FOOT PAIN: Let us understand why our foot hurts
The human foot is truly a complex structure. It is made up of 26 bones, 33 joints and a multitude of crisscrossing ligaments, tendons and nerves, The bones are arranged such that our feet have two arches (longitudinal and transverse) that act as shock absorbers and maintain stability while we walk and run.
As our feet bear the entire body weight, they are subjected to great stress which making them vulnerable to injury. Foot pain is usually a result of poor biomechanics and inappropriate training techniques.
Foot pain can be understood better by classifying it as hind foot, midfoot and forefoot pain.
7 Reasons why our heel hurts
The heel of the foot is made up of two bones- the calcaneus (heel bone) and talus. Along with the lower ends of tibia and fibula (bones of the shin), they form the ankle joint.
The two main soft tissue structures of importance in the heel are the achilles tendon and plantar fascia.
The achilles tendon or tendon of the calf muscle inserts in the calcaneus (heel bone) and contracts when we push off the toes during gait. The achilles tendon is commonly injured in athletes, especially where there is a sudden increase in training intensity or load.
Plantar fascia is a thick band of fibrous tissue that extends from the heel to the toes and supports the arches of the foot. When the plantar fascia is a source of pain it is generally termed plantar fasciitis. This generally comes on gradually with time and clinically is often seen in older individuals that enjoy walking.
- PLANTAR FASCIITIS: It is the inflammation of the plantar fascia. Injury to the plantar fascia can cause pain and tenderness under the heel and on the inner side of the sole. The athlete typically complains of severe pain when his feet touch the ground early in the morning. This is because during the night, feet are in resting position allowing the fascia to shorten. Early morning weight bearing stretches the fascia causing pain. Walking stretches out the fascia gradually which helps to ease the morning pain. In the athletic population, this condition is more common in jumpers, runners and dancers. Certain factors such as pronated foot, high arch foot, tight calf muscles and excessive weight may act as predisposing factors for plantar fasciitis.
A combination approach involving rest, calf muscle stretching & strengthening is effective in treating this condition. Wearing comfortable footwear; inserting arch supports in shoes; taping and night time splinting also play a vital role in the early recovery of plantar fasciitis.
- ACHILLES TENDONITIS: It is an overload condition of the lower end of the achilles tendon usually due to overuse. The athlete complains of pain behind the ankle along with reduced movement at the ankle joint. Elderly athletes are more prone to this condition due to age related degenerative changes occurring in the tendon.Incorrect training techniques (too much too soon), running uphill, tight calf muscle and faulty lower limb biomechanics increase the risk of developing achilles tendonitis. Early identification & treatment of this injury is vital to prevent it from becoming chronic and necessitating a prolonged period out of sport.
Treatment of achilles tendonitis usually includes rest and calf muscle stretching. Eccentric strengthening of the calf during the rehabilitation phase is particularly helpful in faster recovery. Heel pads and tendon taping help to offset the strain on the injured tendon and can be used as adjuncts to the main treatment.
- Bruised Heel: This is also known as Policeman’s heel. It is an overuse injury of the soft tissues present under the heel particularly the fat pad. Typically seen in runners or soldiers, this condition occurs due to repeated heel strike as in long distance running, or landing from height. Bruised heel is quite often mistaken for plantar fasciitis and thus treated incorrectly. In fact there are subtle differences between the two. The pain in a bruised heel is located at the centre or slightly outer side of the heel as opposed to plantar fasciitis where in the pain is more on the inner side of the heel.
Significant pain relief is achieved through rest, icing, protective taping and use of heel cups or silicone gel heel pads.
- Retrocalcaneal bursitis: This is a common cause of hind foot pain in athletes, especially runners. Also known as Achilles tendon bursitis, it can coexist with achilles tendonitis (Haglund’s syndrome). The athlete complains of pain at the back of the heel, especially when running uphill or on soft surfaces. Swelling and tenderness is present behind the heel which may make it difficult to wear shoes with high heels. The condition is usually managed by rest and protective taping using a donut shaped pad. As pronation of the foot can predispose to retrocalcaneal bursitis, insoles to correct pronation and stretching of calf muscles also help to relieve the pain.
- Stress fracture of Calcaneus: Stress fracture of the heel bone or calcaneus is an overuse injury due to repeated heel strike as seen in road runners. It is the second most common stress fracture seen in the foot. The hairline fracture causes intense pain during running or jumping. The symptoms resemble that of a bruised heel. A physiotherapist can diagnose the fracture by squeezing the heel between his thumb and finger. The Treatment of calcaneal stress fracture involves 6-8 weeks of compulsory rest followed by gradual return to training.
- Sever’s Disease: It is a common cause of heel pain in kids aged between 8-15 years as a result of overuse. The young athletes complain of pain and tenderness at the back of the heel that increases with activity. This is accompanied by tightness of calf muscle and restricted ankle movement. Sever’s disease is usually seen in children who undergo a sudden growth spurt. Although young athletes generally outgrow this condition, training modification and alterations in training intensity are advisable during this phase. Weight bearing and high impact activities should be avoided.
- Heel Spur: A heel spur is a bony outgrowth from the base of the calcaneus (heel). It often occurs alongside plantar fasciitis, however the two conditions are not the same. There is debate in the literature as to whether this bony growth is actually the cause of pain as bone spurs are also present in those who are not suffering with pain and therefore much of the pain may originate in the surrounding muscles. The patient complains of severe pain under the heel especially during walking. Treatment involves rest, plantar fascia stretching and correction of foot biomechanics.
3 Common causes of midfoot pain
The mid foot is made up the cuboid, navicular and 3 cuneiform bones that make up the transverse arches.
- Navicular stress fracture: This is the most common stress fracture affecting athletes, especially those in explosive events such as sprinting and jumping. The athlete complains of midfoot pain that radiates along the medial arch of the foot. The pain increases with training and decreases with rest. The navicular bone may be tender to touch. The stress fracture is an overuse injury usually seen in runners and jumping sports and is attributed to errors in training technique. The treatment usually involves rest in a cast for around 6 weeks followed by active lower limb strengthening exercises. Correction of foot biomechanics is extremely helpful in preventing recurrence of the injury.
- Tarsal tunnel syndrome: This involves compression of the posterior tibial nerve in the groove behind the medial malleolus. This causes pain and a burning sensation under the heel that may radiate up to the toes. It may be associated with a sensation of pins and needles in the soles of the feet. The symptoms get worse with walking or during the night. A positive Tinel’s test helps the therapist to differentially diagnose tarsal tunnel syndrome from plantar fasciitis. Treatment of tarsal tunnel syndrome involves a full rehabilitation program that includes lower limb stretching and strengthening.
- Mid tarsal joint pain: The midtarsal bones comprise of the cuboid, navicular and the three cuneiform bones connected to each other by short ligaments. A mid tarsal joint sprain is an injury of these ligaments and is commonly seen in gymnasts and footballers. The patient complains of pain in the midfoot region towards the outer side of the foot. Swelling and tenderness is normally present. The treatment includes rest, elevation and compression followed by a graduated rehabilitation programme and a return to training.
Some common painful forefoot conditions
The forefoot comprises of several bones (5 metatarsals & 14 phalanges) and a number of ligaments and tendons passing between them.
- Turf Toe: This is basically an injury of the ligaments situated below the big toe. A sudden upward movement of the great toe as in gymnastics or martial artists stretches the ligament resulting in pain and tenderness under the great toe. Treatment in the acute phase comprises of rest, ice, compression and elevation to alleviate the pain and swelling. It is important not to bear weight on the foot for early recovery. Once the pain and swelling has subsided a gradual return to training begins. A turf toe taping technique is helpful to support the ligament in the early stages
- Metatarsalgia: The term refers to inflammation of the metatarsophalangeal joints (the knuckle of the toes). The symptoms include intense forefoot pain, especially during the stance and push off phases of gait cycle. The pain is localised under the ball of the foot especially under the heads of 2nd, 3rd and 4th metatarsal bones (the padded region under the toes). Incorrect foot biomechanics, excessive pronation and improper footwear are the main predisposing factors for this condition. A metatarsal lift compression pad or soft insoles placed under the ball of the foot help to alleviate pain. Wearing shoes with wider toe box and performing regular calf stretches can help relieve pain. This should be followed by dynamic foot posture correction exercises that are designed to correct faulty foot biomechanics.
- Sesamoiditis: Is an inflammation of the sesamoid bones of the 1st metatarsophalangeal joint (pad under the big toe) causing pain in the forefoot, particularly on weight bearing. Dancers are more prone to this condition. Sesamoid bones are small bones located within the tendon of a muscle, in this case, the flexor hallucis brevis. These muscles act as pulleys providing greater mechanical advantage to the muscle action. The athlete presents with gradual onset of pain on weight bearing activities. Sometimes the pain may be severe enough to cause limping.
There can also be a stress fracture of the sesamoid bones as a result of overuse injury due to repetitive impact. This is often seen in change of direction sports such as tennis. Faulty biomechanics such as excessive pronation is also one of the causative factors. The treatment of sesamoiditis in the acute phase involves rest, ice and cushioning under the forefoot to help distribute the pressure while walking. Correcting faulty foot biomechanics, especially over-pronation, is extremely important.
- Bunion: Otherwise known as Hallux valgus, this condition is usually the result of wearing shoes with narrow toe boxes and high heels. The high heels cause plantar flexion of the ankle and widening of the forefoot. But the narrow toe box in such shoes forcibly compresses the toes together. Prolonged use of such footwear causes the toes to adapt resulting in an angular deformity of the 1st metatarsophalangeal joint resulting in a bunion. The patient usually complains of gradually worsening pain and calluses around the bunion. Treatment includes ice, rest, foot posture correction exercises, taping and splinting.
- Hammer toe: Hammer toe is a condition in which one or more of the smaller toes become bent at the proximal interphalangeal joints (middle joint of the toe). The toe can be straightened in the early stages. If ignored, the condition may become a permanent deformity with pain and swelling in the affected joint. As the joint rubs against the footwear, the patient presents with corns or calluses in this area. Ill-fitting shoes or muscle imbalance between the extensor digitorum tendon and flexor digitorum longus tendon results in this deformity. The condition can be corrected initially by manually straightening the joints and performing foot muscle stretching exercises. Severe cases may require surgical correction.
- Gout: Gout is a form of arthritis caused by a build-up of uric acid within the body. The symptoms include intense pain in the big toe accompanied by swelling, itchiness and skin changes. Rest, icing, elevation and weight reduction can help to relieve pain in this condition. Dietary modification to reduce uric acid formation is the mainstay of the treatment.
Other common foot deformities
Pes cavus or claw foot is usually a congenital deformity of the foot. The arch of the foot is exaggerated with accompanied tightness in the calf and sole of the foot. A high arch foot may not be painful in itself, but it makes the foot prone to injuries. A lot of calf and foot stretches help to make the foot flexible so that it can cope with the day to day demands of walking and running. Shoe inserts to support the arch also help to prevent injuries due to pes cavus.
Pes planus or flat feet is another congenital deformity in which the arch of the foot is collapsed. A rigid flat foot increases stress along the whole lower limb and the person complains of pain in the hip, knee and low back. It has been observed that posterior tibial tendon dysfunction (PTTD) causes development of flat foot in adults. Shoes with supportive insoles for the arch help to prevent injury due to flat foot.
Say Goodbye to Foot pain at Naas Physiotherapy Clinic
At Naas Physiotherapy clinic we focus on developing individualised treatment plans for each patient. We provide:
- Complete Biomechanical Analysis
- Gait analysis
- Correction of muscle strength imbalance
- Eccentric strengthening exercises
- Analysis of training volume
- Post-operative rehabilitation after corrective foot surgery
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