If you believe that you are suffering from bone pain, it is useful to find out what may be causing your problem. Given the entire workload of your body, it is not surprising that your foot can be prone to injury or condition that results in bone pain. Anatomy wise, the foot is more complicated than most people realize. There are 26 bones in the foot, and the bones of the feet are organized into several small joints, as well as the normal joint between the ankle and foot. The whole body weight is supported by only two feet, it is subjected to considerable forces during normal walking. When it comes to a more vigorous activity such as running or jumping, the forces can become excessive and lead to injury. Bone pain that results from an injury is a common problem in the general population and in athletes especially. A more serious cause of bone pain is a tumor. Tumors can occur in any of the 206 bones in the body. In the foot, a common place for tumors to occur is in the rearfoot in the region of the heel and ankle. Tumors of the bone in the foot can be benign or malignant. Given the complex anatomy of the foot and the multitude of forces it is subjected to, foot bone pain is a common symptom with a myriad of potential causes. The pain in the foot need not be associated with an obvious acute injury such as a broken bone to be a serious problem. A stress fracture is a small crack in a bone usually caused by repetitive stress, often generated over time from activities such as jumping. Stress fractures in the foot are common in athletes, especially those requiring repetitive impact. There are also medical conditions which predispose the individual to stress fractures such as osteoporosis or peripheral neuropathy. A stress fracture can be a source of chronic pain if not diagnosed and treated properly. High impact acute injuries such as a fracture or a more subtle injury like a stress fracture can lead to altered joint mechanics and a potential cause of post-traumatic arthritis. Arthritis is a common cause of foot pain. The 33 joints in the foot are susceptible to the degenerative changes that characterize osteoarthritis. Inflammatory arthritis can also affect the joints of the foot. An example is gout which commonly affects the joint at the base of the big toe. Arthritis in any joint of the foot can be a debilitating problem given the necessity of the foot to perform the activities of daily living.
Understanding Foot Bone Pain
Common cases of front foot bone pain that Dr. Kevin Koo has encountered are patients having pain at the ball of the foot just behind the toes. These patients usually complain of pain and stiffness while walking and getting up from a chair. This condition is known as metatarsalgia and it is an inflammation of the metatarsal bones. In more serious cases, patients feel as if they are walking on pebbles and there is a presence of sharp shooting pain. This is most likely due to Morton’s neuroma, a compression of an interdigital nerve between the metatarsal heads. In a severe state, patients may feel numbness between the interdigital space. This is a worrying sign as the nerve might be permanently damaged.
Foot bone pain can commonly be described as pain around the foot, heel, and toes. According to Dr. Kevin Koo, foot bone pain is a global problem and has recently become a high-impact sports-related and fitness problem. Patients who are active in sports and fitness activities are prone to foot bone pain. Static foot malalignment and imperfect footwear are also key contributing factors. Static foot malalignment happens when the foot has a high or low arch and is off its normal alignment. High or low arch feet affect normal biomechanics and also increase the risk of foot injury. Persons with flat feet or high arch feet are more prone to foot injuries. Dupont (2009) has mentioned that there is a higher risk of injury at the non-dominant foot due to its poor balance and forefoot landing. This triggers the development of foot pain at the non-dominant foot. Imperfect footwear is also another key contributor. Unsuitable footwear, such as those that do not provide sufficient support and cushioning, are known to be the major culprits of foot pain. This is because footwear that does not have good support and cushioning greatly affects shock absorption in the foot. Most people are not aware that foot pain is due to front or rear foot bone injury.
We had the pleasure of accomplishing this comprehensive research report, which started off with a visit to Tan Tock Seng Hospital. Tan Tock Seng Hospital is generally located at 11 Jalan Tan Tock Seng, Singapore 308433. We managed to meet up with Dr. Kevin Koo, who was kind enough to provide his insights and professional opinion on foot bone pain. Dr. Kevin Koo is a consultant at the Department of Orthopaedic Surgery at Tan Tock Seng Hospital. His contributions and expertise in the subject definitely made our research much more informative and beneficial to others.
Causes of Foot Bone Pain
Bone pain occurs when there is injury within the bone. There are a few common causes of foot bone pain, among them is a stress fracture. This refers to the overuse of a muscle which can lead to a slight break in the bone. In the foot, the 2nd and 3rd metatarsals are the most common bones to be affected. Other causes can be direct injury to the bone causing a contusion. This can happen from an acute trauma like dropping something heavy onto the foot or from some sort of collision. The little toe is particularly vulnerable to a fracture because it is small and easily stubbed. If swelling and bruising occurs after the trauma, it could be an indication of a broken bone. The 5th metatarsal and the navicular are the most susceptible to breaks. A fracture from acute trauma will cause severe pain and impaired walking. Over time it may develop into a stress fracture. Any direct trauma to the foot could also cause a fracture to the toes. A high impact injury like landing from a fall or a jump from a great height can cause a fracture in the heel or in the ankle joint. Any sort of fracture will cause pain and swelling to the affected area and impair walking. Another common cause of bone pain is osteoarthritis. This is a degenerative joint disease characterized by the breakdown of the joint’s cartilage. It is common in the elderly and can cause pain and deformity to the joint, clinically known as a “bump,” due to the extra growth of bone which is the body’s attempt to repair the damaged joint. When arthritis affects the foot, it can lead to an alteration in foot function. This can cause an abnormal walking pattern which leads to increased stress on the specific part of the foot and can then cause pain due to a stress fracture in the bone at an area of increased stress.
Importance of Seeking Treatment
The alignment of foot bone pain causes increased pain and excessive health deficits. Bone pain may be musculoskeletal in origin; it can be caused by trauma, and as the presenting symptom in a number of metabolic bone diseases. The structures that make up the foot complex can all be affected by trauma, disease, or inherited behavior. Musculoskeletal injuries are the most common source of severe foot pain. Treatment of foot pain is directed at the precise orthopedic diagnosis, provide measures to preserve and enhance the function of the foot and to prevent disablement and additional defects. Effective treatment can result in a significant reduction in the symptoms and improvement in the quality of life. Patients with any systemic symptoms, pain that is not resolved with simple painkillers, worsening pain, or severe pain should seek consultation.
Diagnosing Foot Bone Pain
2.3. Specialist Referrals Your specialist may need to refer you to another specialist in a related field, for example, a rheumatologist or endocrinologist. This will enable a further understanding and treatment of the underlying cause of the bone pain. If there is uncertainty in the diagnosis, then your specialist may refer you to have a bone scan or MRI. This will enable a clear view of the affected bone and help decide the best course of treatment.
2.2. Physical Examination and Imaging Tests The physical examination will include a general assessment of health and a specific examination of the painful area and any other related issues that may have bearing on the diagnosis. Various tests may be done, including muscle strength testing, to see if there is muscle wasting or weakness, and range of motion tests to see if there are any restrictions in movement. Feeling for any abnormalities and tender or swollen areas will help to pinpoint the cause of the pain. This part of the examination is vital as it will direct the specialist in making a diagnosis.
Medical Evaluation and History Medical history is an important factor as conditions such as arthritis or diabetes can affect the bone and lead to secondary bone pain. It is important to tell your specialist of any underlying conditions or illnesses. Previous injury or trauma to the affected area can also result in an orthopedic condition, so it is important to give information on any injuries to that area. Any medication you are taking, recent changes in health, and family history of bone disorders will also be useful information.
During the first meeting, your specialist will discuss your symptoms and when they began. This will help to find the cause of the pain and pinpoint where it is coming from. The specialist will want a clear description of the pain, if it’s increased in severity or frequency, how long it lasts, and whether anything has helped to relieve it. It is important to be honest and open during this conversation, as it will help your specialist to get a better understanding of your condition.
Medical Evaluation and History
A diagnosis is made through a careful examination of the history and symptoms and by exclusion of any other causes. Often there will be no specific tests or procedures to confirm the diagnosis. In some cases, blood tests to rule out systemic diseases or medical conditions may be necessary. An example could be a patient presenting with generalized foot pain and fatigue, with a history of a recent sore throat. The podiatrist may consider referring the patient back to the GP for tests to rule out rheumatic fever. A diagnosis of soft tissue or bone pain may suggest the need for further imaging tests to pinpoint an exact location and underlying cause of pain.
A thorough medical evaluation is extremely important in reaching the correct diagnosis for foot bone pain. The podiatrist will obtain a complete medical history from the patient. Details such as a description of when the pain started, what type of activities precipitate the pain, any changes in activity level, use of different footwear, a past history of trauma or a specific injury, and any systemic diseases are all very important. Often the podiatrist will find it helpful to map the location of the pain and ask the patient to rate the type and intensity of the pain. This process is a useful guide to monitoring how the patient responds to different treatments. Usually the podiatrist will encourage the patient to actively participate in the decision-making process when reaching a diagnosis and also when formulating treatment plans. This represents a shared decision-making model and reflects a more patient-centered approach to the care of the individual.
Physical Examination and Imaging Tests
Plantar fasciitis is a commonly found foot ailment that is the result of progressive degeneration and inflammation of the plantar fascia. This is a single thick band of connective tissue that runs along the bottom of the foot and is attached to the heel bone. The fascia is responsible for maintaining the structure of the arch and also helps in distributing the weight of the foot. Micro tearing at the origin of the fascia on the heel bone causes inflammation and is often a result of a sudden change in activity level. Heel spurs are a bony growth that occurs on the calcaneus or heel bone. It is often associated with plantar fasciitis; however, it can also occur alone with no pain or symptoms. This is usually detected through X-Ray. The heel spur itself is not the cause of pain; it is when inflammation has developed around the spur that gives the patient pain. Tarsal tunnel syndrome is the last condition that mimics similar pain to plantar fasciitis. Tarsal tunnel is the result of compression on the posterior tibial nerve that runs along the inside of the ankle into the foot. This compression or entrapment will cause sensations of tingling, burning, or shooting pain. Stress fractures in the foot can cause pain with swelling on the top of the foot in the mid-region. This is a thin hairline break in the bone often caused by repetitive force and overuse. Recording a patient’s medical history prior to the physical examination is an essential part of diagnosing foot pathology. This will allow the doctor to understand the patient’s activities, when the pain started, and their symptoms. With a clearer understanding, the doctor can develop a differential diagnosis in order to rule out other conditions with similar pain symptoms.
Specialist Referrals
Occasionally, the diagnostic process may require consultation with medical doctors in different specialties. These doctors usually include physiotherapists, orthopedic surgeons, rheumatologists, and neurologists. These physicians have special training which focuses on the bone and soft tissue injuries and will be able to confirm the diagnosis and stage of the stress fracture and specifically tailor a treatment plan appropriate to the individual. This may involve a further series of imaging studies such as a bone scan, MRI, or CT scan. These studies are helpful when the diagnosis is unclear or to assess the extent of certain stress fractures which may alter the treatment or the time to return to activity. Physical examination and imaging tests. A neurologist may be asked to assess a stress fracture, which has occurred in a location corresponding to a nerve and causing symptoms such as numbness or weakness in a specific part of the lower extremity. Assessment of the nerve function is important in determining the prognosis and an appropriate treatment plan to prevent long-term disability. A rheumatologist is usually involved when a stress fracture is related to an abnormal problem with the bone, such as a stress fracture caused by osteoporosis or in the case of a stress fracture of the tibia in a runner, with underlying excessive pronation of the foot and arch dysfunction. Assessment of bone strength and alignment of the lower extremity is important in these cases to prevent recurrence of the stress fracture.
Non-Surgical Treatment Options
The aim of rehabilitation is to increase the strength and flexibility of the foot and lower leg. Much foot pain can be attributed to lack of strength and flexibility in the region. A podiatrist will often know the physical and biological characteristics of the patient’s problem and can recommend suitable exercises to affect these characteristics. Exercises are specific to individual conditions.
Physical therapy and rehabilitation There are several exercises which can further the diabetic foot pain treatment process. Some patterns of exercise put too much stress on the foot and can actually worsen the condition. The most suitable exercises are low impact sports, such as swimming or cycling. These will increase overall fitness without subjecting the feet to further stress.
Medications for pain management The main step to diabetic foot pain treatment is to lower the pain and inflammation. As that is achieved, the effectiveness of other treatments increases. The types of medication used to treat foot pain can be separated into two categories: prescribed and non-prescribed. Of the non-prescribed medications, the most often used are NSAIDs (non-steroidal anti-inflammatory drugs) which include aspirin and ibuprofen. It is important to consult your doctor before starting on a regimen of NSAIDs. The prescribed medications are varied, ranging from drugs to improve the state of the bones to injections to stem the pain.
Medications for Pain Management
NSAIDs, on the other hand, are more effective in reducing both pain and swelling. They are suitable for almost all types of musculoskeletal pain. There are many types of NSAIDs with various brands available. Diclofenac, Naproxen, and Ibuprofen are among the NSAIDs that are commonly used. The effective dose varies among the types. Usually, it is 50-75% of the maximum dose given for rheumatoid arthritis. Side effects of NSAIDs include gastric irritation, stomach peptic, water retention in the body, raised blood pressure, and reduced kidney function. Therefore, they should not be taken by people with gastric ulcer disease, renal insufficiency, and congestive heart failure. Long-term abuse of NSAIDs will lead to kidney and liver dysfunction.
There are 2 important groups of painkillers: Acetaminophen (Tylenol) and Non-Steroidal Anti-Inflammatory Drugs (NSAIDs). Acetaminophen or Tylenol is usually used for mild to moderate pain. It does not reduce swelling as with NSAIDs. Usually, the effective dose is 500-1000 mg every 6 hours. It has to be noted that an overdose of Tylenol, especially together with alcohol abuse, will result in liver failure. Therefore, a maximum dose of 4000 mg per day should be observed.
One of the most preferred ways of reducing pain in the foot bone is taking oral painkillers. It is suitable for mild to severe pain, short-term or chronic pain.
Physical Therapy and Rehabilitation
Both osteopathy and chiropractic treatment may sometimes seem as though they are the same thing; however, many patients feel that one is more beneficial than the other for them. High velocity thrusts are often used in chiropractic treatment, whereas osteopathy uses a broader range of treatment which varies depending on the individual.
Offering similar benefits, chiropractic treatment is also an option. This is a manual therapy that involves highly-skilled manipulation of the spine. Treatment also includes joints and soft tissue. The desired effect of these actions is to increase movement and function within the area that has been treated. This, in turn, reduces pain and inflammation while improving the function of both the area treated and also the areas connected to it.
One widely-used form of physical therapy and rehabilitation for bone pain is osteopathy. This is a system of diagnosis and treatment for a wide range of medical conditions. It works with the structure and function of the body and is based on the principle that the well-being of an individual depends on the skeleton, muscles, ligaments, and connective tissues functioning smoothly together. Osteopaths will not only treat the pain, but through manual techniques that involve stretching, mobilizing, and manipulating the body, they will increase the mobility of the joints, relieve muscle tension, enhance the blood and nerve supply to tissues, and allow the body’s own healing mechanisms to improve the health and well-being of the patient.
Orthotic Devices and Shoe Modifications
The modification of footwear to accommodate an orthotic device is cost-effective and simple. By creating extra depth or width in the shoe, pressure is relieved from problem areas, and the overall comfort of the shoe is increased. This kind of modification tends to benefit those suffering from or at risk of developing skin breakdown, ulcers, or who have foot deformities.
Shoe modifications such as a rocker sole or footwear that is designed to accommodate a specific orthotic device are often effective in alleviating foot pain. A rocker sole is useful for people suffering from forefoot pain or a condition such as metatarsalgia. It works by reducing the stress on the ball of the foot, which in turn diminishes the force required for push-off. This also helps to keep the swelling down as it prevents the toes from bending during gait.
Rigid orthotic devices are designed to control function and are used to treat a specific condition. They are made from a firm material such as plastic or carbon fiber and are molded to the shape of the foot. This will be specific to each patient depending on their condition and activity levels. Soft orthoses are generally used to absorb shock, increase balance, and take pressure off uncomfortable or sore spots. This can be as simple as an insole to a whole shoe.
An orthotic is a device that is placed inside your shoes to control abnormal foot function. It is a custom-made insole designed from a plaster cast or 3D image of your foot. This video goes through the process of orthotic prescription. An off-the-shelf insole is a less precise and cheaper alternative to custom orthotics and is not as effective. They are constructed of various materials such as felt, foam, or semi-rigid plastic.
Orthotic devices and shoe modifications are often used as part of a comprehensive treatment plan for many foot problems. The primary objective of these interventions is to reduce or eliminate pain, although they will not address the underlying structural abnormalities. They are aimed at improving the overall function of the foot. This mode of treatment tends to be conservative and less expensive than others. It is often used before surgical intervention is considered, and in many cases, orthotic therapy will be used post-surgically.
Lifestyle Changes and Self-Care Tips
Lifestyle changes are an important aspect to treat ongoing foot pain. The truth is, if we return to the same footwear and activity level that caused the condition, the pain will likely return. Changing the type of footwear is important, and most of the time a shoe with a stiff sole is best. A stiff sole does not allow the foot to bend in the area of pain, and will reduce the load and pull on the plantar fascia. An easy way to tell if a shoe has a stiff sole is to try and bend the shoe in the middle with your hands. If it does not bend, then it has a stiff sole. The most effective shoe for this condition has been found to be a running shoe. This is because running shoes have a solid heel counter, which is beneficial for the patient with heel pain. Another important aspect to this condition is an increase in weight can increase the load on the plantar fascia, and make the condition more painful. Research has proven that a higher body mass index increases the strains on the plantar fascia, so weight reduction is an important aspect to treatment. High impact activity should also be decreased, or ceased if possible. If the aforementioned is not changed, then the treatment for foot pain will be very difficult and a long process. It is definitely better to try and cure this condition sooner, rather than later. And finally, if your job requires a lot of standing and or walking, a break or change in activity may be beneficial. This is a difficult aspect to change, especially if the activity puts food on the table, but ignoring this may make the condition worse.
Surgical Treatment Options
Types of foot bone surgeries Surgery is often recommended by doctors if initial for foot bone pain treatment, such as a change in footwear or use of an orthotic, do not relieve the symptoms. There are many different types of foot bone surgeries, depending on the location and severity of the problem. Generally, the surgery can be classified into those that are corrective, those that are removal of problematic bone, and those which are a fusion of a joint. Examples of corrective surgery are the straightening of a bunion or the repositioning of a long bone in the foot which has changed position over time, usually due to flat feet. Fusing a joint involves the removal of the cartilage that lines the ends of the bone before it is then fixed in place with pins until it heals. This is to prevent movement between the two bones at the joint. The most common foot bone fusion is of the big toe due to arthritis in that joint, while the cartilage removal and fixing of the bones together can also be performed on other joints in the foot. The time required to heal from the surgery can vary widely, from just a few weeks to several months, during which weight bearing with the operated foot is usually not allowed. The success of the surgery is very dependent on compliance with this, as early weight bearing can stop the bones from healing and require another operation. An unsuccessful surgery can lead to a prolonging or worsening of the original symptoms, so it is important to fully consider the pros and cons of surgery and consult the opinions of more than one surgeon. Risks and benefits of surgery The advantages of foot bone surgery are a resolution of pain that has been present for many years and the preventing of further problems caused by the pain. Correction of bone positioning can also stop the progression of deformity and arthritis in that area. However, surgery is unlikely to give a complete cure for problems like arthritis, and it is possible that pain will return after a number of years, the result being further operations. This is especially true for removal surgeries, where a deformity in bone shape is the cause of problems, as it is impossible to change the shape of the bone without risking a recurrence of the problem. High blood sugar and smoking are inhibiting factors for surgery due to their effect on bone healing, and there are also considerably higher risks involved for older people. These include the possibility of a fracture at the site of a fusion, damage to soft tissue, and infections due to longer wound healing times. A patient’s occupation and lifestyle should also be considered as some surgeries can cause prolonged periods of time off the feet and an inability to perform vigorous activities.
Types of Foot Bone Surgeries
Overview There are several types of surgeries to correct bunions. The first is a traditional exostectomy in which the bump is removed. This is often inadequate in correcting the cause of the bunion. Another type of surgery is an osteotomy in which the metatarsal bone is cut just below the neck and shifted over towards the middle of the foot. The choice of procedure will be determined by the severity of the bunion. Flexible hammertoes are generally best treated with a bone cut to straighten the toe. If the hammertoe is still in its early stages (i.e. the joint is still flexible), a simple debridement or arthroplasty of the joint may be sufficient to correct the deformity. This is often done in conjunction with an exostectomy of a bunion. A rigidly fixed hammertoe is more complicated to treat and often needs fusion of the joint in combination with a wire or an implant in the toe. Both metatarsophalangeal (MPJ) joint and interphalangeal (IPJ) joint fusions are effective for correcting a hammertoe. A mallet toe also requires a fusion of the distal interphalangeal (DIP) joint. A DIPJ implant for a mallet toe often does not yield good results as the implant is commonly dislodged.
Risks and Benefits of Surgery
There is a potential for great benefit in terms of pain relief and improvement of function with foot bone surgery. This will largely depend on the procedure performed and how well the bone pathology can be addressed. All surgical intervention carries inherent risks. A key misdemeanor by many is to underestimate the period of pain and functional limitation after surgery, often due to unpredictable intra-operative findings. This plays a large role in patient dissatisfaction with surgery. It is essential to address patients preoperatively on the probable clinical course in the short and long term and to set realistic goals. Understandably, the most common reason patients do not undergo surgery is the fear of pain and complications related to surgery.
Surgical intervention is a significant step in the management of foot bone pain. It usually is reserved for severe to end-stage deformity or arthritis. Surgical treatments include various forms of osteotomy and fusion of the hind foot and ankle. Excision of accessory bones or masses often can be performed through smaller incisions, using new techniques and fixation methods. All surgical recommendations hinge on precise diagnosis, which will dictate each patient’s individual prognosis. The decision to proceed with surgery is taken in context with the patient’s occupation, activity level, general health, and expectations for surgery, and the potential benefits weighed against the risks.
Postoperative Care and Rehabilitation
Postoperative care and rehabilitation. Postoperative care refers to the process of caring for a person after he or she has undergone a surgical procedure. It’s important to make sure that you take care of your foot after your surgery, to ensure the best possible results. During the postoperative period, excessive swelling should be controlled with an elastic bandage. Keeping your foot elevated higher than your heart will also help decrease swelling and pain. Elevation is most effective during the first 48 hours after surgery. Pain not relieved by elevation and rest may be treated with an over-the-counter or prescription medication. It is important to follow the instructions provided to you by your surgeon. Sometimes they may prescribe a period of non-weight bearing with the use of crutches to keep weight off of the foot. Other times when the surgical procedure is minor you may be allowed to bear weight on the foot right away. This is the case with procedures like a bunionectomy where you can walk immediately in a special surgical shoe. It is important to keep in touch with your surgeon to make sure you are progressing as planned. A return to a normal shoe is a sign of progression. Be aware that sudden increase in activity can cause recurrence of symptoms. This is because even though your foot may be feeling better, the bones and soft tissue are still healing. So it is important to slowly ease back into full activity.
