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Foot Pain

Foot Pain

The foot has many structures that can become damaged and develop abnormalities. It is important to seek out a physician who can properly differentiate between the various causes of foot pain and identify proper treatment. Below is a list of some of the most common problems:

-Plantar fasciitis
-Pes planus (flat foot)
-Pes cavus (high arch)
-Morton’s neuroma
-Bunions
-Gout
-Tarsal Tunnel Syndrome
-Osteoarthritis
-Metatarsalgia

Plantar Fasciitis

Plantar fasciitis is an irritation of the connective tissue of the foot that runs from the toes and ball of the foot to the heel. Recent studies show that plantar fasciitis is less inflammatory and more degenerative in nature leading to some professionals wanting to change the name. The plantar fascia structure is important in maintaining the arch of the foot and even acts as a spring that assists gait. So why does it become so irritated? You can think of the plantar fascia as a fibrous web that connects from one end of the arch of the foot to the other. The plantar fascia is actually more of an aponeurosis than a fascia. This structure is almost like a ligament in that it helps to check the motion of the foot and ties structures together and gives the arch a bit of spring. If you jump up and down, the weight of your entire body is loading on the arch of your foot. The plantar fascia helps to maintain that arch during such times of loading. It acts like an ultimate barrier. The muscles in the foot are supposed to be powerful enough to maintain that arch, but can become weak or inactive and passes this stress onto the plantar fascia. If the stress occurs for long enough it begins to repetitively damage the plantar fascia and it will eventually become symptomatic. Surprisingly enough, high arches (which would indicate a tighter/shortened plantar fascia) as well as flat arches are associated risk factors for developing plantar fasciitis. In fact, so is just about any factor that would alter or increase load to the plantar fascia or inactivity of the supporting musculature including: obesity, change in foot wear, change in exercise habits (especially excessive or in bad form), tight calves, leg length inequality, sedentary life style, or standing on hard surfaces for long periods. I know that some of those factors sound contradictory, but remember that all of those things can change foot structure and change the muscular and mechanical dynamics of the arch. It is common for structures in the body to become calcified when under stress. This is true of the plantar fascia at its insertion on the heel. This is the body’s attempt to reinforce the area under stress by depositing calcium in soft tissues. This can lead to a heel spur at the calcaneal bone, but please understand that this is a reaction to the problem and a heel spur is not itself the problem or cause of plantar fasciitis, though it can help with diagnosis.

Treating plantar fasciitis usually involves ultrasound to promote healing, manipulation to correct bony alignment, stretching the calf muscles, and strengthening the intrinsic foot muscles. In more serious cases, I may refer out for shockwave therapy (originally designed to break up kidney stones). In some cases, certain injections may be warranted. Personally, I do not recommend any release surgery because this alters the length of the plantar fascia and usually does not have a good long-term outcome.

Pes Planus

This is commonly referred to as flat foot/feet. This is a condition where the arch of the foot is lost under weight-bearing conditions and the top of the foot typically rolls inward during gait. Pes planus usually leads to altered mechanics and stress in joints which can cause arthritis, plantar fasciitis, corns, calluses and general foot pain. The solution usually involves foot orthotics, manipulation of the foot, and strengthening exercises to retrain the arch of the foot.  

Pes Cavus

Just like flattening of the foot, a high arch causes altered dynamics of the foot as well and can lead to excessive stress. There is a propensity to develop hammer toes with pes cavus which can lead to arthritis and tendinopathy. Manipulation and stretches is warranted for this condition. Shoe inserts can help. In severe cases, surgery may be necessary.  

Morton’s Neuroma

This is a kind of benign tumor (not malignant) that can grow on the nerves that pass between the metatarsal bones in the foot causing compression of the nerves. Symptoms include pain and numbness or altered sensation in the foot/toes. Avoiding compressive footwear is important. I refer out for this condition, and only do minimal treatments myself.  

Bunions

This is a bony outgrowth of the base of the big toes and an altered angle of the toe and foot. This condition actually begins in the midfoot at the base of the metatarsal bone at the tarsal-metatarsal joint. The angle of the metatarsal is altered causing the bone to travel outward while the toe compensates by leaning inward. Manipulation, ultrasound, and rehab are the mainstay of conservative therapy. Altered footwear and/or inserts are warranted. However, there is a misconception about footwear’s roll in this condition because even people who have never worn shoes in their lives have developed bunions. In severe cases, surgery is necessary.  

Gout

Gout is a systemic arthritis. It is one of the metabolic arthritides associated with increases in uric acid levels. In high concentrations, uric acid can aggregate and form crystals in the joints that irritate and cause damage. The first place this shows up is usually the base of the big toe. Changes in diet and exercise are very important to treat this condition. Ultrasound and gentle manipulation are a good conservative approach, but I also refer out for this condition to the patient’s family doctor or a rheumatologist. Gout is a team approach.

Tarsal Tunnel Syndrome

This is a space along the inside of the ankle where the tibial nerve and artery pass from the lower leg into the foot. Inflammation, irritation, trauma, misalignment of the bones of the foot, and arthritis can all cause compression of the nerve and/or artery in this space. Symptoms are typically heel and foot pain with numbness, but if the entrapment occurs high enough the entire foot can become involved. It is more common for pain to radiate into the big toe and the or first three toes. Manipulation and retraining the arches of the foot are key here.

Osteoarthritis

Also called the wear and tear disease of the joints, OA can happen anywhere in the body but prefers to develop in weight bearing joints. Manipulation and ultrasound can work wonders in the foot and ankle. See the section on arthritis for more detail.

Metatarsalgia

This is essentially stress on the balls of your foot. There are bones in your feet called the metatarsals. These are long bones that connect to your toes also called the forefoot. People who have mechanical changes that result in shifting more weight to their forefoot are at risk for developing this. For example: during pregnancy, changing shoe ware, change in activities, tight calves, or lax plantar fascia can all start overloading the heads of the metatarsals experiencing pain and inflammation in the balls of their feet. Manipulation and foot taping along with ultrasound are great care combos for metatarsalgia.

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