Non-surgical treatment for foot pain

Ross Hauser, MD, Danielle R. Steilen-Matias, MMS, PA-C

When we see patients for foot pain and the various disorders they have, these patients have usually been through all the conservative care options that can be offered for foot problems and they still suffer from conditions and symptoms that are not responsive to any treatments.

The people that contact us tell stories that go something like this:

My doctors have described me as a complicated case. I have learned what the word “refractory,” means. It means my conditions are stubborn. But to me, it means that nothing is helping. I have had many scans and MRIs. I have been offered one possible explanation after another for my foot problems.

I have been diagnosed with:

Hallux Rigidus, bone spurs, the pain of unknown origin in the ball of the foot, and sesamoiditis.

My treatments have included:

Shoe orthotics, custom-made shoes, extensive rest, walking boots, anti-inflammatories because the boots and shoes caused swelling.

I have been recommended to various surgeries including various types of fusions and tissue retractions to alleviate nerve compression.

No one can seem to help me with my simple goal: I want to be able to walk and live a normal life without constant preoccupation with my foot pain.

Non-surgical treatment for foot pain

In this article, we will examine various options for the treatment of foot pain.

If you are reading this article there is a very strong chance that you have already tried many types of self-help, self-management, and other remedies to help get you through your foot pain problems. There is also a strong likelihood that you do physically demanding work or you are an athlete or dancer trying to stay in shape or are working your way through pain or trying to stay on the field or court.

So what have you tried so far?

Over-the-counter medications?
- Many people we see have tried Non-steroidal anti-inflammatory (NSAIDs) and pain medications. Initially, they helped. Then they didn’t. What many people find troubling is that when they see a pain specialist and tell them that they are not getting relief with NSAIDs, they simply are prescribed stronger doses.
Shoe inserts, foot, and ankle braces?
- Many people tell us that they have been online, bought some foot braces and shoe supports. They did not help. When they went to a pain specialist a custom orthopedic was made and for some this help relieve some of the symptoms. For many, however, relieving the symptoms, while very desirous, the shoe supports did not address the weakness or problems that need to be corrected so they could resume their demanding line of work or their sport or dance.
Physical therapy?
- For some people, physical therapy works very well. For others, not. If you are reading this article it is very likely that physical therapy did not help you achieve your treatment goals.
Cortisone injections?
- If there is chronic swelling and pressure in the foot a cortisone injection may have been recommended and given. For many people, this worked very well and provided a great deal of pain relief and the inflammation diminished. For some, while initial pain relief was attained, subsequent cortisone injections provided less relief.
Platelet Rich Plasma injections?
- Many times we will receive an email from someone who has tried Platelet Rich Plasma injections from their pain specialist that did not help them and they want to know why. As this is a treatment we offer we will explain PRP below in more detail.
- PRP treatment takes your blood, like going for a blood test, and re-introduces the concentrated blood platelets from your blood into areas of chronic joint and spine deterioration.
- Your blood platelets contain growth and healing factors. When concentrated through simple centrifuging, your blood plasma becomes “rich” in healing factors, thus the name Platelet RICH plasma. Platelets play a central role in blood clotting and wound/injury healing.
- The procedure and preparation of therapeutic doses of growth factors consist of an autologous blood collection (blood from the patient), plasma separation (blood is centrifuged), and application of the plasma rich in growth factors (injecting the plasma into the area.) In our office, patients are generally seen every 4-6 weeks. Typically three to six visits are necessary per area.
Platelet Rich Plasma therapy may fail if it is given once.
- In our experience, PRP is usually not a one-time treatment that will bring the patient their desired pain relief and function improvement. For many people, the degenerative conditions in their feet did not occur overnight and therefore cannot be expected to be repaired overnight. PRP therapy should, for most people, not be thought of as a single one-and-done treatment.

Prolotherapy: Alternative treatment for foot pain

For people like those that contact us with these complicated cases and where conservative care treatment has not helped them and now a decision on surgery needs to be made, we offer one possible solution. Prolotherapy injections.

Prolotherapy injections. This is the injection of dextrose, a simple sugar that provokes a healing response in damaged soft tissue.

Injection treatments to treat the toe and foot complex

In our experience with athletes, there is almost always a great sense of urgency to “do something . . . anything,” to get these athletes back on the field or back to training, ASAP.” Our preferred methods are regenerative medicine injections that rebuild, restore, regenerate damaged connective tissue, and the tissue’s elastic strength. Explosive power generated from the toe and foot comes from this strength and resilience of the ligaments and tendons.

The patient is comfortable during treatment

In the video below you will hear Danielle R. Steilen-Matias, MMS, PA-C describe this patient’s treatment for turf toe.

This is a Prolotherapy treatment. The Prolotherapy injection consists of simple dextrose. The dextrose is given in the areas of the ligament attachments. This creates a controlled inflammation at the ligament attachments surrounding the big toe. This stimulates and accelerates healing and strengthens the ligaments to stabilize the toe joint and repair problems of hyperextension and hyperflexion. Dozens of research studies have documented Prolotherapy’s effectiveness in treating chronic joint pain.
The whole toe joint capsule is treated. This means a lot of injections to make sure all the ligaments are treated.
After the treatment, the patient is told to rest for about 4 days and then they can start resuming their exercise gradually or as tolerated.

MOVEMENT: When Prolotherapy is given, the patient is encouraged to move the toe. Toe crunches can be recommended. This can be done with toe spacers in place if there is a bunion forming or the tow is not anatomically aligned.

In this video, Ross Hauser, MD explains and demonstrates the treatment for Prolotherapy for toe pain, instability, and bunions.

The treatment begins at 1:12.

In this video, a medical professional is being trained on the Prolotherapy technique by Dr. Hauser. Dr. Hauser is the one making the pointing gestures to guide the injections.

Prolotherapy injections involve using a simple and safe base solution, dextrose as the primary proliferant (treatment), along with an anesthetic (such as procaine or lidocaine), that is given into and around the entire painful/injured area(s). Many injections are given during each treatment. Most treatments are provided every 4 to 6 weeks to allow time for the growth of new connective tissues.
We recommend toe crunch exercises in most patients. This is discussed at the time of the treatment.
If there is a valgus deformity, we may suggest “Yoga Toes,” or other toe separation or toe stretching apparatus.
If sesamoid bone pain or sesamoiditis was present, we would have continued the treatment to address those concerns.

Perhaps no activity, sports or work, puts as much pressure and demand on the feet as dancing does. If you can show improvement in dancers then you can reasonably expect a high level of success in foot problems in other patients.

In this article, we will examine treatment options and the research behind Prolotherapy for foot pain.

Writing in The Journal of Orthopaedic and Sports Physical Therapy doctors reported on a case where Prolotherapy injections successfully treated a dancer who had suffered from foot instability due to the excessive force she was placing on her metatarsophalangeal joints (the foot area formed by the metatarsal and phalangeal bones of the toes).

In their case presentation the doctors reported that the 33-year-old dancer with insidious onset (meaning slowly developing and without symptoms) of the medial arch and second and third metatarsophalangeal joint pain had imaging studies revealing:

osteoarthritis of the first metatarsophalangeal joint,
second metatarsophalangeal joint calcification,
capsulitis (ligament inflammation),
and plantar plate rupture (ligament tear), leading to a diagnosis of instability.

The dancer underwent a treatment program that included taping, padding, physical therapy, a series of prolotherapy injections, and activity modification.

One year after discharge, the dancer reported pain-free dancing with no taping or padding. (1)

Ligaments of the toes and feet – the cause of foot pain and instability

In the case study above the stress of dancing severely compromised the structures of the foot and caused degenerative conditions throughout the foot.

In 2012, Ross Hauser, MD, and Wayne A. Feister DO publish findings in the Foot and Ankle Online Journal from the International Foot and Ankle Foundation.

In this research, the doctors examined the foot for hallux valgus, a precursor to bunions, and hallux rigidus stiffness in the big toe and associated ligament laxity is known to cause these problems.

In this study, twelve patients were treated with a series of Prolotherapy injections to stimulate the regeneration of tendons and ligaments and to promote the repair of articular cartilage. Upon completion of three-to-six therapy sessions, eleven of twelve patients had a favorable outcome—the relief of symptoms—with an average of four treatments. (2)

One year earlier in 2011, health professionals here at Caring Medical published their findings on alternative treatments for foot pain. The main treatment tested was Prolotherapy. Here is what Ross Hauser, MD and colleagues published in the Journal of Prolotherapy:

The goal of the observation study was to test the effectiveness in patients using comprehensive dextrose Prolotherapy treatments on foot and toe pain. Patients were chosen who were given varied diagnoses as to the cause of their foot pain. Some of the most common is hallux rigidus (stiff big toe) and hammertoes. Prolotherapy is an injection treatment used to initiate a healing response in injured connective tissues such as tendons and ligaments, common in painful foot and toe conditions.

Study highlights:

Nineteen patients who had been in pain for an average of 54 months were treated quarterly with Prolotherapy. This included eight patients who were told by their medical doctor(s) that there were no other treatment options for their pain.
Patients have contacted an average of 18 months following their last Prolotherapy session and asked questions regarding their levels of pain, physical and psychological symptoms, as well as activities of daily living, before and after their last Prolotherapy treatment.

Results:

In these 19 patients, all 100% had improvements in their pain and stiffness.
Eighty-four percent experienced 50% or more pain relief.

Prolotherapy helped the patients make large improvements in walking and exercise ability, as well as produced decreased levels of anxiety and depression.

One-hundred percent of patients said Prolotherapy changed their lives for the better. (3)

What are we seeing in this video?

In this video, Ross Hauser MD discusses a brief ultrasound examination that can show how your big toe pain is coming from toe joint instability. In the video, this is demonstrated by gently pulling on the toe to check for toe ligament damage and laxity or looseness.

Prolotherapy for Metatarsalgia and Tarsal Tunnel Syndrome

Please see our companion article for questions on Morton’s Neuroma.

Doctors writing in the medical journal Foot and Ankle Clinics noted: “The traditional open surgical options for the treatment of metatarsalgia and lesser toe deformities are limited and often result in unintentional stiffness.”(4)

Metatarsalgia is an umbrella term and not the name of an actual injury. It can be a pain in the ball of the foot with or without inflammation. Sometimes the diagnosis is isolated down to Tarsal Tunnel Syndrome.

Tarsal Tunnel Syndrome is very similar to Carpal Tunnel Syndrome. The tibial nerve runs in a canal on the inside of the foot called the tarsal tunnel. When the tibial nerve gets pinched here, it is called Tarsal Tunnel Syndrome. The symptoms described for this syndrome include pain in the ankle, arch, toes, or heel.

Recent research found that one of the many reasons Tarsal Tunnel Syndrome treatment fails is the lack of an accurate diagnosis or lack of understanding or appreciation of the actual anatomy involved. (5)

Dancers again. Most research however points to simple wear and tear as the main culprit, and to demonstrate this in the extreme doctors writing in the medical journal Medical Problems of Performing Artists, looking at female professional flamenco dancers and found that the evidence for high heels or other shoe problems as the cause of their chronic foot pain was not as common as chronic repetitive trauma suffered during the practice of footwork dancing. (6)

Surgery questionable

In the journal Foot & Ankle Specialist, Dr. Valerie L. Schade wrote that advanced metatarsalgia can lead to conditions of Avascular necrosis (bone death) of the second metatarsal head. Conservative treatment includes nonsteroidal anti-inflammatory medication, reduced activity, padding, orthotics, and immobilization. When conservative treatments fail, a wide variety of surgical procedures exist; however, the optimal procedure is unknown. (7)

Plantar Fasciitis

The pain associated with plantar fasciitis is usually described as a pinpoint or knife-like pain in the heel pad. Pain is usually worse in the morning when the plantar fascia is stiff, cold, or tensed. The pain is caused when the damaged tissue is stretched, so when the person begins to bear weight on the foot, the pain level is very high but lessens as he/she continues to walk/run, presumably as the plantar fascia becomes more flexible. The pain typically originates very gradually; starting only with pain at the beginning of the exercise. However, without appropriate treatment; even walking becomes too painful.

Plantar fasciitis can occur for any number of reasons, most having their root in simple overuse. The pain is a result of the weakness of the plantar fascia, which then inflames. Please see our article on Plantar fasciitis and Plantar Fasciopathy for a more detailed discussion on these problems.

A heel spur forms because the plantar fascia is barely connected. Thus, the heel spur is not the cause of the pain, but rather the result of plantar fasciitis. By administering Prolotherapy, the spur-producing process stops. This idea is applicable to any osteoarthritis process in the body. Prolotherapy stops every arthritis-producing process because it corrects the root of the problem, which is a tendon, ligament, and fascia weakness. Prolotherapy has corrected many a foot problem that would otherwise have had to have surgery that is often unsuccessful.

Toe Pain

The toes of the feet are held together in part by capsular ligaments. These ligaments keep the toes pointed straight. Capsulitis is an inflammation of these ligaments.

Turf toe is a very common condition among football players, as well as other “turf” sports. Turf toe is, simply, a sprain of the ligament of the great toe.

Turf toe may cause severe and chronic pain. If there is an injury to the MPJ, it can lead to prolonged disability, because the MPJ joint is vital to walking. This is the joint involved in the push-off phase of walking and running. If untreated, turf toe can cause hallux rigidus or an immobile joint in the great toe. Other long-term injuries include painful arthritis and bunions.

In the Journal of Foot and Ankle Surgery, doctors write: Surgical treatment of moderate hallux rigidus remains controversial and the optimal surgical technique has yet to be defined. (8)

Bunions also referred to as hallux valgus or hallux abducto valgus, and hammertoes (hallux malleus), are two common diagnoses for toe pain whose etiologies can be related to the structures of the forefoot. A multitude of diagnoses can be arrived at for foot/toe pain, though many times the underlying problem, weakness, or injury in the ligaments, tendons or cartilage, is the culprit. For a more detailed discussion on Bunion pain and Prolotherapy.

Sesamoiditis

Runners and dancers are most likely to suffer from sesamoiditis, but really anyone can experience this type of pain in the big toe. It occurs in the ball of the foot as the sesamoid bones become irritated. Like the kneecap, the sesamoid bones act as a pulley. Unlike the kneecap, the sesamoid bones are tiny bones that run along the tendon to the big toe. As they become irritated, they can cause inflammation in the tendon in which they reside. Standard treatment for sesamoiditis includes rest, ice, and special shoe pads. Unresolved sesamoiditis pain involves removing the sesamoid bones. See our article on Sesamoiditis Pain Treatment

Small toe the fifth metatarsal

Researchers at Sechenov University in Moscow teamed with members of the Russian Football (Soccer) Federation to examine the use of Platelet Rich Plasma in professional soccer players who suffered from an injury to the fifth metatarsal in the “pinky” toe. Here are the summary highlights published in the journal Foot and Ankle Specialist (x), June 2021.

“The treatment tactics depend on the localization of the fracture. . . Fractures located in zones 2 and 3 (Zone 1 is the base where the toe meets the foot, zone 2 is the connection between base and tip of the toe, zone three is the remaining toe to the tip) belong to a high-risk group due to delayed consolidation and nonunion and therefore athletes are most often treated with osteosynthesis (toe fusion) using intramedullary screws. The minimal recovery time for this type of treatment is at least 8 weeks.

In this case report, the doctors described seven cases of fifth metatarsal bone fractures, located in zones 2 and 3 in professional football (soccer) players and their treatment with an immobilization boot, cryotherapy, nutritional supplements of calcium and vitamin D, and local injections of platelet-rich plasma, which contains numerous growth factors. The seven players were able to return to regular training activities within 43 to 50 days, (better than the surgical recovery time) and there was no relapse of damage within 6 months of follow-up.

Summary and contact us. Can we help you?

Questions about our treatments? If you have questions about your foot pain and sesamoiditis treatment and how we may be able to help you, please contact us and get help and information from our Caring Medical staff.

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References

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This article was updated July 5, 2021