Plantar Fasciitis
Plantar fasciitis is inflammation of the plantar fascia.
The plantar fascia is thick connective tissue. It attaches to the calcaneus at the heel, travels along the sole of the foot and branches out to connect to the flexor tendons of the toes.
Presentation is with a gradual onset of pain on the plantar aspect of the heel. This is worse with pressure, particularly when walking or standing for prolonged periods. There is tenderness to palpation of this area.
Management involves:
- Rest
- Ice
- Analgesia (e.g., NSAIDs)
- Physiotherapy
- Steroid injections (can be very painful and rarely cause rupture of the plantar fascia or fat pad atrophy)
Rarely, specialist management may be required, with:
- Extracorporeal shockwave therapy
- Surgery
Fat Pad Atrophy
Fat pad atrophy affects the fat pad over the heel of the foot (under the calcaneus). The fat pad protects the heel from impact.
Atrophy (wasting away) of the fat pad can occur with age or inflammation from repetitive impacts, such as jumping activities, running, walking, and obesity. Local steroid injections (used to treat plantar fasciitis) can cause fat pad atrophy.
Symptoms are similar to plantar fasciitis, with pain and tenderness over the plantar aspect of the heel. Symptoms are worse with activities, particularly when barefoot on hard surfaces.
The thickness of the fat pad can be measured with an ultrasound scan.
Management involves comfortable shoes, custom insoles, adapting activities (e.g., avoiding high heels) and weight loss if appropriate.
Morton’s Neuroma
Morton’s neuroma refers to the dysfunction of a nerve in the intermetatarsal space (between the toes) towards the top of the foot. The abnormal nerve is usually located between the third and fourth metatarsal. It is caused by irritation of the nerve relating to the biomechanics of the foot. High-heels or narrow shoes may exacerbate it.
Typical symptoms are:
- Pain at the front of the foot at the location of the lesion
- The sensation of a lump in the shoe
- Burning, numbness or “pins and needles” felt in the distal toes
There are several ways to test for Morton’s neuroma:
- Deep pressure applied to the affected intermetatarsal space on the dorsal foot causes pain
- Metatarsal squeeze test – squeezing the forefoot with one hand to create a concave shape to the plantar aspect while using the other hand to press the affected area on the plantar side of the foot causes pain
- Mulder’s sign – a painful click is felt when using two hands on either side of the foot to manipulate the metatarsal heads to rub the neuroma
Ultrasound or MRI can be used to confirm the diagnosis.
Management options include:
- Adapting activities (e.g., avoiding high heels)
- Analgesia (NSAIDs if suitable)
- Insoles
- Weight loss if appropriate
- Steroid injections
- Radiofrequency ablation
- Surgery (e.g., excision of the neuroma)
Bunions (Hallux Valgus)
The medical name for bunions is hallux valgus (hallux refers to the big toe, and valgus refers to the angle of the deformity).
A bunion is a bony lump created by a deformity at the metatarsophalangeal joint (MTP) at the base of the big toe. The first metatarsal becomes angled medially, the big toe (hallux) become angled laterally (towards the other toes), and the MTP joint becomes inflamed and enlarged. Over time, additional stress on the joint can result in osteoarthritis.
Bunions develop slowly. The cause is not clear. They can be painful, particularly when walking and wearing tight shoes.
Weight-bearing x-rays can be used to assess the extent of the deformity.
Conservative management is with wide, comfortable shoes and analgesia. Patients can use bunion pads to protect the bunion from friction inside their shoes.
Surgery is the definitive treatment. There are various options depending on individual factors. The aim is to realign the bones and correct the deformity.
Gout
Gout is a common cause of pain and swelling in the metatarsophalangeal joint (MTP) at the base of the big toe. It can also affect the ankle, wrists, base of the thumb or knee.
Gout is a type of crystal arthropathy associated with chronically high blood uric acid levels. Urate crystals collect in the joint, causing it to become acutely hot, swollen and painful.
Diagnosis is usually made clinically. It is essential to exclude septic arthritis as a differential diagnosis. This may require joint fluid aspiration.
Aspirated fluid will show:
- No bacterial growth
- Needle shaped crystals
- Negatively birefringent of polarised light
- Monosodium urate crystals
Management during the acute flare is with:
- NSAIDs (e.g. ibuprofen) are first-line
- Colchicine second-line
- Steroids can be considered third-line
Allopurinol is a xanthine oxidase inhibitor used for the prophylaxis of gout. It reduces the uric acid level.
Lifestyle changes can reduce the risk of developing gout. This involves losing weight, staying hydrated and minimising the consumption of alcohol and purine-based foods (such as meat and seafood).
TOM TIP: Do not initiate allopurinol prophylaxis until after the acute attack has settled. Starting allopurinol can cause or worsen an attack of gout. When a patient is already using allopurinol, they can continue taking it during further acute episodes.
Last updated August 2021