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• Highlights
• Introduction
• Causes
• Risk Factors
• Prevention
• Shoes
• Insoles and Orthotics
• Foot Injury Treatment
• Toe Pain
• Forefoot Pain
• Heel Pain
• Arch Pain
• Resources
• References

Foot pain

Description

An in-depth report on the causes, diagnosis, treatment, and prevention of foot pain.

Alternative Names

Bunions; Corns; Hammertoe; Plantar fasciitis

Toe Pain

A corn is a type of callus, a protective layer of dead skin cells that form due to repeated friction. It is cone-shaped and has a knobby core that points inward. This core can put pressure on a nerve and cause sharp pain. Corns can develop on the top or between toes. If a corn develops between the toes, it is may be called a soft corn if it is kept pliable by the moisture from perspiration.

Corns develop as a result of friction from the toes rubbing together or against the shoe. They often occur from the following:

• Shoes, socks, or stockings that fit too tightly around the toes
• Pressure on the toes from high-heeled shoes
• Shoes that are too loose can also cause corns due to the friction of the foot sliding within the shoe
• Deformed and crooked toes

Preventing Corns and Calluses and Relieving Discomfort. To prevent corns and calluses and relieve discomfort if they develop:

• Do not wear shoes that are too tight or too loose. Wear well-padded shoes with open toes or a deep toe box (the part of the shoe that surrounds the toes). If necessary, have a cobbler stretch the shoes in the area where the corn or callus is located.
• Wear thick socks to absorb pressure, but do not wear tight socks or stockings.
• Apply petroleum jelly or lanolin hand cream to corns or calluses to soften them.
• Use doughnut-shaped pads that fit over a corn and decrease pressure and friction. They are available at most drug stores.
• Place cotton, lamb's wool, or mole skin between the toes to cushion any corns in these areas.

Removing Corns and Calluses. To remove a corn or callus, soak it in very warm water for 5 minutes or more to soften the hardened tissue, then gently sand it with a pumice stone. Several such treatments may be necessary. Do not trim corns or calluses with a razor blade or other sharp tool. If the cutting instrument is not sterile, infection can result, and it is easy to slip and cut too deep, causing excessive bleeding or injury to the toe or foot.

Medicated Solutions and Pads. There are numerous over-the-counter pads, plasters, and medications for removing corns and calluses. These treatments commonly contain salicylic acid, which may cause irritations, burns, or infections that are more serious than the corn or callus. Use caution with these medications. The following people should not use them:

• Patients with diabetes
• Patients with reduced feeling in the feet due to circulation problems or neurological damage
• Patients who do not have the flexibility or eyesight to use them properly

Bursitis of the Toe

Bursitis is an inflammation of the fluid filled sacs that protect the toe joints.

Ingrown Toenails

Ingrown toenails can occur on any toe but are most common on the big toes. They usually develop when tight-fitting or narrow shoes put too much pressure on the toenail and force the nail to grow into the flesh of the toe. Incorrect toenail trimming can also contribute to the risk of developing an ingrown toenail. Fungal infections, injuries, abnormalities in the structure of the foot, and repeated impact on the toenail from high-impact aerobic exercise can also produce ingrown toenails.

Caring for Toenails. Toenails should be trimmed straight across and long enough so that the nail corner is not visible. If the nail is cut too short, it may grow inward. If the nail does grow inward, do not cut the nail corner at an angle. This only trains the nail to continue growing inward. When filing the nails, file straight across the nail in a single movement, lifting the file before the next stroke. Do not saw back and forth. A cuticle stick can be used to clean under the nail.

Treatments . To relieve pain from ingrown toenails, try wearing sandals or open-toed shoes. Soaking the toe for 5 minutes twice a day in a warm water solution of Domeboro or Betadine can help. People who are at increased risk for infections, such as those with diabetes, should have professional treatment.

Antibiotic ointments can be used to treat ingrown toenails that are infected. Apply the ointment by working a wisp of cotton under the nail, especially the corners, to lift the nail up and drain the infection. The cotton will also help force the toenail to grow out correctly. Change the cotton daily and use the antibiotic consistently.

In severe cases, more intensive treatments are needed. Surgery involves simply cutting away the sharp portion of ingrown nail, removal of the nail bed, or removal of a wedge of the affected tissue. Three nonsurgical methods involve using chemicals (usually phenol), cauterization (heating), or lasers to remove the skin. A major review of studies reported that the use of phenol along with simple separation of the nail was more effect than surgery alone in preventing recurrence, although infections were more common after the chemical procedure.

Bunions

A bunion is a deformity that usually occurs at the head of one of the five long bones (the metatarsal bones) that extend from the arch and connect to the toes. A bunion typically develops in the following way:

• Most often it occurs in the first metatarsal bone (the one that attaches to the big toe). A bunion may also develop in the bone that joins the little toe to the foot (the fifth metatarsal bone), in which case it is known as a bunionette or tailor's bunion.
• A bunion begins to form when the big or little toe is forced in toward the rest of the toes, causing the head of the metatarsal bone to jut out and rub against the side of the shoe.
• The underlying tissue becomes inflamed, and a painful bump forms.
• As this bony growth develops, the bunion is formed as the big toe is forced to grow at an increasing angle towards the rest of the toes. One important bunion deformity, hallux valgus , causes the bone and joint of the big toe to shift and grow inward, so that the second toe crosses over it.

Bunions can be caused by several conditions:

• Narrow high-heeled shoes with pointed toes can put enormous pressure on the front of the foot.
• Injury in the joint may cause a bunion to develop over time.
• Genetics play a role in 10 - 15% of all bunions.

Flat feet, gout, arthritis, and occupations (such as ballet) that place undue stress on the feet can also increase the risk for bunions.

Shoes and Protective Pads. Pressure and pain from bunions and bunionettes can be relieved by wearing appropriate shoes, such as the following:

• Soft, wide, low-heeled leather shoes that lace up
• Athletic shoes with soft toe boxes
• Open shoes or sandals with straps that don't touch the irritated area

A thick doughnut-shaped, moleskin pad can protect the protrusion. In some cases, an orthotic can help redistribute weight and take pressure off the bunion. Nonsteroidal anti-inflammatory drugs (NSAIDs) or corticosteroid injections may offer some pain relief.

Surgery. If discomfort persists, surgery may be necessary particularly for more serious conditions, such as hallux valgu s. There are over 100 surgical variations ranging from removing the bump to realigning the toes.

The most common surgery, an office procedure known as bunionectomy, involves shaving down the bone of the big toe joint. In one procedure the surgeon uses a very small incision, through which the bone-shaving drill is inserted. The physician shaves off the bone, guided by feel or x-ray. It is not a cure, but patient satisfaction is high and results are long-lasting.

More extensive surgeries may be required to realign the toe joint. Although there are variations of each, they generally involve one or more of the following:

• Osteotomy (cutting and realigning the joint). Long-term studies on osteotomies report that 90% or more of patients are satisfied with the procedure.
• Exostetectomy (removal of the large bony growth. Only useful when there is no shift in the toe bone itself.)
• Arthrodesis (removal of damaged portion of the joint, followed by implantation of screws, wires, or plates to hold the bones together until they heal.) This is the gold standard for very severe cases or when previous procedures have failed. Good results have been reported in most patients.
• Arthroplasty (removal of damaged portion of the joint with the goal of achieving a flexible scar). This offers symptom relief and faster rehabilitation than arthrodesis, but has risk for deformity and some foot weakness. It tends to be used in older patients. Biologic or synthetic implants for supporting the toes are showing promise as part of this procedure.
• Tendon and Ligament Repair. If tendons and ligaments have become too loose, the surgeon may tighten them.

In severe cases, surgeons are testing bone grafts to restore bone length in patients who have had previous bunion surgeries or when damage from osteoarthritis has occurred.

Complications, though uncommon in even the most complex procedures, can include:

• Continued pain
• Infection
• Possible numbness
• Irritation from implants used to support the bone
• Sometimes, the metatarsal bone is excessively shortened.

Recovery from more invasive procedures, such as arthrodesis or osteotomy, may take 6 - 8 weeks before a patient can put full weight on the foot. In such cases, patient will need to wear a cast or use crutches. Elderly patients may need wheelchairs.

Hammertoes

A hammertoe is a permanent deformity of the toe joint in which the toe bends up slightly and then curls downward, resting on its tip. When forced into this position long enough, the tendons of the toe contract, and it stiffens into a hammer- or claw-like shape.

Hammertoe is most common in the second toe but may develop in any or all of the three middle toes if they are pushed forward and do not have enough room to lie flat in the shoe. The risk is increased when the toes are already crowded by the pressure of a bunion. Lying down for long periods, diabetes, and various diseases that affect the nerves and muscles put people at risk.

Treatment for Hammertoe. At first, a hammertoe is flexible, and any pain it causes can usually be relieved by putting a toe pad, which are sold in drug stores, into the shoe. To help prevent and ease existing discomfort from hammertoes, shoes should have a deep, wide toe area. As the tendon becomes tighter and the toe stiffens, other treatments, including exercises, splints, and custom-made shoe inserts (orthotics) may help redistribute weight and ease the position of the toe.

Surgery . Surgery may be needed in some severe cases. If the toe is still flexible, only a simple procedure that releases the tendon may be involved. Such procedures sometimes only require a single stitch and a Band-Aid. If the toe has become rigid, surgery on the bone is necessary, but it can still be performed in the doctor's office. A procedure called PIP arthroplasty involves releasing the ligaments at the joint and removing a small piece of toe bone, which restores the toe to its normal position. The toe is held in this position with a pin for about 3 weeks, then the pin is removed. A 2000 study reported that after 5 years, 92% of patients who had arthroscopy were still pain free.

• Review Date: 12/4/2006
• Reviewed By: Harvey Simon, MD, Editor-in-Chief, In-Depth Reports; Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital

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