PRACTICE RECOMMENDATIONS
• Advise patients with metatarsalgia to use metatarsal pads, consider orthotics, use contrast baths, and avoid high heels and pointy-toed shoes. C
• Recommend that runners with stress fractures of the foot have at least 4 weeks of rest before a gradual return to activity. C
• Consider short-term physical therapy for patients with plantar fasciitis to enable them to learn proper stretching and strengthening techniques. C
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
CASE Jim F, 40 years old and overweight (BMI=28 kg/m2), has come to see you because of foot pain that began shortly after he took up running. Jim tells you that turning 40 was “an eye opener” that prompted him to “get healthy.” He says that while he was a competitive athlete in high school, he never ran regularly—until he embarked on a running program 3 months ago.
Jim denies acute injury, bruising, swelling, redness, fever, or chills, but states that the pain, which he describes as dull and achy, is gradually getting worse. It hurts the most when he stands for long periods of time. He says that he occasionally takes ibuprofen for the foot pain, but has not tried icing or stretching. When you ask him what kind of sneakers he wears during his runs, Jim reports that his running shoes—purchased at a discount store—are about 5 years old.
Participation in running has grown by more than 40% in the United States in the past decade.1 As a result, patients like Jim are bound to have their share of aches, pains, and injuries that prompt them to visit their family physician. And that’s where this review can help. This rundown of the most common foot pain diagnoses, as well as the at-a-glance summaries of the differential diagnosis (TABLE 1)2-5 and treatment options (TABLE 2),3,6-25 can help you quickly get patients the relief they need to return to running.
TABLE 1
Differential diagnosis for runners’ foot pain2-5
| Symptom | Differential diagnosis |
|---|---|
| Foot pain |
|
| Heel pain |
|
| *Represents a more common diagnosis. | |
TABLE 2
Diagnosing and treating common runners’ injuries
| Diagnosis | History | Physical exam | Interventions |
|---|---|---|---|
| Metatarsalgia | Plantar foot pain, insidious onset; occasional swelling, bruising, or deformity | Tenderness of MT heads; possible edema or hyperkeratosis; negative tuning fork test | Footwear: cushioning, wide toe box, MT pads; consider orthotics. Contrast baths; NSAIDs6-9 |
| Stress fracture | Pain, insidious onset, increasing in intensity and duration | Localized TTP; possible swelling or bruising; positive tuning fork test; X-rays/MRI may be helpful | Boot for minimum of 3-4 weeks, followed by PT for foot/ankle ROM, strength, proprioception Ice, acetaminophen (NSAIDs controversial)10-12 Progressive return to running* |
| Plantar fasciitis | Plantar foot/heel pain, worse with first steps in AM and after prolonged weight-bearing | TTP at medial calcaneal tubercle | Relative rest, NSAIDs, PT for HEP, Graston technique, taping; possible night splinting13-15 Consider ESWT, corticosteroid injection for refractory cases16-18 |
| MAT | Posterior heel/Achilles pain in midportion; insidious onset, increasing in intensity, worse with activity | Tenderness midportion Achilles; possible tendon thickening; warmth, crepitus, nodules | Relative rest; PT for eccentric exercises; heel lift, with or without orthotics19-22 Consider PRP, prolotherapy, ESWT, or ultrasound in refractory cases†23,24 Surgical intervention rarely indicated3 |
| IAT | Posterior heel/Achilles pain in insertion of Achilles; insidious onset, increasing in intensity; swelling possible; worse with activity | Tenderness with or without swelling; deformity at Achilles insertion | Relative rest; footwear modification (heel lift, possibly with orthotics); PT for eccentric exercises, though less valuable than for MAT†25 |
| *Starting with cross-training exercise, progressing to running on a treadmill, then to running outdoors. †Corticosteroid injection contraindicated. ESWT, extracorporeal shock wave therapy; HEP, home exercise program; IAT, insertional Achilles tendinopathy; MAT, midportion Achilles tendinopathy; MRI, magnetic resonance imaging; MT, metatarsal; NSAIDs, nonsteroidal anti-inflammatory drugs; PRP, plasma-rich protein; PT, physical therapy; ROM, range of motion; TTP, tenderness to palpation. | |||
Metatarsalgia: Pain on the plantar surface
Typically associated with a recent increase in activity or change in footwear, metatarsalgia is defined by pain on the plantar surface of the forefoot in the area of the metatarsal heads. The second, third, and fourth metatarsals are the most common offenders, and the pain may or may not be accompanied by swelling, bruising, or deformity.
Mechanical irregularities in the foot are thought to contribute to the development of metatarsalgia, which is typically inflammatory in nature. Physical exam often reveals tenderness at the affected metatarsal heads, with or without pain in the corresponding metatarsophalangeal joint, and occasionally, with overlying edema or hyperkeratosis.
Tuning fork test. Commonly used but weakly supported, this diagnostic test is performed by applying a vibrating tuning fork to a site of possible fracture. If the maneuver produces focal pain, the test is positive and may be helpful in ruling in metatarsal stress fractures.26