MEN'S HEALTH MATTERS:The commonest cause of pain in the front of the feet is related to flat feet and metatarsalgia
Q I am 62 and having a lot of trouble with pain in my feet. It is just a dull ache near the base of my toes but is annoying and worse at the end of the day. Can anything be done?
AThere are some 28 bones, numerous joints, nerves, ligaments and arteries in the foot, which is anatomically divided into three parts – hind, mid and forefoot (front). It is a complex and much abused part of the body. Any of these can be a source of pain but by far the commonest cause of pain in the front of the feet is related to metatarsalgia (pain behind the base of the toes) and flat feet.
Pain arising from around the metatarsal heads (metatarsal bones are at the base of the toes) can occur from several causes, including types of arthritis like Sero-negative Spondyloarthropathy (inflammatory joint diseases) which may show sausage digits or puffy toes (Dactylitis).
There are numerous other causes of pain in the feet. In the hind foot it is mainly Plantar Fasciitis which is an inflammatory process of the plantar fascia. Other causes include athletic injuries, overuse and unsuitable footwear.
A fallen arch is by far the commonest cause of “my feet are killing me”. When flattening of the front of the arch occurs then the pain progresses and is often worse at the end of the day. Symptoms may be made worse by bad footwear and management is usually straightforward.
Wearing sensible shoes may be all that is required. Exercises may also help to re-tone the muscles. Physiotherapy or podiatry testing is very important. You could have a foot arch problem in addition to metatarsalgia. Your doctor will advise further and may have you assessed by a podiatrist, physiotherapist, chiropodist and/or a rheumatologist. Treatment in this situation may include custom-made devices to support the foot. The outcome from these measures is usually very successful.
Q I am 36 and recently noticed that my legs get tired very easily. I have large veins visible on the lower part of my right leg with an overlying rash, which can be very itchy. These have been present for the past six months. My doctor diagnosed varicose veins, suggested surgery might help and referred me to a vascular surgeon. What does surgery involve? I still play rugby and wondered if I should wait until I finish playing rugby?
AYou are describing the appearance of varicose veins and the tiredness associated with them. The itchy area is most likely eczema: it can be treated with a steroid cream and support stockings, but the underlying condition will need to be dealt with.
The cause of varicose veins is leaky valves in the veins in your leg. Normally the valves in the veins allow blood to flow in the direction of the foot to the heart but with varicose veins these valves don’t function properly. This results in backflow of blood and increased pressure within the veins, which then fill with blood and become dilated.
Your doctor has referred you to a vascular surgeon and when you are seen in the hospital an ultrasound scan of your legs will be performed which will demonstrate where the leaky valves are. The most common sites of these are in the groin and at the back of the knee.
The options are to wear graded compression stockings (which will keep your veins under control but never get rid of the problem); injections; conventional surgery; or treatment with keyhole techniques.
During conventional surgery, a small cut is made in the groin or behind the knee and the junction between the superficial and deep veins is identified and tied-off. When the groin is involved, the superficial vein is commonly stripped to below the level of the knee. Multiple incisions may be made in the skin to treat other prominent veins.
Treating your varicose veins with surgery is relatively safe. Wound infections occur infrequently and can be treated with antibiotics. In about 15 per cent of patients, a nerve that runs down the inside of the leg can get bruised during surgery resulting in tingling or numbness on the inside of the ankle joint. This generally passes within six weeks.
Newer keyhole techniques are not universally available. They involve the passage of a wire and sheath into the incompetent vein from the knee or lower calf. A probe is then passed into the vein allowing it to be sealed and occluded.
As for the timing of the surgery, it should be possible to have something done at the end of the rugby season so as not to interfere with next season.
- This column is edited by Thomas Lynch, consultant urological surgeon, St James's Hospital, with a contribution from Dr Eoin Casey, consultant rheumatologist, the Private Clinic, St James's Hospital, and Prakash Madhavan, consultant vascular surgeon, St James's Hospital
