Teresa’s TCM Clinical Reflections (22)
I Didn’t Twist or Injure My Foot — So Why Did It Suddenly Start Hurting?
Subtitle: How Teresa looks at bones and joints, tendons, nerves, inflammation and circulation when foot pain appears without an obvious injury
By Teresa Shen, BHSc (Acupuncture), ACC Registered Treatment Provider, Registered Chinese Medicine Practitioner (NZ)
Patients sometimes ask me:
“I haven’t twisted my ankle, knocked my foot or done any major exercise. Why has my foot suddenly started hurting?”
Foot pain does not always begin with an obvious injury.
When I see a patient like this, I do not immediately treat it as a simple “foot problem”. I first want to know: Where exactly is the pain? When does it occur? Is it worse with walking or also present at rest? Is there swelling, redness or warmth? Does the patient describe numbness, burning, tingling or an electric-shock sensation?
Different answers take the assessment in very different directions.
1. No Injury Does Not Completely Exclude a Bone or Joint Problem
A bone problem does not always require a fall or obvious accident.
A stress injury, for example, may develop after an increase in walking, running, weight-bearing or prolonged standing. The pain may be quite localised, become worse with loading, and produce focal bony tenderness.
Joint problems can also develop without a recent injury. Osteoarthritis, degenerative changes, subtalar or sinus tarsi problems and disorders affecting the first metatarsophalangeal joint can all cause foot pain.
So “I didn’t injure it” only excludes some possibilities. It does not tell us that the bones and joints are normal.
2. Tendons and Soft Tissues Can Become Painful Without One Major Injury
Another common group involves tendons, fascia and other soft tissues.
The plantar fascia, Achilles tendon, posterior tibial tendon, peroneal tendons and the flexor and extensor tendons of the foot can all become symptomatic after repeated loading.
A patient may not play sport but stand all day. Someone else may recently have increased their walking or changed footwear. Sometimes the daily routine has barely changed, yet symptoms gradually reach a point where the patient finally notices pain.
When assessing these problems, I pay particular attention to three things:
Local tenderness, resisted movement and stretch.
For example, if pain is located behind the lateral ankle, there is clear tenderness along a peroneal tendon, and resisted movement reproduces the patient’s familiar pain, that gives me more useful information than simply calling it “ankle pain”.
Where it hurts is one clue. Which movement reproduces the pain can be an even more useful clue.
3. Numbness, Burning or Electric Pain Makes Me Think About Nerves
Some foot pain does not feel like ordinary aching.
Patients may describe numbness, burning, pins and needles, stabbing or electric-shock sensations. This makes me pay more attention to possible peripheral nerve irritation or entrapment.
Different nerves supply different sensory regions of the foot. Tibial nerve or tarsal tunnel problems may affect the plantar foot. The superficial peroneal nerve supplies much of the dorsum, while the deep peroneal nerve has a characteristic sensory territory around the first web space. The sural nerve contributes sensation around the lateral ankle and lateral foot, while the saphenous nerve reaches the medial ankle and medial foot. Anatomical variation means these distributions are useful clinical guides rather than absolute boundaries.
Burning or tingling pain around the forefoot and between the toes, sometimes described as feeling like there is a pebble under the foot, may also raise the possibility of a Morton neuroma.
This is why I often ask patients to show me the exact area of pain, numbness or altered sensation.
The distribution of neurological symptoms can tell us where to look next.
4. The Foot Hurts, but the Problem May Be Higher Up
Even when symptoms appear neurological, the irritated nerve may not be in the foot.
L4, L5 or S1 nerve root problems, or more proximal peripheral nerve problems such as common peroneal nerve involvement, can produce pain or altered sensation further down into the foot.
If foot pain is accompanied by calf symptoms, numbness, burning, side-to-side sensory differences or weakness, I extend the examination proximally.
The lower back, sensation, strength, reflexes and relevant neurological tests may all become important.
Pain in the foot does not necessarily mean the problem is in the foot.
5. Sudden Redness, Swelling, Heat and Pain Change the Clinical Picture
If there has been no injury but a joint suddenly becomes red, swollen, hot and painful, I start thinking differently.
Gout commonly affects the first metatarsophalangeal joint, although other joints of the foot and ankle may also be involved.
Rheumatoid arthritis, psoriatic arthritis and other inflammatory conditions may also produce painful and swollen foot joints.
In this situation, I want to know whether similar episodes have happened before, whether other joints are involved and whether further medical investigation is appropriate.
A suddenly hot, swollen joint and a tendon that has gradually become painful after repeated loading may both be described as “foot pain”, but they require very different clinical reasoning.
6. Vascular Problems Must Not Be Missed
Vascular disease is not the most common cause of foot pain, but it matters when the clinical pattern suggests it.
Pain accompanied by significant changes in skin colour, temperature or swelling should raise concern about circulation.
Some arterial circulation problems cause pain during walking that improves with rest. More urgently, sudden severe pain with a foot that becomes unusually cold, pale or numb, particularly with weakness, requires prompt medical assessment rather than routine musculoskeletal treatment.
Once the Cause Is Clearer, TCM Treatment Has a Direction
The same symptom — foot pain — can therefore require very different approaches.
For muscle, tendon and soft-tissue problems, I combine the structures identified during examination with the relevant TCM channel pathways. I may treat local tenderness and involved tissues, combine this with distal channel-based points, and then reassess using the movement that originally reproduced the symptoms.
If peripheral nerve entrapment or mechanical nerve irritation appears more likely, I do not focus only on the painful part of the foot. I follow the nerve pathway and look for possible sites of irritation and surrounding soft-tissue tension. The clinically relevant area may sometimes be in the lower leg, around the knee or even more proximally.
For chronic joint or periarticular problems suitable for conservative care, joint movement, local tenderness and the condition of surrounding muscles and tendons all influence the treatment approach.
TCM pattern differentiation adds another layer.
If the foot feels heavy, achy and cold, with symptoms aggravated by cold conditions, I may consider a Cold-Damp pattern and, where appropriate, use acupuncture together with moxibustion.
When pain is fixed, long-standing and associated with marked local tenderness, a pattern involving Qi Stagnation, Blood Stasis and channel obstruction may lead to a different approach. Depending on the individual patient, acupuncture and selected techniques such as bloodletting or cupping may be considered.
But if my assessment raises concern about a fracture, acute inflammatory or infectious process, significant vascular problem or another systemic condition, choosing acupuncture points is no longer the first question.
Investigate what needs investigation. Refer what needs referral.
A Note for Patients
If your foot starts hurting without an obvious injury, you do not need to diagnose it yourself.
Notice where the pain is, when it occurs, whether swelling is present and whether there are sensory changes such as numbness or burning.
Persistent or worsening pain, significant redness or swelling, weakness, altered sensation, or changes in foot colour or temperature deserve appropriate assessment. Sudden severe pain with a cold, pale foot or new neurological loss requires urgent medical attention.
No injury does not mean no cause. Finding the cause gives treatment its direction.
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Disclaimer
This Clinical Reflection is provided for general health education and shares Teresa’s clinical observations. It does not provide an individual diagnosis or replace appropriate medical assessment.
Persistent or worsening foot pain, significant redness or swelling, neurological changes, or changes in foot colour or temperature should be appropriately assessed. Sudden severe pain associated with a cold, pale foot, sensory loss or weakness requires urgent medical attention.
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