Foot and Ankle Problems

The average person takes between 8,000 and 10,000 steps per day (1). In addition many of us participate in activities such as running and aerobic exercise that add many more steps and stress to feet. It’s not surprising that people have aches and pain in this part of the body. Factors such as flat feet or over-pronated feet, our walking and running style, the type of shoe wear can determine if we will get foot and ankle pain. The health of your feet can affect the biomechanics of the whole body especially your back, ankles, knees and legs (3).

The natural motion of the foot is to roll inward (pronate) after making contact with the ground. Pronation allows the foot to adapt to the contour of the ground and act as a shock absorber to the body. Over- pronation can lead to problems including (2,3,4):

1.    Ankle injuries
2.    Flat feet
3.    Plantar fasciitis (heel pain)
4.    Bunions
5.    Pain in the ball of the foot (metatarsalgia)
6.    Achilles and ankle pain
7.    Knee pain
8.    Patellar tracking problems
9.    Low back pain
10.  Shin pain

1. Ankle injuries

The ankle is one of the most commonly injured joints. Most people involved in sport will have “rolled “ their ankle at some stage.  The ankle may roll in either direction, though sprains occur more often on the outer side when the foot rolls with the sole facing inwards.  This can overstretch or tear the supporting ligaments, causing internal bleeding, swelling and pain around the joint.

Chronic or recurrent ankle sprains often occur when people have a decreased capacity to judge where their foot is in relation to their leg (called a proprioceptive deficit).  These people may require additional stability exercises such as “wobble boards to strengthen the muscles that stabilise the ankle (3,5).  Appropriate treatment, rehabilitation and soft tissue work can help restore function(12,13).

2. Pes Planus ( Flat Feet )

Flat feet or Pes Planus is very common, it is estimated that at least 25% of the population has flat feet. We are all born with flat feet and somewhere between the ages 3-10 we develop and arch. However in certain people this development never occurs. Besides genetic causes, there are a number of factors that can cause flat feet or predispose people to the condition. Sometimes people develop arches only to have them collapse later in their life. This often depends upon their lifestyle, job and level of activity. Age and weight also play a role in the condition's development (6).

The symptoms associated with an acquired flat foot are various and range from little or no overt symptoms to a selection of chronic soft tissue and joint pain. This condition shows extensive mechanical derangement of the foot which in some cases may lead to structural abnormalities and abnormal stress and strain, not only in the foot but further up the leg and in the lower back region (3,15). It is suggested that if not treated, the functionality of the foot and lower limb will be compromised which may ultimately lead to reduced mobility, the susceptibility to chronic injuries and the reduced capacity to optimise the foot and lower limb in locomotion (6).

3. Plantar Fasciitis (Heel Pain )

One of the most common of the foot ailments is heel pain and the cause is usually inflammation of the plantar fascia or heel spurs (3,4). The plantar fascia, is a band of connective tissue that surrounds the muscles on the bottom of the foot. It connects the heel bone to the ball of the foot, supporting the arch, protecting the foot and absorbing shock.

Patients with plantar fasciitis often complain of pain in the morning after first standing when they get out of bed and when the stand after prolonged sitting. The pain originates just in front of the heel bone, but can spread over the entire bottom of the foot. Over time, inflammation associated with the condition can lead to the development of scar tissue, calcium deposits and eventually heel spurs. These spurs are a bony growth on the front part of the calcaneus of heel bone where the plantar fascia attaches and can cause sharp stabbing pain with walking.

Other factors that stress the plantar fascia include: sudden strenuous activity after a period of long-term inactivity, abnormal walking patterns, improper footwear, walking on hard or uneven surfaces especially barefooted, and obesity (7). Plantar fasciitis can become very painful and persistent. Someone who is experiencing these symptons should consider consulting a qualified professional for advice on management such as taping, massage, icing and stretching (3,14).

4. Hallux Valgus - Bunions

Hallux valgus is a condition when the big toe or hallux deviates towards the outside of the foot often almost overlapping the adjacent toe. It is a slow developing condition that usually develops a bump on the inside of the big toe often called a bunion (2,3,4).



The pain associated with Hallux Valgus is usually felt during weight bearing activities such as walking or prolonged standing. However if someone has developed a bunion the pain can be present at rest and if often described as a "numbing" or "burning" sensation in the big toes.

The condition is usually the result of wear and tear over a long period of time from factors such as over-pronation which causes abnormal pressure on the big toe and first metatarsal during walking. Other causes of hallux valgus include inflammatory arthritis that can damage the joint and cause degenerative changes. A broken toe that does not heal properly can also predispose a person to hallux. However one of the more common causes of the problem is high heeled and pointed shoes that women often wear (9,10). These shoes not only put extra stress upon the joint but also help to push the big toe to the outside. It is know wonder that women have the condition much more often than men.
 
If the condition is caught early enough conservative treatment may help in preventing further progression of the condition (11).  If you have a more advanced hallux valgus, a qualified practitioner may use a number of techniques and modalities to decrease pain and improve your foot's function (4).

5. Metatarsalgia ( Pain in the ball of the foot )

Metatarsalgia is sometimes called ball-of-foot pain, a pain in the area on the sole of the foot just behind the toes where the foot bends during walking. The pain is actually caused by a problem in one or more of the five metatarsal bones that extend from about half way up the foot to the toes (4).

While many patients with metatarsalgia feel pain where their metatarsal bones join their toe bones, some also feel pain along the entire length of the metatarsals and possibly between them. Problems in this area can vary from a stiff and stiff feeling when you move these bones to a burning or stinging sensation. This depends upon whether the problem is due to a dysfunction in the joints or an irritation to the nerves as they travel along the metatarsals.
 

6. Achilles Tendinopathy

Achilles tendinopathy is a painful and often debilitating inflammation of the Achilles tendon. This large tendon is an extension of the two biggest calf muscles and runs down the back of the lower leg attaching to the heel bone. The problem may be caused by a sudden single incident such as jumping, but more commonly it results from an accumulation of smaller stresses that produce small tears in the tendon over time (4). In most cases, the appearance of symptoms is gradual. The discomfort may be relatively minor at first, but gradually worsens if the patient tries to "work through" the pain. In severe cases, a total rupture of the tendon can occur, resulting in traumatic damage and severe pain. Such injuries can make walking virtually impossible and may require corrective surgery.

Achilles tendonitis often appears in middle-aged people, especially men who are athletes, due to the changes that occur in the foot as we age (17). Our arch tends to flatten as we grow older causing over-pronation and increased stress upon the Achilles tendon and the calf and foot muscles. Similarly, problems are also common in the "weekend warrior" who exercises infrequently, and those who are just starting to exercise. In such people, the muscle and tendon have little flexibility due to inactivity and overdoing exercise in the beginning can cause tendonitis. Therefore, people who are just starting to exercise after a long layoff should stretch properly, start slowly, and increase gradually. Women who wear high-heeled shoes very regularly are also at risk (16,17).

Someone who is experiencing the symptoms of Achilles tendonitis should consider consulting a qualified practitioner to manage the problem (8,12,16).



References:
1. The Australian Bureau of Statistics. http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/4364.0.55.004Chapter5002011-12
2. Magee DJ (2008). Orthopedic Physical Assesment Ed 5. pg 972-1012. Saunders Elsevier. ISBN-13:978-0-7216-0571-5 (2)
3. Page P, Frank C, Lardner R, (2010) Assessment and treatment of Muscle Imbalance. The Janda Approach. Human Kinetics. ISBN10:0-7360-7400-7

4. Brukner P, Karim K (2012). Clinical Sports Medicine 4th Ed. McGrath-Hill Education. ISBN:9780070998131.
5. Wright CJ, Linens SW, Cain MS (2016). Randomized Controlled Trial Comparing Rehabilitation Efficacy in Chronic Ankle Instability. J Sport Rehabil. 2016 Feb 26. 

6.  Ashford RL, Kippen C,  Rome K (2005). Intervention for Pes Planus. Cochrane Musculoskeletal group. DOI: 10.1002/14651858.CD005120.
7. Prichasuk, S Subhadrabanhdhu, T (1994) The relationship of Pes Planus and calcaneal spur to plantar heel pain. Clin Orthop Relat Res. Sep: (306):192-6.
8. Roos EM, Engstrom M, Lagerquist A et al (2004). Clinical improvement after 6 weeks of eccentric excercise in patients with mid_portion Achilles Tendinopathy-a randomised trial with 1 year follow up. Scand J Med Sci Sports 14 (5):286-95

9. Coughlin MJ, Jones CP "Hallux valgus: demographics, etiology, and radiographic assessment" Foot Ankle Int. 2007 Jul;28(7):759-77.

10. Roddy E, Zhang W, Doherty M "Prevalence and associations of hallux valgus in a primary care population" Arthritis Rheum. 2008 Jun 15;59(6):857-62.

11. Kim MH, Kwon OY, Kim SH, Jung DY (2013). Comparison of muscle activities of abductor hallucis and adductor hallucis between the short foot and toe-spread-out exercises in subjects with mild hallux valgus. J Back Musculoskelet Rehabil. 2013;26(2):163-8. doi: 10.3233/BMR-2012-00363.
12. The effect of a sports chiropractic manual therapy intervention on the prevention of back pain, hamstring and lower limb injuries in semi-elite Australian Rules footballers: a randomized controlled trial. BMC musculoskeletal disorders, 2010, 11, 64
13. Pellow JE and Brantingham JW , The efficacy of adjusting the ankle in the treatment of subacute and chronic grade I and grade II ankle inversion sprains.  Journal of manipulative and physiological therapeutics, 2001, 24(1), 17
14.DiGiovanni Be, Nawcoczenski DA et al (2003). Tissue specific plantar fascia-stretching excercises enhances outcomes in patients with chronic heel pain. A prospective randomised study. J Bone Joint Surg Br : 85 B (7):1270-7
15. Mankey MG. A classification of severity with an analysis of causative problems related to the type of treatment. Foot and Ankle Clinics 2003;8(3):461-71.
16. Achilles tendonitis, Medline Plus, US National Library of Medicine and the National Institutes of Health US. https://medlineplus.gov/ency/article/001072.htm

17. Irwin TA. Tendon injuries of the foot and ankle. In: Miller MD, Thompson SR eds. DeLee and Drez's Orthopaedic Sports Medicine. 4rd ed. Philadelphia, PA: Elsevier Saunders; 2014:chap 117.


Links:

 https://medlineplus.gov/ency/article/001072.htm

https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/achilles-tendonitis