toe.

·Wear trainers as often as possible, especially when walking.

·Avoid narrow-toed shoes and high heels.

·Replace running shoes frequently.

·Warm up before exercise, cool down after exercise, and stretch adequately.

·Increase the amount of exercise

slowly over time to avoid putting excessive strain on feet.

·Lose weight.

·Learn exercises to strengthen feet

and avoid pain; this can help flat feet and other potential foot problems.

·Keep feet dry to avoid friction; this

may help prevent corns and calluses.

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