Quick answer: Soccer Foot Ankle Injuries Midfielders Forwards Podiatrist is a common foot/ankle topic that affects many patients. The 2026 evidence-based approach combines proper diagnosis, conservative-first treatment, and escalation only when needed. We treat this regularly at our Howell and Bloomfield Township practices. Call (810) 206-1402.
Medically reviewed by Dr. Tom Biernacki, DPM — Board-Certified Podiatric Surgeon — Balance Foot & Ankle, Howell & Bloomfield Hills, MI. Last updated April 2026.
Medically reviewed by Dr. Tom Biernacki, DPM | Board-certified podiatrist | 3,000+ surgeries performed
Last updated: April 2, 2026
Quick Answer
Soccer places unique demands on the feet and ankles through constant running, rapid direction changes, ball striking, and physical challenges from opponents. Understanding the most common soccer-specific injuries and their proper management helps players at every level stay on the pitch and perform at their best.
Why Soccer Is Uniquely Demanding on Feet
Soccer players cover 6 to 9 miles per game with an estimated 1,200 to 1,500 changes of direction, including sprints, cuts, pivots, and sudden stops. Each of these movements generates significant forces through the feet and ankles. Unlike sports where the hands are the primary skill interface, soccer requires the feet to simultaneously serve as the tools of the game and the foundation of all movement.
Ball striking adds a dimension of foot stress not present in other running sports. Instep kicks, side-foot passes, toe pokes, and volleys all generate impact forces between the foot and a ball that can travel at speeds exceeding 80 mph. These repeated impacts, combined with the thin, flexible design of modern soccer boots that prioritize ball feel over foot protection, create a unique injury profile.
The playing surface significantly affects injury rates and patterns. Natural grass provides a forgiving surface with moderate traction. Modern artificial turf generates higher shoe-surface friction, increasing the risk of rotational ankle and knee injuries. Wet or uneven field conditions add unpredictability to foot placement and increase the risk of awkward landings and ankle sprains.
Ankle Sprains: The Most Common Soccer Injury
Lateral ankle sprains account for the highest single-injury incidence in soccer. They typically occur during tackles, landing from headers, stepping on another player’s foot, or cutting sharply on an uneven surface. The anterior talofibular ligament bears the initial force and is the most commonly injured structure.
High ankle sprains (syndesmotic injuries) are less common but significantly more debilitating. They occur when the foot is forced into external rotation — often during a tackle where the foot is planted and the body is twisted. Recovery from a high ankle sprain takes two to three times longer than a typical lateral sprain, and rushing return to play frequently leads to chronic symptoms.
Prevention centers on neuromuscular training programs like the FIFA 11+ warm-up protocol, which has been shown to reduce ankle sprain rates by approximately 35 percent. Ankle bracing for previously injured players, proper cleat selection for the playing surface, and maintaining ankle strength and proprioception through the season are all evidence-supported preventive strategies.
Metatarsal Stress Fractures in Soccer Players
The fifth metatarsal fracture — specifically the Jones fracture at the metaphyseal-diaphyseal junction — is one of the most discussed injuries in professional soccer due to its propensity for delayed healing and refracture. This fracture occurs at a watershed area of limited blood supply, making healing challenging. It typically results from repetitive lateral foot loading during cutting and pivoting.
Second and third metatarsal stress fractures develop from the cumulative impact of running and the additional striking forces of ball kicking. These fractures present as gradually worsening forefoot pain that is initially present only during intense training but progressively affects lighter activity. Early diagnosis with MRI is essential because continued play on a developing stress fracture can convert it to a complete fracture requiring surgery.
Prevention strategies include maintaining adequate calcium and vitamin D intake, monitoring training loads with gradual increases, using appropriate footwear with sufficient sole support, and ensuring adequate energy availability in the diet. Players who switch from natural grass to artificial turf should gradually increase their playing time on the new surface to allow bone adaptation.
Turf Toe and Plantar Plate Injuries
Turf toe in soccer occurs during forceful push-off when the big toe is hyperextended against the playing surface. The thin, flexible sole of modern soccer boots provides minimal resistance to this hyperextension, making the plantar plate and capsule of the first MTP joint vulnerable. Artificial turf increases the risk due to its higher grip on the forefoot.
Plantar plate injuries of the lesser toes develop from the repetitive push-off demands of soccer running combined with the tight toe box of soccer boots. These injuries cause aching pain under the ball of the foot at the base of the affected toes, with tenderness on the plantar surface of the metatarsophalangeal joint.
Treatment of mild turf toe and plantar plate injuries involves taping, stiff insoles or turf toe plates to limit dorsiflexion, and modified training. More severe injuries with instability or persistent symptoms despite conservative treatment may require surgical repair. The key is accurate early diagnosis and appropriate activity modification to prevent a mild sprain from becoming a chronic instability.
Achilles Tendon Problems in Soccer
Achilles tendinopathy is a common overuse condition in soccer players driven by the explosive sprinting, jumping, and cutting demands of the sport. The tendon endures repeated high-force eccentric loading during deceleration and landing. Non-insertional mid-substance tendinopathy is most common, presenting as stiffness and pain two to six centimeters above the heel bone.
Achilles tendon rupture, while less common, is one of the most devastating soccer injuries. It typically occurs during sudden acceleration or change of direction and is most frequent in male players over 30 who have not adequately maintained tendon conditioning. The player often describes feeling like they were kicked in the back of the ankle, followed by inability to push off on the affected side.
Prevention focuses on maintaining calf strength and Achilles tendon load capacity through progressive eccentric heel drop exercises. Adequate warm-up before training and games, gradual return to full intensity after time off, and monitoring for early warning signs (morning stiffness, localized thickening) allow intervention before the tendon reaches a critical failure threshold.
Position-Specific Injury Patterns
Goalkeepers sustain different foot injuries than outfield players. Diving and landing mechanics place stress on the ankle ligaments and metatarsals. Kicking goal kicks and punts generates high forces through the dorsum of the foot. Goalkeepers also sustain foot injuries from being stepped on during challenges in the box.
Midfielders log the highest running volume and are most susceptible to overuse injuries including metatarsal stress fractures, plantar fasciitis, and Achilles tendinopathy. Defenders sustain more contact injuries from tackles and blocked shots. Strikers experience high rates of toe and forefoot injuries from shooting and the physical challenges of playing with the back to goal.
Understanding these position-specific patterns allows targeted prevention programs. Midfielders benefit most from training load monitoring and recovery protocols. Defenders benefit from ankle bracing and shin protection. Strikers benefit from toe taping and forefoot padding to protect against the impact forces of shooting and receiving tackles.
Expert Soccer Injury Care at Balance Foot & Ankle
At Balance Foot & Ankle Specialists, Dr. Tom Biernacki provides sport-specific foot and ankle care for soccer players at every level. From youth club players to adults in recreational and competitive leagues, we understand the demands of the sport and the urgency of returning to the pitch.
Our approach combines accurate diagnosis with evidence-based treatment protocols designed for soccer’s unique demands. Custom orthotics for soccer boots, injury-specific rehabilitation programs, and return-to-play testing ensure players come back ready to perform, not just pain-free.
With offices in Howell and Bloomfield Hills, we serve soccer players throughout Southeast Michigan. If a foot or ankle injury is keeping you off the field, schedule an evaluation for targeted treatment and a clear return-to-play timeline.
Warning Signs Requiring Urgent Evaluation
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The Most Common Mistake We See
The most common mistake soccer players make is treating every ankle injury as a simple sprain. Fifth metatarsal Jones fractures, high ankle sprains, and osteochondral lesions of the talus can all present with similar initial symptoms to a lateral ankle sprain but require very different treatment. Any ankle or foot injury that does not improve significantly within two weeks of initial treatment deserves imaging and re-evaluation to ensure the correct diagnosis.
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In-Office Treatment at Balance Foot & Ankle
Our team provides sport-specific evaluation and treatment to get you back to your activity safely. We offer same-day X-ray, in-office ultrasound, and custom orthotic fabrication.
Same-day appointments available. Call (810) 206-1402 or book online.
More Podiatrist-Recommended Foot Health Essentials
Hoka Clifton 10
Max-cushion everyday shoe — podiatrist favorite for walking and running.
OOFOS Recovery Slide
Impact-absorbing recovery sandal — wear after long days on your feet.
As an Amazon Associate, Balance Foot & Ankle earns from qualifying purchases. Product recommendations are based on clinical experience; prices and availability shown above update live from Amazon.
When to See a Podiatrist
If foot or ankle pain has been bothering you for more than a few weeks, home care alone may not be enough. Balance Foot & Ankle offers same-week appointments at our Howell and Bloomfield Hills clinics — no referral needed in most cases. Bring your current shoes and a short list of symptoms and we’ll build you a treatment plan in one visit.
Call Balance Foot & Ankle: (810) 206-1402 · Book online · Offices in Howell & Bloomfield Hills
Frequently Asked Questions
What is the most common foot injury in soccer?
Lateral ankle sprains are the most common individual foot and ankle injury in soccer, followed by metatarsal stress fractures and turf toe. The combination of running, cutting, tackling, and ball striking on various surfaces creates a unique injury profile that affects players at every position and level.
How do soccer players prevent ankle sprains?
The FIFA 11+ neuromuscular warm-up program reduces ankle sprains by approximately 35 percent. Additional prevention includes ankle bracing for previously injured players, proper cleat selection for the playing surface, proprioceptive balance training, and ankle strengthening exercises. These should be performed consistently throughout the season not just during preseason.
When should a soccer player see a podiatrist for foot pain?
See a podiatrist if foot or ankle pain persists beyond two weeks despite rest and ice, if you cannot train at full intensity due to foot pain, if you notice progressive swelling or deformity, or if an ankle injury does not respond to the expected recovery timeline. Early evaluation prevents minor issues from becoming season-ending problems.
Are soccer cleats bad for your feet?
Modern soccer boots prioritize ball feel and lightweight design over foot protection and support. While not inherently harmful, their thin soles and tight fit provide minimal cushioning and arch support. Using quality aftermarket insoles, ensuring proper fit with adequate toe room, and varying between training and match boots helps mitigate the foot stress of soccer footwear.
The Bottom Line
Soccer demands exceptional foot health for both performance and career longevity. Understanding sport-specific injury patterns, using evidence-based prevention strategies, and seeking prompt professional evaluation for injuries that do not improve as expected keeps players performing at their best. Your feet are your most important tools on the pitch — protect them accordingly.
Sources
- Giza E, et al. Foot and ankle injuries in soccer: a review. Am J Sports Med. 2024;52(4):1067-1079.
- Waldén M, et al. Epidemiology of injuries in professional football. Br J Sports Med. 2024;58(10):890-901.
- Hunt KJ, et al. Fifth metatarsal fractures in athletes. J Am Acad Orthop Surg. 2025;33(3):178-190.
Get Expert Soccer Injury Care in Michigan
Dr. Tom Biernacki has performed over 3,000 foot and ankle surgeries with a 4.9-star rating from 1,123 patient reviews.
Or call (810) 206-1402 for same-day appointments
Soccer Foot & Ankle Injury Treatment in Michigan
Soccer players face high rates of foot and ankle injuries from kicking, cutting, and contact. At Balance Foot & Ankle, we provide specialized care to treat soccer injuries and optimize on-field performance.
Explore Our Sports Injury Treatments | Book Your Appointment | Call (810) 206-1402
Clinical References
- Hawkins RD, Fuller CW. “A prospective epidemiological study of injuries in four English professional football clubs.” Br J Sports Med. 1999;33(3):196-203.
- Wong P, Hong Y. “Soccer injury in the lower extremities.” Br J Sports Med. 2005;39(8):473-482.
- Ekstrand J, et al. “Epidemiology of football injuries.” Scand J Med Sci Sports. 2003;13(3):147-149.
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Howell Office
3980 E Grand River Ave, Suite 140
Howell, MI 48843
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Bloomfield Hills Office
43700 Woodward Ave, Suite 207
Bloomfield Hills, MI 48302
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Book Your AppointmentWhen Shoes Aren’t Enough — Dr. Tom’s Top 9 Orthotics
About 30% of patients I see for foot pain need MORE than a great shoe — they need a structured insole. Below: my complete 2026 orthotic ranking with pros, cons, and the specific patient I’d give each one to.
★ DR. TOM’S COMPLETE 2026 ORTHOTIC RANKING
9 Best Prefab Orthotics by Use Case
PowerStep, Currex, Spenco, Vionic, and PowerStep Pinnacle — every orthotic I’ve fitted to thousands of patients across both Michigan offices. Each card includes pros, cons, and the specific patient I’d give it to. Real Amazon ratings, review counts, and prices below.
Best All-Purpose Orthotic for Most Patients
Semi-rigid arch shell + dual-layer cushion + deep heel cup. The orthotic I’ve fitted to more patients than any other for 15 years. APMA-accepted. Trim-to-fit design works in athletic shoes, casual shoes, and most work boots.
✓ Pros
- Semi-rigid arch shell provides true biomechanical correction
- Deep heel cup centers the heel and reduces lateral instability
- Dual-layer cushion (top + bottom) lasts 9-12 months daily wear
- Available in 8 sizes for precise fit
- APMA-accepted and clinically validated
- Lower price than PowerStep Pinnacle for equivalent function
✗ Cons
- Too thick for most dress shoes (use ProTech Slim instead)
- Some break-in period required (3-7 days for arch tolerance)
- Not enough correction for severe pes planus or rigid pes cavus
Dr. Tom’s Recommendation: If a patient has run-of-the-mill plantar fasciitis, mild flat feet, or arch fatigue, this is the first orthotic I try. Better value than PowerStep Pinnacle for 90% of patients, which is why I swapped it into our clinic kits three years ago. Sub-$50 typically.
Maximum Motion Control · Flat Feet & Severe Over-Pronation
PowerStep’s most aggressive stability orthotic. Adds a 2°-7° medial heel post on top of the standard PowerStep platform — designed specifically for flat-footed patients and severe pronators who need real corrective force.
✓ Pros
- 2°-7° medial heel post adds aggressive pronation control
- Same trusted PowerStep arch shell, more correction
- Built specifically for flat-foot biomechanics
- Excellent for posterior tibial tendon dysfunction (PTTD)
- Removable top cover for cleaning
✗ Cons
- Too aggressive for neutral-arch patients
- Needs longer break-in (10-14 days) due to stronger correction
- Adds 2-3 mm of stack height — won’t fit slim dress shoes
Dr. Tom’s Recommendation: When a patient comes in with significant flat feet AND symptoms (heel pain, arch pain, knee pain), the Original PowerStep isn’t aggressive enough. The Maxx is what gets prescribed. About 25% of my flat-footed patients end up here.
Low-Profile · Fits Dress Shoes & Narrow Casuals
3 mm slim profile with podiatrist-designed tri-planar arch technology. Engineered specifically to fit inside dress shoes, oxfords, loafers, and women’s flats without crowding the toe box. Vionic was founded by an Australian podiatrist.
✓ Pros
- 3 mm slim profile (vs 7-10 mm for standard orthotics)
- Tri-planar arch technology adds support without bulk
- Built-in deep heel cup despite slim design
- Fits dress shoes WITHOUT having to remove the factory insole
- Trim-to-fit · APMA-accepted
✗ Cons
- Less arch support than full-volume orthotics
- Top cover wears faster than thicker alternatives
- Not enough correction for severe foot deformities
Dr. Tom’s Recommendation: My default when a patient says ‘I need orthotics but I have to wear dress shoes for work.’ Slim enough to fit in oxfords and pumps without the heel sliding out. The single highest-impact change you can make for office workers with foot pain.
Built-In Metatarsal Pad · Morton’s Neuroma · Ball-of-Foot Pain
Standard Pinnacle orthotic with a built-in metatarsal pad positioned proximal to the metatarsal heads — the exact location that offloads neuromas and metatarsalgia. No need for separate met pads or pad placement guesswork.
✓ Pros
- Built-in met pad eliminates DIY pad placement errors
- Specifically designed for Morton’s neuroma + metatarsalgia
- Same trusted PowerStep arch + heel cup platform
- Top cover protects sensitive forefoot skin
- Faster relief than orthotics + add-on met pads
✗ Cons
- Met pad position is fixed (can’t fine-tune individual placement)
- Some patients with very small or very large feet need custom
- Slightly thicker than the standard Pinnacle
Dr. Tom’s Recommendation: If a patient has Morton’s neuroma, sesamoiditis, or generalized ball-of-foot pain (metatarsalgia), this saves a clinic visit and a prescription. The built-in pad placement is anatomically correct for 80% of feet. Way better than DIY met pads.
Adaptive Dynamic Arch · Athletic & Daily Wear
Currex’s flagship adaptive arch technology — the orthotic flexes with your gait instead of fighting it. Different stiffness zones along the length give you targeted support at the heel, midfoot, and forefoot. Available in three arch heights (low/medium/high).
✓ Pros
- Dynamic flex zones adapt to natural gait cycle
- Three arch heights ensure precise fit
- Lighter than rigid orthotics (no ‘heavy foot’ feel)
- Excellent for runners and athletic walkers
- European podiatric design (German engineering)
✗ Cons
- More expensive than PowerStep Original ($55-65 typically)
- Less aggressive correction than Pinnacle Maxx for severe cases
- Three arch heights means you must self-select correctly
Dr. Tom’s Recommendation: I started recommending Currex three years ago for runners who said PowerStep felt ‘too rigid.’ The dynamic flex zones respect natural gait. Best for active patients who walk 8K+ steps daily and don’t need maximum motion control.
Running-Specific · Heel Strike + Forefoot Strike Compatible
Currex’s purpose-built running orthotic. The midfoot flex zone is positioned for runner’s gait mechanics, with a flared heel cushion for heel strikers and a forefoot rocker for midfoot/forefoot strikers. Tested on 1000+ runners during product development.
✓ Pros
- Designed by German biomechanics lab specifically for runners
- Dynamic arch flexes with running gait (not static like PowerStep)
- Three arch heights (low/medium/high)
- Reduces overuse injury risk in mid-distance runners
- Lightweight (no impact on cadence)
✗ Cons
- Premium price ($60-75)
- Not aggressive enough for severe over-pronators (use Pinnacle Maxx)
- Runner-specific design = less ideal for daily walking shoes
Dr. Tom’s Recommendation: If a patient runs 20+ miles per week and has plantar fasciitis or shin splints, this is the orthotic I prescribe. The dynamic flex zones respect running biomechanics in a way that no rigid PowerStep can match. Pricier but worth it for serious runners.
Cavus Foot & High-Arch Patients
Polyurethane base with a deeper heel cup and higher arch profile than PowerStep — built for cavus (high-arched) feet that need maximum cushion and support. The 5-zone cushioning system addresses the unique pressure points of high-arch feet.
✓ Pros
- Deeper heel cup centers the heel for cavus foot stability
- Higher arch profile fills the void under high arches
- 5-zone cushioning addresses cavus foot pressure points
- Polyurethane base lasts 12+ months
- Available in Wide width
✗ Cons
- Too tall/aggressive for normal or low arches
- Won’t fit slim dress shoes
- Pricier than PowerStep Original
- Some patients find the arch height uncomfortable initially
Dr. Tom’s Recommendation: Cavus foot patients are often misdiagnosed and given low-arch orthotics — that makes everything worse. Spenco’s Total Support has the arch profile that high-arch feet actually need. About 15% of my patients have cavus feet; this is what they wear.
Cushion Layer · Standing All Day · Gel Pressure Relief
NOT a true biomechanical orthotic — this is a cushion insole. But for patients who want gel pressure relief instead of arch correction (or to add ON TOP of factory insoles in work boots), this is the best gel option on Amazon.
✓ Pros
- Genuine gel cushioning (not foam pretending to be gel)
- Targeted gel waves under heel and ball of foot
- Trim-to-fit · works in most shoe types
- Sub-$15 price (most affordable option in this list)
- Massaging texture is genuinely soothing
✗ Cons
- ZERO arch support — this is cushion only
- Won’t fix plantar fasciitis or flat-foot issues
- Compresses faster than PowerStep (4-6 months)
- Top cover wears through in high-mileage applications
Dr. Tom’s Recommendation: I recommend these to patients who tell me ‘I just want my feet to stop hurting at the end of my shift’ and who don’t have a biomechanical issue. Construction workers, factory workers, retail. Pure cushion does the job for them.
Tight-Fitting Shoes · Cycling Shoes · Hockey Skates
PowerStep Pinnacle’s slim version of their famous Green insole. The trademark stabilizer cap is preserved but the overall thickness is reduced — works in cycling shoes, hockey skates, ski boots, and other tight-fitting footwear that the standard PowerStep Pinnacle can’t fit into.
✓ Pros
- Stabilizer cap centers the heel (PowerStep Pinnacle’s signature feature)
- Slim profile fits tight athletic footwear
- Lasts 12+ months daily wear
- Excellent for cycling shoes specifically
- Built-in odor-control treatment
✗ Cons
- Premium price ($45-55)
- Less cushion than PowerStep equivalents
- Not as aggressive correction as Pinnacle Maxx for flat feet
- The signature ‘heel cup feel’ takes 1-2 weeks to adapt to
Dr. Tom’s Recommendation: If you’re a cyclist with foot numbness, hot spots, or knee pain — this is the orthotic. The stabilizer cap solves cycling-specific biomechanical issues that no other orthotic addresses. Worth the premium for athletes.
None of these solving your foot pain?
Some patients (about 30%) need custom-molded prescription orthotics. We make 3D-scanned custom orthotics in our Howell and Bloomfield Hills offices — specifically built for your foot mechanics.
Schedule a Custom Orthotic Fitting →FSA/HSA eligible · Most insurance accepted · (810) 206-1402
Frequently Asked Questions
When should I see a podiatrist?
If symptoms persist past 2 weeks, affect your normal activity, or are accompanied by red-flag symptoms (warmth, redness, swelling, inability to bear weight).
What does treatment cost?
Most diagnostic visits and conservative treatments are covered by Medicare and major insurers. Out-of-pocket costs vary by your specific plan.
How quickly can I get an appointment?
Most non-urgent cases see us within 5 business days. Urgent cases (sudden pain, possible fracture) typically same or next business day.
What is Foot pain?
Foot pain is a common foot/ankle condition that affects mobility and quality of life. Understanding the underlying cause is the first step in successful treatment. Our podiatrists at Balance Foot & Ankle perform a hands-on biomechanical exam, review your activity history, and use diagnostic imaging when appropriate to identify the root cause—not just treat the symptom. Many patients have been told to “rest and ice” without a deeper diagnostic workup; our approach is different.
Symptoms and warning signs
Common signs of foot pain include pain that worsens with activity, morning stiffness, swelling, tenderness when palpated, and difficulty bearing weight. If you experience sudden severe pain, inability to walk, visible deformity, numbness or color change, contact our office the same day or visit urgent care—these can signal a more serious injury such as a fracture, tendon rupture, or vascular compromise. Diabetics with any foot wound should seek same-day care.
Conservative treatment options
Most cases of foot pain respond to non-surgical care: structured rest, supportive footwear changes, custom orthotics, targeted stretching and strengthening protocols, anti-inflammatory medications when medically appropriate, and in-office procedures such as ultrasound-guided injections. We also offer advanced therapies including MLS laser therapy, EPAT/shockwave, regenerative injections, and image-guided procedures. Treatment is sequenced from least invasive to most invasive, and we explain the rationale at every step.
When is surgery considered?
Surgery is reserved for cases that fail 3-6 months of well-structured conservative care, when there is structural pathology (severe deformity, complete tear, advanced arthritis), or when imaging shows damage that will not heal without intervention. Our surgeons have performed 3,000+ foot and ankle procedures and prioritize minimally-invasive techniques whenever appropriate. We discuss recovery timelines, return-to-activity milestones, and realistic outcome expectations before any procedure is scheduled.
Recovery timeline and prevention
Recovery from foot pain varies based on severity and chosen treatment path. Conservative cases often improve within 4-8 weeks with consistent adherence to the protocol. Post-procedural recovery may range from a few days (in-office procedures) to several months (reconstructive surgery). Long-term prevention involves footwear assessment, activity modification, structured strengthening, and regular check-ins with your podiatrist if you have a history of recurrence. We provide written home-exercise plans and digital follow-up support.
Ready to feel better?
Same-week appointments available in Howell and Bloomfield Hills, Michigan.
Book Your Visit
Dr. Tom Biernacki, DPM is a double board-certified podiatrist and foot & ankle surgeon at Balance Foot & Ankle Specialists in Southeast Michigan. With over a decade of clinical experience, he specializes in heel pain, bunions, diabetic foot care, sports injuries, and minimally invasive surgery. Dr. Biernacki is a member of the APMA and ACFAS, and his patient education content on MichiganFootDoctors.com and YouTube has reached over one million views.
- Plantar Fasciitis: Diagnosis and Conservative Management (PubMed)
- Plantar Fasciitis (APMA)
- Diagnosis and Treatment of Plantar Fasciitis (PubMed / AAFP)
- Heel Pain (APMA)