FOOT AND ANKLE PAIN
Foot and heel pain are two of the most common problems for which people consult us at Catskill Rehabilitation and Sports Medicine. This is of special concern in the athletically active 20 to 55 age group.
Characteristically, the classic complaint is of pain, localized to the inner aspect of the heel, worse in the morning on getting out of bed. Arising to one’s feet after prolonged sitting can be an epic pain experience, so can a nice long, or a run. Commonly the pain comes on after an increase in training time and/or intensity. It usually subsides after several steps, but then recurs with increasing frequency and severity with progressively less provocation. Often the pain extends forward to involve the arch.
A thick band of tissue extends from the heel to the ball of the foot. It is called the plantar fascia and is an essential part of the support mechanism of the sole of the foot. It is actually continuous with the Achilles tendon, and through it, with the calf muscles: the gastrocnemius and the soleus. Muscles move bones. Ligaments are the principal support mechanism of the joints of the foot and ankle (and of joints everywhere in the body). As we age, or as we subject our feet to repetitive trauma, an interesting thing happens: the ligaments stretch. Since they are more plastic than elastic, they don’t resume their prior length. Those of us significantly past the age of consent notice that our guts are not the only parts of our anatomy that sag. The ligaments supporting our feet are also prey to the forces of gravity. The result is that the shoe size goes up for the simple reason that our feet are now bigger! Bigger and more painful. Who ever heard of kids with foot pain? Who ever heard of seniors without foot pain?
Ligaments and fascia have within them nerve endings extremely sensitive to stretching. When over-stretched, either actively or passively, they transmit impulses to the spinal cord and thence to the brain where they are finally recorded and interpreted as pain.
As your foot sags, the plantar fascia, because of the increased distance between its connections at the heel and the ball of the foot, is stretched. It pulls at its attachment to the heel. This tension causes inflammation with bleeding into the soft tissues. The body attempts to keep the fascia attached. Fibrous tissue is laid down. Calcium is deposited, replaced by bone, and as a result, a spur or traction osteophyte may be formed. This is the so-called "heel spur." Since no weight is actually borne directly on it, the spur is not the cause of the pain. Rather, it is the result of the process causing the pain. Since the plantar fascia is actually a continuation of the calf muscle and Achilles tendon, the more stress on the plantar fascia and/or tension in the calf muscles, the more pain and the more spur growth. The process is gradual, and you may have a very large spur without being aware of it. As a matter of fact, if we x-rayed everyone’s foot, we would probably find heel spurs in about 40% of adults only a few of whom would have heel pain!
The runner with Achilles tendinitis complains of pain and stiffness directly behind the ankle, having a gradual onset. It usually starts with stiffness and morning tightness of the calf, is most painful upon initiation of activity, subsides with moderate activity, then progressively increases in intensity proportional to duration and intensity of activity. The pain may be associated with a grinding sensation. It is usually worse going uphill.
The Achilles tendon represents the extension of the calf muscles into and around the heel, thence into the plantar fascia, extending to the ball of the foot. Essentially, there is a degenerative change in the tendon/ paratendon associated with microtears. This is the result of a combination of faulty biomechanics and repetitive overload stress as occur in running. It takes a long time for this combination of circumstances to produce these changes. They show up, on average, after 12 years of training. The faulty biomechanics involved is usually functional overpronation during the landing phase of running, and supinatory push-off. Often, an unstable lateral ankle joint (recurring episodes of "turning" or spraining) may also predispose the Achilles tendon to high shearing forces.
The complaint is usually of pain at the medial border of the tibia, the bone on the inside of the lower leg. It involves degeneration and micro-tearing of the tendons of the muscles that flex the toes and the forefoot- the flexor digitorum longus, flexor hallucis longus and tibialis posterior. The usual biomechanical source of the syndrome is either functional lowering of the longitudinal arch together with hyperpronation which is normally compensated for by the tendons of those muscles; or through weakness and overloading of the muscle in front of the shin, the tibialis anterior.
Shin splints are characterized initially by pain related to impact activity. Later, pain and tenderness may occur in the lower third of the shin unrelated to exercise.
Of course, there are many other lower extremity injuries related to running and other athletic activities, but we are slaves to space limitations.
Now that we’ve piqued your interest (I hope) what can YOU do about these problems?
Since you only spend a relatively short time in your running or athletic shoes, your daily footwear is of primary importance to the health of your feet. Tennis, walking shoes, or cross-trainers, with an elevated heel and good support through the mid and hindfoot are your best options if you need to be on your feet for prolonged periods. Avoid flat shoes at all times. When you wear dress shoes for any prolonged period, make sure the soles are soft. Lace-ups, of course are best because of the support they give. Hard rubber lifts approximately ¼ inch thick may be placed in the heels of your shoes.
In physically active people, regular and effective stretching is essential to the self-management and prevention of all these conditions. Self-massage and ice applications are appropriate measures as is the judicious use of non steroid anti-inflammatory medication, such as ibuprofen. Rest must be selective. Physical activity should be maintained at the highest possible level without incurring re-injury. If you can’t run, certainly you can bike, lift weights, swim, or (ugh!) use an upper body exerciser, etc. Maintaining and even improving your aerobic conditioning during the injury recovery period is essential to successful care. Probably the most important contribution you can make to your own welfare is timely recognition of the existence of a problem and then early and appropriate care by a health professional. If you continue to have foot and/or ankle pain and you’ve done all the above, maybe it’s time to give us a shot (no pun intended) at it.