Specific causes of Foot pain (podalgia) Flashcards
Vascular causes
The main problem is ischaemic pain that occurs only in the foot.
The commonest cause is atheroma.
Symptoms:
claudication (rare in isolation)
sensory disturbances, esp. numbness at rest or on walking
rest pain—
- at night
- interfering with sleep
- precipitated by elevation
- relieved by dependency
Complex regional pain syndrome 1
Originally known as reflex sympathetic dystrophy,
- usually a sequel of trauma,
- usually lasts 2 yrs
- and recovery to normality usually follows.
Clinical features include:
- sudden onset in middle-aged pts
- pain worse at night
- stiff joints and skin warm and red.
X-rays that show patchy decalcification of bone are diagnostic.
Treatment includes:
- reassurance
- analgesics
- mobility in preference to rest and physiotherapy.
Osteoid osteoma
Benign tumours of bone that
- typically occur in older children and adolescents.
Nocturnal pain is a prominent symptom with pain relief by aspirin being a feature.
Diagnosis is dependent on clinical suspicion and then X-ray
- which shows a small sclerotic lesion with a radiolucent centre.
Treatment is by surgical excision.
Osteochondritis/aseptic necrosis
Three important bones to keep in mind are:
- the calcaneum—Sever’s disease
- the navicular—Kohler’s disease
- the head of the second metatarsal—Freiberg’s disease
Sever’s disease is traction osteochondritis
- while the other disorders are a ‘crushing’ osteochondritis with avascular necrosis.
Skin disorders
Two conditions commonly seen in teenagers are
- pitted keratolysis
- juvenile plantar dermatosis.
Pitted keratolysis
This malodorous condition which has a pitted ‘honeycomb’ appearance is usually seen at 10–14 yrs.
Known as ‘moccasin foot’, ‘stinky feet’ or ‘sneaker’s feet’, it is related to sweaty feet.
Treatment includes:
- keeping the feet dry
- wearing all-leather shoes
- cotton or woollen socks (not synthetics)
- charcoal inners and
- ointment such as Whitfield’s or an imidazole or sodium fusidate or benzoyl peroxide 2.5–5% to remove the responsible Corynebacterium organism.
Use a drying agent to decrease sweating:
- formaldehyde soaks nocte or
- aluminium chloride 20% in alcohol solution (e.g. Driclor, Hidrosol, Neat Feat) applied nocte for 1 wk then 1–2 times/wk.
Juvenile plantar dermatosis ‘Sweaty sock dermatitis’
is a painful condition of weightbearing areas of the feet.
The affected skin is red, shiny, smooth and often cracked.
It usually starts in school years and resolves in mid-teens and is rare in adults.
The treatment is to change to leather or open shoes and to cotton socks.
A simple emollient cream gives excellent relief.
Arthritic conditions
Arthritis of the foot or ankle is caused by:
- osteoarthritis (commonly)
- rheumatoid arthritis
- gout and
- the spondyloarthropathies (uncommon).
Foot strain
is probably the commonest cause of podalgia.
A foot may be strained by abnormal stress or by normal stress for which it is not prepared.
In foot strain the supporting ligaments become stretched, irritated and inflamed.
It is commonly encountered in athletes who are relatively unfit or who have a disorder such as flat feet.
The strain may be acute or chronic.
Symptoms and signs:
- aching pain in foot and calf during or after prolonged walking or standing
- initial deep tenderness felt on medial border of plantar fascia
Treatment:
- Acute strain is treated with rest and by reducing walking to a minimum.
- Try the application of cold initially and then heat.
- The management of chronic strain is based on an exercise program and orthotics, including arch supports, to correct any deformity.
Metatarsalgia
Refers to pain and tenderness over the plantar heads of metatarsals.
Causes includ:
- foot deformities (esp. with depressions of the transverse arch)
- arthritis of the MTP joints
- trauma
- Morton’s neuroma
- Freiberg’s disorder
- entrapment neuropathy.
It can occur in normal feet after prolonged standing.
Treatment involves:
- treating any known cause
- advising proper footwear and
- perhaps a metatarsal bar.
Stress fractures
Clinical features
Aches or pains may be slow in onset or sudden
A bone scan is the only way to confirm the suspected diagnosis
Basis of treatment is absolute rest for 6 or more wks with strong supportive footwear
A walking plaster is not recommended
Stress fractures can occur in:
the base of 5th metatarsal (an avulsion fracture)
neck of metatarsal (usually second)—the ‘march’ fracture
tarsal bones, esp. the navicular (mainly athletes)
Morton neuroma
Probably misdiagnosed more often than any other painful condition of the forefoot.
Clinical features
Usually presents in adults <50
Four times more common in women
Bilateral in 15% of cases
Commonest between 3rd–4th metatarsal heads (Fig. F3), then 2nd–3rd
Severe burning pain between 2nd–3rd or 3rd–4th toes
Worse on weight-bearing on hard surfaces (standing and walking)
Aggravated by wearing tight shoes
Morton neuroma: typical site and pain distribution
Foot ache
Treatment
Avoid wearing high heels.
Wear insoles to support the foot arch.
Perform foot exercises.
Soak the feet in a basin of warm water containing therapeutic salts (Epsom salts is suitable).
Massage feet with baby oil followed by a special ribbed wooden foot massager.
