🔑 Key Learning

  • Plantar fasciitis: most common cause of heel pain. Pain worse on first steps after rest.
  • Morton’s neuroma: neuropathic forefoot pain due to digital nerve entrapment, often between 3rd and 4th toes.
    • 'Pebble in shoe', Mulder’s click

🦶 Plantar Fasciitis

🧬 Pathophysiology

  • Chronic degeneration (not inflammation) of the plantar fascia, a fibrous band connecting the calcaneus to the forefoot.
  • Microscopic tears, collagen breakdown, and scarring from overuse or biomechanical stress.
  • Risk factors:
    • Age 40–60
    • Obesity
    • Flat feet or high arches
    • Prolonged standing/running

đź‘€ Clinical Features

  • Gradual onset of sharp pain in the heel or medial arch of the foot.
  • Classically worse after rest, e.g. first few steps in the morning.
  • Improves with gentle activity, but can worsen again after prolonged standing.
  • Examination findings:
    • Tenderness on palpation of the medial calcaneal tuberosity (heel).
    • Positive Windlass test: dorsiflexion of the 1st MTP joint reproduces the pain.

đź’Š Management

  • Lifestyle advice: Rest foot, avoid prolonged standing or walking. Wear cushioned shoes. Try over-the-counter insoles/heel pads. Lose weight if overweight/obese.
  • Pain relief: Paracetamol and/or NSAIDs if appropriate. Apply ice packs (15–20 min every few hours).
  • Exercise: Daily plantar fascia and calf stretches for 4–6 weeks.
  • Ongoing symptoms:
    • Consider referral to podiatry
    • Consider corticosteroid injection
      • Be aware of post-injection pain, recurrence risk, and rare complications (e.g. fat pad atrophy, rupture).
    • Consider referral to orthopaedics:
      • Extracorporeal shockwave therapy (ESWT).
      • Surgery (e.g. endoscopic plantar fasciotomy, gastrocnemius release).

👣 Morton’s Neuroma

🧬 Pathophysiology

  • Perineural fibrosis and thickening of the common digital plantar nerve.
  • Most often occurs between the 3rd and 4th metatarsal heads due to entrapment and repetitive trauma.

đź‘€ Clinical Features

  • Intermittent sharp or burning pain in the forefoot.
  • Sensory changes: numbness, tingling, or paresthesia in the adjacent toes.
  • Described as a “pebble in the shoe” sensation.
  • Pain is worse with walking, narrow shoes, or high-impact activity.

đź©ş Examination

  • Localised tenderness between metatarsal heads (often 3rd interspace).
  • Mulder’s click: compressing the forefoot and applying pressure between metatarsals reproduces pain with a palpable click.
  • Altered sensation in the adjacent toes.

đź’Š Management

  • Footwear modification, ativity modification, analgesia: Paracetamol or NSAIDs.
  • If persistent:
    • Steroid injection into the neuroma.
    • Podiatry referral: Orthotics/metatarsal dome support.
    • Consider surgical excision of the neuroma may be offered.

đź“ť Exam Clues & Clinchers

  • Heel pain worse on waking + improves with walking = think plantar fasciitis.
  • Sharp forefoot pain + pebble-in-shoe + Mulder’s click = think Morton’s neuroma.
  • Windlass test = plantar fasciitis
  • Morton’s most common in women, tight footwear may trigger symptoms.