Foot Pain and Associated Hindfoot Conditions

One in five adults suffers from significant foot pain. Since feet are essential to getting around, this pain can limit a person’s ability to function. Foot pain and its associated conditions can lead to disability and an impaired quality of life. Foot pain and limited mobility can lead to depression, particularly in older adults.

The foot has three main regions: the back of the foot (heel), the middle of the foot (arch) and the forefoot (toes and associated bones). The most common source of foot pain comes from the forefoot. Women suffer from foot pain more often than men.

You are more likely to experience foot pain if you have any of the following traits: older in age, obese, an athlete with substantial running or jumping (gymnastics, football, and ballet in particular), or active military personnel.

It is recommended that primary care providers routinely conduct foot examinations for all of their older patients. Elite Pain Management specializes in pain related to orthopedic problems and we utilize a multidisciplinary approach to treat symptoms. It is important to correct pain related to the feet because it can lead to knee pain, hip pain, and lower back pain if a patient continues to walk abnormally.

Foot Anatomy

A human foot is much more intricate than it appears. A lot goes into being able to walk upright, using only two feet. The foot is divided into 3 main regions:

• The hindfoot includes the talus (ankle bone) and the calcaneus (heel bone). These connect at the subtalar joint. The two long bones of the leg (tibia and fibula) connect to the top of the talus and work as part of the ankle. The calcaneus sits on top of a layer of fat which helps to cushion the heel.
• The midfoot includes the navicular (inner side) and cuboid (outer side). Three cuneiform bones connect them together. This creates the arch of the foot.
• The forefoot includes the five toes (phalanges) and their corresponding long bones (metatarsals) in addition to small sesamoid bones found on the big toe and sometimes other areas of the foot.

The human foot has several arches:

• The Medial Longitudinal Arch is the largest and most prominent. It runs along the interior side of the foot (the side that runs from the big toe to the heel).
• The Lateral Longitudinal Arch runs along the outer side of the foot (small toe to heel). It joins the medial longitudinal arch at the heel.
• The Anterior Transverse Arch runs along the ball of the foot from the inner side to the outer side. This connects the medial longitudinal arch to the lateral longitudinal arch. Together, the arches form a triangular shape when looking at the underside of the foot.

How the Foot Works

Humans use their feet for balance when standing and for getting around by walking or running. Each foot needs to be able to absorb impact when it hits the ground while maintaining flexibility to push off the ground for the next step. Multiple bones, muscles, joints, and tendons have to work together in order for a person to walk properly.

The way a person walks is referred to as their gait. Normal gait involves a heel to toe transfer of energy. When taking a step, the various arches of the foot are being manipulated to act as a spring in order to continue forward movement. A number of additional muscles, tendons and joints are moving throughout the phases of gait.

There can be a bit of variation in foot appearance, length, width, and arch. Different foot types will affect the ability of the various parts to work in allowing the person to walk properly. The foot type will also affect where the foot strikes and what specific area of the foot takes on the most impact.

Assessment for Foot Pain

If you are experiencing foot pain, especially if it is affecting your daily functions, it’s best to see your primary care provider. The first step in the evaluation will be to take a detailed history that seeks to understand where the pain is coming from in the foot and if it is following a particular pattern that would explain the underlying issue. If possible, have answers ready to questions such as:

• Is the pain constant or occasional?
• How would you describe the pain (such as dull, sharp, burning, stabbing, etc.)?
• Are you experiencing any other symptoms (such as numbness, tingling, pricking sensations, etc.)?
• Does the pain start in one area of the foot and spread to other areas?
• Does the pain occur only when you apply pressure to the foot (such as standing or walking) or does it occur when you are sitting as well?
• Did you sustain a prior injury to the foot (even if this injury was quite some time ago)?
• Have you recently changed your shoe type?
• Do you have any other illnesses (such as diabetes)?
• Have experienced weight gain in the last year?
• Does heel pain occur with walking?
• Does anything in particular help to lessen the pain, even if it does not totally get rid of it?
• Do you have family members that have experienced foot problems?
• If you were recently pregnant, how much weight did you gain and did your shoe size increase?

Next there should be a physical examination of the foot. In order to asses any motion limitations or other conditions that may cause foot pain, the provider will:

• Look for physical issues such as swelling, color changes, height and shape of arches, and any asymmetries between the two feet
• Compare the feet and their position when sitting verse standing
• Apply pressure to various areas around the foot to localize any tenderness or warmth that could indicate inflammation
• Assess major joint motions contributing to the problem such as knee pain, hip pain, lower back pain
• Watch your gait, as you walk at a slower speed and at a normal speed, paying particular attention to where your foot makes an impact with the ground (called the foot strike)
• Possibly have you walk on your toes only or your heels only, to assess the strength and functionality of particular parts of the feet
• (For runners) watch you run without shoes and then with your running shoes on

Further testing may include using an ultrasound to visualize issues within the foot.

Conditions that cause Hindfoot Pain

Pain that is localized towards the back of the foot, around the ankle and heel, can be caused by a variety of conditions.

• Plantar fasciitis The plantar fascia is a long, thick piece of connective tissue that runs from the heel to the toes. When this tissue becomes inflamed it leads to plantar fasciitis, one of the most common causes of rear foot pain. Planters fasciitis pain is worst at the beginning of the day when stepping out of bed. The intensity will decrease as the foot is being used but there may be a dull ache throughout the course of the day. The cause of plantar fasciitis is not completely understood. However, the plantar fascia is thought to experience a great amount of rotational force during regular walking, and this may be a contributing factor for heel pain. Planters fasciitis should be evaluated quickly to prevent the symptoms from worsening.
• Achilles tendinopathy The Achilles tendon runs along the back of the foot, from the heel to the calf. This tendon can become inflamed and cause pain in the area. This is often due to an injury of the Achilles tendon or a bony enlargement at the back of the heel, called Haglund’s deformity, which rubs against the tendon, causing irritation. Both conditions are most common in athletes involved in running and jumping sports.
• Tarsal tunnel syndrome The tarsal tunnel is a small space that runs along the inside of the ankle. The tunnel has a number of tendons, arteries, veins, and nerves that run through it. When this tunnel is compressed, typically due to a previous injury, it can cause pain usually associated with the tibial nerve. Many times, this pain will start around the ankle and spread to other regions of the foot and lower leg. Ball of foot pain may indicate tarsal tunnel derangement.
• Peroneal tendon injury The peroneal tendons run down the leg, along the fibula, and behind the ankle bone. When this tissue gets irritated, it can become inflamed, resulting in foot pain. This is usually caused by excessive use, like running or jumping too much, and is often found in athletes. Ill-fitting shoes can also contribute to irritation in these tendons.
• Ankle Rotation Pain Pain when rotating the ankle is attributed to ankle impingement and can occur at either the front or the back of the ankle. The pain is from compress of the bone or soft tissue. This compression comes from repeated flexing or pointing the foot to its maximum ability. Athletes commonly have to utilize these movements on a regular basis and are therefore more likely to incur this type of injury. Heel pain can occur with this condition.
• Sinus tarsi syndrome The sinus tarsi is a tunnel between the ankle bone and heel bone. When this area is compressed, it can irritate the soft tissue, causing inflammation. The pain is located on the outer side of the foot, between the ankle and heel, and is often accompanied by swelling. In adults, it is often a chronic condition. It is thought to be caused by multiple sprains and injuries to the ligaments supporting the joint between the ankle bone and heel bone.
• Piezogenic papules These are small, roundish bumps found around the heel. Small amounts of the fat tissue (that cushions the heel) squeeze through the connective tissue and closer to the surface of the skin. Most patients do not notice pain associated with the papules, but it could possibly indicate a very hard heel strike when walking or a connective tissue abnormality.
• Heel Contusion A bruise on the heel of the foot is similar to that of any other contusion. This will cause heel pain. Blood capillaries rupture and cause discoloration of the skin while inflammation causes acute pain. A bruise can be caused by trauma, minor injury or overuse. The heel may be more prone to contusion if the fat pad, underneath it, erodes.

Conclusion

Foot pain is very common in adults. If left untreated it will lead to knee pain, hip pain, and lower back pain. The foot is an intricate system of different parts working together to enable standing and walking. It is essential to get a thorough workup from a healthcare provider that is comfortable assessing all the various parts of the foot’s anatomy. The foot is broken up into three main regions: the hindfoot, midfoot and forefoot. Hindfoot pain can be caused by a variety of conditions. A proper foot and gait evaluation should be to sufficient for an accurate diagnosis of the cause of foot pain.

Treatment options for foot pain is best achieved through a combination of injection in conjunction with graded rehabilitative exercise. Individual programs may include correcting abnormal gait, shoe inserts, a cortisone shot, regenerative medicine, PRP injection, PRP treatment or stem cell therapy which boosts the body’s natural ability to heal.

If your pain does not resolve after a brief period, contact us so that we may help diagnose the problem and treat the underlying cause. Do not let pain persist or else it may become chronic.