Midfoot Pain

Overview

Osteoarthritis in the foot can be very painful and disabling. It’s often neglected when it comes to clinical trials and medical funding. However, recent studies show medial mid-foot OA (affecting the big toe side of your foot) to be far more common than previously thought, with prevalence in the older population at 88% and 7.8% in the younger community.

It causes pain in the mid-foot and arch, particularly during the propulsive phase of walking, and may continue into the night and disturb your sleep. As well as pain, you may notice changes to foot shape, foot position, and increased callus due to higher plantar pressures. Intermittent swelling may also occur.

To diagnose this condition and identify the painful structure and likely causative factors, we will conduct an in-depth assessment, including:

• Thorough history
• Strength and range of motion testing
• Biomechanical and gait assessment
• Evaluation of work, leisure activities and training programs that may exacerbate the condition
• Evaluation of footwear
• Referral for appropriate imaging (x-ray, ultrasound, MRI, CT etc.).

Treatment

Often, patients are told nothing can be done to treat Osteoarthritis. However, there is a range of therapies that can help reduce pain and improve mobility. These include joint mobilisation, strapping, footwear advice, western medical acupuncture and foot orthotics with design features to support the joints and stabilise the heel.

To read more about osteoarthritis click here 

Overview

This condition causes significant and consistent pain in the top of the foot (dorsal surface) during weight-bearing activity. Repetitive trauma at the surface of the dorsal mid-foot joints results in inflammation in the capsular ligaments. Barefoot or low-heeled shoes may exacerbate the pain, while shoes with a slightly higher heel may reduce symptoms.

If you are a runner who prefers to forefoot strike and/or run in minimalist footwear, you may find that you are more prone to ‘top of foot pain’ as the dorsiflexion movements of the forefoot on the rear-foot are increased.

To diagnose this condition and identify the painful structure and likely causative factors, we will conduct an in-depth assessment, including:

• Thorough history
• Strength and range of motion testing
• Biomechanical and gait assessment
• Evaluation of work, leisure activities and training programs that may exacerbate the condition
• Evaluation of footwear
• Referral for appropriate imaging (x-ray, ultrasound, MRI, CT etc.).

Treatment

Treatment involves reducing the inflammation (Ice therapy, anti-inflammatories) and eliminating the biomechanical factors causing the increased compression forces. This can involve stretching exercises, mobilisation, dry needling, footwear advice, heel lifts and/or foot orthotics.

For runners, reviewing running techniques and training load – whether temporarily or permanently – may be beneficial, as may the above-mentioned therapies.

Overview

Flat feet, or over pronation, is a common biomechanical problem that occurs in the walking process when a person’s arch collapses upon weight bearing. Pronation refers specifically to the natural inward flexing motion of the arch and ankle. Running, walking and standing cause the ankle joint to pronate which helps the body to absorb shock and control balance. This motion can cause extreme stress or inflammation of the plantar fascia, possibly causing severe discomfort and leading to other foot problems.

There are many causes of flat feet, including:

• Obesity
• Pregnancy
• Tendon dysfunction
• Genetics
• Repetitive pounding on hard surfaces.

People with flat feet often do not experience discomfort immediately and some never suffer any discomfort at all. However, when symptoms develop and become painful, walking becomes awkward and causes increased strain on the feet and calves.

To diagnose this condition and identify the painful structure and likely causative factors, we will conduct an in-depth assessment, including:

• Thorough history
• Strength and range of motion testing
• Biomechanical and gait assessment
• Evaluation of work, leisure activities and training programs that may exacerbate the condition
• Evaluation of footwear
• Referral for appropriate imaging (x-ray, ultrasound, MRI, CT etc.).

Treatment

Treatment for flat feet includes:

• Custom made foot orthotics
• Over-the-counter orthotics
• Arch support and/or
• Medial rearfoot posting
• Supportive footwear with a firm heel counter.

Overview

The Lisfranc joint is part of the transverse and longitudinal arch and the ligament spans from the medial cuneiform to the base of the second metatarsal. When this is injured it is classified as either stable or unstable. This can occur from a fall from a height, a motor vehicle accident or a direct crush or twist like in netball or other competitive sports. When you have this, the top of your foot will appear swollen and the bottom of your foot, often under your arch will be bruised and you will find walking painful on the effected foot as the foot rolls in.

To diagnose this condition and identify the painful structure and likely causative factors, we will conduct an in-depth assessment, including:

• Thorough history
• Strength and range of motion testing
• Biomechanical and gait assessment
• Evaluation of work, leisure activities and training programs that may exacerbate the condition
• Evaluation of footwear
• Referral for appropriate imaging (x-ray, ultrasound, MRI, CT etc.).

Treatment

Although the occurrence of these injuries is not common, when they do occur, they are associated with high levels or morbidity and require urgent treatment. The treatment is to stabilise this joint and initially, you will be advised to not put weight through the effected foot for several weeks and apply ice and take over the counter pain medication. Once the injury has been rested, you will progressively commence weight bearing. Long term treatment of this condition includes footwear recommendation and functional foot orthoses. Your podiatrist will continue to rehabilitate you with working on range of motion, balance and load bearing.

Sometimes this injury will require surgery to stabilise it, and if so your podiatrist will work closely with orthopedic surgeons to ensure that a quality outcome is achieved with the multidisciplinary team.

The process for rehabilitation of a Lisfranc injury is a long one and outcomes vary.

Overview

A plantar fibroma is a fibrous knot or nodule in the arch of the foot, embedded within the plantar fascia. A plantar fibroma can develop in one or both feet, is benign and will usually remain unchanging unless treatment is commenced. There is no definite cause for plantar fibromas.

The characteristic sign of a plantar fibroma is a noticeable lump in the arch that feels firm to the touch. This mass can remain the same size or get larger over time or additional fibromas may develop.

People who have a plantar fibroma may or may not have pain. When pain occurs, it is often caused by shoes pushing against the lump in the arch, although it can also arise when walking or standing barefoot.

To diagnose this condition and identify the painful structure and likely causative factors, we will conduct an in-depth assessment, including:

• Thorough history
• Strength and range of motion testing
• Biomechanical and gait assessment
• Evaluation of work, leisure activities and training programs that may exacerbate the condition
• Evaluation of footwear
• Referral for appropriate imaging (x-ray, ultrasound, MRI, CT etc.).

Treatment

Nonsurgical treatment may help relieve the pain of a plantar fibroma, although it will not make the mass disappear. The foot and ankle surgeon may select one or more of the following nonsurgical options:

• Steroid injections. Injecting corticosteroid medication into the mass may help shrink it and thereby relieve the pain that occurs when walking. This reduction may only be temporary and the fibroma could slowly return to its original size.
• Orthotic devices. If the fibroma is stable, meaning it is not changing in size, custom orthotic devices (shoe inserts) may relieve the pain by distributing the patient’s weight away from the fibroma.
• Physical therapy. The pain is sometimes treated through physical therapy methods that deliver anti-inflammatory medication into the fibroma without the need for injection.

If the mass increases in size or pain, the patient should be further evaluated.

Surgical treatment to remove the fibroma is considered if the patient continues to experience pain following nonsurgical approaches. Surgical removal of a plantar fibroma may result in a flattening of the arch or development of hammertoes. Orthotic devices may be prescribed to provide support to the foot. Due to the high incidence of recurrence with this condition, continued follow-up with the foot and ankle surgeon is recommended.

Overview

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To diagnose this condition and identify the painful structure and likely causative factors, we will conduct an in-depth assessment, including:

• Thorough history
• Strength and range of motion testing
• Biomechanical and gait assessment
• Evaluation of work, leisure activities and training programs that may exacerbate the condition
• Evaluation of footwear
• Referral for appropriate imaging (x-ray, ultrasound, MRI, CT etc.).

Treatment

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Overview

Avulsion fracture of the 5^th metatarsal styloid, also known as a pseudo-Jones fracture or a dancer fracture, is one of the more common foot avulsion injuries and makes up 90% of fractures of the base of the 5th metatarsal.

Traditionally this avulsion fracture has been attributed to the insertion of the peroneus brevis tendon and is caused by forcible inversion of the foot in plantar flexion, as may occur while stepping on a curb or climbing steps.

It is also relatively common among tennis players, accounting for it sometimes being referred to as a “tennis fracture”.

To diagnose this condition and identify the painful structure and likely causative factors, we will conduct an in-depth assessment, including:

• Thorough history
• Strength and range of motion testing
• Biomechanical and gait assessment
• Evaluation of work, leisure activities and training programs that may exacerbate the condition
• Evaluation of footwear
• Referral for appropriate imaging (x-ray, ultrasound, MRI, CT etc.).

Treatment

In general, these fractures can be treated conservatively, and heal well. Functional weight-bearing such as Robert Jones bandage or elastic bandaging and stiff-soled shoes has better outcomes than non-weight-bearing in a short leg cast.

For large or very displaced fragments with intra-articular extension then operative fixation may be indicated.

Overview

Kohler disease is a condition that affects a bone at the arch of the foot called the navicular bone. X-rays show that this bone is initially compressed and later breaks into pieces before healing and hardening back into bone. It occurs most frequently in children between the ages of 5 and 10 years. Although the exact underlying cause of Kohler disease is unknown, some scientists suspect that it may be caused by excessive strain on the tarsal navicular bone and its associated blood vessels before the bone is completely ossified (hardened). The condition typically resolves on its own with or without treatment; however, pain relievers, rest, avoidance of weight-bearing activities, and/or casting may be recommended to help manage symptoms.

The signs and symptoms of Kohler disease vary, but may include:

• Swelling of the foot
• Redness of the affected area
• Tenderness, particularly along the length of the arch
• Limp or abnormal gait (style of walking)

Symptoms may worsen if weight is put on the affected foot, which can make walking painful and difficult.

To diagnose this condition and identify the painful structure and likely causative factors, we will conduct an in-depth assessment, including:

• Thorough history
• Strength and range of motion testing
• Biomechanical and gait assessment
• Evaluation of work, leisure activities and training programs that may exacerbate the condition
• Evaluation of footwear
• Referral for appropriate imaging (x-ray, ultrasound, MRI, CT etc.).

Treatment

Kohler disease typically resolves over time with or without treatment. However, pain relievers, rest and avoidance of weight-bearing activities can help alleviate some of the symptoms. In some cases, a plaster walking cast and/or arch supports may also be recommended.

The long-term prognosis for people with Kohler disease is usually excellent. Symptoms can last from a few days to two years; however, most cases resolve within a year. People affected by the condition typically recover all function of the affected foot and have no lasting consequences.

Overview

The accessory navicular is an extra bone or piece of cartilage located on the inner side of the foot just above the arch. It is incorporated within the posterior tibial tendon, which attaches in this area and can lead to Accessory Navicular Syndrome.

An accessory navicular is congenital (present at birth). It is not part of normal bone structure and therefore is not present in most people.

People who have an accessory navicular often are unaware of the condition if it causes no problems. However, some people with this extra bone develop a painful condition known as accessory navicular syndrome when the bone and/or posterior tibial tendon are aggravated. This can result from any of the following:

• Trauma, as in a foot or ankle sprain
• Chronic irritation from shoes or other footwear rubbing against the extra bone
• Excessive activity or overuse

Many people with accessory navicular syndrome also have flat feet. Having a flat foot puts more strain on the posterior tibial tendon, which can produce inflammation or irritation of the accessory navicular.

Adolescence is a common time for the symptoms to first appear. This is a time when bones are maturing and cartilage is developing into bone. Sometimes, however, the symptoms do not occur until adulthood. The signs and symptoms of accessory navicular syndrome include:

• A visible bony prominence on the midfoot (the inner side of the foot, just above the arch)
• Redness and swelling of the bony prominence
• Vague pain or throbbing in the midfoot and arch, usually occurring during or after periods of activity

To diagnose this condition and identify the painful structure and likely causative factors, we will conduct an in-depth assessment, including:

• Thorough history
• Strength and range of motion testing
• Biomechanical and gait assessment
• Evaluation of work, leisure activities and training programs that may exacerbate the condition
• Evaluation of footwear
• Referral for appropriate imaging (x-ray, ultrasound, MRI, CT etc.).

Treatment

The goal of nonsurgical treatment for accessory navicular syndrome is to relieve the symptoms. The following may be used:

• Immobilization. Placing the foot in a cast or removable walking boot allows the affected area to rest and decreases the inflammation.
• Ice. To reduce swelling, a bag of ice covered with a thin towel is applied to the affected area. Do not put ice directly on the skin.
• Medications. Oral nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may be prescribed. In some cases, oral or injected steroid medications may be used in combination with immobilization to reduce pain and inflammation.
• Physical therapy. Physical therapy may be prescribed, including exercises and treatments to strengthen the muscles and decrease inflammation. The exercises may also help prevent recurrence of the symptoms.
• Orthotic devices. Custom orthotic devices that fit into the shoe provide support for the arch and may play a role in preventing future symptoms.

Even after successful treatment, the symptoms of accessory navicular syndrome sometimes reappear.  When this happens, nonsurgical approaches are usually repeated.

If nonsurgical treatment fails to relieve the symptoms of accessory navicular syndrome, surgery may be appropriate. Surgery may involve removing the accessory bone, reshaping the area and repairing the posterior tibial tendon to improve its function. This extra bone is not needed for normal foot function.

Overview

A tarsal coalition is an abnormal connection that develops between two bones in the back of the foot (the tarsal bones). This abnormal connection, which can be composed of bone, cartilage or fibrous tissue, may lead to limited motion and pain in one or both feet.

The tarsal bones include the calcaneus (heel bone), talus, navicular, cuboid and cuneiform bones. These bones work together to provide the motion necessary for normal foot function.

Most often, tarsal coalition occurs during fetal development, resulting in the individual bones not forming properly. Less common causes of tarsal coalition include infection, arthritis or a previous injury to the area.

While many people who have a tarsal coalition are born with this condition, the symptoms generally do not appear until the bones begin to mature, usually around ages 9 to 16. Sometimes no symptoms are present during childhood. However, pain and symptoms may develop later in life.

The symptoms of tarsal coalition may include one or more of the following:

• Pain (mild to severe) when walking or standing
• Tired or fatigued legs
• Muscle spasms in the leg, causing the foot to turn outward when walking
• Flatfoot (in one or both feet)
• Walking with a limp
• Stiffness of the foot and ankle

To diagnose this condition and identify the painful structure and likely causative factors, we will conduct an in-depth assessment, including:

• Thorough history
• Strength and range of motion testing
• Biomechanical and gait assessment
• Evaluation of work, leisure activities and training programs that may exacerbate the condition
• Evaluation of footwear
• Referral for appropriate imaging (x-ray, ultrasound, MRI, CT etc.).

Treatment

The goal of nonsurgical treatment of tarsal coalition is to relieve the symptoms and to reduce the motion at the affected joint. One or more of the following options may be used, depending on the severity of the condition and the response to treatment:

• Oral medications. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may be helpful in reducing the pain and inflammation.
• Physical therapy. Physical therapy may include massage, range-of-motion exercises and shockwave therapy.
• Steroid injections. An injection of cortisone into the affected joint reduces the inflammation and pain. Sometimes more than one injection is necessary.
• Orthotic devices. Custom orthotic devices can be beneficial in distributing weight away from the joint, limiting motion at the joint and relieving pain.
• Immobilization. Sometimes the foot is immobilized to give the affected area a rest. The foot is placed in a cast or cast boot, and crutches are used to avoid placing weight on the foot.
• Injection of an anesthetic agent. Injection of an anesthetic into the leg may be used to relax spasms and is often performed prior to immobilization.

If the patient’s symptoms are not adequately relieved with nonsurgical treatment, surgery is an option. A surgeon will determine the best surgical approach based the patient’s age, condition, arthritic changes and activity level.

Overview

Cuboid syndrome happens when the joint and ligaments near the cuboid bone in your foot become injured or torn. It’s also known as cuboid subluxation, which means that one of the bones in a joint is moved but not fully out of place.

Knowing how to recognize cuboid syndrome and treating it at home can help you avoid further foot injuries.

Cuboid syndrome is thought to be caused when your cuboid bone everts (moves outward) from your foot while your calcaneus, or heel bone, inverts (moves inward) from your foot. This can dislocate one or both bones or tear nearby ligaments. Sprains or injuries to your ankle are among the most frequent causes of this.

Cuboid syndrome can result from foot injuries like twisting your ankle by falling, mis-stepping, or doing other activities that put intense strain on your ankle bones and ligaments. Cuboid syndrome can also result from overuse or repetitive strain to your foot. This is common if you play sports or do other activities that involve a lot of sudden jumping, running, or moving from side to side.

Excessive foot pronation, often called flat feet, can also cause cuboid syndrome.

The most common symptom of cuboid syndrome is pain on the lateral side of your foot where your smallest toe is. This pain might feel sharper when you put your weight on that side of your foot or when you push on the arch on the bottom of your foot.

The pain associated with cuboid syndrome might spread to other parts of your foot, too, when you stand on the front of your toes.

Other possible symptoms of cuboid syndrome include:

• redness near the area of injury
• loss of mobility in your ankle or lateral side of the foot
• weakness of your toes on the lateral side of the foot
• tenderness of the lateral side of your foot or your leg
• swelling near the dislocated ligaments or the ankle due to fluid buildup

It may also cause antalgic gait, which happens when you change the way you walk to minimize the pain of cuboid syndrome. An antalgic gait can take the form of limping or swaying from side to side.

Common risk factors for cuboid syndrome include:

• being overweight or obese
• wearing shoes that aren’t supportive or too tight
• not stretching your foot properly before a workout
• not resting your foot long enough before doing physical activity again
• walking, running, or doing physical activity on surfaces that aren’t flat
• fracturing a bone connected to the cuboid
• practicing ballet

Conditions that can increase your risk of cuboid syndrome include:

• several types of arthritis, including osteoarthritis and gout
• bone conditions, such as osteoporosis

To diagnose this condition and identify the painful structure and likely causative factors, we will conduct an in-depth assessment, including:

• Thorough history
• Strength and range of motion testing
• Biomechanical and gait assessment
• Evaluation of work, leisure activities and training programs that may exacerbate the condition
• Evaluation of footwear
• Referral for appropriate imaging (x-ray, ultrasound, MRI, CT etc.).

Treatment

Use the RICE method to help treat pain:

• Rest your foot.
• Ice your foot with cold packs for 20 minutes at a time.
• Compress your foot with an elastic bandage.
• Elevate your foot above your heart to reduce swelling.

Treatment of cuboid syndrome involves manipulation of the cuboid. In cases in which cuboid syndrome was secondary to an ankle injury, treatment may be postponed until the ankle has healed sufficiently.

If there is redness, swelling, or a hematoma present on the foot, those conditions should also be adequately resolved before manipulation of the cuboid is attempted.

Treatment of cuboid syndrome may be done by a qualified clinician such as a podiatrist, physiotherapist, or physical therapist.

There are two forms of therapy for the treatment of cuboid syndrome, the cuboid whip and the cuboid squeeze.

After manipulating the cuboid bone, the clinician may further manage the patient’s discomfort with massage, cryotherapy (ice), non-thermal ultrasound, or electrical stimulation. In some cases, manipulation may need to repeated.

Other treatments may be used to prevent the injury from recurring or to provide relief from any lingering symptoms after manipulation.

Padding and taping: Supporting the cuboid bone with padding or a wedge may help prevent recurrence. Taping may also be used to support and stabilize the bones of the midfoot.

Exercise: The clinician treating the cuboid syndrome may prescribe some exercises that can help with symptoms and prevent the injury from occurring again. These exercises could include stretching the ankle up and down or in and out for a number of repetitions several times a day.

Orthotic Therapy: Because many people who develop cuboid syndrome also overpronate, orthotics may be useful in preventing recurrence. Orthotics are worn inside the shoe to promote the proper alignment of the foot. Orthotics are available commercially, but may also be custom made.