How your feet work
Feet have a complex structure consisting of 26 bones, more than 30 small joints (where bones meet) and many muscles, tendons, ligaments and nerves.
Problems in the feet and ankles are often, but not always, associated with arthritis.
Most feet have an arch shape that spreads the body's weight evenly over many bones and joints. Feet with lower arches tend to be more flexible, while feet with higher arches are generally less flexible. High or low arches aren’t necessarily a problem but they can increase your chances of developing other foot problems.
The structure of the foot changes as we get older or if arthritis affects the foot joints, and many people will notice changes, particularly in the arch of the foot.
When to see a doctor
For most people foot problems can come and go without any prescribed treatment, or can respond well to self-treatment.
Even if you don't have any significant health conditions, you should still seek help if your foot problem:
- involves ulceration of the skin or is infected
- impairs the blood flow to the skin
- has caused pain for more than three months
- is getting noticeably worse
- is changing the colour of your skin, especially if it's dark blue or black
- is leading to progressive changes in the shape of your foot.
You should also seek help if you develop foot problems and you have increased swelling, you're on drugs which suppress your immune system (including steroids or biologics) or if you have a history of poor skin healing.
How are foot problems diagnosed?
In most cases a simple clinical examination is all that is required. This usually involves looking carefully for signs such as swelling, combined with a short hands-on exam to work out which structures might be involved. Sometimes it is helpful to have the person walk up and down to see what happens during weight-bearing and routine activities.
It is less common for foot problems to require blood tests or imaging (for example, X-ray or ultrasound) to reach a diagnosis.
The feet and ankles can be affected by several types of arthritis, including osteoarthritis and inflammatory arthritis.
Osteoarthritis can affect any joint in the foot. Osteoarthritis is a chronic problem that may cause episodic pain and swelling in a joint or joints; it can also cause bone enlargement. As people get older, osteoarthritis can be linked to changes in the shape of feet, which may cause pain.
Osteoarthritis often affects the big toe joint. The joint will become stiffer and the range of movement will be reduced. Often the bones become larger and knobbly due to an overgrowth of new bone. These changes may accompany a bunion (a lump on the side of the big toe joint). You may also notice a bunionette (a lump on the side of the little toe joint).
Recent findings suggest that osteoarthritis is more common in the arch area of the foot than previously thought. Osteoarthritis can also develop in the ankle, but this is usually following a previous injury or damage to the joint from long-standing inflammatory arthritis. Osteoarthritis in the feet often accompanies osteoarthritis in other joints.
Read more about osteoarthritis.
There are various forms of inflammatory arthritis, which can affect feet in different ways.
- Rheumatoid arthritis can affect many joints in the feet.
- Reactive arthritis usually affects the ankle or the area around the heel. It may also affect the toes, causing pain and swelling, which is known as dactylitis.
- Psoriatic arthritis often causes dactylitis.
- Gout most commonly affects the big toe joint. It is a very painful type of arthritis. Gout causes severe inflammation and makes the joint red, hot and swollen during an attack, which typically lasts one to two weeks. Without treatment, repeated attacks can cause permanent damage to the joint and lead to osteoarthritis. It is caused by the formation of urate crystals in a joint. However, gout can usually be well controlled with medications.
- Ankylosing spondylitis mainly affects the spine but may also affect the heels.
Apart from problems in the joints themselves, people with inflammatory arthritis may have inflammation and discomfort in the tendons and the other soft tissues in the feet. The part under or behind the heel where the tendons attach to the heel bone (the Achilles tendon) is quite often affected in this way.
Dactylitis causes pain and swelling, usually in just one or two of the toes and can be referred to as 'sausage toe'.
Connective tissue disease
Raynaud's phenomenon is a circulatory problem that causes the blood supply to certain parts of the body to be reduced, especially when exposed to cold conditions. It more commonly affects fingers, but it can also cause toes to temporarily cold and numb and turn white, then blue, then red. These attacks often only last a few minutes, and moving into a warmer environment often stops the attack. Wearing warm gloves and socks may help to prevent an attack.
Raynaud's phenomenon can occur with the conditions:
Watch out for ulcers on the toes, or a colour change which doesn't go away as quickly as usual. These problems are usually very painful. If you develop one of these symptoms, you should see your doctor or contact your rheumatology nurse specialist as soon as possible.
Sometimes with lupus the joints and tendons are affected and you may notice that the toes drift outwards and the arches may flatten. This can be painful and may cause a feeling of stiffness after periods of rest.
Why does foot pain become persistent?
In most cases foot problems will not become persistent. Painful heels for instance can settle down spontaneously even after many months of causing trouble. Some foot problems though will go on to be persistent, osteoarthritis is a good example.
If you have foot symptoms that have persisted for more than three months it's worth seeking a professional opinion.
Most foot problems will be helped by finding footwear that has more room and is more comfortable, and by losing weight if you're overweight. A number of specific treatments can also help.
Non-steroidal anti-inflammatory drugs (NSAIDs)
NSAIDs can help to relieve painful inflammation, for example in the arch or heel area. Like all drugs, NSAIDs can sometimes have side-effects, but your doctor will take precautions to reduce the risk. For example, by prescribing the lowest effective dose for the shortest possible period of time.
NSAIDs can cause digestive problems (stomach upsets, indigestion or damage to the lining of the stomach) so in most cases they will be prescribed along with a drug called a proton-pump inhibitor, which will help to protect the stomach by reducing the secretion of gastric acid.
NSAIDs also carry an increased risk of heart attack or stroke. Although the increased risk is small, your doctor will be cautious about prescribing them if there are other factors that may increase your overall risk, for example, smoking, circulation problems, high blood pressure, high cholesterol or diabetes.
Insoles, which are sometimes used with special shoes, can relieve arch pain or tiredness and can help to correct less severe cases of valgus heel.
A steroid injection may be recommended if just one or two joints are inflamed and painful, and it might help inflamed tendons and bursae, neuromas and plantar fasciitis. You'll need to rest the foot for up to 48 hours after the injection to get the best result.
Disease-modifying anti-rheumatic drugs (DMARDs)
DMARDs are prescribed for some people with inflammatory arthritis. They act by altering the underlying disease rather than treating the symptoms. They're not painkillers, though they'll reduce pain, swelling and stiffness over a period of weeks or months by slowing down the disease and its effects on the joints. A common example is methotrexate.
There are a few foot-specific points to consider in relation to biologic drugs used to treat inflammatory arthritis. First, if you have persisting foot involvement while on other disease modifying anti-rheumatic drugs (DMARDs) you should discuss with your rheumatologist or nurse the options for starting a biologic. Often the feet are inadvertently overlooked.
If you're already on a biologic there are a few other considerations you'll need to bear in mind. Because biologics suppress the immune system, you need to be aware of the effect of biologics on infection. We don't think biologics make a difference to the overall risk of infections in your feet, but biologic use does seem to make infections take hold more quickly and cause greater trouble.
If you're on biologics do not use corn plasters or skin scrapers and if you do have an ulcer or infection it is very important to make sure you let your rheumatologist know as soon as possible.
In some people starting a biologic drug can result in a big improvement in joints in the upper body but problems can persist in the leg joints. We think this is because these weight-bearing joints may have already been damaged. If you do have ongoing aches and pains in your feet, ankles and knees after starting biologics, again let your rheumatologist or nurse specialist know. There are often additional treatments that can help.
Surgery is sometimes recommended to improve the structure of your feet. If other treatments haven’t helped, surgery may be suggested to:
- correct valgus heel or hammer toes
- remove a neuroma or rheumatoid nodule
- remove part of the bone from a bunion and reshape your toes
- relieve pain.
Joint replacements for the ankle and foot aren't yet as successful as replacement knees and hips. Most foot surgery is aimed at correcting the positions of the joints by resetting the bones or fusing the joint in the corrected position. Your surgeon will discuss the potential pros and cons of all the available options before you decide to go ahead with surgery.
Complementary and alternative therapies and medicines
Therapeutic massage can help to reduce pain or tiredness in the feet. Massage can be combined with a relaxing warm-water footbath, and both of these are fine as long as you don't have any open wounds or sores on your feet.
The effectiveness of treatments such as accupressure sandals and magnetic insoles isn't supported by evidence.
Generally speaking, complementary and alternative therapies are relatively well tolerated, although you should always discuss their use with your doctor before starting treatment. There are some risks associated with specific therapies. In many cases the risks associated with complementary and alternative therapies are more to do with the therapist than the therapy. This is why it's important to go to a legally registered therapist, or one who has a set ethical code and is fully insured.
If you decide to try therapies or supplements, you should be critical of what they're doing for you, and base your decision to continue on whether you notice any improvement.
A regular footcare routine can help to keep problems to a minimum but seek advice from your doctor or a podiatrist first, especially if:
- you have vasculitis
- you have scleroderma
- you're taking steroids or biologic drugs
- your skin is slow to heal.
The routine should include regular nail cutting, filing the skin and applying appropriate foot care cream. Choosing the right footwear is important.
Good footwear, which is supportive and comfortable, is essential to improve pain and discomfort in the feet.
You may need to take special care of your feet if you have arthritis, either because of the condition itself or because of the medications you take. A good, regular footcare routine will usually keep problems to a minimum:
- Wash your feet daily and dry them thoroughly, especially between your toes.
- Surgical spirit, which you can buy from chemists, helps if the skin between your toes becomes white and soggy-looking. Don't apply to sore or cracked skin.
- Use a dedicated foot cream with 100% urea concentration for dry skin.
- Cut your toenails every six to eight weeks. Cut straight across and use an emery board to file down the sharp edges.
- Treat minor cuts, blisters or grazes by covering them with a dressing and keeping them dry. If they don't heal in two to three days, seek professional advice.
- If you suffer from ulcers on your feet, make sure you apply an appropriate dressing to broken skin and take advice from your GP, nurse or rheumatology team. You may need antibiotics if the ulcers become infected. If you're on biologics seek medical advice within 24 hours, because of risk of infection.
- If you have athlete's foot (a fungal skin infection, causing itching and sometimes a rash), thorough washing and drying between your toes will help. A cream or powder from the chemist will speed up the healing process.
- Toenails can be affected by fungal infections. Topical application of anti-fungal paints and/or oral anti-fungal therapy can be obtained on prescription from a GP.
If you have rheumatoid arthritis, you should have your feet checked by a professional just after your diagnosis and then once a year. This can be done by your GP, rheumatologist or nurse, and if you have problems you should be referred to an HCPC-registered podiatrist.
Some people with rheumatoid arthritis have a burning sensation in their feet at night. Using a hot-water bottle filled with cold water can help but you should speak to your doctor about it, especially if this is a new symptom.
Calluses can usually be scraped away using a pumice stone or abrasive board. You should never use an open blade such as a scalpel or razor blade. Special skin files and scrapers may be suitable as long as you and your skin are in good health, although these will not help much with corns where the nucleus goes deeper into the skin. Check with your doctor or an HCPC-registered podiatrist first, especially if:
- you have lupus, vasculitis or scleroderma
- you have a history of skin ulcers
- you suffer with a circulatory disorder such as Raynaud's phenomenon
- you're on steroid tablets.
Pads and cushions available from the chemist may help with painful pressure points, but over-the-counter creams and medicated corn plasters aren't generally recommended. If you're on steroids or biologics, or if you have vasculitis or your skin heals slowly you should avoid these treatments altogether.
If you can't care for your feet yourself, your GP or hospital consultant can refer you for professional care within the NHS. Podiatry services accept patients on a self-referral basis. An HCPC-registered podiatrist will help with troublesome nails, corns and calluses, and they'll provide advice on finding special shoes or orthoses. Some centres have access to an orthotist who will be able to assess and provide ready-made or custom-made shoes as required.
Other foot problems
Problems in the ankles and heels
Pain in the ankles and heels can come from joints themselves, or from muscles and tendons around the joints. Osteoarthritis isn't very common in the ankle but can be the result of previous damage from an injury or due to inflammatory arthritis.
When inflammatory arthritis affects the ankle, the joint may be sore or stiff first thing in the morning or after sitting for a while.
Exercises to manage foot pain
The foot can be affected by many different conditions. Two causes of foot pain are plantar fasciitis and Achilles tendinitis. Try the exercises suggested here to help ease pain and prevent future injuries. Your pain should ease within 2 weeks and you should recover over approximately a 4-6 week period.
Sitting plantar fascia stretch
Sit down and cross one foot over your knee. Grab the base of your toes and pull them back towards your body until you feel a comfortable stretch. Hold for 15-20 seconds. Repeat 3 times.
Plantar fascia stretch
Sit down and rest the arch of your foot on a round object (e.g. a tin of beans). Roll the arch in all directions for a few minutes. Repeat this exercise at least twice daily.
a) Facing a wall, put both hands on the wall at shoulder height and place one foot in front of the other. The front foot should be approximately 30 cm (12 inches) from the wall. With the front knee bent and the back knee straight, bend the front knee towards the wall until the calk in your back leg feels tight. Relax and repeat 10 times.
b) Repeat a) but bring the back foot forward a little so that the back knee is slightly bent. Repeat the 10 times.
Sit down with a towel on the floor in front of you. Keeping your heel on the ground, pick up the towel by scrunching it between our toes. Repeat 10-20 times. As you improve, add a small weight such as a tin of beans to the towel.
Achilles tendon and plantar fascia stretch
Loop a towel around the ball of your foot and pull your toes towards your body, keeping you knee straight. Hold for 30 seconds. Repeat 3 times on each foot.
- The foot can be affected by many different conditions. Two causes of foot pain are plantar fasciitis and Achilles tendinitis.
- Finding comfortable footwear and using insoles if needed can help with symptoms.
- You can take painkillers to ease pain. Taking them before exercise can help you stay active without causing extra pain.
- Try the exercises suggested here to help ease pain and prevent future injuries.
- Your pain should ease within 2 weeks and you should recover over approximately a 4-6 week period.
Exercise is important to keep your joints moving and helps you keep to a healthy weight. Losing weight if you're overweight can be difficult, but will help ease the pressure on painful feet. Swimming and other non-weight-bearing exercises are best if painful feet make it difficult to exercise. A Health and Care Professions (HCPC)-registered physiotherapist or podiatrist may be able to suggest exercises to help with particular foot problems.
If your ankles feel stiff in the morning, allowing some time for your joints to loosen up will usually help. You might find that having a bath or shower helps because the warm water can ease stiffness. During the day, alternate between sitting and standing activities to take the pressure off your feet. Resting for 10 minutes at a time throughout the day can be helpful, especially if you keep your feet raised. This is particularly useful if you have plantar fasciitis or swollen ankles.
Getting the right footwear will make a difference for almost all foot problems and the importance of appropriate footwear should not be underestimated. A bit of trial-and-error to get the right footwear might remove the need to seek out professional help.
Changes to footwear will be part of most professional discussions about foot problems. Comfort should be the main consideration when choosing shoes.
High-heeled shoes or shoes that pinch your feet can contribute to the development of deformities such as bunions or hammer toes.
Your feet may change shape as you get older, especially if you have arthritis, so you may need to try a different size or width fitting. If the footwear protects your feet against injuries, supports them and keeps them warm, dry and comfortable, it's doing its job.
An adequate fastening will improve fit generally and help if the feet swell.
Leather uppers are usually the most comfortable if you have foot problems, although many modern materials offer breathability, flexibility and comfort. Look for a cushioning sole unless you've been advised by a doctor or podiatrist that rigid soles are better for your particular foot problem.
If you have hammer toes or prominent joints, look for a smooth lining without seams.
If you need special insoles or orthoses, make sure there's enough room to fit them, especially in the toe area.
Around the house, slippers may feel the most comfortable for hammer toes and prominent joints, but make sure the soles provide adequate cushioning. You should also make sure that they are non-slip/trip. Always wear shoes when you're outside to make sure your feet are properly supported. Factors to consider when buying shoes
Have your feet measured if they've become wider over the years or have changed shape because of arthritis. Your feet may change shape when you stand up, so have them measured while standing. Many shops have experienced fitters.
Try shopping later in the afternoon. If your feet tend to swell, they'll be at their largest at that time.
Judge a shoe by how it feels on your foot and not just by the size marked on the shoe. Size varies between shoe brands and style. Think about how the shoe fits around your toes, under the soles and at the back of the heels.
Always buy your shoes to fit the larger foot; many people have one foot bigger than the other. An insole can be used in the other shoe. There can be at least 1 cm (3/8 inch) of room at the front of the biggest toe.
Try shoes on with the type of socks or stockings you normally wear or with any insoles or orthoses you normally use. Some insoles may need extra depth, especially in the toe area.
Don't buy shoes to break in later; the right shoes for you will be comfortable when you first try them on.
Buy shoes that have both leather uppers and inners (the inner lining), if possible. These are more breathable than inners made of synthetic materials and will help to avoid dampness and fungal infections.
Look for dark colours and a suede finish if you're worried about the appearance of your feet, they'll help to disguise the problem.
You may need insoles in your shoes for a number of reasons. An insole, or orthosis, can help to support the arch of your foot. If you have arthritis in the joint across the middle of your foot (the midtarsal joint), a rigid insole may help. If you have one foot bigger than the other, an insole can help to pad out the shoe of your smaller foot.
Insoles will often take up half a shoe size, so take along your largest shoes when you go for an insole fitting. Sometimes you may need to purchase a larger shoe to accommodate an insole, although this is not always the case. Take your insoles along when you buy new shoes.
If you need to wear a prescribed insole, don't try to wear the new insole all day when you first receive it. Wear it for a short period at first and gradually build up to longer periods. Don't use them for heavy duty activity or exercise.
If you change your shoes indoors, either have a second pair of insoles for your indoor shoes or remember to swap the insoles over. Your feet will return to their old shape while indoors and will never be comfortable if you don't continue to wear your insoles.
Lace-up shoes can be difficult to fasten if you have arthritis in your hands. Here are a few alternatives:
- Elastic laces can be easier to use because one pull ensures a snug fit and they don't need to be tied.
- Many shoes are now available with Velcro fastenings, which can be done up and adjusted using only one hand.
- A zip fastening can be easier to manage than laces or buckles, and a ring (such as a keyring) added onto the zip pull can make it easier to pull up.
There are also a number of devices available to help people with putting on socks, tights/stockings and shoes. Useful leaflets on this and other subjects related to the feet and footwear are available from the Disabled Living Foundation or through your local occupational therapist.
Struggling to find the right shoe?
People with permanently swollen feet, very narrow, long, or broad feet, or with hammer toes or bunions may find it difficult to find shoes that fit them well.
A number of retailers are beginning to stock shoes with extra width and depth, which can help. It may be possible to have high-street footwear adapted by an orthotist - ask them for advice.
Some people may have footwear prescribed by their consultant, GP or by a Health and Care Professions (HCPC)-registered podiatrist, but they're usually provided by an orthotist. You can also opt to see an orthotist or orthopaedic shoemaker privately. Each NHS hospital trust will have its own arrangements for footwear referral and entitlements.
Wearing slippers around the house
Many people prefer to wear slippers around the house. However, slippers aren't a good idea for those who have to wear special insoles. They also sometimes contribute to falls in the elderly. The uppers of slippers are often soft, so they're comfortable for hammer toes and prominent joints, but the soles may lack adequate cushioning and grip.
Like outdoor shoes, slippers should fit properly and shouldn't be too loose. Backless slippers and slippers with high heels really should be avoided. The features of the ideal slipper are generally the same as for the ideal shoe.
Wearing safety footwear
If you need to wear safety boots for work, they should display the British Kitemark or CE mark.
If your existing safety footwear is uncomfortable, you may need to talk to your employer about getting alternatives. Safety versions of extra-depth and cushioned shoes are available. If you suffer from toe or foot ulceration, make sure that safety footwear is not causing pressure or pain to the wounds.
Dealing with cold feet
Many slippers, shoes and boots are available with linings such as sheepskin or synthetic fur to help keep the feet warm. Wearing thicker socks or two pairs (as long as they're not too tight) not only helps to keep the feet warm but also provides extra cushioning under the soles of the feet.
Keeping the feet warm will also be easier if you keep the rest of your body warm.
Scleroderma & Raynaud's UK produce a leaflet containing tips for keeping warm.