Pain in your feet and ankles can be due to a great number of conditions and these conditions present for a variety of reasons. When your feet hurt, you hurt all over! So the sooner you address pain in your feet, the better off you will be. Foot and ankle pain can be categorized in several ways. First, pain in the feet can be due to an injury. Secondly, it can be due to overuse which causes irritation to certain parts of our foot anatomy. Thirdly, it can be due to abnormalities in the nerves of the feet – this can be due to nerve entrapment in the foot or even the back but can also be due to systemic issues. Finally, there are some underlying systemic conditions which cause inflammation in joints and tendons or insufficiencies in blood flow that can cause pain in the feet.
The good news is that the most common cause of foot pain are well managed conservatively. After the initial flare up of pain is alleviated, keeping yourself from having pain is largely done by simply wearing something in your shoe. That’s right, after your foot pain is better after trauma or an overuse condition, the ‘maintenance’ is relatively passive. It comes in the form of a custom orthotic.
Our feet are what connects us to this planet. They carry us from one place to another. They absorb shock from the ground and they can turn or pivot at one of many joints in order to balance us and keep us upright. This is what makes custom orthotics such a HUGE part of treating foot and ankle conditions. If we can optimize the way our feet function and more evenly distribute the forces going through our feet and the body above them, it overall helps to decrease wear and tear that may otherwise localize on a particular joint, tendon or bone. Everyone has a different foot structure and it is amazing that we can improve our foot structure without surgery – with just the use of a properly fitted custom orthotic – in a great many cases.
When considering the first cause of foot and ankle pain – injury – this is anything from twisting your ankle on a curb, to falling off of a ladder to being hit/kicked while playing sports. This type of pain seems to have an obvious onset or cause. Between fractures, sprains and tendon tears there can be freak accidents but there are also instances where underlying stress built up to a particular area of the foot making it weaker and more susceptible to damage when you hit the tipping point. What does this mean?
Foot and Ankle Injuries
When it comes to fractures, some are the result of foot or ankle instability which can be inherent or from previous injuries. Some are due to an untreated/undiagnosed stress fracture. With a complete history, physical exam and a quick set of weightbearing digital x-rays, we can determine if the injury you had was a long time coming. Stress fractures are often the result of overuse and the location of a stress fracture is predictable based on foot structure. Someone with a bunion or arthritis in their big toe joint will often place more stress on the adjacent bone and when the energy through that bone reaches a certain point a hairline or stress fracture can develop. If you have a high-arched foot, the metatarsal bones which connect to the toes are often under excessive stress. If the symptoms of the stress fracture are ignored, the bone is unable to recover and rebuild from the stress and the area of weakness can break through when you take that one wrong step. We know as podiatrists that having had a previous ankle sprain is the greatest risk factor in having another because many ankle sprains are insufficiently treated which leads to more instability of the ankle. If this is not properly supported, the ankle can turn in further and further which places the bone at higher risk of injury when the ligament can no longer holds the ankle in proper position.
- On the topic of ankle sprains and ankle or foot instability, the tendons which provide motion and balance of our foot when we area active work much harder when the ligaments no longer hold the joints in proper alignment. Over a period of time the stress to these tendons causes inflammation which when left untreated leads to a process of scarring. Scar tissue is not as resilient and elastic, so the tissue becomes more brittle and more susceptible to tearing. The posterior tibial tendon is the tendon which holds up our arch structure. In some foot structures, this tendon has to work harder against an arch that collapses when stepping down. Over time the arch may continue to lower and the tendon will stretch only so far before it can develop a tear. A custom orthotic which resists that flexible flattening of the arch structure is going to help reduce the work of that posterior tibial tendon. This does not mean that we are using the orthotics as a crutch though. On the contrary, custom orthotics help to allow overworked tendons to rest respectively from the overuse and the tendons which were rendered inefficient can now fire appropriately and strengthen. This results in better balance within the foot. The sooner we address the issues, the less likely it is that the joints in our feet will adapt to this abnormal and harmful position. On the other hand, continuing to walk on an unsupported foot eventually can lead to a more rigid and abnormally shaped foot which is much harder to treat conservatively.
- Achilles tendon ruptures often occur to a tendon which was already experiencing inflammation and has underlying damage and scarring. Having a tight achilles tendon (we call this equinus) is seen in nearly all patients with foot pain. Even though a rupture injury happens in a split second, it is a culmination of years of neglect from stretching and the tight achilles tendons often are worsened by the foot structure. As we get older, the soft tissue (tendons and ligaments) in our body are more stiff and it takes more for them to recover from injury or abuse. This happens not only for Achilles tendons but also for other tendons in the foot – again based on which tendons are under more stress from your foot structure.
Of course there are those freak accidents. Maybe you experienced a fracture or tendon or ligament damage as the result of a car accident or being kicked and suffering an impact injury in sports. These cases may not have been due to your foot mechanics, so there truly was no way to prevent this from happening. However, in cases where an injury is severe enough, the foot structure can change as a result and our foot mechanics can change. This means that your foots needs change after these types of incidents. It can mean that the changed foot structure is now more susceptible to having other issues later. Fractures often lead to arthritis in the feet. It may not be symptomatic for years or decades later, but that destructive process starts after fractures which injury the joint. If a tendon or ligament tear occurs as the result of a traumatic injury, surgery may help the foot to heal properly but custom orthotics may also be of benefit for residual pain or instability.
Overuse Conditions in Feet and Ankles
In the second cause of foot pain, our normal and daily activities and the shoe types we wear place certain stresses on our feet. Over a period of time, some tendons will experience more strain and some bones will experience more stress. A very common overuse condition is plantar fasciitis. This is a condition whereby the plantar fascia (a ligament that runs along the arch of the foot) becomes inflamed and painful. The arch, heel or even ball of the foot may experience pain due to plantar fasciitis. In many cases our patients wake up with pain in the heel that is so crippling, but they cannot recall any injury or cause at first. When we question our patients about changes in their daily routine or the types of shoes they wear in the prior months, we start to put the pieces together and find a cause. Treating plantar fasciitis acutely or even when the pain has been there months/years, a lot of work must be done to help re-establish normal function in the foot. This involves improving flexibility, decreasing inflammation, supporting the foot during activity and sometimes physical therapy to reduce adhesions that have resulted from walking differently in accommodating the pain in the foot. After this pain has finally resolved, custom orthotics promote normal function in the foot and reduce excess strain in the ligament. Walking in a custom orthotic for a majority of activity helps reduce the likelihood that this condition rears its ugly head again.
The third and fourth causes of pain in the feet and ankles are best managed by treating the underlying cause which may not be with your
podiatrist. In the incident of neural abnormalities, addressing impingement in the back may require evaluation by a back specialist,
orthopedic surgeon, physiatrist or chiropractor. Rheumatology and vascular doctors may need to be involved in these cases. Not to say that these two categories wouldn’t benefit from custom orthotics, but it is much less likely that orthotics alone will provide appropriate and inclusive care for the underlying condition.
We all know that keeping up with maintenance on our car is critical to reduce the likelihood of breakdown or a flat tire. Your feet should be considered similarly – consider also that we can just get a new set of tires or a new car! However, this body is yours for the long haul. If the wheels on your car are not aligned, this results in uneven wear in the tread of the tires and undue stress on the wheels. If your feet are not well supported and optimally aligned, the same thing happens to our tendons, ligaments and bones. A well supported foot is a happy foot. They will serve you well for all the miles you roam, through all the places you dream to visit someday. The better your feet feel, the more active you will be which has a critical impact on your overall health. If you are curious whether custom orthotics are right for you, please call our office for an appointment today!