1. The painful foot Pain is usually well localized to a single area that can be the heel, midtarsal region or the forefoot. A. The painful heel: In children the most likely cause is Sever’s disease (apophysitis). It is not really a disease but a mild traction injury occurring in boys around 10 years. Pain and tenderness are localized to the tendo Achilles at is insertion. The heel of the shoe should be raised a little and strenuous activities restricted for a few weeks. In adolescent girls a calcaneal knob is common. The posterlateral portion of the calcanium is too prominent and the shoe rubs on it causing pain. If attention to footwear does not help, the bony knob is removed.

2. Young adults sometimes develop pain above the heel. The tendo Achilles is thickened and tender. It is common in athletes and is due to a peritendinitis. The acute form may be relieved by rest, ice packs and strapping. The chronic form may need operation to divide the tendon sheath and fascia; if there is a necrotic area in the tendon, this may need excision. Acute Plantar fasciitis: Pain is under the heel and sharply localized tenderness may occur in gout or in Reiter’s disease, or Rh. arthritis. It is due to inflammation of the tough ligamentous tissue inserting into the undersurface of the calcanium (the planter fascia of the foot). The underlying disorder should be treated and the painful area protected from uneven pressure.

3. Older adults (40-60 years) may also develop a painful plantar fasciitis usually less distressing than the acute disorder. It’s very common, its related to chronic stress as longtime standing or overweight (‘policeman’s heel’), but more often the cause is not apparent. Clinically the patient presents with chronic pain on the inferior aspect of the heel that has the character of relapse and remission, it occurs as a result of long standing or prolong walking. The tenderness on examination is localized to the site of attachment of the planter fascia to the under heel, pain is characteristically present and severe after periods of rest as after getting up from sleep as the patient complain of inability of normal walking and painful heel after getting out of bed and they use to tip-toe for few minutes until the acute pain is relieved as they can walk normally and plantigrade. A pressure-relieving pad together with an arch support if there is flat foot, may help with the use of NSAID and possibly local steroid injection. Sometimes it’s resistant to treatment and may indicate surgery.

4. B. Painful tarsus: In children Osteochondritis of the navicular bone (Kohler’s disease) may cause pain and tenderness over the dorsum of the mid-foot. If activities are restricted for a few weeks, the pain usually disappears. In young adults, pain over the medial aspect of the naviculum may due to a congenital accessory navicular bone. The accessory bone may be prominent under the skin and feels tender. X-ray will show the type of this accessory segment that may need surgical removal; otherwise simple adjustment of shoe wear can be of great help. In adults, pain in the same region is sometimes associated with a prominent ridge of bone. X-rays show osteophytes formation at the joint between the media] cuneiform and first metatarsal. If shoe adjustment fails to provide relief the lump may be removed surgically.

5. C.Painful forefoot (metatarsalgia): Any foot abnormality that results in faulty weight distribution may cause nagging pain in the forefoot. It is therefore a common complaint in patients with: 1.Hallux valgus. 2.Claw toes. 3.Pescavus. 4.Flat foot. 5.Foot strain. 6.Freiberg ‘s disease. 7.Stress fracture. 8.Morton’s metatarsalgia. 9.Gout. 10.RA.

6. Freiberg ‘s disease: This is a ‘crushing’ type of osteochondritis of the second metatarsal head (rarely the third). It affects young adults, usually women. A bony lump (the enlarged head) is palpable and tender; the joint is irritable. X-rays show the head to be wide and flat. If discomfort is marked the metatarsal head is excised. Stress fracture: Usually of the second or third metatarsal occurs in young adults after unaccustomed activity. The affected shaft feels thick and tender. The x-ray appearance is at first normal; but later shows fusiform callus around a fine transverse fracture line. Rest is all that is needed. Morton’s metatarsalgia: The patient usually a woman of 40-50 years complains of sharp pain in the forefoot, radiating to the toes. Tenderness is localized to one of the interdigital spaces - usually the third - and sensation may be diminished in the cleft and adjacent toes. This is essentially an entrapment syndrome affecting one of the digital nerves, but secondary thickening of the nerve creates the impression of a ‘neuroma’. If symptoms do not respond to protective padding the ‘neuroma ‘is excised.

7. Toenail disorders: The toenail of the hallux may be ingrown, overgrown or undergrown. Ingrowing toenail: The nail burrows into the nail groove, which ulcerates, and its wall grows over the nail, so the term (embedded toenail) would be better. The patient is taught to cut the nail square, to insert a cotton-wool pieces under the ingrown edges and always to keep the feet clean and dry. If these measures fail, the gutter treatment is worth trying, a small wedge of soft tissue (where the nail digs in) is excised; a fine polythene tube is cut vertically in half and a segment inserted between nail and soft tissue. More radical measures include partial or complete removal of the nail, taking care to remove the whole germinal matrix. Overgrowing nail (onychogryposios): The nail is hard, thick and curved. A chiropodist (person who care for feet) can usually make the patient comfortable, but occasionally the nail may need excision. Undergrown nail: A subungual exostosis usually grows on the dorsum of the terminal phalanx and pushes the nail upwards. The exostosis should be removed.