[Health Lecture] Same foot pain, different causes

In order to ensure the popularization effect of learning health knowledge in the 3rd China Senior Health Knowledge Competition, the organizer has collected various health science articles suitable for elderly people to learn from various hospitals. We will share them through the "Health Lecture Hall" column.

Today, Dr. Liu Botao from the Pain Department of the China-Japan Friendship Hospital brings us “Same foot pain, different causes”. Elderly friends are welcome to learn.

Master Wang retired gloriously this year, and he planned to travel with his old partner, Master Li. But before departure, Master Wang suddenly felt severe pain in the sole of his right foot, which made Master Wang afraid to get out of bed. In fact, the pain in the sole of his right foot often occurred before, sometimes better and sometimes worse, and Master Wang didn't pay much attention to it because he was busy with work. Who would have thought that it would come out to make trouble again at the critical moment. Because he couldn't travel, Master Wang had to call Master Li and say that he couldn't go. The result was ridiculous. Master Li also had pain in the sole of his right foot. It didn't hurt when he was sitting or lying down, but it was excruciatingly painful as soon as he stood up. He took "ibuprofen" and used special orthotic insoles, but the effect was not good. Now that the two can't go out to travel as planned, let's go to the pain clinic together to see what's going on with the pain in the sole of the foot.

The two went to the pain department, where the doctor interviewed and examined them separately, and then asked them to undergo a skeletal muscle ultrasound examination of the soles of their feet. After the results came out, the doctor gave them different treatment plans. The doctor asked Master Wang to receive "radiative shock wave therapy" and Master Li to receive "fascial tissue closure". The two looked at each other in confusion, with a big question mark in their minds: We both have pain in the right sole of our feet, why are the treatment plans different?

“Radial Shock Wave Therapy”

The doctor seemed to see the two people's confusion, so he took out the results of their ultrasound examinations and patiently explained them to them. It turned out that although both of them had pain in the soles of their feet, and both were on the right side, the causes of their pain were different. Master Wang's pain in the soles of his feet was on the front and inside of his heels. The nature of the pain was sharp. The pain was particularly obvious when he just got up in the morning. After gritting his teeth and walking a few steps, the pain would gradually ease, but if he continued to walk or run for a long time, or after a long period of standing, the pain would become obvious again. If Master Wang pays attention to rest or sits down and rubs his heels, the pain will be relieved or disappear.

The pain in Master Li's sole is in the forefoot, between the 3rd and 4th toes (i.e. the 3rd toe web area). Master Li often feels burning pain, tingling pain and swelling pain between the 3rd and 4th toes of his right foot, which worsens after activities. He also feels differently when wearing shoes - in Master Li's words, it is "feeling like stepping on a stone" or "the socks on the soles of his feet are not worn flat and are wrinkled" - take off the shoes and massage the forefoot, and the pain and abnormal sensation will be relieved. In addition, Master Li will feel obvious pain as soon as he wears pointed leather shoes, so he wears wide-mouth shoes all year round. After listening to the doctor's description, both of them nodded frequently - it is true. Although both of them have pain in the soles of their feet, if you think about it carefully, the pain is in different parts.

What was the cause of the pain for the two? The doctor continued: After listening to the two people's descriptions of their pain and conducting a careful physical examination, the doctor made a preliminary judgment on the two people's conditions: Master Wang's cause was "plantar fasciitis (also called plantar fasciitis)", and Master Li's cause was "interplantar neuroma (also called Morton neuroma)". The cause of the former is that the plantar fascia (also called plantar fascia) tissue and its attachment point on the calcaneus are repeatedly overloaded and stretched, and the repeated micro-injury of this attachment point causes aseptic inflammation; the cause of the latter is still unclear, and it is currently believed that it may be caused by repeated compression of the plantar nerve by the deep transverse ligament between the metatarsals, accompanied by subsequent perineural fibrosis.

The doctor was afraid that the two people might not understand, so he gave an analogy: the fascia on Master Wang's heel was like a spring that was wound too tight and had spasms; the tissue around the nerves between Master Li's feet had hardened, like a thin stone embedded in the flesh, which would hurt his feet when he walked.

Plantar Fasciitis

In order to further clarify the diagnosis, judge the current condition and provide a basis for subsequent treatment, the doctor arranged for both of them to undergo ultrasound examinations. For Master Wang, ultrasound examinations can observe the thickness of the plantar fascia and the inflammation and edema around it; for Master Li, ultrasound examinations are a fast, economical and highly reliable examination method that can help confirm the diagnosis through typical ultrasound images.

This doubt was solved, and a new doubt arose in the minds of the two people: How to treat these two kinds of plantar pain? For Master Wang's plantar fasciitis, in fact, the doctor will also differentiate it from heel fat pad atrophy, plantar muscle tendon injury or tarsal sinus syndrome during the diagnosis process. After confirming that it is "plantar fasciitis", the treatment is mainly conservative measures, including: oral non-steroidal anti-inflammatory drugs, physical therapy (radiative shock wave therapy or high-frequency electrical stimulation therapy), local cold compress, massage and Chinese medicine foot bath, etc., all of which aim to relieve and eliminate inflammation and restore muscle strength and fascia elasticity.

Using functional orthopedic insoles to raise the arch of the foot and reduce the tension of the plantar fascia is also a treatment measure that can be considered. Conservative treatment takes 4 weeks to 1.5 years, which can be said to be a long process. If conservative treatment is not effective, further treatment measures include: local pain point injection (using local anesthetics and hormones) or surgical treatment (such as plantar fascia release). For Master Li's Morton neuroma, the doctor will differentiate it from these diseases: plantar plate injury, metatarsal stress fracture, metatarsophalangeal joint bursitis, soft tissue tumors, etc. After a clear diagnosis, conservative or surgical treatment methods are selected according to the severity of the disease. Conservative methods include: wearing loose shoes and using orthopedic insoles, local pain point injection (also using hormones and local anesthetics), oral or topical non-steroidal anti-inflammatory drugs, ultrasound-guided local nerve radiofrequency ablation, etc.

Surgical treatment is currently the most effective method for treating Morton's neuroma, which is to remove the proliferative tissue and its branches. However, due to possible complications such as symptom recurrence, incision infection or hematoma, and numbness of the skin distal to the incision, doctors generally recommend conservative treatment first, and then consider surgical treatment when conservative treatment is ineffective.

After listening to the doctor's comprehensive explanation, Master Wang and Master Li finally dispelled their doubts. They hurried to receive corresponding treatments, intending to cure their respective foot pains as soon as possible and then continue their travel plans.

About the Author:

Liu Botao, attending physician, Department of Pain Medicine, China-Japan Friendship Hospital. Specialties: 1. Drug treatment and surgical treatment of postherpetic neuralgia; 2. Standardized treatment of cancer pain; 3. Standardized treatment of osteoporosis-related pain; 4. Comprehensive treatment of pain caused by spinal degenerative lesions. Clinical research directions: 1. Standardized treatment of herpes zoster-related pain; 2. Rational use of anesthetic drugs; 3. Minimally invasive interventional technology pathways related to the spine.

Social part-time jobs: Member of the Branch on Rational Use of Narcotic Drugs of the China Association for the Prevention and Treatment of Drug Abuse; Young Member of the Pain Medicine Professional Committee of the Chinese Association of Integrated Traditional Chinese and Western Medicine; Member of the Expert Pool of the Beijing Chaoyang District Medical Association; Member of the Soft Tissue Pain Branch of the China Association for the Promotion of Traditional Chinese Medicine Research; Corresponding editor of the Chinese Journal of Pain Medicine; Young editor of the Chinese Edition of BMJ Quality & Safety.