The document provides information on common foot pain problems including their anatomy, causes, symptoms, physical exam findings, investigations, and treatment options. It discusses issues such as plantar fasciitis, heel fat pad syndrome, stress fractures of the calcaneus, navicular, and cuboid bones, tarsal tunnel syndrome, lateral plantar nerve entrapment, tibialis posterior tendinopathy, extensor tendinopathy, cuboid syndrome, and midfoot issues. Conservative treatments include rest, ice, stretching, orthotics, and strengthening exercises while surgical options are considered for more severe or chronic cases.

1. Foot pain Problems
Mohamed Aouini
nsmp physiotherapist

2. Your Foot
_ The feet are flexible structures of bones, joints,
muscles, and soft tissues that let us stand
upright and perform activities like walking,
running, and jumping.
_ The foot contains
 26 bones
 33 joints
 19 muscles
 107 ligaments.

3. The feet are divided into three sections
- Forefoot
- Midfoot
- Hindfoot

5. Forefoot
Contains the five toes (phalanges) and the five longer bones
(metatarsals).
Midfoot
Pyramid-like collection of bones that form the arches of the
feet.
Include the three cuneiform bones, the cuboid bone, and the
navicular bone.
Rearfoot
Forms the heel and ankle.
The talus bone supports the leg bones (tibia and fibula),
forming the ankle.
The calcaneus (heel bone) is the largest bone in the foot.

6. Foot arches
Foot has three distinct arches.
Two "longitudinal" arches (one on each side)
run from front to back
One "transverse arch"
runs across the midfoot from inside to outside.

7. Foot arches

8. Functions of foot arches
- The structure of an arch is the spread the load out so it
can be supported with the least amount of effort and
material.
- Some shock absorbency,
- Prevents blood vessels and nerves from being crushed.

9. Functions of the foot
 Proper functioning of the foot is required for normal
gait

10. Weight Distribution
Weight of the body is supported by the foot, and is
transmitted and distributed over 6 areas
Functions of the foot

11. foot pain complaints
- Heel pain ( arising the rear foot )
- Midfoot pain
- Forefoot pain

12. • Rear foot pain
the most common cause of rear foot (inferior heel)pain is :
- Plantar fasciitis
- fat pad (Bursitis )
The less common cause of rear foot is :
- calcaneal stress fracture
-Tarsal tunnel syndrome
- lateral plantar nerve entrapment

13. • Anatomy of the Plantar Fascia
• Broad, dense band of longitudinally
arranged collagen fibers
• 3 bands: medial, central, lateral
• Origin: anterior aspect of calcaneal tuberosity
• Distally divides into 5 digital bands
at the metatarsophalangeal joints
• Each digital band pass on either side of flexor
tendons and inserts dorsally at the base of the toes.

14. • Anatomy of the Heel Fat Pad
• Within the heel pad region, particular attention is paid to the calcaneal fat pad, which is
the portion of the plantar region interposed between the calcaneus and skin that plays a
fundamental role in foot mechanics (Natali et al., 2010).
• The calcaneal fat pad is mainly organized according to a honeycomb configuration
(Jahsset al., 1992a-1992b; Snow and Bohne 2006).
• Fat tissue chambers are embedded and separated from each other by connective septa .

15. • Roles of Plantar Fascia and the heel fat pad
_ Plantar Fascia:
• is a ligament structure that supports on static the
longitudinal arch of the foot and dynamic shock absorbation
_ The heel fat pad:
• Acting as a shock absorber, protecting the
calcaneus at heel strike

16. • Pathophysiology
- Plantar Fasciitis :
• Pain on the inner-bottom of the heel.
• Decreased vascularity
• Perifascial inflammation
• Thickening of the proximal plantar fascia
- fat pad (Bursitis ) or (contusion)
• The patient often complains of marked heel pain during weight-bearing
activities
• Thick fat pad covering calcaneus bruises from sport activities
• The pain is often felt laterally in the heel due to the pattern heel strike
• Examination reveals tenderness often in the posterolateral heel region
• There may be an area of redness

17. • Physical Exam
_ plantar faciitis
• Tenderness to palpation on the
anteromedial aspect of the heel.
• Ankle dorsiflexion limited by
calf tightness.
• Pain increased by toe extension
or by standing on toes.

18. • Physical exam (con’t)
_ The heel fat pad:
• The patient often complains of
marked heel pain particularly during
weight bearing activities.
• The pain is often felt laterally in
the heel due the pattern of heel strike.
• Tenderness often in the
posterolateral heel region.

19. Causes
Plantar fasciitis :
• Occupation requiring prolonged standing.
• Pes planus (low arches flat feet) or pes cavus ( high arches).
• Activities require maximal plantar- flexion of the ankle and
simultaneous dorsi-flexion of metatarsophalangeal joints.
• in older patient Excessive walking inappropriate or non-supportive
footwear
• Obesity
• Reduced ankle dorsiflexion

20. the heel Fat pad:
• Fat pad contusion or fat pad syndrome may develop either
acutely after a fall onto the heels from a height or
chronically because of the excessive heel strike with poor
heel cushioning or repetitive stops, starts and change
direction

21. Treatment plantar fasciitis
• Avoidance of aggravating activity
• Cryotherapy after activities
• Stretching of the plantar fascia, gastrocnemius and soleus
• Night splints or strasbourg socks
• Self massage with a frozen bottle of golf ball
• Strengthening exercises for intrinsic muscles of the foot to improve
longitudinal arch support and decrease stress on the plantar fascia
• Taping
• Silicone gel heel pad
• Soft tissue therapy both to the plantar fascia and proximal myofascial
regions including calf, hamstring and gluteals

23. Heel fat pad treatment
• Treatment consists primarly of avoidance of aggravating activities, in
particular,excessive weight bearing
• RICE
• Silicone gel heel pad
• Good footwear are important as a athlete
• Heel lock taping will often provide symptomatic relief.

24. Calcaneal stress fractures
• Calcaneal stress fractures are the second most common tarsal
stress fracture. They occur most commonly at two main sites:
• Upper posterior margin of the os calcis
• Adjacent to the medial tuberosity

25. Causes
• Calcaneal stress fracture were first described among the
military and are related to marching; they also occur in
runners, ballet dancers and jumpers.
Symptoms
• Patient give history of heel pain that aggravating with weight
bearing activities especially running .
• Examination reveals tenderness over the medial or lateral
aspects of the posterior calcaneus
• Pain produced by squeezing the post aspect of the calcaneus
from both sides.

26. Investigation
• X-ray may show a typical appearance on the
lateral X-ray, parallel of the posterior margin of
the calcaneus

27. Treatment
• Reduce activity
• For who with marked pain a short period of non-weight
bearing may be required
• Program of gradually increased weight bearing can occur
• Stretching of the calf muscle and plantar fascia
• Joint mobilization For long term recovery
• Soft heel pads if required are recommended

28. Lateral plantar nerve entrapment
• An entrapment of the first branch of the lateral plantar nerve occur
between the deep fascia of the abductor hallucis longus and the medial
caudal margin of the qudaratus planus muscle
• Pain radiates to the medial inferior aspect of the heel and proximally
into the medial ankle region
• Patient do not normally complain of the numbness in the heel or the
foot
• A diagnostic injection with local anesthetic will confirm the diagnosis

29. Treatment
• Treatment consist of rest
• NSAIDs and iontophoresis
• Arch support using taping or an orthosis is helpful in
athletes with excessive pronation

30. tarsal tunnel syndrome
• impingement and inflammation of the posterior tibial nerve
within the tarsal tunnel

31. Causes
• in approximately 50% of cases the cause of tarsal tunnel syndrome is
idiopathic, it may also occur as a result of trauma ( e.g inversion injury to the
ankle) or overuse associated with excessive pronation.
• EV or PF/EV ankle injury or Forced PF
• Repetitive stress associated with pes planus foot
• Possible related factors :raining surface ,Distance ,Shoes
Symptoms
• pain, numbness, or
• parasthesia along
medial or plantar aspect
of foot
• Point tenderness
proximal, over, and
distal to the flexor
retinaculum

32. Examination
• Pain is usually aggravated by activity and relieved by rest
• Swelling , varicosities or thickening may be found on examination
around the medial ankle or heel
• A ganglion or cyst may be palpable in the tendon sheaths around the
medial ankle
• Tapping over the posterior tibial nerve (Tinel’s sign) may elicit the
patients pain and occasinally cause fasciculation
• AROM normal EV may reproduce symptoms
• PROM PF & EV may reproduce symptoms
• RROM may demonstrate weakness of toe flexors
Investigation
• Ultrasound or MRI may be required for the space-occupaying lesion as
a cause of the syndrom

34. Treatment
• Conservative
_Treatment with NSAID and, if required an injection of a
corticosteroid agent into the tarsal tunnel may be helpful
_ if excessive pronation is present , an orthosis should be
utilized
• surgical
_ if there is mechanism cal pressure on the nerve a
decompression of the posterior tibial nerve and its branches
should be performed

35. Talar stress fracture
• During weight bearing activity compressive forces are placed
through the talus. When these forces are excessive, too
repetitive and beyond what the bone can withstand, bony
damage gradually occurs.
• This initially results in a bony stress reaction, however, with
continued damage may progress to a talus stress fracture.

36. Causes
• Stress fractures of the talus typically occur gradually over time with
excessive weight bearing activity such as running.
• occur following a recent increase in activity or change in training
• in athletes involved in running sports such as football and athletics.
Signs and symptoms
• deep ankle pain that increases with weight bearing activity.
• walking may be enough to aggravate symptoms.
• night ache, pain during certain movements of the foot and ankle
• pain on firmly touching the talus.
Diagnosis
• thorough subjective and objective examination from a physiotherapist
may be sufficient to diagnose a talus stress fracture.
• Investigations such as an MRI, CT scan or bone scan are usually required
to confirm diagnosis.

37. Treatment
• Reduce activity
• For who with marked pain a short period of non-weight bearing
may be required
• Program of gradually increased weight bearing can occur
• Stretching of the calf muscle and plantar fascia
• Joint mobilization For long term recovery
• Soft heel pads if required are recommended

38. Mid foot pain
• the most common cause of mid foot:
- Navicular stress fracture
- Midtarsal joint sprain
- Extensor tendinopathy
- tibialis posterior tendinopathy
• Less common causes
- Cuneiform stress fracture
- Cuboid stress fracture
- stress fracture of base second Metatarsal
- Peroneal tendinopathy
- Abductor hallucis strain
- Cuboid syndrome

39. Navicular stress fracture
• Patients who develop navicular stress fractures will present with a chronic
mid-foot ache.
• The injury may begin after a series of repetitive loading episodes.
• In sport involving sprinting,jumping,hurdling
Causes
• Overuse and training errors plays
• Impingement of the navicular bone occur
between the proximal and distal tarsal
bones when muscle exert compressing
and bending forces .

40. Symptoms
• vague arch pain with midfoot tenderness
at the ‘N-SPOT’, located at the proximal
dorsal portion of the navicular.
• the pain radiates a long the medial aspect
of the litudonginal arch or the dorsum of
the foot .
• the symptoms abate rapidly with rest.
investigation
• X-RAY in the navicular stress fracture
is poor.
• CT scan or MRI is required

41. Treatment
The treatment of navicular stress reaction is :
• Weight bearing rest, often in an air cast until symptoms and signs have
resolved
• Gradually return to activity
The treatment of navicular stress fracture is :
• not bear weight on their foot for at least 6 to 8 weeks with immobilzation
In a cast .
• At the end of this period the cast should be removed and palpate the ‘N-
SPOT’ normally will be no tender .
• Some clinician advocate surgical treatment with the insertion of a screw
where there is significant separation of the fracture.
• It is essential to mobilize the stiff ankle after the cast and soft tissue
therapay and strengthening
• Gradually return to activity

42. Extensor tendinopathy
The extensor dorsiflexion of the foot comprise the :
• Tibialis anterior
• Extonsor onghallucis Lus and brevis
• Extensor digitorum longus and brevis
• Tibialis anterior is the most common tendinopathy
Causes
• Tibialis anterior tendon resists plantarflexion of the foot and
heel strike and Is ,therefore , sucpetible to over use injury.
• Extensor muscle Weakness.
• Increase training load or compression tight shoelaces.
• Stifness of the first metatarsophalangeal and midfoot may
contribute.

43. Symptoms
• patient complains of an aching dorsal aspect of the midfoot
• Examination reveal tenderness with mild swelling
• At the insertion of the tibialis ant tendon at the base of the first metatarsal
and cuneiform.
• Resisted dorsiflexion and eccentric inversion may elicit pain .
Investigation
• ultrasound and MRI may reveal swelling of
the tendon at it is insertion and exclude the
presence of degnerative tear .
Treatment
• Rlative rest
• Soft tissue therapy
• Extensor muscle strengthening

44. Tibialis posterior tendinopathy
• starts at a muscle in the calf, runs down the inside of the lower
leg and then travels around the ankle before attaching to bones
navicular in the arch of the foot.
• helps point the foot down and in to stabilize and support the
arch of the foot.

45. Causes
• occur from overuse of the tendon where it is attached to the navicular
bones and helps to stabilize your arch. If your arch flattens out more than
normal when you walk or run you strain more your tendon.
• With excessive, repetitive loading .
• posterior tibial tendon dysfunction is more common in women and in
people older than 40 years of age. Additional risk factors include obesity,
diabetes
signs and symptoms
• Pain or tenderness on the inner
side of the shin ankle or foot.
• Pain with lifting up your foot.
• Pain walking or running .
• Resisted inversion will elicit pain and
Weakness .

46. Investigation
• MRI or ultrasound may confirm diagnosis
• And reveal the extent of tendinosis.
• In cases of suspected inflammatory tenosynovitis ,blood test for
serological martand inlammatory markers should be performed
• Treatment
• Conservative treatment consisits of:
- Control pain with ice
- Concentric and eccentric tendon loading exercises
- Soft tissue therapy to the belly muscle and tendon
- Rigid orthosis to control excessive pronation

47. - in severe cases a period of immobilization in air cast has been
prescribed to provide short-term symptom relief.
- If there is tendon rupture or failed conservative treatment
surgery is recommended.

48. Cuboid syndrome
• The cuboid is one of the small bones on the outer side of the
midfoot,due to the excessive peroneus longus the cuboid
becomes subluxated
• With an inversion sprain of the ankle this is when the foot and
heel bone are forced inwards while the cuboid is forced
outwards.

49. Sings and Symptoms
• Pain with weight bearing down the outside of the foot
• quickly changing direction, jumping or hopping and
symptoms tend to ease with rest.
• quickly changing direction, jumping or hopping and
symptoms tend to ease with rest.
• There is may a visible depression over the dorsal aspect of
the cuboid.
Treatment
• Treatment involves a single manipulation to reverse the
subluxation
• The cuboid should be pushed upward and laterally from the
medial plantar aspect of the cuboid

51. Cuneiform stress fracture
• The stress fracture of the cuneiform bones are rare and
described in military recruits and athletes
• they are thought to occur secondary to repetitive loading of the
bone
Management
• Limited weight-bearing rest for the medial cuneiform
• Surgical reduction and fixation for adequate healing for the
intermediate cuneiform

52. Cuboid stress fracture
• Stress fracture of the cuboid are rare and occur secondary to
compression of the cuboid between the calcaneus and the fourth
and fifth metatarsal bones when exaggerated plantar-felxion is
undertaken
Treatment
• In absence of displacement is non weight-bearing for 4 to 6
weeks.
• Graduated return to activity
• If displacement are present surgical reduction and fixation are
required

53. Fore foot pain
Hallux valgus
• Hallux valgus means lateral deviation of great toe
• Commonest of foot deformities
• Not a single disorder; but a complex deformity of the first ray
• Frequently accompanied by deformity and symptoms in lesser toes

54. Spectrum of hallux valgus
• Varus deformity of first metatarsal
• Valgus of great toe
• Great toe bunion formation
• Arthritis of 1st MP joint
• Hammer toe
• Toes corn
• Calluses
• Metatarsalgia
• Stress fractures of lesser metatarsals

55. Causes of Hallux Valgus
• High-heeled or ill-fitting shoes
• Inherited foot type
• Foot injuries
• Deformities present at birth (congenital)
• May be associated with various forms of arthritis and an activities
that puts extra stress on the feet (eg. Bunions are common in
ballet dancers.)

56. Bunions

57. Symptoms and Signs
• Foot pain in the involved area when walking or wearing shoes.
That is relieved by resting.
• Bulging bump on the outside of the base of big toe
• Swelling, redness or soreness around big toe joint
• Thickening of the skin at the base of big toe
• Restricted movement of big toe
• Positioning of the big toe toward the smaller toes.

58. Classification of hallux valgus
• Mann and conghlin(1993) classified HV into 3 types based on
Hallux valgus angle
– Mild: Angle < 20 degree, intermetatarsal angle usually less
than 11 degree
– Moderate: Angle 20 - 40 degree, intermetatarsal angle
between 11 and 18 degree
– Severe: Angle > 40 degree, intermetatarsal angle > 16-18
degree

59. Treatment of hallux valgus
• Management:
– Young and asymptomatic patients
• Proper fitting shoes with wide deep toe boxes
• Night splinting and other orthosis
– Once the deformity is established, it is difficult to check the progression
of disease by conservative measures.
– In more severe cases surgery may be required to reconstruct the first
metatarsophalangeal and remove the bony exostoses .

60. Hammertoes
• A hammer toe or contracted toe is a deformity of the proximal
interphalangeal joint of the second, third, or fourth toe causing it
to be permanently bent, resembling a hammer.

61. Hammertoes Causes
 Wearing poorly fitting shoes that can force the toe into a bent
position (eg. High heels)
 Muscle, nerve, or joint damage resulting from conditions such
as osteoarthritis, rheumatoid arthritis, stroke or diabetes
 Often found in conjunction with bunions or other foot
problems

62. Hammertoes signs and sympotms
 Pain with walking
 Difficulty moving the toe
 Corns and calluses resulting from the toe rubbing against
the inside of footwear

63. Hammertoes Conservative treatment
• New shoes with soft, spacious toe box
• Physical therapy
• Wear shoe inserts (orthotics) or pads
to reposition the toe and relieve pressure and pain.
Surgical treatment
• If the toe has become tight and inflexible

64. Morton's neuroma
• Morton's neuroma is a painful condition that affects the ball of
your foot, most commonly the area between your third and
fourth toes.
• Involves a thickening of the tissue around one of the nerves
leading to your toes.
• May occur in response to irritation, injury or pressure

65. Morton's Neuroma Symptoms
• A feeling as if you're standing on a pebble in your shoe
• A burning pain in the ball of your foot that may radiate
into your toes
• Tingling or numbness in your toes
• Pain relieved with non-weight bearing
• Toe hyperextension increases symptoms

66. Morton's Neuroma Treatment
• Ice to alleviate acute tenderness
• Arch supports and foot pads fit inside your shoe help to reduce
pressure on the nerve.
• An “Arch Cookie” pad can help to spread the metatarsals and
give the nerve more space
• Intrinsic Muscle strengthening exercises to maintain the
transverse arch .
• Injection of steroids into the painful area .
• If the patient obtains no relief, surgical excision of the damaged
nerve is indicated

67. Athlete’s foot
• Very common skin condition that affects the sole of the foot and
the skin between the toes.
• Usually a scaly, red, itchy eruption( occasionally may be weepy
and oozing.)
• Athlete's foot, also called tinea pedis, is the most common type of
fungal infection.
• Athlete's foot is contagious and can be spread by contact with an
infected person or with contact with contaminated surfaces, such
as towels, floors and shoes

68. Athlete’s foot Risk factors
• Frequently wear damp socks or tight fitting shoes
• Share mats, rugs, bed linens, clothes or shoes with someone who
has a fungal infection
• Walk barefoot in public areas where the infection can spread,
such as locker rooms, saunas, swimming pools, communal baths
and showers
• Have a weakened immune system

70. Athlete’s foot.... Causes
 Caused by a fungus (group of mold-like fungi called
dermatophytes ).
 Can be contracted in many locations, including gyms, locker
rooms, swimming pools, nail salons, airport security lines, and
from contaminated socks and clothing
 Athlete's foot is closely related to other fungal infections,
including ringworm and jock itch- change the towel when
drying off!

71. Athlete’s foot... Symptoms
 Itching, stinging and burning
 Cracked and peeling skin
 between your toes
 on the soles of the feet
 Excessive dryness of the skin on the bottoms or sides of the
feet
 Toenails that are thick, crumbly, ragged, discolored or pulling
away from the nail bed

72. Athlete’s foot… Treatment
• Make the infected area less suitable for the athlete's
foot fungus to grow
• Keeping the area clean and dry.
• Absorbent socks like cotton that wick water away

73. References
• Clinical Sports Medicine 4th edition Brukner & Khan Brukner & Khan McGraw-
Hill Sydney; 2009
• http://orthoinfo.aaos.org/topic.cfm?topic=a00166
• https://www.physioadvisor.com.au/8131291/stress-fracture-of-the-talus-ankle-pain-
ankle-s.htm
• www.leedscommunityhealthcare.nhs.uk/msk
• Miller CM, Winter WG, Bucknell AL, Jonassen EA. Injuries to mid-tarsal and lesser tarsal
bones. J Am Acad Orthop Surg 1998;6:249–58.
• Shindle MK, Endo Y, Warren RF, et al. Stress fractures about tibia, foot and ankle. J Am
Acad Orthop Surg 2012;20:167–76.
• Watson TS, Shurnas PS, Denker J. Treatment of Lisfranc joint injury: current concepts. J
Am Acad Orthop Surg 2010;18:718–28.