Category Archives: Pain in the top of the foot

Article about pain in the top of the foot

Osteoarthritis… what is it?

Osteoarthritis (OA) is the most common joint disease.  It affects approximately 28 million Americans and tends to become more common with increasing age. It is a universal condition in people past the age of 70 although not everyone is symptomatic. It is a disease that affects articular cartilage, the gristle that caps the ends of long bones.cartilage_0

There are risk factors for the disease.  Increasing age, as mentioned earlier is one.  In addition, female gender, genetic predisposition, obesity, and trauma are the other important items.

The most frequent targets for OA to strike are the neck, low back, fingers, base of the thumb, knees, and hips.

Less commonly the ankles, shoulders, and elbows are involved.  In these areas, antecedent trauma appears to be the primary cause.

knee-arthritisOA is what is called, a focal disease.  What that means is that it doesn’t affect the whole joint.  It preferentially attacks certain areas within the joint.  An example would be the knee where the medial (inside) part of the joint cartilage-defectis affected far more often than the lateral (outside) part.

In the hip, the top part of the joint tends to become involved while the rest of the joint is relatively spared.  The same is true for other joints affected by OA.

Symptoms of the condition consist of pain that is aggravated by use and relieved by rest.  Also, there is short term stiffness with inactivity. This is called “gelling.” Night time pain is also a common feature. Another common lament is crunching of the joint with movement.  This is called “crepitus.”

On exam the rheumatologist will often spot swelling due to the formation of bone spurs, called “osteophytes.”  There can be tenderness of the joint, pain with movement, swelling due to fluid accumulation, and muscle wasting around the joint.

In advanced cases, there is clear deformity and sometimes evidence of instability.

Laboratory tests are usually normal.  Imaging studies can help with the diagnosis.  Magnetic resonance imaging will pick up early changes.  X-ray findings also can help with the diagnosis.  The problem is that if x-ray changes are evident, then the disease has progressed substantially.  The primary changes seen on x-ray are narrowing of the joint, bone spurs, and changes in the bone underlying the cartilage.

Joint fluid, if present, should be aspirated.  The joint fluid is typically viscous, translucent, and has fewer than 200 white blood cells per cubic milliliter.  Occasionally the white blood cell count will be higher if a patient has a particularly inflammatory form of osteoarthritis. This is the conundrum of OA.  While the old thinking was that the condition was primarily a mechanical disease, it has become quite clear that OA has a significant inflammatory component as well.

What has been a perplexing question is, “What causes pain in OA of the knee?”  Cartilage has no blood vessels nor does it have nerves.  So the topic of pain mechanism in osteoarthritis has been the subject of intense interest.knee

There are a number of potential suspects.  For example, when osteophytes (bone spurs) develop, they can lift the periosteum (the thin top layer of the bone).  Periosteum is rich in nerve fibers and certainly can be a source of pain.

It has been noted that blood vessels in bone underlying osteoarthritic cartilage can become engorged and this may elevate the pressure inside the bone which could also, theoretically, cause pain.

The lining of the joint (synovium) becomes inflamed in OA.  Pain fibers are located within the joint capsule and these inflammatory processes could irritate them.

The joint capsule can contract or shrink leading to irritation of nerve fibers located within the capsule.

By the same token, if fluid builds up within the joint, it can stretch the joint capsule again leading to stimulation of pain fibers.

As mentioned earlier, there are two small pieces of fibrocartilage located within the knee.  These pieces of fibrocartilage (menisci) have a rich blood and nerve supply where they attach to the joint capsule.  OA often leads to tearing of these menisci. This can cause damage to the capsular attachment leading to pain.

Spasm of the muscles surrounding the knee can also lead to pain.

Finally, there is increasing interest in the role of the central nervous system- the brain- in causing the pain of knee OA.  Recent studies showing the effectiveness of drugs like Cymbalta, a drug originally prescribed for depression, but also showing beneficial effects on pain relief in patients with OA, led to FDA approval for this indication in 2011.

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Osteoarthritis

OA is the most common form of arthritis and affects more than 20 million adults.  It’s been estimated that by the age of 70 almost all people have OA to some extent.

OA is a disease of articular cartilage, the gristle that caps the ends of long bones.  Cartilage is a complex substance consisting of two basic materials: collagen and proteoglycans and one type of cell- the chondrocyte.  Cartilage provides shock absorption as well gliding functions.

With OA, there is premature wear and tear that occurs as a result of a metabolic abnormality that causes the chondrocyte to produce destructive enzymes.  There is a complex interplay of the cartilage, the synovium (lining of the joint), and the subchondral bone (the bone that lies underneath the cartilage. The result is premature wear and tear as well as local inflammation.

While OA is primarily a condition that affects weight-bearing joints such as the neck, low back, hips, and knees, it also affects other areas such as the hands and feet, particularly in women.

Risk factors for the development of OA include genetics, trauma (injury to the joint), and weight in the case of weight-bearing areas such as the low back and knees.  There is less evidence that weight plays a role in inducing OA of the hips.  However, once OA in the hips is present, weight plays a key role in making the symptoms worse.

Symptoms of OA include morning stiffness lasting less than one-half an hour, stiffness during the days with prolonged sitting, crepitus (crunching sounds that accompany joint movement), pain, and joint swelling. Joint fluid, called an “effusion” can develop.

As osteoarthritis progresses, it becomes harder for patients to limber up and to move without pain.

Diagnosis is usually suspected by history and physical examination.  While confirmation can be obtained by x-rays, unfortunately, by the time x-ray changes occur in OA, it is late in the course of disease.

While magnetic resonance imaging is much more sensitive for making the diagnosis, because of expense, it is often not used.

Laboratory tests are usually negative or normal.

Current forms of treatment for this condition are inadequate.

While advising a patient who is heavy to lose weight and exercise is admirable and necessary, it is an admonition that is usually ignored.

In addition, other measures such as analgesic medications (pain killers), non-steroidal anti-inflammatory drugs, physical therapy, bracers, and injections of glucocorticoids and viscosupplements provide only temporary and palliative relief.

Ultimately, patients will go on to get knee replacements.

In a recent report, Madonna Behan writing for Healthday reported, “The number of new-knee procedures doubled over the last decade, reached more than 620,000 in 2009, and the researchers said younger patients — those 45 to 64 — accounted for a disproportionate amount of that growth. In addition, researchers “estimate that nearly 53 percent of men and 52 percent of women diagnosed with symptomatic knee [osteoarthritis] will receive a total knee replacement in their lifetimes.”

Knee replacement surgery is not an innocuous procedure with the potential for complications such as infection, excessive bleeding, blood clots, worsening pain after the procedure, nerve damage, and death.

So what else can be done?  Attempts to find a pharmacologic solution, so-called disease modifying anti-osteoarthritis drugs (DMOADS) have been disappointing at best.

The most promising new development is the use of autologous mesenchymal stem cells.  These are adult stem cells found within many areas of the body including the bone marrow, fat, deciduous teeth, and periosteum of bone.

Anecdotal reports and small uncontrolled studies in both animal models as well as humans appear promising as a method for slowing down the rate of cartilage loss in knee OA and possibly even allowing for cartilage regeneration.

(Wei N, Beard S, Delauter S, Bitner C, Gillis R, Rau L, Miller C, Clark T. Guided Mesenchymal Stem Cell Layering Technique for Treatment of Osteoarthritis of the Knee. J Applied Res. 2011; 11: 44-48)

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Pain in the top of the foot

Foot pain is ubiquitous in society since most people get around by walking.

top-of-the-footThe foot consists of 26 bones which are held together with a complex arrangement of ligaments, muscles, and tendons.

In addition, multiple nerves and blood vessels traverse the foot.

While much attention is placed on disorders of the arch of the foot and the heel, the top of the foot is often the site of discomfort.

The reason this area is susceptible to pain is because of the anatomy.  In addition to being an area where many of the small bones of the foot interact, it is also a location where many of the critical nerves and blood vessels traverse.

The most common cause of pain in the top of the foot is osteoarthritis.  Osteoarthritis is a disorder due to derangement in cartilage metabolism.

Cartilage is the gristle that provides the cushioning between bones.  It consists of cartilagea matrix made up of collagen and proteoglycans.  Proteoglycans are complexes of proteins and sugars.  Within this matrix are cells called chondrocytes which help manufacture and nourish the matrix.  When a trigger such as trauma occurs, there is a change in the complexion of cartilage.  The chondrocytes begin to make destructive enzymes and the cartilage begins to wear away.  The underlying bone starts to react by forming bony spurs.  These spurs, particularly in the top of the foot, impinge upon nerves and blood vessels.  The spurs also rub against each other leading to pain.

Anything that magnifies this problem will also magnify the pain.  For example, tight-shoewearing shoes that compress the top of the foot can make pain in the top of the foot worse. The treatment here is, at least early on, to reduce the amount of pressure, use anti-inflammatory medicines either by mouth or topically, and possibly injections of glucocorticoid.  Since this is an area where the joints are narrow and many blood vessels and nerves are located, it is best to use ultrasound guidance for injections.

Since some spurs will continue to irritate nerves, sometimes the best treatment is to remove the spurs using a technique called tenotomy where a sharpened needle bevel is used to “chisel” the spurs, and then platelet-rich plasma (PRP) is prpused to heal the area.  In our hands, this technique, again using ultrasound guidance, has been very successful.

gout-footAnother cause of pain in the top of the foot is gout.  Gout is a metabolic disease due to the excessive accumulation of monosodium urate crystals. The treatment is to reduce the uric acid load in the body.  This is best accomplished with a combination of dietary as medicine therapies.

Tendonitis can also occur in the top of the foot.  This is sometimes seen in people who have walked or run a long distance wearing tight shoes or other footwear that irritates the top of the foot.

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