Foot

CONDITIONS OF THE BIG TOE

There may be a number of causes for pain in your big toe. Turf toe is a name given to a sprain of the joint at the base of your first toe. Hallux limitus (stiffness of the first metatarsalphalangeal joint), as its name suggests, is a condition that causes limited movement at this toe, as well as pain. Bunions, as they are known colloquially, is a condition where the first toe progressively deviates and begins to point toward the second toe (sometimes overlapping it). Another cause of big toe pain is gout, an inflammatory arthritis that leads to joint pain, swelling and redness. 

Tell me more about these conditions

Turf toe is a name given to a sprain of the joint at the base of your first toe (first metatarsophalangeal). It is caused by an injury such as hyperextension or stubbing of the big toe. This leads to pain around the big toe joint, with associated swelling and sometimes bruising. In more severe cases, the plantar plate that stabilises the joint on the underside of the foot may be torn.

Hallux limitus (stiffness of the first metatarsalphalangeal joint), as its name suggests, is a condition that causes limited movement at this toe, as well as pain. The progressive stiffness can lead to arthritis and the development of small bone spurs that limit joint movement. In later stages, the condition is sometimes called hallux rigidus. Movement at the big toe is very important for walking, and stiffness can affect the way you walk.

Hallux valgus, or bunions as they are known colloquially, is a condition where the first toe progressively deviates and begins to point toward the second toe (sometimes overlapping it). This leads to a bony prominence at the inside of the first toe joint, and is associated with pain and sometimes limited joint movement and problems with walking.

Another cause of big toe pain is gout, an inflammatory arthritis that leads to joint pain, swelling and redness. Unlike other types of inflammatory arthritis, gout often will only affect one joint at a time of ‘attack.’ The big toe is a common site of gout and is not usually preceded by an injury. Gout attacks are often recurrent.

What causes big toe pain?

Turf toe is caused by a hyperextension or hyperflexion of the big toe. Playing on artificial turf and wearing soft footwear may increase the risk.

Hallux limitus may occur as a result of previous trauma (such as a turf toe injury) or previous high big toe loads. It may also be related to general inflammatory arthritis or osteoarthritis.

Hallux valgus is up to 10 times more prevalent in women. It has been associated with wearing pointed or narrow footwear (such as high heels). It is also associated with a congenital deformity (birth defect) or laxity of the big toe joint, and an excessively flat (pronated) foot.

How do I know if I have a condition of the big toe?

All of the conditions listed above typically present with pain at the joint of the big toe, often with limited movement that affects walking. Hallux limitus and valgus are more progressive, longer-term conditions and typically (though not always) affect older people. Turf toe, on the other hand, is the result of an acute injury, and is seen more commonly in sporting situations. Your physiotherapist will be able to diagnose the cause of your big toe pain. They will assess the movement at your big toe and around the foot. In some cases, if a fracture or other diseases are suspected (such as gout or other types of arthritis), they may refer you to a GP for investigation and treatment.

How can physiotherapy help with conditions of the big toe?

Turf toe

Your physiotherapist will attempt to settle pain and inflammation in the early stages of the injury by advising to ice and offload the foot. You may speak with a GP or pharmacist about whether taking anti-inflammatory medications may be appropriate for you. In more severe cases, the injury may need to be X-rayed and you may need to immobilise the foot or use crutches for a period of time. In milder cases, taping of the big toe may be useful to help you return to your desired activity.

Hallux limitus

The goal of physiotherapy for this condition is to improve the range of movement at the big toe and to improve affected function, such as walking. Treatment may consist of joint mobilisation of the big toe and other joints of the foot. You may also be given stretching exercises at home, and also exercises to strengthen muscles around the foot. Assessment of footwear and prescription of an orthotic may also be considered. In more severe cases, surgery may be required.

Hallux valgus

Management of hallux valgus should consist of careful assessment of footwear. Modifications to footwear, by prescribing an orthotic or using different shoes altogether, may be necessary. Taping techniques or toe spacers may provide symptom relief. Your physiotherapist can prescribe strengthening exercises for the foot muscles. Medications may be considered to help settle any acute pain. In severe cases, surgery may be required. It is also important to assess and treat any issues with foot movement during walking motion.

Gout

For gout and other inflammatory conditions of the big toe, physiotherapy is not first-line management.

How effective is physiotherapy for conditions of the big toe?

There is a lack of high-quality research investigating big toe conditions. A Cochrane Review showed that physiotherapy treatment (consisting of mobilisation, stretching and exercises) is effective at improving pain in people with osteoarthritis of the big toe joint. Another Cochrane Review found that custom orthoses for hallux valgus reduced foot pain in the short-term, but surgery was superior in the long-term.

What can I do at home?

For turf toe injuries, management of acute swelling and pain will be most important. You may be advised to avoid weight-bearing on the foot, or use crutches or a walking boot in severe cases. For hallux valgus or limitus, your physiotherapist may prescribe mobilising exercises to improve the movement of the big toe. They may also give you strengthening for your foot and lower leg.

How long until I feel better?

For turf toe injuries, return to activity depends on the severity of injury. Minor injuries will be able to return to weight-bearing activities and sport within a week. More severe injuries may take up to three months. As hallux valgus and limitus are more progressive conditions, it is much more difficult to set time frames, and you may be unable to regain full movement and function of the big toe.

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MORTON’S NEUROMA

A Morton’s or intermetatarsal neuroma is pain from the nerves that pass between the bones that join onto your toes (metatarsals). Nerves pass between each of the metatarsal bones to supply the toes. Small fluid filled sacs called ‘bursa’ also sit in this gap to act like a cushion. There is no tumour in this condition. Instead, pain from a Morton’s neuroma is caused by a combination of irritation of the nerve, scar tissue that develops around the nerve, and inflammation and swelling of the bursa. This leads to a nerve entrapment—the nerve becomes compressed and cannot move as freely. It occurs most commonly between the second and third, or third and fourth metatarsals. 

What causes Morton’s neuroma?

Morton’s neuroma is usually caused by excessive loading to the metatarsals. The reason for this may vary between different people—in runners it may be due to load on the metatarsal arch, for example. This is different to the larger foot arch. Morton’s neuroma is commonly associated with narrow-fitting shoes and high heels. It is up to 10 times more common in women and usually seen in those aged 40–60 years old.

How do I know if I have a Morton’s neuroma?

A Morton’s neuroma causes pain between the metatarsal bones of the foot with weight-bearing (such as standing or walking). This pain can often ‘shoot’ down into the toes and sometimes can feel like burning or tingling. It may also lead to numbness of the affected toes. Your physiotherapist will be able to diagnose this condition by carefully questioning how your symptoms behave. They may try and reproduce your symptoms in certain weight-bearing positions, and may also examine your foot posture and footwear. It will also be important for your physiotherapist to carefully diagnose the cause of your pain, as a number of different conditions also cause pain in the same area, including stress fractures and arthritis, which require different management.

How can physiotherapy help with a Morton’s neuroma?

Your physiotherapist will need to investigate what is mainly causing your pain and make modifications (it may be advised to change from narrow constricting footwear to something wider). To settle pain quickly, you may be advised to avoid any aggravating activities for a short period. Your physiotherapist can provide exercises to strengthen the foot muscles. They may also tape your foot or prescribe an orthotic to help with pain. Often a small dome of padding placed under the middle of your forefoot is effective at settling pain and supporting the metatarsal arch across your foot. In cases where conservative treatment is not effective, it may sometimes be necessary to consider a surgical review.

How effective is physiotherapy for a Morton’s neuroma?

A lack of research exists studying treatments for Morton’s neuroma. A recent Cochrane Review (summary of other previous research) reported that there was insufficient evidence to assess the effectiveness of any treatment for this condition. Most research focuses on surgical techniques, which are only necessary in severe circumstances, or corticosteroid injections. Further research is required in this area.

What can I do at home?

Trying to avoid aggravating activities for a short period may be helpful for your pain. Ice over the painful area may also help with symptoms. Wearing shoes with a wide toebox and avoiding narrow shoes is advisable. Activities that don’t require weight-bearing through the foot (such as seated exercise or swimming) should not cause any pain and may help to maintain activity levels.

How long until I feel better?

Outcomes for Morton’s neuroma are hugely variable and depend on the severity of the case. For mild cases, if simple changes such as altering footwear are effective, symptoms may resolve within 1–2 months. More complex cases may require injections and at least six months for complete resolution. In some cases, people have surgery, though this is uncommon.

PLANTAR FASCIOPATHY (PLANTAR FASCIITIS)

Plantar fasciopathy (or fasciitis) is pain under the heel during weight-bearing activities. It is also sometimes called plantar heel pain. The plantar fascia is a strong band of connective tissue that supports the structure of the foot. It connects the heel bone (calcaneum) with the metatarsal bones in the forefoot, which link to the toes. Plantar fasciopathy refers to an irritation and overload of the plantar fascia and is seen in both active people, such as runners, as well as less-active (sedentary) people. It has been shown to be more common in people who are overweight. 

What causes plantar fasciopathy?

Previously, this condition was thought to be related to inflammation; however, studies have shown this is not the cause of pathology or pain in this condition. Pain is often worst first thing in the morning when getting out of bed and taking your first few steps, as well as after prolonged rest. The condition is most common in people 40–60 years old and often affects both feet.

Plantar fasciopathy is a complex condition with many associated factors, although many are related to increased force being transmitted by the plantar fascia. Sharp changes in load, such as spikes in training load, or starting new physical activity after being inactive, is associated with development of symptoms. High body mass index (BMI) is also linked with plantar fasciopathy. This may be due to an increased amount of fat cells in the blood and connective tissue, as well as excessive load on the plantar fascia structure itself. Excessive rolling in of the foot during weight-bearing (pronation) may be associated with this condition, but the evidence isn’t clear.

How do I know if I have plantar fasciopathy?

Plantar fasciopathy is characterised by pain under your heel. Your physiotherapist or podiatrist will be able to diagnose the source of your pain. They will perform tests to assess the support structures of your foot, as well as the range of motion at your ankle and toes. A number of other conditions also cause pain in a similar area; however, your practitioner will be able to differentiate these with a combination of questions and tests. Imaging such as ultrasound scans or X-rays is not required, unless cases are not responding as expected to treatment. Importantly, ‘heel spurs’—or bony growths under the heel—are not always associated with pain or plantar fasciopathy.

How can physiotherapy help with plantar fasciopathy?

A wide variety of treatments are suggested for plantar fasciopathy; however, evidence for many is lacking. All treatment should be based on individual assessment. Options include: 

Load management

It will be important for your physiotherapist to identify the overloading factor and try to modify and temporarily decrease it. This may be running load in athletes or standing time in workers. Importantly, prolonged or complete rest will not lead to resolution of symptoms.

Exercises

Strengthening exercises for the foot and calf muscles can help improve the load tolerance of your foot complex. For these to be effective, they need to have enough load to challenge the foot structures. Stretching of the plantar fascia is also often used as a treatment; however, strengthening exercises will lead to better outcomes.

Taping

Taping of the foot can be an effective way to decrease pain in the early stages of this condition. There are a number of different techniques that can support the foot to relieve symptoms.

Orthotics

Generic orthotic devices can be inserted into your shoe to provide extra support to the structure of your foot. These can decrease pain. Custom-made orthotics have not been found to be superior to generic, off-the-shelf orthotics.

Adjunct treatments

Treatments such as massage, mobilisation and dry needling are not supported by research studies. They may manage your symptoms, but must be used with an exercise program.

Extracorporeal Shockwave Therapy (ESWT)

ESWT delivers high-energy shockwaves to the painful area. Evidence suggests it may be useful in the treatment of plantar fasciopathy; however, it should not be considered a first-line treatment, and if used, should be in conjunction with other treatments mentioned above. 

How effective is physiotherapy for plantar fasciopathy?

A recent randomised controlled trial in 2015 supports the use of strengthening exercises over stretching-based ones for patients with plantar fasciopathy. Systematic reviews (analysis of multiple studies) show taping can be effective in decreasing pain in the short-term; however, the evidence is only limited. Systematic reviews also support the use of orthoses for decreasing pain, and improving function. However, custom-made devices may not be superior to generic ones.

What can I do at home?

Your physiotherapist will prescribe you a program of exercises to complete at home. For symptom relief, ice may help over the affected area, as well as use of orthotics or gel heel inserts. Wearing supportive shoes at home may decrease pain when compared with barefoot walking. It may also be helpful to learn to tape your foot yourself (before exercise or sport). Ask your physiotherapist to show you how to do this, if this is part of your treatment plan.

How long until I feel better?

Symptoms can be controlled if the overload is modified early after onset of symptoms; however, it may take up to six months. Without appropriate management, symptoms may persist. It will be important to modify the overloading factors while working on other aspects of your treatment, such as strengthening.

 

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STRESS FRACTURE & OVERUSE INJURIES

Stress fractures form part of what is known as ‘bone stress injuries’. These occur when a bone is unable to handle repetitive loads put through it and cause localised pain over an area of bone. These injuries start out as a stress reaction that is not yet a full fracture but causes pain. A stress fracture is a progression of this and is a small break in a bone. When a stress fracture is not treated, the injury can progress to becoming a complete fracture. Find out the common areas of bone stress injuries below. 

What causes stress fractures/injuries?

Bone stress injuries are thought to be due to an imbalance between normal microdamage and bone remodelling. These injuries are seen in both elite level athletes and inactive people. Women sustain 2–10 times more bony stress injuries than men. These injuries can be caused by:

  • high training loads
  • a sudden increase in physical activity or training
  • biomechanical factors such as muscle strength, footwear and technique
  • factors that increase risk due to impact on bone health or remodelling
  • diet and nutrition—deficits in calcium and vitamin D increase risk, as well as low calorie intake
  • hormonal balance—menstrual disturbance and post menopause
  • systemic bone illnesses and steroidal or anticonvulsant medications
  • genetic factors.

How do I know if I have stress fractures/injuries?

Bone stress injuries such as stress reactions and stress fractures typically cause localised pain over the affected bone. Usually, this pain has a gradual onset and, in the beginning, may only hurt with activities such as jumping, running or walking. As it progresses it may cause pain when resting or at night. If a bone stress injury is suspected, after thorough assessment, your physiotherapist or GP will refer you for a scan to evaluate the integrity of the bone. An MRI scan is best—X-rays and CT scans are poor at picking up these injuries. A nuclear medicine bone scan may also be used; however, it does not provide as much information as an MRI and has a higher dose of radiation.

Bone stress injuries can theoretically occur anywhere; however, the most common sites in the foot are:

  • the small bone on the inside of the foot below the ankle (navicular)
  • the bone connecting to the fifth toe on the outside of the foot (fifth metatarsal)
  • the bone connecting to the second toe in the middle of the foot (second metatarsal)
  • the bony knob on the inside of the ankle (medial malleolus).

How can physiotherapy help with stress fractures/injuries?

Your physiotherapist will be able to help assess and diagnose any bone stress injuries. These injuries may be more difficult to pick up in the early stages, hence thorough assessment is important. They will be able to refer you for investigations. In some cases, you may be referred to your doctor to further investigate and manage any nutritional, mineral or hormone deficiencies.

Management of bone stress injuries varies hugely between which bone is affected and how severe the presentation is (stress reaction vs fracture). In all cases the overloading factor should be identified, and training or activity may be decreased or stopped temporarily to allow the bone to heal. It may be necessary to have a period of non-weight bearing in a cast or boot. Certain types of stress fracture may also require surgical fixation. Your physiotherapist will need to advise you on what course of action should be taken.

Once the fracture or stress reaction has healed, any deficits in muscle strength, foot posture or other regions should be treated. They will then advise on a plan for a structured gradual return to your desired activities.

How effective is physiotherapy for stress fractures/injuries?

Given the multifactorial nature of bone stress injuries, and the collaborations required for their management between doctors and physiotherapists, studies looking at the effectiveness of physiotherapy for bone stress injuries are scarce.

A research paper summarising other previous studies supported the conservative management of a variety of bone stress injuries in runners. A study investigating navicular stress fractures showed that conservative management was as successful as surgical management on pain and function.

What can I do at home?

It is extremely important to adhere to the plan your physiotherapist or doctor has given you, including periods of non-weight bearing to allow the bone to heal, followed by a gradual increase in loadbearing activity.

It is possible to do exercises on the unaffected leg when resting the bone. Your physiotherapist can advise you of exercises to complete at home. This may be helpful to maintain strength, as a portion of gains can be carried over from the uninjured side to the affected side to maintain strength even while you are resting it. This may help in a quicker return to activity or sport.

How long until I feel better?

Time frames on return to activity or sport vary depending on the bone stress injury itself. A period of at least six weeks of offloading may be necessary, followed by a period of gradual increase in activity, which may take up to three months depending on your demands. More complex injuries may take as long as 12 months for full resolution. Time frames may differ because of where the fracture is in the bone, and which bone is affected.

 

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TIBIALIS POSTERIOR TENDINOPATHY

The tibialis posterior is a muscle that attaches from the tibia and fibula (bones in the lower leg) to many small bones of the inside of the foot. It helps stabilise around the ankle and point the foot inwards. Tibialis posterior tendinopathy is an overload of this tendon, causing pain and discomfort where the tendon wraps under the bony knob on the inside of the ankle, called the medial malleolus. The condition is also often associated with tenosynovitis—an irritation of the sheath (covering) that wraps around the tendon. When this is involved, it may feel like you have subtle crackling or squeaking (called crepitus) of the tendon as you move your foot. 

What causes tibialis posterior tendinopathy?

As with other tendinopathies, it is thought that tibialis posterior tendinopathy is caused by excessive load beyond a tendon’s capacity. Compression of the tendon at the ankle is linked to pathology in the tendon and sheath (covering). Exact causes of this condition are not known; however, some consider rolling in of the foot (pronation) as an important factor to address. Tibialis posterior tendinopathy is most often seen in people over the age of 40 and is not common in younger patients.

How do I know if I have tibialis posterior tendinopathy?

Tibialis posterior tendinopathy is characterised by pain and sometimes associated creakiness (crepitus) and swelling under the bony knob on the inside of your ankle (medial malleolus). Your physiotherapist or podiatrist will be able to assess and manage this injury. Your physiotherapist will examine the strength and function of the muscles around your ankle, often by asking you to perform a single or double-leg heel raise, which may be painful or difficult to complete if the condition is present. Imaging and scans are not used in the diagnosis of tibialis posterior tendinopathy.

How can physiotherapy help with tibialis posterior tendinopathy?

Physiotherapy management can improve pain and symptoms of tibialis posterior tendinopathy. Exercises can be used to improve the strength of the tibialis posterior muscle, as well as other associated muscles, such as those of your calf and foot. For these to be effective, they will need to be challenging to improve the strength of the muscle and capacity of the tendon. Orthotics may be helpful to provide extra support to the foot, which in turn may offload the tendon. A heel raise or wearing shoes with heels can decrease the compression and therefore the pain.

No evidence supports the use of techniques such as soft tissue massage or joint mobilisation—these should be considered adjuncts to an adequate loading program and never used alone. If your treating physiotherapist suspects an associated irritation and inflammation of the covering of the tendon (tenosynovitis), they may refer you to a GP for a course of non-steroidal anti-inflammatory medication.

How effective is physiotherapy for tibialis posterior tendinopathy?

Treatment for this condition is poorly researched. A recent randomised controlled trial showed adding resisted strengthening exercises to prescribing orthoses and stretching had better results than orthoses alone. These findings are supported by other smaller studies. Further research is required to better understand this complex condition. 

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