Education And Debate

ABC of Rheumatology: PAIN IN THE FOOT

BMJ 1995; 310 doi: https://doi.org/10.1136/bmj.310.6983.860 (Published 01 April 1995) Cite this as: BMJ 1995;310:860
  1. S G West,
  2. J Woodburn

    Foot pain is common, whether local to the foot or due to systemic disease, mechanical dysfunction, degeneration, or inflammation. In general a multidisciplinary approach to treatment is best, and this is reflected in increasingly close liaison between podiatry, rheumatology, and orthopaedics. Podiatrists (chiropodists) offer a range of treatments from surgery to orthoses. To understand dysfunction, clinicians should be familiar with the normal development and anatomical variants of the foot.

    fig 1

    Abnormally pronated feet with Haglund's deformity of heel (left); abnormally supinated feet (right).

    Characteristics of the adult foot

    Three main types:

    • Normal

    • Pronated (flat)

    • Supinated (high arch)

    Examination:

    • Examine the foot when bearing weight and when unloaded

    • Inspect patient's shoes for abnormal or uneven wear

    • Consult a podiatrist if a structural or mechanical abnormality is suspected—many can be treated with orthoses

    Characteristics of child's foot

    Normal foot

    Abnormal foot

    • Flexible foot structure (may look flat with a valgus heel)

    • Inflexible

    • Rigid valgus or pronated heel

    • Medial longitudinal arch forms when child stands on tiptoe

    • High arch foot with toe retraction and tight extensor tendons

    • Heel to toe walking

    • Toe walking

    • Delay or difficulty in walking or running

    • Forefoot in line with rear foot

    • Abducted or adducted forefoot relative to heel

    • Mobile joints with pain free motion and no swelling

    • Pain, swelling, or stiffness of joints

    • Adopts adult morphology by about 8 years of age

    • Lesser toe deformities

    • Hallux deformity

    Pain in the forefoot (metatarsalgia)

    This is one of the most common forms of foot pain and has several possible causes.

    Morton's metatarsalgia (interdigital neuroma)

    This normally affects the proximal part of the plantar digital nerve and accompanying plantar digital artery. Trauma to these structures leads to histological changes including inflammatory oedema, microscopic changes in the neurolemma, fibrosis, and, later, degeneration of the nerve.

    Clinical features include a gradual onset with sudden attacks of neuralgic pain or paraesthesia during walking, often in the third and fourth toe. Examination may reveal …

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