Foot pain diagnosis

by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

Click here: Second Opinion Arthritis Treatment Kit

There are many conditions that may cause foot pain. Here are the more common categories.

• The cause of much foot pain is poorly fitting shoes. High-heeled shoes concentrate pressure on the toes and are major culprits for aggravating, if not causing, problems with the toes.
• Temperature, and therefore weather, affects the feet: they contract with cold and expand with heat. Feet can change shape and increase in size by as much as 5% depending on whether a person is walking, sitting, or standing.
• Improper walking due to poor posture can cause foot pain.
• Any medical condition that causes imbalance or poor circulation can contribute to foot pain.
• Inherited abnormalities in the back, legs, or feet can cause pain. For example, commonly one leg is shorter than the other, causing an imbalance.
• High-impact exercising, such as jogging or strenuous aerobics, can injure the feet. Common injuries include corns, calluses, blisters, muscle cramps, acute knee and ankle injuries, plantar fasciitis, and metatarsalgia.
• Because of the effects of work-related repetitive stress on the hand, there has been considerable interest in the effect of work-stress on foot pain. In general, the foot is designed for repetitive stress and few jobs pose the same stress on the feet as many do on the hands. Nevertheless, certain professions, such as police work, are associated with significant foot pain. More research is needed.


Multiple medical conditions cause foot pain.

Arthritic conditions, particularly osteoarthritis and gout, can cause foot pain. Although rheumatoid arthritis almost always develops in the hand, the ball of the foot can also be affected.

Diabetes is an important cause of serious foot disorders. It is discussed in a separate section.

Diseases that affect muscle and motor control, such as Parkinson's disease, can cause foot problems.

High blood pressure can cause fluid build-up and swollen feet. The effects of high blood pressure on the nervous and circulatory systems can cause pain, loss of sensation, and tingling in the feet, and can increase the susceptibility for infection and foot ulcers.

Osteoporosis, in which bone loss occurs, can cause foot pain. The cause is stress fractures.

Pregnancy can cause fluid build-up and swollen feet. The increased weight and imbalance of pregnancy contributes to foot stress.

Diseases that affect the nervous and circulatory systems, such as anorexia, can cause pain, loss of sensation, and tingling in the feet, as well as increase the susceptibility for infection and foot ulcers. A number of conditions, including heart failure, kidney disease, and hypothyroidism, can cause fluid build-up and swollen feet.

Some medications, such as calcium channel blockers, drugs used for high blood pressure, can cause foot swelling.

A careful history, physical examination, laboratory tests, and imaging procedures such as x-ray, ultrasound, and magnetic resonance imaging (MRI) are all useful in making diagnoses.

An estimated 15% of diabetics experience serious foot problems. They are the leading cause of hospitalizations for these patients. Research has demonstrated that following a strict preventive program can significantly reduce serious complications, including amputations.

People with diabetes are at risk for problems, particularly infections, resulting from blood vessel injury, which may be severe enough to cause ulcers in the legs and feet. Numbness from nerve damage, which is common in diabetes, makes this a significant problem, since the patient may not be aware of injuries. Even minor infections can develop into severe complications. In study of patients with type 2 diabetes, those at highest risk for foot ulcers were those who were less sensitive to sensation in the foot, who had a higher intake of alcohol, and who put more pressure on their feet.

Extensive surgery may be required, and, in extreme cases, amputation may be necessary. Diabetes is responsible for more than half of all the lower limb amputations performed in the US each year and every year there are over 86,000 foot amputations due to this disease. According to a 2002 study, about one quarter of these amputations are performed on the toe, nearly 6% are mid-foot, 38% below the knee, and 21.4% above the knee. The remaining 10% of amputations are performed on the hip, pelvis, knee, and other sites.

Charcot foot or Charcot joint (medically referred to as neuropathic arthropathy) is of particular note. Previously seen in patients with lues (syphilis), Charcot joints are usually associated with diabetes now. Between 1% and 2.5% of people with diabetes suffer from this condition, which is caused by abnormalities in the nerves in the feet. This condition can numb the feet so that the sufferer does not feel pain at first and is not aware of injury. Instead of resting an injured foot or seeking medical help, the patient often continues to walk, causing further damage. Early changes appear like an infection, with the foot becoming swollen, red, and warm. A seriously affected foot can become deformed. The bones may crack, splinter, and erode, and the joints may shift, change shape, and become unstable.

Preventive foot care could reduce the risk of amputation in people with diabetes by 44% to 85%. Some tips for preventing problems include the following:

• Patients should inspect their feet daily and watch for changes in color or texture, odor, and firm or hardened areas, which may indicate infection and potential ulcers.
• When washing the feet, the water should be warm (not hot) and the feet and areas between the toes should be thoroughly dried afterward. Check water temperature with the hand or a thermometer before stepping in.
• Moisturizers should be applied, but not between the toes.
• Corns and calluses should be gently pumiced and toenails trimmed short and the edges filed to avoid cutting adjacent toes.
• Patients should not use medicated pads or try to shave the corns or calluses themselves.
• Well-fitting footwear is very important. In a 2001 study, 30% of diabetic patients wore shoes that were too narrow. Patients should also avoid high heels, sandals, thongs, and going barefoot.
• Shoes should be changed often during the day.
• Wear socks, particularly with extra padding (which can be purchased).
• Seek footwear that reduces foot pressure. For example, custom-molded boots are designed to increase the surface area over which foot pressure is distributed. This reduces stress on the ulcers and allows them to heal. Researchers report pressure loads that are about a third lower than with standard casting technology. Special insoles (e.g., the Rocker insole) have also been designed to reduce pressure on the front of the foot, in one study by 48%.
• Patients should avoid tight stockings or any clothing that constricts the legs and feet.
• Foot pain, numbness, or tingling is worse at night; diphenhydramine (Benadryl) may help.

A specialist in foot care should be consulted for any problems. About one-third of foot ulcers will heal within 20 weeks with good wound care treatments. Some treatments are as follows:

• In virtually all cases, wound care requires debridement, which is the removal of injured tissue until only healthy tissue remains. Debridement may be accomplished using chemical (enzymes), surgical, or mechanical (e.g. irrigation) means. Hospitalization and intravenous antibiotics for up to 28 days may be needed for severe foot ulcers.
• Charcot foot is initially treated with strict immobilization of the foot and ankle; some centers use a cast that allows the patient to move and still protects the foot.. When the acute phase has passed, patients usually need lifelong protection of the foot using a brace initially and custom footwear.


A number of recent investigative measures include the following:

• A number of treatments that use human skin equivalent or HSE are now available that stimulate new cell growth and help heal skin ulcers or use cultures of human skin cells. Studies are showing that HSE promotes healing and the risk for rejection of such grafts is low. Adverse effects include infections at other sites.
• Administering hyperbaric oxygen (oxygen given at high pressure) is showing promise in promoting healing and preventing amputation.
• Granulocyte-colony stimulating factor, or G-CSF is showing promise as an effective alternative to antibiotics. Studies are reporting that G-CSF accelerates healing and significantly reduces the need for surgery.
• Total-contact casting (TCC). This approach uses a cast that is designed to contact the exact contour of the foot and distribute weight along the entire length of the foot. It is usually changed weekly. In one trial, it healed ulcers in nearly 90% of selected patients. It is also useful for Charcot foot.
• A device that compresses the foot (NuPulse) appears to increase the circulation, reduces edema (swelling), and improves wound healing.

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